On job satisfaction

Just in the last week I’ve had a few people tell me about how dissatisfied they are because they’re working in a big corporation and a few others have told me that they are dissatisfied because they’re working in a small business. There are plenty of things that can make you dissatisfied at work or about work, but it got me thinking a bit about whether the size of a company really does influence our general satisfaction levels and mood. Industrial and organizational psychologists will tell us that, yes, it can and there are some people who will thrive in one industry model and others in an alternative one. Anecdotally, I can attest to that statement based on the people I’ve met at work either as patients or colleagues. I can also tell you my own personal experiences.

What’s the good thing about working about for a big company? As an employee, the budget seems endless. You need what you need to do your job and you can access it reasonably easy. What’s the bad thing about it? If you need things other than those that relate to your job, especially that stuff of being human (e.g. holidays, time to recuperate from illness, or even just to be given a little slack when your personal life isn’t going so well), it is hard for a corporate machine to accommodate. Most companies will have a policy, but unfortunately that policy also tends to be quite strict. For example, bereavement leave may be just 2 days and turns out you may not be a human being that can get back to being your old productive self after the death of your parent after just 2 days. Then there’s also usually a hierarchy and a certain type of anonymity amongst very many employees. Yet both of those things can be positives: the hierarchy can give you motivation to progress; and the anonymity can afford you the space to work with less interruption. On the other hand, the hierarchy can lead to frustration when someone very distant from the sphere you work in makes decisions that affect you at your level without the direct knowledge of what things are like there. There is no perfect big company, and most try very hard to be, but there’s no escaping the fact that we are all human first and workers second.

Is small business, then, the answer to overcoming that barrier between being a worker and also being human? I don’t believe so either. The positives boasted about it are a much smaller hierarchy, often having direct communication with the big-decision makers, and much greater flexibility in work because you can discuss it directly with another human being. Then what’s so bad about it? Been wary of the much smaller budget at all times, and more human-human interaction and therefore greater possibility for human conflict with other workers.

Is there a perfect system? No, and there probably never will be a model that is right for everyone. As an employee all you can do is try to find that model that is best suited to your interpersonal and working style (and tools like the Myers-Briggs questionnaire can help).

In the last few months I’ve come to realize certain things about myself, and certain things about industry - and yet this is unfortunately knowledge that I have only gained through experience. I’ve noted that the greatest teams, the most successful companies, the greatest productivity out of a group of people is achieved when every member of that team feels useful, appreciated, and proud of achieving. In a working environment the reward for achievement is money: our salaries. Even a person who is not someone you’d call material and superficial engages in paid employment for exactly the reason of getting paid; after all, money pays for our daily necessities of life. One thing I’ve noted is that the more a person is paid, the more aware they become of the emphasis his company has for his role – in turn he becomes aware of his responsibility to represent his company in the best light he can. Pride. Pride in our work and feeling useful: tick. And if you feel a person does a good job, isn’t paying them their worth a good way to show your appreciation? I’ve also noted that when an employee stops feeling appreciated in his workplace, despite acknowledging his usefulness, he cannot maintain his pride and enthusiasm. I’ve seen it too often. And, I have to confess, I’ve felt it too.

On prescribing choice... and the hypocrite's spiel

There are many people who will tell you that pharmaceutical companies are the devil. I say the devil is the devil, but I also say the pharmaceutical companies are no angels. Let me first disclose something to you: I eat the lunches brought in by the pharmaceutical sales representatives (almost everyday at my work!), I give my patient’s their drug samples, I enjoy their “educational” dinners at expensive restaurants, I am grateful at their supply of products ‘directly related to my clinical practice’, and I miss the days of the free drug-stamped stationery and random gifts. I do not claim to be immune to their marketing tactics simply because I am aware of them; both they and I know that I am human and the tactics exist because they do work. There are those who directly embrace the drug companies with the attitude of ‘hey, if they want to give money away, they may as well give it to me and I will do what they want me to do’. And there are those that completely shun them, who demonize them, who accuse them of being a… a business. Aren’t we all in business? Those who claim they aren’t, aren't in business very long.

Just this past week I recognized a tactic by the sales reps I hadn’t noticed before: bullying. Now, what I mean to say is not that they wanted to humiliate or hurt me, but they sure as hell wanted to make me feel guilt. Now if I remember correctly from my industrial psychology and marketing readings, creating negative emotions in targets is one of the least effective methods to inspire change of behaviour (in this case, prescribing more of the drug they’re promoting); however, least effective doesn’t mean ineffective. The rep was telling me of some new medication; was I using it, she wanted to know? I said no, I studied a little pharmacology too and I felt more comfortable with another medication. She was horrified! Did I not know that it was the most popularly prescribed medication in its class, prescribed by the greater majority of my peers?! My mind was thinking ‘yes, and?’, but I said, ‘Oh, ok. I’ll keep that in mind. Anyways, thanks for the lunch.’ I went away thinking, wow, really, everyone but me uses it, was she implying that I am doing the wrong thing by prescribing something other than “the most popular”? Is it the most popular because it’s the most effective, because it the newest (and newest we are told is better), because they are better doctors than me and if I want to be good then I must be like them. As I walked towards my consulting room from the lunch room where I had the food brought in by the friendly drug rep, I realised it had worked. I was here second-guessing my clinical management not based on clinical data or evidence, but based on simple human emotion: everyone likes to be liked and to be like the rest. I then laughed at myself.

A few weeks ago another drug sales rep was speaking of a medication for erectile dysfunction. Of course it was about the drug, but they alway tells everyone “it’s about the patient”, thinking of what’s best for them. There’s no news or controversy in saying this; no matter what industry you work in, at the end of the day everyone must eat (and you need money to buy food, right?). Every drug rep walks in to that lunch room and comes with 1) our daily bread (or gourmet lunch), and 2) the “educational material” to impart to us that just so happens to show that the drug their company sells is better for our patients for some or another important reason. But this drug rep wanted not to tell me about why their erectile dysfunction drug was better than the other two, but wanted to know what I based my choice on. I’ll tell you what I answered but first I just want to consider another point on prescribing choice.

Now, you could have five different drug reps talk to you about five different drugs from the same class, both targeting the same “disease” (I’ll explain later why a disease is worthy of my quotation marks here), and they can all show you with ‘real clinical evidence’ and ‘scientific studies’ that their company’s drug is the best. The first rep will say their antihypertensive is the best because it, say, doesn’t have this bad side effect. The second one says theirs is better because it reduces blood pressure quicker than the others. The third one says theirs is better because the effects on reducing blood pressure last longer. The fourth one says it their drug tastes better and is in a smaller pill and that this is very important to patient compliance, therefore in fact being the best drug because patients will actually take it. The fifth one will say theirs is the newest and is so many times better than a placebo. Who wants to be associated with the old and outdated, right? Ah, the stories…

What I answered my friendly drug rep is actually not anything new to them. Why do I prescribe a certain erectile dysfunction drug versus another? Honestly, I confessed, my choice was based on whatever sample pack was in stock in our drug samples cupboard. They know this, that’s why they like to stock our cupboard, not because they like to give away “free samples”, but because it works at securing consumers. I have to clarify a little, though, I use this rather non-clinical method to guide my prescription choice only in certain conditions that in my experience the medications are only slight variations on each other with similar clinical effects, for example as in erectile dysfunction. The second reason to why I do this is because these medications are very expensive and I want my patient to try it first before he goes and spends his hard-earned money on something that may or may not be right for him. Most doctors do this, too. You give the patient the sample pack and a script to purchase the medication if they are satisfied with the effect or tolerant of its side-effects. In cases like this, I prescribe what is in the drug cupboard because I know the brand name will make little difference to the clinical effect I am trying to achieve in a patient. For some reason my honesty seemed to surprise the rep and I think it is because there must be some secret pact that we, both the pharmaceutical companies and doctors, must deny that our interactions are in fact business transactions and we should pretend they are purely “educational” and clinical.

As a medical student I did a placement at a clinic that strictly forbade pharmaceutical reps from visiting to promote their products (or should I say, educate us). It was a clinic were most of the clinicians also held academic posts at the university and they were thoroughly involved in evidence-based medicine. I remember one doctor specifically telling me about how he always prescribed the generic version of a particular drug because it was the cheapest and therefore it meant less money spent on government subsidies paid to the drug companies, and subsequently more money left in the health budget for other essential matters. It made sense to me.  Some years later I worked at another clinic where another very noble and more senior doctor advised me that I should prescribed the brand-specific version of a medication for depression that was now off patent. The reasoning was that the company that made this brand of antidepressant was highly involved in drug research and development and also at producing patient education and support materials, but they obviously can’t afford to do that unless they are making money also. It made sense. Yes, besides I also knew that once you allow for the generic version of a medication to be dispensed by the pharmacist, he incidentally happens to supply the patient by the generic version of a medication which is made by his pharmacy chain. Oh, everybody is a businessman. So my choice is then, who do I feed? The pharmaceutical company making the brand-label stuff or the pharmacy chain making the exact same but generic-labelled stuff (which in most cases cost no different to the brand-label medication). Ah, such decisions… Oh yeah, that’s right, this was mean to be about the patient!

Another thing that the pharmaceutical companies are accused of is not only of making healthcare a business (which I don’t believe they are solely responsible for), but of also creating disease. What do I mean ‘creating’? This is mostly in reference to the medicalization, the labelling, of certain human existential states as disease. Some years ago I read a story about how bad it apparently is that we have made things like pregnancy and ageing disease-states. In a similar vein, drug companies have been accused of doing either a good or bad thing, depending on your point of view. One could say that thanks to the educational and public awareness campaigns directed by our blessed pharmaceutical industry, so many people can be diagnosed and directed towards the treatment of many ails such as depression, anxiety, mood swings, hyperactivity, etc. etc. Another group of people report that the drug companies directed these campaigns as a diversion to their real campaign: increase uptake of certain medications (mostly psychotropic medications). They convinced people that their sadness, that their agitation and worry, that their child’s childish behaviour, are abnormal and required treatment – by using the drug that their company so happened to manufacture. Oh, so many coincidences…

And what have I achieved in telling you of these few tales? That I am a hypocrite? Maybe. But hopefully I have also reminded us all that we live in a capitalist society and that denying that there is a devil at our table won’t make that devil any more of a saint. Worse than being the devil’s pawn is not knowing that you are. As doctors, as human beings entrusted with the care of others weakened by disease, we must ensure that that truly is the worst thing: that we sell our own souls, and not that we trade in those of our patients for a piece of the devil’s share.