Wednesday, July 9, 2014

Maker's Schedule, Manager's Schedule: What does that mean for Physicians?

Before you read what I am about to write, go read the inspiration for this piece, Paul Graham's 2009 "Maker's Schedule, Manager's Schedule."  Then read everything else Paul Graham has written.  Then, please, come back.

Briefly summarized-- if you must do something that is hard, takes creativity, thought and solves uncertain problems by combining lots and lots of information, then you need uninterrupted time to do so.  You are making, and making is hard. If you must manage people, communicate, socialize, learn, obtain new information, present, etc. then by all means fill up your day with a series of 30 and 60 minute meetings with enough time to get to each.  You are managing, and managing is incredibly time consuming.

Reading Graham's piece was incredibly enlightening as it calls to some of my frustration about not being able to think, being "too busy to get anything done," having days full of meetings and then endless leftover work at night.  Long ago I saw Jason Fried's fantastic Ted Talk on a similar topic: Why Work Doesn't Happen at Work.  (I am writing this entry on a plane....).  If it were not for airlines with Internet I am unsure how I would ever keep up.

So what if your job is to meet with people, obtain new information, socialize ideas, present and teach AND THEN to synthesize large amounts of multi channel information to begin solve a poorly defined problem. Over, and over, and over again.  Are you a maker? Are you a manager?  No, you are a physician.

Such has become of the life of the modern physician, especially the primary care physician.  In our clinical work alone, we are forever switching back and forth between meetings and really big thoughts.  It is challenging, often impossible, and the work really matters.  Add to just our clinical work the numerous interruptions in the day from other team members, scheduled meetings, etc. and it is a wonder anything gets done at all.

What we have developed as physicians is a honed sense of anxiety that something is not finished.  We remember using check lists, to do lists, fear, emotion, sticky notes, anything that we have to go back to where we were.  When given long blocks of time, I find that I work at a furious pace, assuming that some interruption is coming somewhere, so I better finish before it happens.

The toll it has taken on our profession (and therefore our patients, you know, everyone) is staggering.  Some physicians abdicate the "maker" portion of their job.  They simply meet with patients all day and do the bare minimum cognitive work necessary to bill.  If you have pain in your chest, you get sent to a cardiologist.  If you have pain in your back, you get a prescription for naproxen.  Patient and provider satisfaction is low, quality is abysmal, and patients end up ping-ponged around the medical system racking up risky tests, procedures, therapies and costs.

So what about the physicians who focus on minimizing interruptions and doing the cognitive work necessary to be successful and useful to their patients?  Enter the stereotype of the asshole physician.  The inverse response to interruptions is to block them out at all costs.  Don't answer calls, put up elaborate triage systems to keep people away.  Yell at people that interrupt you so they don't do it again.  Others do not have the temperament for this so they limit access and thereby interruptions in other ways.  Concierge physicians charge a lot to keep most people away.  Other arrangements see panel sizes get reduced (to arguably reasonable levels) so as to minimize the baseline interruption rate.

There has to be a better way.  We are physicians--we listen, examine, teach and interact.  We also think, deduce, reflect, review, synthesize disparate data and write all of this down to our future selves and colleagues.  There are two, related ways forward to preserve this vital role we provide to society.

First, we need to do less as physicians.  Not worse, but less.  Fewer forms, fewer check boxes.  We need to stop satisfying our vague managers, who generally do not recall their days in this role if they ever had them.  The mounting tide of regulation and billing related documentation is frankly terrifying.  It was made by managers and it will destroy us as makers.

Second, we need to find ways to minimize interruptions.  Perhaps it is time to recognize that a series of scheduled visits is not the optimal way to care for patients.  Rather, let us use time to our advantage to proactively manage our patients using data and evidence, and teams to carry out our plans.  We have been doing this for some time and watch as our in person visit rate declines as every metric we have improves-- patient willingness to recommend, clinical indicators, cost and utilization metrics, etc.

With fewer visits, we can use makers time to advantage and make something special for our patients.  It is time to get off the visit hamster wheel-- it benefits no one and is merely the status quo.  We need to organize our work to protect both the meeting and the thinking.  We need to organize ourselves and our teams to minimize the impact of the documentation insanity, and perhaps organize ourselves to fight it all together.

With every interruption we lose something we can regain-- our focus, our thoughts, our time.  We do not benefit, our patients do not benefit.  We must be mindful and fuse our inner manager with our inner maker.

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