How do we find more hours in the day?
As the stress and strain of the past 2-plus years have continued, they have revealed even more of the pressures on those of us practicing on the front lines trying to do our best to take care of patients.
We have responded to a deadly pandemic, transformed the way we practice, taken care of critically ill patients when we didn’t know what this disease was or how it would affect people, created new models to allow remote monitoring and virtual healthcare, and opened up new conversations around helping achieve equity across all facets of healthcare, all while trying our best to reach our most vulnerable patients who needed us the most.
Our providers, the doctors, nurses, nurse practitioners, technicians, people answering the phones, and everyone else involved in our teams, are all tired, all worn down to the bone, and showing the strain and signs of burnout and fatigue, even as we continue to do the work that needs to be done. People are working late into the night, finding the time to squeeze things in, often at the expense of their personal lives and the self-care that we all need to practice.
The Tyranny of the In-Basket
In-basket messages are piling up and results are waiting to be reviewed. There are emails, phone calls, and portal messages from patients with questions about when they should get their next booster, what their labs mean, why their basophils aren’t higher, and “What did you mean when you wrote this in my office visit note?” All of this leads to an endless level of nonstop background noise — a pressure wave that never relents.
On the one hand, we are being told to see more and more patients, while on the other we have our innate desire to do what’s right, to close the loop, and to do what’s best for each individual patient. If it were up to us, we’d have unlimited time to spend with each patient, doing whatever we needed to do to address all of their healthcare needs, understand where they’re coming from, engage in shared decision-making, review all the risks, benefits, and alternatives, answer all of their questions. Instead, we are often rushed, and end up over-ordering tests and referring patients out, reverting back to paternalistic medicine.
It would be wonderful if we could develop a better system that took care of us also as we try to care for our patients. It would be great if we had access to all the resources we needed to be thoughtful about each patient interaction, to really spend the time to address everything that needs addressing and then to do all the appropriate follow-up. But if our visits are 20 minutes, where does the accounting come in that accounts for the 20 minutes of pre-charting; the 20 minutes of order entry, note editing, and billing documentation; and the 20 minutes of reviewing labs, contacting patients, and speaking with collaborating doctors? You do the math.
Who Has Failed Whom?
As I’ve said before in so many columns about patient-centered care, the fraction of time our patients spend with us is such a tiny part of their lives, a tiny part of the work that needs to be done to get and keep them healthy. When my patients return after a year away, and say they are here for their annual physical, I look back and see that the things I’d ordered for them ended up not getting done — they never ended up calling their gastroenterologist to schedule that colonoscopy, or the gastroenterologist’s office noted that they tried to reach them on the phone once and then nothing happened after that.
How many ways do we fail our patients, and how many ways does the system fail us? I know what I’m talking about is an expensive proposition — giving us all the support we need to make sure that all the i’s are dotted and the t’s are crossed — but wouldn’t we be a lot better off if we really could get to a place where the healthcare system in this country provided every single patient with exactly what they needed: the right care at the right time, no more and no less?
I don’t want my fellow doctors writing their office notes at 11 o’clock at night in their pajamas after they finally got the kids to bed and managed to wolf down some dinner. Or spending all weekend closing their notes, doing their billing, reviewing labs. And when is the time going to come where we have the chance to do some research, to be thoughtful about our practice, to read our journals, to interact with colleagues, to go to meetings, to do continuing medical education that actually continues our medical education?
Getting Away From the Wartime Mentality
It’s true, the past 2 years have been in survival mode, a wartime mentality, a let’s-all-get-through-this-together way of life. But now, as things at least for the moment seem to be abating, perhaps we can take an opportunity to look inward, to really address what needs fixing, and stand up to the commitment to do right by our patients, our society, and all of the healthcare workers who are fighting the good fight.
I know this is just me getting a little preachy again, but all I heard about this past week was how tired everybody was, how stressed, how weary of doing all the things that get in the way of us taking care of our patients. Why does a request for a medication refill lead to four messages in the electronic health record, and then when we do it, yet another message and more boxes to click?
I remember several years ago when a surgeon stood up at a meeting and said, “Can we just eliminate all these notes, all this stuff we have to do in the electronic health record that has nothing to do with surgery? Why can’t you just let me operate? That’s what you hired me for.”
Something is seriously wrong when everybody, no matter where they are in this big machine we call the healthcare system, feels this way about not being able to get to the job they want to do — the job we love to do, the job we need to do. So please, in the comments below, tell me what you think we can do to make things better. Some of it will require seismic system changes, and some of it can just be something you’ve found that made some small part of your day that much better.
For years I’ve written about how we need to extend the care of our patients beyond the confines of our office visits, and this will take resources. We need to hear the voices of everyone who sees what’s missing, who sees what we’re doing wrong, and who can come up with better ways. There’s not going to be any one answer, any one thing that’s going to fix this mess, but perhaps if we have enough voices raised calling for help, demanding answers, insisting we fix things, then maybe those who have the means to bring about change, to pay for all this stuff, will finally stop and listen.
Let’s figure out how to make the most of those 24 hours in each day.