Primary care doctors don’t usually have scheduled blocks of time to read incoming reports, refill prescriptions, answer messages or, what we are told the future will entail, manage their chronic disease populations. Instead, we are generally expected to do all those things “between patients”.
This involves doing a little bit of all those things in the invisible space between each fifteen minute visit, provided we can complete those visits, their documentation and any other work generated in those visits, in less than he fifteen minutes they were slotted for.
If we can’t capture (steal, really) enough time from our scheduled visits, we are still expected to somehow get that work done, but then on our own time. This results in most primary care doctors logging in to their EMRs from home after supper and on the weekends. Mismatched workloads and work schedule are a major source of professional burnout.
Compare this with air safety. Are airplanes scheduled to be in the air all the time, with refueling and maintenance squeezed in only if they happen to land ahead of schedule?
Quickly reviewing a couple of messages, a few lab results and some imaging reports, and then rushing in to see the next patient is an extremely inefficient and sometimes unsafe way of working.
I have likened this to jumping back and forth between baking a cake, balancing your checkbook and mowing the lawn. Normal people don’t work that way. Why do we expect doctors to?
Neuroscience teaches us that there is no such thing as multitasking. We really only do one thing at a time, and every time we switch from one task to another, we expend mental energy and brain glucose. Switching rapidly between tasks reportedly reduces usable IQ by ten points. Maybe doctors in general have IQ points to spare, but why organize our work that way on purpose?
MIT neuroscientist Earl Miller points out that juggling multiple plates floods the brain with cortisol (the stress hormone) and adrenalin (the fight or flight hormone), which prevents clear thought.
And those are the chemicals involved in burnout. In moderate doses, they are known to boost performance, but constant, low levels of them are the biochemical basis for burnout. We all know that.
My ideal way to work would be “protected” time for Results Review and Care Planning, and then, while another doctor does that, give me two medical assistants and double my number of exam rooms for efficient visits where I have already studied the charts and know better what I’m supposed to accomplish.
And, let me do slow visits grouped together, like physicals and wellness visits, and quick visits together, like sore throats, earches, rashes and knee pains. Slow and fast visits require different mindsets and skill sets. Again, comparing with everybody’s personal life, playing ping-pong or whack-a-mole interspersed with practicing or teaching yoga is very unintuitive an inefficient, at least as far as the yoga part goes.
Kind of like scheduled refueling and maintenance for aircraft…
A Country Doctor Writes: 
makes good sense. perhaps the insurance world should notice.
It wouldn’t be airplanes in the sky all the time, it would be pilots working other tasks between flights. Different?
I noticed on a recent visit to eye doctor for my daughter that the doctor had an assistant typing all the notes as she dictated during the exam. Probably smoothed the work flow a lot. Need to get yourself some interns or med students to ease the burden.
The majority of heavily medically-based eye care professionals do already have this in place. It has become a necessity rather than a privilege. Even with scribes, doctors are stretched far too thin. Why not just schedule more time? Well, then the problem becomes not enough availability and accessibility for the patients. The most challenging thing about this is the governmental controls that are requiring more and more ‘paperwork,’ and calling it in the name of quality of care. It is a real problem.
The mental health field is similarly disrespectful (in my opinion) to therapists. We’re mandated to complete documentation, but not paid to do so!
Shortage of doctors can be also explained by this same illness in our health system you describe. How can physicians be enticed to work for government regulators, insurance regulators, patients (whom should be first), and expect them to be reasonable parents, community givers and else? If we are spread to thin in the name ‘of better care’, and become either subclinically ill (really) or overtly ill, where will the compassionate doctors come from? I will have to argue then with the expression: “Doc, heal thyself”. It is a real problem. I do honor those clinicians (doctors, nurses, mental health providers, etc.) who do continue fighting straight in the trenches and front lines pro our patients!
We must work at seeing and doing what really matters, and remembering the reasons for being in the healing professions. Distractions abound.
I used 1 MA to get vitals and chief complaint, list anything new or changed. I would go from room to room w a scribe computer on rolling cart. She knew my routine, I ever did manipulation, I would tell her and patient my findings, diagnosis and treatment Rx etc. She would handle routine refills, referrals or tests, outside orders would flip to lab girl. While this was going on I was in another room with another scribe…. Repeating the cycle. If a test was done, it typically required a visit. Rx requires a visit. A change of medication by an insurance company required a visit. They encroach on my time I get paid. When patients left, they had an appointment for a follow-up to review test results etc. I had about 15-20 minutes at the end of my day, reviewing incoming results or direct to staff to call patient or have them return to clinic. I comfortably saw 50/ day, but might work till 6 or 7:00 if needed. I started at 8:00. You have to delegate. I set with the patient, no computer. On occasion I might look at computer, but did my best to avoid that unless I was reviewing lab or tests sitting on exam table with the patient.
How about seeing a new patient every 20 minutes.
For example a patient who is taking 15 meds( 2red, 3white and rest unknown), recently discharged from a hospital with life threatening stroke, completing pristine medical records as well as ICD code it to highest level of reambursment.
But wait, right on the screen when you are doing this, there are 6 pop up stream of messages.
1. Your nurse has a question about previous patient.
2. Pharmacist wants numbers of calculated pills were not written so it can’t be prescribed.
3. Your phone has pinged you that your next patient is checked in and is sitting in lobby for 5 minutes.
4. You get a pop-up message that your lunchtime webinar is to start in 20 minutes.
5. Your nurse texts you again that staples are out and patient is asking wound care instructions.
6. Three doctors from from different geographical location are chatting about how to find a particular specialist for the patients problems.
7. Your pager is going off, you have a patient fainting during phlebotomy.
8. Lab is calling you that, blood sugar of a patient that you saw yesterday was 55- “it is critical so we report, please give me your full name, account number, please spell your first name”.
This all is happening at the same time on a single screen of patients EMR of a new patient whou you are supposed to see and treat with in 20 minutes.
You are supposed to pay attention to all this with in the 20 minutes you are allotted for the new patient.
If you miss any of these, you are inefficient, snob, not a team-player, slow, dumb and what not..
All are spot on. Add though that now, the patient gets lab results posted in their portal and can view them even before you do! ( since your schedule is packed). Hence, a flurry of panic emails and phone pings!