Measuring Up: Musings of a Family Doctor on the Employee Time Clock

I loved this article on the "humanity" of the time clock. There is no doubt that the clock can make us feel a bit like a worker bee, less like a caring phsyician. I found myself smiling along with the story of the struggle to make it through the day, with just enough strength to get back home. I am sure that this story is already a familiar one to most all of us family physicians, and I thank Ruth of putting such a compelling narrative together.

To put on my "solve the problem" hat, I feel that this article further reinforces the need of family physicians to be engaged both within our existing health systems, as well as within the realms of the Health Ministry and the politial system itself, in order to have our voice, and the voice of our patients, heard.

Competing interests: ?? None declared

The current obsession with measurement, monitoring, accountability and so on, is a major challenge to the whole concept of medicine as a free profession. The ever delicate balance with management is being seriously distorted. This can only push the profession away from the public sector into the comfort of self-employment - but this will be to the immense detriment of the population. We must urgently re-negotiate our social contract if we are to continue to provide the best humane care to the patients who really need it. Ruth Kannai's lyrical essay is a most convincing document that must persuade anyone who reads it. At the very basis of all clinical encounter is trust. Only where the doctor can trust the patient to come without manipulative intent, and the patients can trust the doctor to be truly committed to their welfare, can healing happen. Managerial monitoring is a sure sign that the intermediary that comes between doctor and patient in the public sector, does not trust the doctor. This is sabotage of the whole enterprise at its most fundamental and its most vulnerable level. I know of no serious evidence that our family doctors deserve this lack of trust. My experience as a medical manager of a large public community health centre in a socio-economically deprived area, over more than three decades leads me to the opposite conclusion. When left to organise themselves to cope with the immense and complex demands of their clinical work, almost all doctors provide an excellent service almost all of the time. It is when they are constrained by organisational rules and regulations that they chafe at the bit - and it is the patients who suffer most from this. Public health service managers must understand that investment in the self -efficacy of their family physicians will give the best returns - but most of them are simply too scared to do this.

Competing interests: ?? None except that I personally admire Dr Kannai as a person and as a professional and I am proud to call myself a colleague of hers.

I have read Dr Ruth Kannai's article, and found it both very familiar, but also thought provoking: Is it the time or the time clock? What is so challenging about the TIME in family medicine? Would it be a better world without the time limits in our work?

Putting a time clock into our workplace has made a big difference in the physicians' feelings, more than anything else: Time limits have always been there! But now "big brother is watching"! This has caused feelings of suspicion, distrust, and general dissatisfaction among family physicians in Israel.

I think that the time clock has done more damage than good to our profession.

Any workplace or health care system, introducing such "simple", technological changes, should address its consequences in terms of its direct effects and secondary outcomes, such as employees' feelings and morale.

Time will tell us if my assumptions are right!

Competing interests: ?? None declared

Thank you for publishing such a wonderful and evocative piece of writing. It captures so accurately the everyday realities of primary care, the inner dialogues of Dr Kannai's patients, and her own inner dialogue as she tries to manage the unmanageable. I can't imagine any committed family physician failing to say: 'Yes, that's what my job is really like'. But Dr Kannai presents her narrative within the context of (yet another) managerial demand that seems brutally at odds with the 'values of service, listening, compassion, and simply being there for the patient' that she believes in. There is a real dilemma here, and also an implicit question: what is to be done? It's tempting to offer some knee-jerk answers. These include: don't clock in and out, just wait for a confrontation'. Or: 'sabotage the clock when no- one is looking!' But I think it's worth asking some wider questions instead.

What will happen if Dr Kannai (and maybe her colleagues) note down every time they are unable to clock in on time, with the reason, and send these to their manager? What consequences will there be if they regularly overrun in the interests of patient care, and the clock records this every time? What kind of dialogue has happened with managers, and what might be possible? Do any of the managers relate to the kind of narrative she tells? Have they seen it, or should they? Are there some doctors in the building who quite like the discipline of keeping to time? Do more flexible doctors like Dr Kannai ever see any advantage to this? I guess what I'm trying to do with these questions is to point out that the clock isn't intrinsically a tyrant. It is a piece of kit, representing one set of beliefs about efficient practice. But the beliefs aren't inside the mechanism of the clock. They are held by people. However rigid and inflexible they may be in our eyes - and we in theirs - we should try to carry on talking.

None of this takes away from the beautiful poetry of the writing, or the professional and personal virtues that inspired it!

Competing interests: ?? None declared