The Silent Parts
In the meanwhile, we need to say the silent parts aloud. If an institution is truly, deeply committed to providing outstanding patient care, then it needs to give practicing physicians an adequate amount of time to provide such care. How much time would be easy enough to determine: Take the number of minutes I am logged into my electronic medical record and divide by the number of patients in my panel. Because my electronic medical record kicks me out after a few minutes of disuse—and because I don’t log into my electronic medical record recreationally—that statistic should be a reasonably accurate representation of the amount of time I spend delivering patient care.
I would guess this calculation will yield a number far greater than the length of an average clinic appointment.
If an institution is truly, deeply committed to providing outstanding patient care, it also needs to acknowledge that physicians cannot do this alone. Like many physicians, I also function as a nurse, a pharmacist, a counselor and a social worker. I have no training in any of these roles; I am sure I do them badly. But I do them because the healthcare system refuses to pay for the many allied health professionals who my patients need, are well trained in these areas and are eager to jump into the fray.
Innovative approaches are afoot. At Johns Hopkins Bayview Medical Center, Baltimore, the Aliki Initiative pays for additional hospitalists to absorb patients who otherwise would have been directed to the housestaff services.8 This provides trainees in internal medicine time to identify contextual errors and to get to know their patients in a way that would have been inconceivable when I trained.
At Allegheny Health Network in western Pennsylvania, Sue Manzi is pioneering a sort of patient-centered home for rheumatic diseases, in which every patient is assigned to a multidisciplinary team and may interact with a physician, a pharmacist, a nurse or a social worker, depending on the issue and the team member’s field of expertise.
Both of these initiatives recognize that to deliver truly excellent patient care, we need more time, and that time should not have to be stolen from other pursuits that allow us to rejuvenate and make us whole.
We also need to be more honest about the business of patient care. I accept, intellectually, that I have to perform some paramedical tasks to justify my salary, but administrators should not be allowed to claim they are asking me to perform tasks like signing my notes quickly because “it is important for patient care.” I have never seen a patient who died of an unsigned note. Using the language of patient care to guilt physicians into working even harder than we already do is dishonest, and medical administrators should come clean about this manipulative practice.
In the meanwhile, I feel like I have a pretty good idea of what my job is. And I plan on continuing to prioritize that job, even if my employer and I have different opinions on what that job is. Because I know why I became a doctor, and it wasn’t to earn a green checkmark.
