Inbox Overwhelm
Healthcare floats on a sea of paperwork. Messages, bloodwork, discharge summaries, consult reports from specialists, imaging. Most of them normal. A small proportion containing subtle meaning which might change management. A very few containing urgent results which would certainly alter management and might alter the patient’s life trajectory. Since the advent of more virtual care options in the COVID-19 pandemic, the messages from patients to be called about something have also escalated. Living with one foot in the medical and one foot in the non medical world, I can appreciate the convenience that virtual options offer to patients, but the truth is that 10 5 minute phone calls at the end of an already busy work day extend clinical care by more than an hour. Many of these calls are not necessary to be dealt with in a separate encounter, and if they should be, both sides would benefit from a dedicated time slot to fully review the situation and next steps, rather than a few minutes while the patient is in line at the grocery store.
Downloading Administration
Family physicians bear the brunt of this administrative burden. This is to be expected, as they are the care co-ordinators. However, for medically complex patients, in particular, this is a lengthy and largely unremunerated process. When I have a patient who is followed by several different medical specialities, and I get a letter from their kidney specialist, with medication adjustments, I need to have a look at what they’ve done and decide whether their cardiologist needs to be aware that their lasix has been changed. One could argue that the consultants could coordinate with each other, and when patients are extremely complex, this essentially happens, but best patient care is for the coordination to happen within the medical home.
Cardiology vs. Nephrology – Dr. Glaucomflecken
Another way administration is downloaded onto family physicians is with ever more onerous referral criteria. In one egregious example I saw recently, a clinic ONLY accepted referrals on the third Wednesday of each month (!). Several physicians commented on the thread, describing how they had set personal alarms and faxed referrals themselves in an effort to make sure the referral was received this month. Some commented, asking why the clinic did not just store up referrals and triage them once a month. Medicolegally, this would be risky for the clinic, as they would be responsible for identifying urgent or emergent referrals as soon as they accept receipt of them. Besides, the truth is not that the clinic is bad, but that they are clearly overwhelmed with demand, and underfunded administratively, so they have come up with this rather draconian (and bad for patient care) method of limiting access to patients with the most conscientious and burned out family physicians.
Another admin download which family physicians resent is when a consultant wants bloodwork done and asks the family physician to order it. Or when the family doctor is asked to communicate an appointment time. Or when the consultant requires certain investigations done within a certain timeframe in order to accept a referral, but is delayed in their own admin procedures so the original workup is out of date before the patient is seen. Or when a referral is rejected unless submitted on a form (most of which are a variety of check a box and attach your referral letter – I always feel like the admin staff of the consultant could be reasonably trained to fill these in themselves when receiving referral requests). On the other hand, I have sat with consultants reviewing referrals and seen that some physicians write adequate referrals and some not so much. “Chest pain” was the most memorable one I recall.
Family physicians of course are well known for being compensated more modestly than consultants, and having high overhead costs to begin with. All of these tasks generate more admin time for them, prompt physicians to undertake admin tasks (standing by the fax machine on the third Wednesday of the month), spend hours on their inbox worrying that they will miss some small detail. Naturally, this situation generates a really unhelpful mindset which leads to overwork, burnout and career dissatisfaction.
Mindset
Time flies when you’re having fun.
We all think that the facts of what we have to do lead to our feelings about it. We accept as true that, for example, dealing with our inboxes is an unpleasant, tedious, unrewarding, unremunerated task which is exacerbated by the nefarious actions of our patients, our admin staff, our consultant colleagues and of course the government (in single payer systems) or insurer (US, I’m looking at you).
I’m here to tell you some great news. How you THINK about your circumstance determines how you feel about it. I’ll never forget a consultant cardiologist I worked with in residency.
It was late afternoon on a Friday. We were heading towards the inpatient psych ward to complete a consultation on a young patient (no cardiac history or substance use of concern) with very marginal changes on ECG which are common in young people. The cardiology fellow was bellyaching about the ridiculousness of the consult to the staff, a practice which I saw demonstrated many times in my training (which by the way leads to dangerous reluctance on the part of sensitive physicians to ask for advice if they are not sure they definitely need it. Nobody likes to feel stupid, but physicians particularly abhor it.) Anyway, the fellow was engaging in badmouthing the psychiatry service who had requested the consult and the staff wasn’t saying much. But he had a little smile. The fellow eventually realized that his negativity wasn’t getting the expected response and there was a little conversational pause.
The attending physician then said to us all, with a calmness I still remember: “I used to get upset about these kinds of consults but now I just try to keep in mind that if the team taking care of the patient was confident there was no heart issue, they wouldn’t ask for a consult. Besides, it’s a quick and easy consult for me.”
The compassion for the most responsible team and empathizing with their uncertainty and the joy of working easily within his zone of expertise has framed how I think about the consults made to me.
When a patient comes in with a viral illness I can be joyfully certain that they don’t need antibiotics at this time. When a patient comes in with a rash I have seen a million times before, I can confidently reassure them and send them on their way. When a patient comes in with exertional chest pain every time they climb the stairs, I know with certainty how to manage them. We can do well to remember that all of the requests from patients that come into our inbox are because the patient is NOT SURE what to do. If they were sure, they would not be spending their time calling your office and leaving a message with your staff.
TL;DR
How you think about what you have to do dramatically influences how efficient you are at getting the essentials done.