This veteran doctor describes how to stop wasting time on the unimportant things.
This veteran doctor describes how to stop wasting time on the unimportant things.
Line one," said Sue, my secretary. "It's Dr. Smith, from the clinic. He wants you for a speech."
"You've got to be kidding," I replied as I picked up the phone.
"I've got a dandy topic for you," said Smith. " 'How to practice efficiently without letting patients know you're doing so.' What do you think?"
Not much, I thought, but when he persisted, I told him I'd give it a shot.
I soon wondered if I'd volunteered too quickly. My practice is not the stuff of which speeches are made. I'm solo, I'm rural, and I'm a family doctora three-time loser. I'm also the son of a family doctor, so I should have known better. If I'd been halfway efficient all these years, I'd be far away by now, clipping coupons and sipping margaritas on a beach somewhere.
The next morning, when Sue thumped a heavy pile of mail on my desk, I asked her, "Have you ever caught me being efficient?"
"You're the most efficient person I've ever met," she replied. "You don't waste time on unimportant things. Look what you're doing this very minute. You're being efficient."
Sure enough, as we talked, I had riffled through the stack of mail, tossing most of it into the wastebasket. Maybe I had the makings of a talk after all.
Don't read all your mail
That evening, I made a list of the things I dislike wasting time on. Right at the top came the mail. The pile on my desk seems to grow and spread like cancer. Nobody uses a 34-cent stamp on a doctor without expecting something in return: Sign the forms; read the reports; approve the orders; return the questionnaires; review the regulations; write the prescriptions. And brace yourself for special delivery letter-bombs from the lawyer down the street.
The next morning, we began measuring the stacks of mail arriving at my ordinary, one-doctor office. They averaged 4 inches a day. That comes to nearly 70 inches a month or 70 feet a yearthe height of a seven-story building. Now, no one can possibly read such a pile and still have time left over for patients. The trick is knowing what to ignore.
Don't answer your own phone
"If you think the mail is bad, what about all the phone calls?" asked Sue. She began keeping score at the front desk, and her final tally shocked us all: Our one-doctor office handles an average of more than 50 calls a day, or 260 a week, or 13,000 a year. While some of those calls are important, not all of them are. Just answering them all yourself could easily become a full-time career, which suggests another guideline for efficient doctoring:
Make hospital charts no longer than needed
I was on a roll. The next stop was the hospital record room, where I confronted an armload of "delinquent records." There were only three charts, to be exact, but each was nearly as thick as a Seattle phone book. I suspected that these, too, might have undergone cancerous growth over the years. To check, I spent several evenings pulling charts and counting pages.
Back in 1959, I discovered, charts in our small, rural hospital averaged slightly more than one page a day for each patient. By 2001, we were churning out some 20 pages per patient per day. In 1959, Fay the chart lady handled the job alone. Today, she's been replaced by Glenna, Cindy, Tara, Jody, Margene, Sally, Esmerelda, and two Annettes.
Back at my office, I compared my own record-keeping with that at the hospital. My charts are compulsively complete, but concise. Theirs are bloated, with vital details often smothered beneath mountains of repetitious gibberish. My charts are used daily for patient care; theirs gather dust. Once dictated and signed, the hospital records are seldom touched again by medical hands. Modern hospital chart work has little to do with patient care. Its purpose is the avoidance of lawsuits and the justification of inflated hospital bills.
Don't waste time on things you can't change
In my own training, I had seen no family doctors, only specialists. When I began practicing, I worried about not mastering everything doctors need to know. "Nobody knows it all," said Dad, "only bits and pieces. If you don't believe it, ask an orthopod the dosage of digitalis or watch an internist suture a wound."
About a year after I came home to practice, I lost my first patient. I'd watched patients die before, in training, but never my own patientsnot folks I'd known and grown attached to. This particular death wasn't expected. Assuming I'd missed something important, I blamed myself. Afterward, I moped around for several days before Dad called me into his office.
"Don't medical schools teach the first damn thing about doctoring anymore?" he grumbled. "Get this through your head, and remember it. Sooner or later, you'll touch something and not feel it. You'll look at something and not see it. You'll listen, but you won't hear. And before you're through, you'll probably cut a few things you weren't particularly aiming at. All you can do is all you can do. Next time, you try to do better. That's what doctoring is all about."
Nothing beats a placebothat works
Little things matter in medicine, my father would explain: the tone of your voice, your look, your choice of words, even the long white coats of university doctors. "All good doctors are at least 20 percent quack," said Dad, "even the professors."
The placebo effect was the safest tool in the doctor's bag, he used to say, as long as you didn't kid yourself that you weren't using it. And it never hurt to change the color of the pills from time to time.
Years after Dad passed away, a lady came in requesting a refill for B12. Dad had written the original prescription many years before, and she'd taken the stuff ever since. She claimed it was the only medicine that helped her problema textbook case of rheumatoid arthritis.
Knowing B12 was worthless for arthritis, I canceled the script and wrote another for a different medicine, one more likely to help. None too soon, apparently, for when the lady returned a few weeks later, she could barely move her puffy, misshapen hands. Over the next few months, I prescribed every up-to-date arthritis drug on the shelf. With each new pill came new side effects. One brought headaches; another brought dizziness. Her ulcers bled, her enzymes skyrocketed, and finally, with gold therapy, came the ugliest case of exfoliative dermatitis I'd ever seen. And her arthritis kept getting worse.
When at last I'd exhausted my list of "proper" medications, she asked me, "Now, may I please have the B12?"
I replied, "Sure, why not?" Two weeks later, her arthritis went into remission, and stayed there. After that, I refilled the B12 whenever she asked. I remember what Dad said, and I know somewhere he's laughing.
Always leave them laughing
Eager to share my "research," I collared one of the young family doctors in the hospital parking lot. He listened attentively and seemed interested. So I unloaded the whole tirade: "All this damned paperwork . . . no time left for patients . . . we've been taken over by idiots, third-party payers, lawyers, people who've never practiced medicine. . . . "
The young doctor's eyes widened. "Were things really so different in the olden days?" he asked.
Come to think of it, I am sort of an expert on the olden days. I've been hanging around a doctor's office since 1933. That's the year I was born, and the year my father opened his practice in Blackfoot, our small Idaho farm town. His office was on the second floor, above the town's pool hall. On quiet days, he'd be downstairs, shooting snooker with the boys.
I grew up as a small-town "doctor's brat." When my mother helped out at the office, she brought me along. I'd play with blocks and tin soldiers on the back room floor, between the recovery bed and the autoclave sterilizer. On "tonsil days," the place reeked of ether, and the kid in the bed puked blood into a white enamel basin.
After medical school, I eventually returned to Blackfoot to practice with my father for the last six years of his life. In those few years, I learned more about doctoring than in all the rest put together. Before I came home, my dad had kept no charts. Important stuff he remembered tenaciously; minutiae he promptly forgot. There was no appointment schedule; Dad made time for folks who really needed him, morning, noon, or night. Bills went out once or twice each year, usually after crops came in. Those were the days of the Great Depression. "Pay me when you can," is what Dad said, and what most folks did.
Instead of seeking "efficiency," my father had his own shortcuts to healing. First and foremost, he listened to what people said. There's no way to cure patients without first hearing them out, he told me. After that came talking, but no more than was necessary.
When I see folks today whom Dad first treated in 1933, they still speak of the things he did long ago: the tractor ride through the snowdrifts, or the night he huddled with them by the potbellied stove, waiting for the baby to come. For many, he was part of the family, popping through the front door without knocking.
Dad believed laughter is the quickest shortcut to making people feel better. He always had a funny story to tell, and many of his patients still remember them. There was one about the farmer with pneumonia who passed the doctor's nurse in the street. He'd had so many penicillin shots, he didn't know whether to tip his hat or drop his pants. Some of Dad's patients recall the one about the guy with laryngitis who knocks on the doctor's door and whispers, "Is the doctor in?" The nurse opens the door and whispers back, "No, come on in."
Bury your mistakes and get back to work!
Whenever my father and I discussed the problems of medicine, he always quoted Sir William Osler, with the reverence normally reserved for saints. According to Dad, Osler was the only man who truly understood the practice of medicine. Among Dad's favorite "Osler" quotations was actually a paraphrase of Alexander Pope: "Don't be the first to embrace the new, nor the last to abandon the old."
Recently, while browsing through the library stacks, I noticed a small, leather-bound book titled Counsels and Ideals from the Writings of William Osler, published in 1905. I only intended to thumb through it at first, but I couldn't put it down. I found that Osler makes as much sense in the 21st century as he did nearly 100 years earlier. Maybe more. Consider these examples:
"Errors in judgment must occur in the practice of an art which consists largely in balancing probabilities." What about "failure to diagnose"? I wondered.
"As no two faces, so no two cases are alike in all respects, and unfortunately it is not only the disease itself which is so varied, but the subjects themselves have peculiarities which modify its action." I wonder if the practice guidelines people know about this?
"When . . . you summon up the remembrance of your own imperfections, the faults of your brothers will seem less grievous." Sure enough, a motto for peer review.
"The practice of medicine is an art, not a trade; a calling, not a business." Of course, Osler never heard of managed competition or market share.
I sometimes wonder if patients will still speak of me in 30 years the way they do today about my father. And what will they remember about me? The loving care with which I filled out their durable medical-equipment certificates? My compassion as I signed their HCFA-1500 forms? Or the nights I stayed late completing their HCFA-484 oxygen-therapy reports?
My father used to end each visit by asking, "Is everything else okay?" This is not an efficient question, particularly in today's carefully managed schedule of 7-minute time slots. Physicians who offer their patients such an open-ended opportunity to talk about their troubles will often miss lunch.
But I can imagine no other question that so separates providers from doctors, technicians from healers, or the trade of health care from the practice of medicine. Perhaps the real inefficiency these days is anything or anybody that stands between us and our patients.
A.E. Miller. 8 ways to get more done. Medical Economics Dec. 9, 2002;79:74.