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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.
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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 name tag, 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?
Consider for a moment why young people go into medicine; consider why you went into medicine. Our successful matriculates express sincere desire to help others, to be good listeners and to provide comfort through words of reassurance and the laying on of hands. These are noble goals, and these things require time. The reality of modern medical practice is that schedules must be overcrowded based both on demand for service, and based on a widening economic overhead burden. Add to that a huge amount of uncompensated professional overhead (requests for prior authorization, prescription renewals, third-party requests for medical statements, etc), and there is major competition between time required for tangible economic survival and for altruistic fulfillment. If you remember your hierarchy of needs, altruism goes on the back burner when you’re hungry. You can’t eat hope.
Time and pressure are the most important geological forces. Professionally, and in life at large, my contention is that time is pressure. It smoothes and scars, shapes and erodes, but most definitely changes everything. Of all the commodities I can think of, the least pliable is time. You can choose how you spend it, but you can’t get more than 24 hours in a day, 168 hours in a week, or 8,760 hours in a year (except in a Leap Year, when you actually do get an extra 24 hours. But only every 4 years!). In the operations world, they say time is money. Put another way, time frittered is time (money) lost. So, operationally, efficiency is the coin of the realm. To maximize profits, you must minimize down time and idle time.
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. It seems evident that “the system,” headed by CEO-types, favors the “too busy” model as opposed to “not busy enough.” Work in the system long enough and you are pressured toward that. It is a strong current; some drown, others are swept away, and the idealistic few cling to the rocks and debris of hope. All are tested, none are impervious.
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 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 coats, 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, FACP, FACE, is an Associate Professor of Clinical Medicine at the University of Missouri-Columbia, School of Medicine, and is an Endocrine Today Editorial Board member.