Physicians die from a death by a thousand messages


There are a couple of times a year when there are no house staff to be found anywhere in the hospital or the outpatient practices. These include the holiday and end-of-year parties, resident retreats, and the annual house staff picnic.

The house staff picnic is a particular favorite among the interns and residents, a full day away from the hospital, dressed like civilians, fun in the sun, barbecue, softball with their colleagues, and an extra day off work.

In our practice, what happens on those days is that those of us left behind, who were scheduled originally to supervise residents, end up handling all of the phone calls that come in on that day regarding the residents’ patients.

So my job Tuesday this week was covering the calls of fully half of our residents, the telephone and in-basket messages for 10 of our pods, each of which includes a panel of five to seven residents. Not surprisingly, this works out to a lot of messages.

I started out the morning early sitting at my desk, and when I logged onto all of the different pods, including the access team which handles routine refills and urgent clinical phone calls, my previously empty in-basket suddenly filled with 45 messages.

A quick review showed that many of them were left over from the week before and even just the day before — reminders for someone to follow up on an imaging that had been ordered or a message that had been left for a patient who was unreachable. Once I cleaned these up, however, the minute I called one patient, refilled one prescription, or printed out one durable medical equipment (DME) prescription, I would blink, and there would be a dozen new messages.

The messages kept coming. And coming. And coming. Luckily, there were very few messages from my own patients and no one that I needed to squeeze in for an urgent office visit that morning, because it was a nonstop torrent of things that needed getting done.
Mostly what it was, however, was not a lot of doctoring. There were tons of routine refills, minor questions, changing from one brand of a medicine to another, authorizing a generic, printing DME paper prescriptions, calling a visiting nurse service, speaking to a home health aide, answering a family member’s question, talking an occasional patient through an upper respiratory infection or musculoskeletal injury.

And while I was covering far more in-baskets than any one resident would do on a usual day, it still gave me a sense of what it feels like, and why this endless barrage of tiny little things that need to be done might lead to residents not being totally entranced with the idea of choosing a career in primary care.

Every once in a while, I got to explain to a patient about their lab results, talk to them about the things we like to talk to patients about, counsel her, recommend she go up on her insulin dose, work on her cholesterol, work on her compliance, and then get things rechecked in a couple of weeks.

But a lot of these tasks were just rote mechanical stuff, things that needed to be clicked, loaded into the orders section, signed, double authenticated, approved, printed, faxed.

“Patient needs a letter stating that she was seen in the office on August 10.”

Have we really created a world where that’s a doctor’s job? Can’t the patient just tell whoever needs this that she was at the doctor’s office and they should just trust her?

As we have worked over the past months to redesign our access team, we are hoping that we can revamp our workflows to make a lot more of these routine things not fall into the category of doctoring.

Twenty years ago, when I first started working here, we had a nurse in our practice who had been practicing in our office for many, many years. She had a wealth of experience, and we all knew that we could trust her to do the best thing for our patients. Patients knew they could call her and that she would give them sound advice.

In those days, when there were fewer regulations about who could do what, she clearly did things that were beyond the “scope of practice” for a nurse, but not once did her calling in a refill or talking to a patient about an upper respiratory tract infection lead to harm to our patients.

In fact, she probably led to better care and more satisfied patients, and her dedication and efforts made the lives of all those she worked with that much easier.

As we continue to develop and refine our patient-centered medical care model, we need to recognize that the thousands of tiny phone calls, regulatory mandates, and all the things that seem to hamper our healthcare system rather than help it, need to be divided up among the members of the team, until the day we make them finally go away.

It shouldn’t take a picnic for us to realize that we’re far off the path of creating an idealized health care system, a place to care for patients in a truly patient-centered way, a place for our trainees and junior faculty to find a truly satisfying life in medicine.

But sometimes only by walking in their shoes can we really recognize how there is almost no way that they would want to choose this life with its death by a thousand tiny calls.

Prescriptions do need to be refilled, patients need to be called back, orders need to be signed for home care agencies. But I’m calling on all of us to rise up, to call out those who have been part of creating the system that has been forced upon us, to change the system so we can all thrive and survive within it.

The call is coming; the phone is ringing.

Will we answer it?

Fred N. Pelzman is an associate professor of medicine, New York Presbyterian Hospital and associate director, Weill Cornell Internal Medicine Associates, New York City, NY. He blogs at MedPage Today’s Building the Patient-Centered Medical Home.

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