There's No Place Like ... the Office?

The last essay, about the use of Web searching by persons attempting to diagnose their own maladies, focused on one of the many ways modern technology has changed our lives.  Of much greater importance, in the daily routines of some, is the option of telecommuting.

The idea of being able to work from home has tremendous appeal.  Although in my specialty of emergency medicine it really isn't an option, because there are so many reasons we are "hospital based," in decades past some doctors had their offices in their homes.  My first eye doctor was one of them.  But there were still direct personal connections being made between the doctor and his patients and among the office staff.

Nowadays, though, there are many kinds of jobs in which the connections can be made electronically.  We do so much of our work on computers, and when we communicate about that work with our associates, much of that can be done electronically, too.  Imagine an engineer whose work focuses on design or sales. Most of the work is done on a computer, and most of the communication with customers and colleagues is by phone or e-mail.  Often that can be done as readily from home, where the computer and the telephone work quite nicely.

Some people who do this kind of work in an office may adjust their hours, perhaps arriving earlier or leaving later than others.  Road traffic may be part of the motivation, but often it's because those different hours at the beginning or the end of the day are times when one can be most productive because of the lack of interruptions.  So imagine how interruption-free your day could be if you have no children or they are in school, and your spouse (if you have one) is either not home or respects your privacy in a home office.

The key to a job suitable for telecommuting is usually a computer.  And so it is not at all surprising that a company like Yahoo would have many employees who work from home quite a bit.  What is surprising, however, is that Yahoo's CEO, Marissa Mayer, has declared an end to this.  Yahoo employees who telecommute are being pulled back into the office - or dismissed.  If you didn't know who she was, you could be forgiven for thinking she must have come to Yahoo from some company in a traditional manufacturing business.

Nope.  It was Google.  She spent 13 years with Google before becoming, at the age of 37, the youngest CEO of a Fortune 500 company when she moved over to Yahoo last summer.

The news reports say this is all about productivity, and the experts discussing this, during the sort of in-depth programming one finds on NPR, cite studies that show most people are more productive when they work in an office at the company, even if it's work that could be done at home.  And it isn't just a matter of self-discipline or time management, although those are contributing factors.  No, they tell us, it's the opportunity to interact with colleagues face to face, whether it's in formal meetings or just wandering over to each other's cubicles from time to time.

My work involves a great deal of personal interaction.  Doctors interact very directly with patients, nurses, and each other.  It would be difficult for me to teach students and residents, tomorrow's practitioners of my specialty, remotely, even with the advanced video technology now available.

But what about in these other professions?  How important are those direct encounters?  The experts say phone calls and e-mails are less effective forms of communication because of the loss of intonation, inflection, and non-verbal cues, deficiencies incompletely addressed with videoconferencing.  I am inclined to agree with them about that, because a year ago I participated in a board meeting by video link after winter storms made it impossible for me to get from Pennsylvania to Texas.  It just wasn't the same.  I was not a full participant.

I cannot help wondering, though, whether Mayer's directive is the right answer. Are those face-to-face encounters so important that we must have them every working day?  Couldn't Tuesday and Thursday, for example, be enough? Perhaps Yahoo will make this big move and then ease into some level of compromise.

The concern about direct personal interactions seems to me to be chiefly qualitative.  But there are likely some solid quantitative data, too.  Some kinds of productivity do lend themselves to metrics.  If you are assembling widgets (my favorite word for some item that is ill-defined and is to remain unspecified), we can easily measure how many of them come off the line per unit time. Productivity metrics in the kinds of work people do on computers, from home, are more elusive.

Further, it is intuitively obvious that there is tremendous individual variation. Undoubtedly some people have a work style that would cause them to get nothing done if they tried to do it at home, because there are just too many distractions.  Even if it would never cross your mind to turn on a television, if you get the impulse to surf the Web, there's no one around to notice.  The refrigerator is right there.  You can have a beverage or a snack whenever you like, which is not the case in very many offices.  A dog appears in front of you holding a leash in his mouth.  A cat rubs up against you, informing you of a desire to have your undivided attention for a minute or two.  You could brew another pot of coffee, but you cannot help wondering what your work flow might be like if you had a pint of ale instead.

When I'm writing, I need absolute concentration.  Interruptions are most unwelcome.  I think it would not go well if I tried to do it in a cubicle with other people around, people who might wander over to talk to me about something, at any moment, unannounced.  In my day job, which this isn't, every hour of every day is a constant stream of interruptions.  That's just the nature of the work. Learning how to cope with that and not allow it to cause errors is a lifelong endeavor, and few achieve complete mastery.  There is an occasional moment when I want to ask a coworker, "Do you realize that you just interrupted someone who interrupted me while I was talking to someone who interrupted a train of thought that is now hopelessly derailed?"  But I don't.  I just smile, because that's never going to change.  It can't.  I simply have to manage it.

The point is that, for some kinds of work, my productivity would be so much greater if I stayed home, because the work environment there is conducive.  And that's without taking into account all the extra time spent getting to and from work. Oh, and don't forget the time one must spend working to earn the money to pay transportation expenses.  I realize the employer may not care about that, but it's all part of the calculus.

Last spring an engineer missed the last step or two on her way down to the kitchen late at night.  The consequent injury made it impossible for her to go into the office for a couple of months.  I happen to be married to her, so I had ample opportunity to make observations of her adaptation to working from home.  I'm pretty sure her productivity was unchanged or better during that time.

It is my suspicion that Mayer is on the wrong track here.  But then, so is Yahoo, which has had four different people in the CEO job in the last 18 months and has seen its sales slumping badly in the last few years.  If Mayer can turn the company around, she'll get much credit and impress many people.  Probably little if any of such a turnaround will be related to improved productivity.  But it is safe to say that if the company doesn't recover from its doldrums, the end of the era of Yahoo employees being able to work from home will be perceived as just another dumb idea.

The CEO had her first child last fall.  She told a reporter for Fortune magazine, paraphrasing Vince Lombardi, that her priorities were "God, family, and Yahoo" - in that order.  (Lombardi's trinity included the Green Bay Packers.)  Given that sensible ordering of priorities, I suspect she will have reason to work from home quite a few days during her son's infancy and toddlerhood.

Paging Dr. Google

Having grown up in a world without personal computers or the Internet, I am endlessly fascinated by the ways in which new technologies change our lives.  I now find it remarkable that I was ever able to write anything longer than a personal letter with nothing more advanced than a typewriter.  My first typewriter with a memory, which held about a page of text - a forerunner of word processing software - was tremendously helpful.  My writing of e-mails now outnumbers handwritten personal letters by orders of magnitude.

A recent graphic circulated on social media networks delighted my sense of humor.  It posed the question of what would be the most difficult thing to explain to someone who was suddenly transported to today's world from the 1950s.  The answer: I have in my pocket a device (a smartphone) that affords me access to all of the information in the world; I use it to look at pictures of cats and get into arguments with strangers.  What splendid irony.

The impact of technology was at the core of a recent article I read about the use of Internet search capabilities by people trying to figure out what might be causing medical symptoms they are experiencing.  The author referred to this as consulting Dr. Google.

The writer's central thesis was that people who do this are likely to encounter a bewildering array of possible causes and great difficulty in sorting out which ones are worthy of serious consideration. Thus a person who is anxious about something might well embark upon such a search only to have the anxiety greatly intensified rather than assuaged.

The author's recommendation: step away from the computer, pick up the phone, and make an appointment to see your primary care doctor. Spending the money on such a consultation, which might consume 20 minutes of your time at the doctor's office, rather than hours of angst-inducing Web searching, is a good deal (especially if you are insured and have a modest co-pay for an office visit).

As I read this, I was seized by the urge to find this writer, grab him by the lapels of his blazer, shake him vigorously, and say, "No!  What is wrong with you?"

There are two reasons for this.  First, I give people who sit down at a computer and try to fathom a puzzling question credit for having some mental balance and some ability to discriminate sense from nonsense. I realize there are exceptions, but I think most people are on pretty solid ground here. I see people in the emergency department fairly often who have researched their symptoms on the Web and then come in concerned about a specific cause or two. Sometimes they are right on the mark.  And sometimes they don't have what they are worried about, but I know from the get-go what they are worried about and can readily investigate it and reach a reassuring conclusion.

The author of the article engaged in hand-wringing about the fact that there are some sources of information on the Web that are frightfully unreliable.  True, of course.  But I think most folks who search the Web have acquired significant ability to separate wheat from chaff.  And I have found that much of the most useful information comes not from mainstream sites (like WebMD) but from discussion boards and streams of comments on blog sites.

Some years ago I had a patient who complained of a sensation of repetitive electric shocks in his head.  I sat down at a computer and discovered something on discussion boards that I didn't find on any regular medical Website.  Such sensations could be caused by abrupt withdrawal from anti-depressant medicines called SSRIs.  I went back to the patient and learned that, sure enough, he was depressed, had been prescribed such a drug, and, after taking it for months and finding that it wasn't helping his mood, quit taking it - shortly before his electric shocks began.  I told him to start it up again and explained how to taper and discontinue it gradually.  He called me a month later to say that had worked beautifully and to ask me to refer him to a mental health professional who would treat him with conversational therapy instead of medicine.

The second reason I was aghast at the writer's suggestion that you abandon the Web and see your doctor instead is that your doctor already spends an inordinate part of his time in the office reassuring the worried well.  Your primary care doctor has a lot of patients to see: people with chronic heart and lung disease, high blood pressure, and diabetes, whose chronic illnesses require regular visits to assure that they are well-managed and optimally controlled.  When he is not taking care of those people, he should have time to see patients with acute illnesses.  You have a high fever and a terrible cough and think you might have pneumonia?  You have horrid pain in the right upper abdomen that comes on after fatty meals and want to know if it's your gall bladder?  You should be able to get an appointment to see your doctor in a short time frame - today would be nice - without competing with the patients who are worried about a rash that appears between the hours of ten and eleven in the morning on the second and fourth Tuesdays of each month.

Use the Web.  Ask friends, family, co-workers.  Be self-reliant.  Do not seek professional health care for every little thing that doesn't feel quite right.  If you - and all of his other patients - make an appointment to see your doctor for every little thing, thus taking up all of his time reassuring the worried well, guess what will happen when his patient who might have pneumonia calls the office?  That's right.  She will be told there are no appointments left, and she'll have to come see me.

If you are suddenly unable to speak or move your right arm and leg, or if you cannot breathe because there is a ton of bricks sitting on your chest, pick up the phone and call 911.  We will take good care of you in the ED.

But if you are the worried well, please feel free to have a seat in front of your computer.  And if, after you engage in as much searching as it takes for you to get some sense of what the problem might be, you are still baffled, take out your health insurance card and see if there is a phone number for an "ask-a-nurse" line.

Please don't call your doctor's office and make an appointment for every little thing.  He has very few open appointments.  And the doctor shortage is intensifying, so this is only going to get worse.

Is Congressional Self-Respect Delusional?

There has been a pay freeze for federal workers in effect for more than two years. Today the U.S. House of Representatives voted to extend it for another nine months. But with fierce opposition from congressional Democrats and the president, the bill has little chance of passing the Senate or becoming law.  And if Congress doesn't come up with some way to head off sequestration, the set of automatic spending cuts that will take effect at the end of this month if lawmakers don't come up with a more tailored plan, money for pay raises for government employees will be what Mark Twain once said men would be without women: "Scarce, Sir, mighty scarce."

From time to time legislators are asked about their own salaries, which are widely viewed as generous.  The Congress has never been shy about raising its own pay.  Two decades ago we amended the U.S. Constitution so any pay raise enacted by Congress could not take effect until after the next biennial election.  Interestingly, the federal courts have held that cost-of-living adjustments (COLA) to congressional salaries do not violate this amendment, although the Supreme Court has never ruled on that point.

Yesterday House Minority Leader Nancy Pelosi (D-CA) was asked whether congressional pay should be frozen.  "I don't think we should do it," she said.  "I think we should respect the work we do."

Self-respect, and respect for the value of one's work, are good things.  But most of us don't have the power to set our own compensation.  Sure, we can negotiate for raises, and we can always leave one job for another to get a better deal.  But our ability to do those things is heavily dependent on the job market - and on our record of job performance.

Last month public opinion polling pegged congressional approval at 13.9%.

Can you imagine going to your boss and asking for a raise if your job performance was worthy of a 13.9% approval rating?

If all that happened was that you were laughed out of the office, as opposed to being tossed out onto the street or marched down a plank at the point of a sword, you would count yourself fortunate.


It has long been a truism that people have a low opinion of Congress but a much more favorable view, typically, of the individual Member of Congress who represents their district.  I'm not sure about the numbers, and over the course of my adult life I've had a few U.S. Representatives for my district I would have liked to fire personally.  But it so happens I like the congressman I have now.  If I were to speak to him directly, as I do from time to time - most recently during a chance encounter when we had both just arrived at Reagan National Airport - and he asked me if I thought he deserved a raise, I think I'd probably say he was doing a good job but I'd have to check the numbers and see if there was any money available.

Here's an even scarier view of the debt

Ay, there's the rub.  Is there money available?  How can anyone ask that with a straight face, with the national debt now exceeding $16.5 trillion?

We all have families to support, bills to pay, obligations to feed, clothe, and shelter our dependents.  Members of Congress - not including Rep. Pelosi, whose husband is a wealthy real estate developer - struggle with the same kinds of obligations.  The current salary is $174,000, and there are expense allowances and other perks.  Oh, and don't forget that COLA.

Do you get a COLA in your job?  I don't.  I will freely admit that doctors generally earn more than Members of Congress, but we also have a lot more education than most of them.  We don't get a COLA. In inflation-adjusted dollars, I earn only slightly more than I did at the beginning of my career.  Seniority, experience, and accumulated knowledge and skill don't amount to anything when doctors' pay is determined.  What the government pays for physicians' services provided to the beneficiaries of federal programs like Medicare hasn't kept pace with inflation in many years.  It has often been reduced rather than increased.  That means that, in what economists call constant dollars, our earnings have been on a steady decline.

This is not to say that I begrudge our Senators and Representatives a decent living. Certainly not.  But raises?  Once more, with feeling, and for emphasis, what should determine whether folks get raises is first, are they doing a good job, second, are economic conditions consistent with rising incomes, and third, does the employer have the money to spend on this?

We already know what we think about their job performance.
We know the state of the economy, and we know family incomes are falling, not rising.

And we are the employer of our elected representatives.  Do you have the money to pay them more?  I know my answer.