Clinical Leadership—Are We Becoming Too Task Oriented?
Doctors have always preferred to be busy, perhaps too busy, but I have sensed a change that may be making it more difficult for us to be successful in caring for our patients. When I was in training, we made “do lists”—lists of chores that needed to be accomplished during the day. Now many of these chores were in the category we labeled as “scut work” meaning things we did not want to do, but had to, because our supervisors thought it was good for us. Examples were doing our own urinalysis, CBC, and gram stains. Sometime in the 1980’s medical educators decided scut work was a form of hazing, and these activities were phased out.
Now I do not mean to suggest the old way was superior, because I really don’t think it was. However, the tasks related directly to the diagnosis and treatment of the patient. In fact, most of the time was spent on activities that touched the patient directly. All physicians in practice now, though, complain about an ever increasing burden of “tasks.” Some mistakenly think this is because of the electronic medical record. But we have always generated progress notes, operative reports, and so forth. We used to keep these on paper, now we keep them in the computer.
What is different, I think, is that many of these tasks don’t relate directly to patient care. Consider the issue of capturing “core measures.” The people who developed core measures spent considerable effort identifying measures supported by the medical literature as important for good patient outcomes, so arguing against them is like arguing against motherhood, the flag, and apple pie, so I won’t.
I also agree improving performance on core measures, which has been a major effort of physician leaders, is worthwhile. However, since funding is tied to “checking the boxes” in the electronic record, there is a lot of push to get them checked. And the more the push, and the easier it is to check the boxes, the easier it is to forget why we are doing it in the first place.
Medical leaders, with the best of intentions, are fostering this task-oriented, as opposed to patient-oriented, thought process, because they know their institutions will be penalized if the boxes aren’t checked, and getting them checked at all is hard enough. But if we succeed in getting doctors to apply their obsessive-compulsive traits to this activity at the expense of the patient, are we winning? Some will say this is a false argument—being task oriented does not mean you aren’t also patient oriented. True, but the question becomes which is your primary task? If you are a medical leader, you may say: “We know patient outcomes are (generally) improved when patients receive recommended care. Why shouldn’t we push this?”
I think the reason we need to rethink our approach is contained in the phrase “the tyranny of busyness.” Everyone I know seems to have reacted to the changes in the healthcare system by either dropping out or getting on a treadmill and racing to see if they can keep doing what they used to do plus all the things they are now expected to do. It is easier to just “check the box” and move on than it is to think about why we should, or should not, check the box for this particular patient.
I have seen a increasing number of cases where the patient’s overall situation limited effective options for further care. Yet all of the usual care plans had been activated and all of the consultants had ordered the usual tests and made the usual recommendations. When I spoke to them each doctor understood there was little or nothing they could do to improve the patient’s outcome. Clearly, checking the boxes and completing the tasks had taken priority over actually thinking about what might be useful. Now we can blame someone else for this predicament, but maybe it is because we would have an existential crisis if we took the time to think about what we are doing. We might decide we needed to stop chasing our tails, admits the limits of the benefits of our care, and cause us to think about doing it differently. But isn’t that what healthcare reform is supposed to be about? The challenge for medical leaders is to find the time to ask the right questions and insist our colleagues stop clicking boxes long enough to engage in the conversation.
15 March 2015
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