A Country Doctor Writes:

There is a constant tension in medicine between the details and the big picture. Many factors magnify this tension, and they make our work as clinicians harder. We really need to find our own balance between tending to the details and grasping the big picture, or, in optical terms, a myopic or hyperopic view of our work.

A jeweler working on a delicate mechanical watch, with a loupe pinched over his dominant eye, is not well equipped to also watch the front door of his store for shoplifters.

The more pressured I feel from the number and complexity of patient visits in my schedule, and the further behind that schedule I fall, I know that I become increasingly hyper-focused. It is definitely my survival mechanism for days that threaten to spin out of control. I revert to a razor sharp focus on THAT patient in order to make decisions, sometimes in a triage sort of way: What is the WORST thing this could be? What is the NEXT step for this patient? What would make the BIGGEST difference in this situation? If I instead tried to think of how to get the next two or three patient visits to go smoothly, I don’t think I would be much help to the person I am with RIGHT NOW.

I don’t verbalize or claim this nearly enough: If my team wants me to handle THIS MANY patients in THIS LITTLE time, they need to watch the flow for me; there is no way I can do both. I can’t get enough from them of things like:

“I put out the instruments you might need if you decide to lance this.”

“I got a urinalysis/EKG and a copy of the last culture/tracing…”

“You need to look at this ankle ahead of your next patient, because x-ray is leaving in twenty minutes…”

My other persona, the Medical Director, zooms effortlessly between the two focal distances. Unfettered by a near-superhero clinic schedule, I can zero in when consulted by a new nurse practitioner on a clinical case, and the next minute I can watch the clinic flow and sense the energy of a dozen coworkers as they go about their day, or I can glance at lists of data and get the “big picture” or spot incongruences.

The difference is that pressure, which is so insidious that you can’t really understand it until it is gone: When the last patient has left, the phones are off, most people have left the clinic and the sounds of air conditioners and office equipment have eased off, you realize there had been a pressure on your mind and even your body, coming from every angle as if you were a deep sea diver far below the surface.

Suddenly, the air feels lighter, I am aware of my surroundings and not just striving to tune them out. I didn’t feel the pressure building, but when it eases off this suddenly, it is a very physical sensation.

I throw the word “pressure cooker” around now and then. My mother had one back in the early sixties. Long before microwaves and convection ovens, we cooked things faster by using airtight lids on heavy pots. Without that extra pressure, dinner would be late. Without that extra pressure, clinic would run longer and overtime costs would mushroom. Without that extra pressure, revenue would drop. But like kitchen technology, aren’t there more elegant ways of doing this? The heavy iron lids and the steam escaping through their rattling top vents evoke yet more images – steam locomotives of a bygone early industrial era.

Oh well, I’m just letting off some steam…