Robert W. Morrow, M.D.
Among doctors, “burn out” discussions are all the rage.
Hold on a moment here! Aren’t doctors rich professionals who like to pick on their staff and patients, and complain about their stock brokers?
The Doctor in the Little White House
I was asked a few years back to travel around NY State and facilitate interactive seminars on domestic violence. In our group was a public-health expert from Albany. She said: ‘hey I remember when I was a little kid in North Riverdale, I went to my doctor’s office in a little white house, with puppets and stickers.’
I checked my shoes and muttered: ‘Must have been my father,’ (though my father was not the doctor in that little white house… it was me). Smiles all around.
Yes, I was seeing families in the Bronx when this accomplished, professional woman was a kid. And I am still seeing families as they grow and change. Kind of a dinosaur of community continuity. In an artisanal practice with other health care professionals.
My view is that as a professional with roots in a neighborhood, each encounter is a new connection. My attention can focus on the person, with few distractions and more positive feedback.
My task is to provide a good product: supportive, attentive health care.
So why haven’t I burned out yet, when so many others experience the awful sense that they just can’t go on as doctors? Why have I only been singed in 38 years, not burned out?
The New Paradigm for Doctors
Tasks have changed now. According to cognitive load theory, our brains can hold only so many simultaneous active tasks. New, urgent tasks kick out what was previously active in our brains.
How can a doctor focus on the person sitting in front of them relating intimate details of their lives, their pains and fears and the responsibilities they are struggling fulfill… when they have an electronic-record device heckling them to do tests and follow paths that may not be relevant at all.
It’s like a kid when adults are talking, always pulling your arm and interrupting. Does the kid have to pee? Right now? Do they want to have you stop being so boring? Play a game?
So the load of senseless new tasks intrudes on almost every medical-human interaction. Did you score the person’s depression each visit? Write out every aspect of the exam? Record the vaccine manufacturer? Write a set of goals for every healthy 40-year old? And, of course, get to the next patient within 15 minutes?
Short Cuts – the Volkswagen Solution
Luckily, your machine provides buttons to say you did a ton of stuff. Push the button and text fills the screen. Bogus-but a requirement for payment.
Push what I call the ‘Volkswagen button’ (after the car company’s secret way to cheat the emissions tests), which fills the check boxes, and you might get paid. Neglect the button, and either don’t get credit/paid, or you work all evening at home finishing the chart requirements.
Push that button and you’ve lied, but no one yells at you. And you’ve completed your chart entry.
You cannot complete your chart work in primary care during work hours if you are honest. Does this extra, often after-hours, work add benefit to your patients? Not at all.
What Do Doctors Write About?
I get consult notes, from trusted docs, which have pages of words and no discussions of plans or diagnostic puzzles. Lots of text, lots of lists of things checked off as asked or examined, no explanation of thought processes. But what did the doc think was going on with this patient?
From the flood of notes, I have no idea.
Charts used to be a personal place to remind the doc of what was done, what is left to do. It was a way to puzzle out what was causing patients’ complaints. Now it is a vast repository of useless data points.