A doctor’s job is objectively impossible to do well

A doctors job is objectively impossible to do well

Today I’ve been feeling stupid. My job absolutely requires critical, creative thinking and the ability to focus well, which was really hard today. But I don’t think I’m actually stupid. I think it has something to do with the task at hand.

So this is how today went. I think it kind of explains the stupid feeling.

My morning shift started at 7:30am in a small but busy 45 bed hospital that serves a chunk of rural Alaska.  The night shift doc told me about the 13 patients who I needed to take care of that day. Seven of the patients were new to me, admitted the night before. For those patients, I needed to review their medical histories in the computerized medical record and get to know them, with a focused physical exam and an interview to determine what needed to be accomplished in the hospitalization. For all of the 13 patients, I needed to review all of the lab tests completed in the last day  and all of the radiological studies and check their vital signs and review the nurses notes about what had happened in the previous 24 hours. Each person had an average of about 30 blood test values and some of them also had microbiological results that needed to be reviewed.

There were an average of, I’d say, 20 vital signs per patient to review, since some of the patients were in the intensive care unit and had hourly blood pressures and pulses documented. There were inputs and outputs to be reviewed, which were relevant for about 60% of the patients. These data sets were a little difficult to find, and involved adding up numbers of milliliters eaten, drunk, pooped, peed and vomited to come up with an estimation of whether the patient was getting dehydrated or fluid overloaded. On each patient it was important to review the medications that they had been prescribed. This averaged maybe 12 medications per patient since many had been prescribed medications that they might need if they couldn’t sleep, or poop, were nauseated or were in pain. Every day I find a medication on one of my patient’s lists which is inappropriate in some way. I discharged 5 patients. For these I needed to fill out a medication reconciliation form to make sure that the medications that they took before they came in were reviewed and re-started if they were needed, and that any new medications given in the hospital were continued, if needed. I needed to write prescriptions for the new medications.

They also needed things like oxygen and wheelchairs and that sort of thing, and these needed to be checked by the insurance specialists to make sure that they would be covered so that the patient wouldn’t find that something that was unaffordable was the thing that they needed in order to survive at home. I had a meeting with all of the nurse manager type people, and nutritionists and physical therapists and social workers to discuss all of the patients, which took about a half hour. I had two new admissions to the hospital and for this I needed to walk to the emergency department, about 5 minutes away if I really moved, to see and evaluate the patients. One of these came in at 9am and the other at about 2pm. The admissions involved discussing the case with the emergency room doctor, reviewing the computerized chart, including past visits, imaging studies and labs if relevant, reviewing paper chart materials from referring doctors and from the emergency department, vital signs, interviewing and examining the patients and then writing and entering admission orders which included all of the things that I wanted done to the patients for the hospitalization including diets, medications, physical therapy, imaging tests, vital signs and activity.

I dictated notes on all of the patients I visited, discharged, admitted, concisely recounting all of the relevant data I had reviewed, the patient’s history, the physical exam, family history, social history, a review of systems and then my interpretation of the problems and my plans for solving them. Discharged patients needed excellent notes so that their primary care physician would be aware of what had happened. I also answered 12 phone calls about patient care issues, visited the radiologist to review x-ray results, transferred two patients from the intensive care unit to the general medical floor, talked to 6 family members, and had 3 conversations about life and death issues including new diagnoses of cancer and HIV and end stage heart disease. I did 5 bedside ultrasounds, observed 2 echocardiograms and a carotid duplex exam performed by the radiological technician and discussed patient care with 4 referring physicians. I called the pathologist twice for incomplete results on the man with cancer, got the out to lunch message once, busy signal the second time and then forgot to call again before the end of the work day, which potentially will delay the man’s hospital stay by a day. Everyone who needed to be discharged needed discharging at the same time, and the people in the emergency room needed to be admitted at the same time as the people needed to be discharged. At this very same time sick people were having things happen which required measured and creative responses from me in order to continue to progress in the direction of good health.

I felt most stupid when I was dictating my reports. A good dictation includes about 10-15 elements depending upon what it is for, and helps me focus on what is going on with the patient. It is also really difficult for me because I am a very visual person and would do much better if I could see what I was writing rather than have it disappear into a recording device. Even if I take copious notes during the day I always feel like my dictations are missing something important.

But even if it weren’t for the frustrations of dictating into a telephone, it is abundantly clear why I should feel stupid. My job is objectively impossible to do well. As an article in the Wall Street Journal puts it, “Multitasking makes you stupid.”

My standard day consists of maybe 7 distinct activities:

1. interviewing and counseling patient and families.
2. reviewing data.
3. communicating with other doctors and staff.
4. examining patients and performing procedures
5. making orders for patient care.
6. documenting patient care, usually by dictation
7. answering phone calls.

These are very distinct activities and are, of necessity, done either simultaneously or in quick and random succession. I was reading some of the data on multitasking and I do realize that what I do decreases my efficiency and creativity due to the extra time and brain power required to change gears so often. I love every little part of my day, but I don’t necessarily love trying to do all of it at the same time.

For me, heaven would be doing what I do, but one patient and one activity at a time. I would also like to get rid of at least half of the individual pieces of data, vital signs, labs, that sort of thing, and a large portion of the medications, to reduce risk of side effects. I would like to train my computer to present data to me in a way that I can best perceive it, without having to jump from page to page. I would like to see the notes I write as I write them.

It is possible to reduce the data that drowns physicians, and it would probably significantly improve our quality of care. It is possible to make our computer systems present data in a way that doesn’t confuse our brains. I’m not at all sure, though, how to make patients who are sick simultaneously respect a physician’s need to do tasks one at a time.

Janice Boughton is a physician who blogs at Why is American health care so expensive?

Image credit: Shutterstock.com

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  • http://www.facebook.com/Cheryl.A.Handy Cheryl Handy

    I reject the validity of the post’s title.

    • N N

      And you would know, being a lawyer, right?

      • http://www.facebook.com/Cheryl.A.Handy Cheryl Handy

        Not sure what your point is – I don’t believe practicing medicine well is objectively impossible. Everyday doctors perform medicine in not just adequate but amazing ways. I am in awe of their dedication and care of human beings.

        • Janice Boughton

          I agree that the title is not right. It is definitely possible to do it well but not all the time. Also true with most service industry jobs. It’s important to look at what are the elements that make it difficult to try to fix it.

  • drg

    So glad you wrote that. I think that is how many of us feel and yet what is apparent is that especially PCP are getting dumped on. The system is such between insurance reimbursement etc not to have the necessary time to do the job that is required. In essence it would be like being a carpenter trying to build a structure that requires a month, to build the structure in a day without the necessary tools. I suppose that makes anyone feel stupid—or angry. Choose your pick.

    • Janice Boughton

      And two days later I was feeling totally in control of things, had time to teach nurses and sit around and talk with families about their lives. Still, we do need to figure out how to manage bad days like this. If there are too many we get burned out and quit, not to mention the dropped balls.

  • buzzkillerjsmith

    Uh, have you considered a new job? If you like doing what you do, then there’s really no problem here.

    As you know, doc, the more abuse you take, the more abuse you take.

    I myself spent some time doing primary care in rural Alaska, back in the dark ages. It really never took with me.

    • PcpMD

      That’s not really true. A person can like what they do, understand that they’re not going to single-handedly change the system, but have deep concerns about the system nevertheless. Quitting her work won’t really change anything – there will just be some other overworked person who’ll take her place.

      • buzzkillerjsmith

        By my reading, the doc seemed pretty miserable. If not, fine, keep working there and try to change things for the better. Good luck.

        But the idea that an overworked miserable person should continue doing her job so as to prevent another person from having to do the job strikes me as somewhat odd. I doubt it is sustainable in the long term for most docs. Perhaps I’m jaded. I’ve been doing this a long time and have had essentially zero luck changing the circumstances of my work without changing jobs. Your experience might be different.

        • Janice Boughton

          I do like it but I’m committed to changing it so it can work better.

  • PcpMD

    I feel for you Dr. Boughton. In addition to primary care, I also do HBS work periodically, coming on for 4-5 days at a stretch, carrying a panel of 12 to 15 patients (no admission though – we have a person who does these exclusively) . I’ve never understood how some of the docs can be done rounding within 6 hours. This would mean that they spent between 25 and 30 minutes per patient to do everything you mentioned, which I’m pretty confident is impossible, unless one cuts corners. On many days, I’m still struggling to get wrapped up at the 10 hour mark. I don’t consider myself inefficient, though I’m thorough.

    The reality is that > 8 truly sick patients per day will lead to sub-standard care. I don’t blame the doctors for this – they can’t control how many patients are added to their census each morning. I also can’t really blame the hospital – they can only afford to hire so many doctors based on the revenue the census will generate. Even if cost was not an issue, I don’t think there are enough doctors in the country to achieve ideal doctor-to-patient ratios.

    So we keep doing the best we can – juggle multiple high-priority tasks simultaneously hoping we don’t drop the ball along the way.

    • Elegia More

      This is why doctors with no control over their practices – those bought out by hospitals – CANNOT give adequate care. Until doctors refuse to take more patients than they can safely care for, we patients should have MORE LEEWAY to sue you physicians – here is an admission that too many patients ends up with inadequate care.

      Why SHOULDN’T I sue for inadequate care when not reading my file or allergies led me to an unnecessary MI?

      Doctor simply stated that he forgot/too hurried to read my hospital file PRIOR TO TREATING ME (!) while I was his patient – no big deal, right?

      This is no problem for the big hospital groups – in my city, they were caught making treats to a doctor testifying against one of their physicians – telling the truth. The judge simply asked the hospital group to get a new attorney – no punishment at all.

      I wonder what happens when YOU DOCTORS get sick – and receive the careless, half baked service that we chronically ill folks deal with daily.

      • N N

        The doctor does not get a choice in deciding how many total patients they care for – except in private practice concierge care. You can blame insurance companies for that (but you won’t bc it’s always easier to blame the doctor). With patients like you, it’s any wonder medical students are fleeing primary care and going into subspecialty medicine. Good luck finding a doctor with that attitude.

      • Janice Boughton

        You have obviously had some bad service which is partly due to systems that don’t work. Until we change them much of the best service will be done by doctors who are overworked and doing their best. If more patients sue doctors there will be less doctors to do the work and it will get worse rather than better.

    • Janice Boughton

      Also there will always be the issue of varying patient volumes, like during flu season and that sort of thing. We can change things like the excessive testing and user unfriendly documentation and data displays which will make us better able to focus on patients.

  • valendar

    An example why we
    need to go back to the Greatest Generation philosophies. The idea of being
    assertive, only adds to pressure.