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The value of time must be defended
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"Remember us — if at all — not as lost
Violent souls, but only
As the hollow men..."
Excerpt from The Hollow Men by T.S. Eliot, 1925
Fresh faces line up, 100 deep, before an admiring audience of loved ones and life mentors. It is early August, and the annual ritual of renewal begins for the new doctors-to-be on a Sunday afternoon as they receive the symbol of their new profession: their white coats. Some will be comically ill-fitting, far too long or too short, but all will feel changed; it is a mountain-top moment.
All too soon, however, they will enter the valley. Those on the podium, cloaked also in white, vicariously enjoy respite and renewal for a few moments as they welcome the newest members of the profession. In many ways long dead, they feast like vampires on the youthful vitality and idealism of the new doctors-to-be. And with the hugs, handshakes and well-wishes that conclude the happy day, the oxidation and corrosion begin.
Stephen A. Brietzke
As one long-oxidized and partially corroded, it remains a richly rewarding experience to serve in medical education, and I’m grateful that I get to spend time with learners all along the continuum, from early first-year students through senior subspecialty fellows in endocrinology. Increasingly, I draw inspiration and rejuvenation from the young peoples’ idealism and commitment to their patients.
Year after year, I see excitement on the faces of students as they interact with real patients, and the best moments are in the student-run charity clinic. There, the students virtually adopt their patients, doubling as case managers and care providers. Yet, these empathic, humanistic, deeply caring and holistic young physicians gradually morph into cynical automatons, and I am haunted by how and why this transformation occurs. In fact, the idealism and dedication is so pervasive that I am haunted by what happens to make so many of them cynical and burned out before the end of residency.
Clearly, there are many sheer forces in play (including a fair share of the Seven Deadly Sins), but I think the most pervasive is time. Time, as they say, is money. And, as they also say, if you want to know where your values are, follow the money. If you do, you can account for how professional time gets spent.
Shed by its wearer, the white coat carefully hung remains an exoskeleton of the person within. Even without a nametag, one can sometimes know its wearer by the notes and instruments in its pockets. In a doctor’s lounge or resident swamp, one can gaze at the hanging coats and imagine what the wearers would be like in real life, much as one can imagine the knight within a long-empty suit of armor guarding a museum.
Noble goals require time
Back in the day, the knight became a knight for romantic and idealistic reasons, including the vows of chivalry, unaware of the reality to come of bloody, muddy and brutal combat.
Likewise, the neophyte doctors-to-be, in their never-before-worn white coats, know they want to comfort, ease suffering and sometimes heal, and be of general use to their fellow man. They know nothing yet of overbooked schedules, delinquent dictations, prior authorizations, willful and unintended nonadherence, professional misconduct, maintenance of certification and office overhead.
Can they keep their idealism even after they’ve lost their innocence?
Medicine as business
This brings us to the interesting paradox of medicine as a business. It seems to me that medicine has institutionalized inefficiency, not only tolerating but also obligating waste time. The hospital and clinic administrators will, of course, take exception to that tenet, but we have to drill down no deeper than the doctor’s typical day in clinic to see the institutionalization of inefficiency at play (to wit: the ritual of annual prior authorization; requests for re-issue of alternative formulary-specific prescriptions; third-party medical statement requests; Family Medical Leave requests, etc). And make no mistake about it, there is a high cost to that inefficiency.
There is, to be sure, a Starling curve of busy-ness in clinical practice related to the plasticity of time. Not busy enough and you become inefficient; no need to multitask and one has to wait on things to happen before transitioning to the next task. Too busy, and the precious time to think and time to communicate are sacrificed for the sake of flow; check ’em in, get ’em seen, move ’em out. To maximize flow and the business orientation of the profession, we have crafted language to remove notions that medicine is different from other businesses: “Patients” have become “customers” and “physicians” have become “providers.”
Additionally, patient education is outsourced, and open-ended questions are avoided at all costs; fire your losers. We don’t teach those concepts in medical school (well, maybe in The Hidden Curriculum,) but I have actually seen those tenets in print in a “How to Succeed in Practice” bestseller.
Communication suffers
What are the main casualties of excessively time-pressured schedules? I would have to say they are the all-important time to reflect and think, and the time to communicate with both patients and colleagues. Several times a week, I see patients in consultation for which real-time collaboration between me, other consultants and primaries would save financial cost and solve patient problems quickly, without yet-more costly diagnostics. Often, because I’m behind in the schedule, calls don’t get made. Or, if I have time, the doctor on the other end is too busy to talk. And so duplicative tests are ordered, and potentially redundant medications are scheduled. And what about fun and excitement in medicine — two things we grooved on in school, residency, and fellowship — mostly, it derives from thinking about and talking about cases.
What can be done? I believe that time to think, time to communicate with colleagues and patients, and to critically second-guess one’s own work are vital and must be defended at all cost. Creating a payment system that values time to think and communicate will not be easy; we are presently far from it. But, I believe we should try. I do not believe it is in any way partisan; I believe it is health care reform we can all believe in. And I believe it is our main defense against further hollowing of the core of goodness that remains in medicine. And if we can’t change the reality of our practice and our business, we can at least look at our own white coat, hanging on the wall, and think about what our patients need to see in it.
No question about it, the coat on the wall is hollow; the question is, is the wearer within?
Stephen A. Brietzke, MD, is associate professor of clinical medicine in the department of endocrinology, diabetes and metabolism at University of Missouri-Columbia School of Medicine. He is also an Editorial Board member of Cardiology Today’s sister publication, Endocrine Today.
Disclosure: Dr. Brietzke reports no relevant financial disclosures.