Friday, October 23, 2015
Tic - toc......
Or why advising physicians on how to manage their time is not generally a good idea.
I will cut to the chase on this one. The answer is two fold. Medical practice is by its very nature inefficient. Secondly, there are just too many people incentivized to waste physicians' time. After reading another blog on this topic, it is apparent that most people attempting to give advice to physicians either think that we are quite slow on the uptake or they have no appreciation of what medical practice is like. The most misunderstood part is how much time physicians are forced to waste on work that is unnecessary to the work of patient care.
I preface my remarks by saying that in the many visits I have had to physicians of all specialties, I have never been seen on time and consider myself lucky to be seen within 30 minutes. My all-time record was waiting about 30 minutes to be seen in the emergency department one day and then having to wait another 8 hours to be discharged by the physician who saw me for a rather uncomplicated problem. So there is no expedited line for physicians in clinics, EDs, or hospitals. We wait like everybody else.
The premise of efficiency in medical practice is a favorite of administrators and other salespeople pushing valuable time saving devices for physicians. Primary among them has been the electronic health record or EHR. I think there is finally a consensus on the fact that it has basically created a large pool of physician-stenographers that spend additional hours each day typing in documents that are designed for billing and coding purposes rather than enhancing the care of patients. I will roll out my frequently stated comparison. In 1981, two interns and myself could complete all of the daily documentation on a busy 30 bed neurosurgery service during the 2-3 hours that we were rounding with the senior residents and doing all of the other associated work that day. Today it would probably take an additional 4-6 hours to do that work and it would mean less time in the operating room learning neurosurgery and attendings wondering about what happened to the team. I have heard of some surgical services who hire retired surgeons to come in as scribes to do operative notes to reduce the paperwork burden. The documentation burden is worse in primary care. All of the advice on how to shift your time around to allow ample time for the documentation never considers the fact that time slots in clinic are rarely set in stone. People show up 30 - 60 minutes late and expect to be seen. Emergencies happen, and need to be dealt with while people are stacked up in the waiting area. Labs need to be reviewed and all of the outgoing tasks (paperwork, phone calls, prescriptions, consults) need to be handled. None of these are trivial tasks in terms of the time it takes to get them done. Some of my friends in Endocrinology walk in on a typical morning and have over 250 test results stacked up in a computer queue that they need to review on top of the full patient schedule that day and do something about them - in some cases right away!
Outpatient clinics have certain routines every day depending on the specialties involved and the amount of staff available. As an example, primary care clinics generally have many more staff to room patients, take vital signs, handle calls, and schedule patients than outpatient psychiatry clinics. But even clinics that are more fully staffed can easily be overwhelmed by the demands placed on them. There is no end to nonsensical ideas about how physicians can be more efficient, but there are always several facts that all of the advice givers typically ignore:
1. There are mathematical laws called power laws that govern how many patients can be seen by physicians. It is a mathematical fact. All of the speculation about computers doing thousands of physician tasks per second are really meaningless at this point. All of the administrators talking about "productivity" are as meaningless. Productivity happens when real quality treatment occurs that changes a person's life.
2. Despite all of the business focus on productivity, the business administrators in health care have done nothing but create obstacles to physician work. Wasting hours every day doing tasks for insurance companies and the government is basically a case in point. I would estimate at least 40-50% of all physicians time is wasted on these tasks.
3. Every physician in this country who works in a clinic setting is an independent practitioner. They don't need supervision, they just need to keep their license current and abide by the medical practice acts in each state. The only time they are supervised is when they work in a clinic or hospital setting and suddenly they vertically integrated into departments and placed under a supervisory hierarchy. That hierarchy is by definition very inefficient. A lot of time is wasted implementing the next great ideas of the supervisors and in some cases sitting in long drawn out meetings about the financial status of the department. Apart from the administrators needing to demonstrate that they were actually doing something (that is frequently debatable) - these meetings were generally a waste of time. I don't discuss all of my cases with business administrators - why would I want to read their spreadsheets? How can putting 20 or 30 physicians in the same room for a meeting be anything but disruptive to clinic and hospital schedules? The business and government initiatives to force physicians into these employment situations leads even less time to see patients.
4. Physicians have been hit hard by the EHR and more. Like many other jobs there is an implied 24/7 electronic access. When physicians are not completing documentation after hours or at home, they are answering e-mails and texts about patient problems. It is not uncommon to start clinic and notice that is addition to a full schedule of appointments and labs to review that there are also 20 or 30 e-mails and messages through the EHR - many marked urgent. If you are the first appointment in clinic that day and your physician said that she had to respond to an urgent problem - believe her.
I can understand that this post might elicit widely varying emotions. Overworked and burned out physicians will see the obvious truths here and will wearily think: "Been there - done that." There will be readers - like one who suggested that I drive a Porsche rather than a soccer mom van - who will be outraged that a rich doctor dares to complain about working conditions. There will be readers who think that physicians should not complain on basic principles. I guess they don't want physicians acting like other workers when this is supposed to be a privileged and noble calling. They don't recognize that physicians are managed like production workers and not professionals. There will be those trying to silence complaining physicians by suggesting it is "unprofessional" or characterizing legitimate complaints as "whining". They generally have their own political agenda that includes managing physicians like production workers. It should be apparent that there is no extra time to manage. There are many people who will say they are working as hard as doctors and therefore doctors don't have a legitimate point. I would say that I don't doubt it at all that too many Americans are working long and hard hours. The question is whether there is also a public safety consideration. Most workers where there is an element of public safety have limitations on their hours. Practically all physicians are running a huge time deficit that can't be overcome by gaining 5 or 10 minutes from the occasional appointment that goes well.
Irrespective of the emotional reaction to this post there is a very basic thought experiment that anyone can do. It will highlight a suggested orientation to the problem. The question is - when you see a physician do you want to see somebody who is burned out, fatigued from people wasting their time and trying to get them to do more busy work? Or do you want to see a physician who is energetic, enthusiastic and has enough time to dedicate to you or your family member?
I personally will take the physician who is energetic, enthusiastic and has enough time to focus their energy on their family and learning more about their field. That is not happening in many places today.
And for all of those people who want to give physicians more advice on how to be more efficient in cramming 12-16 hours of work (much of it unnecessary) into 8 - here is a bit of advice for you. Step back and let us do our work - we were doing quite well without you.
George Dawson, MD, DFAPA
Clock graphic by Dnu72 (Own work) [CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons.