September 26, 2005
What do airline pilots, computer engineers and physicians have in common?
And lots of other people for that matter. This is not a trick question. But it is fundamental to a lot of current angst.
Answer: the relentless devaluation of skills.
And I mean devaluation as in they are worth less today than yesterday and will be worth less tomorrow. Worth less means what you can get paid for the same knowledge or skill level.
Labor unions recently have been getting more air time often arguing loudly for “wage protection” and job protection. Their call is like calling for stopping the waves of the ocean. The change will keep coming, every day and every night, without stopping.
What is happening now is perhaps the most fundamental change to the way work gets done in the world than at any time since the start of the Industrial Revolution.
If someone actually uttered that famous phase, “The Internet will change everything,” they didn't know how profound it really was. The democratization of information suddenly devalues it. Commoditizes it. Opens it to relentless competition. Makes the artificialities of license and profession much less relevant.
This has become cliché, but not a well-comprehended one.
It is difficult to get our human minds around the idea that what we know and can do becomes worth less in time and not more. This runs counter to our beliefs.
One of the curious aspects of human nature is our seeming abhorrence of change. We like stasis, predictability, and certitude. This was a lot easier when we lived for only 40 years or so and cycles of change were slower. The ideas of structural stasis as integrated into our governments and other organizations became a major pastime in the mid-nineteenth century.
By the mid-twentieth century we became convinced of the paradigm that if we went to school, learned some stuff, and then showed up for work for 20, 30, or more years, we not only could but also should earn more year by year. Experience as defined by time in grade meant higher value.
Ah, the sense of entitlement. It only makes it harder when the change comes.
Although Woody Allen did popularize the linkage of showing up and success with his famous “85% of success is showing up,” the ability to move work to equally capable but cheaper people--especially with access to information technology--has created great dislocation and changed the value relationship of professions.
Airline pilots know about dislocation. Computer engineers know about dislocation.
What about in healthcare?
Physicians have jealously guarded their domain for a couple of hundred years. They have thrown up barrier after barrier to change, generally in the name of public safety.
The question is seldom asked, “What should physicians get paid for?” And since there is no market feedback to direct work done better and cheaper by others, the price for professional services continues ever upward.
So, what should physicians do and get paid for? Medicare has determined that physicians should get paid for collecting and recording data points. Not for judgment. Not for outcomes. The latest is compliance with process now euphemistically called “pay for performance.”
By the way, no one needs to go to school for 20 years and be trained for another 3 to 8 years in order to collect and record data or even to follow the mind numbing repetition of so-called evidence-based medicine. Our government has determined to pay physicians for the least value-added thing they can do. It is amazing.
But despite this tragically deformed system we have, there are some guideposts that suggest what physicians should do and get paid for.
Don't cringe, but Adam Smith told us more than a couple of hundred years ago that scarce skills are and should be more highly valued. Professions and the government have worked together to define medical skills as scarce by definition and to create barriers to entry. The Internet changed everything. They found out. Or are finding out.
But there it is: scarce skills. Continue to develop scarce skills. Leading edge innovation. Do this and your skills will not devalue over time, assuming you are “allowed” to take them to market.
Exercising good professional judgment would be a second thing that should bring value that is worth paying for. The profession has said if you have a license you have good judgment by definition. We know that's not true. The consumer movement, new decision tools, and increasing transparency of medical knowledge may radically change this.
Other things physicians should do and get paid for: managing others who can do the work better and cheaper. Putting more and better knowledge into hands of consumers. Designing the systematic parts of healthcare, those things that can reasonably be done based on rules but don't need a physician to deliver. Research and development. Helping hospitals and institutional care to do a better and more predictable job. Teaching.
The world is changing. We can stop it for a time. Maybe long enough so we don't have to deal with it personally. But maybe not. Pilots know. Computer engineers know.
