On Being a Doctor |

Taylorized Medicine FREE

Michael B. Edmond, MD, MPH, MPA
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From Virginia Commonwealth University School of Medicine, Richmond, VA 23298-0019.

Requests for Single Reprints: Michael B. Edmond, MD, MPH, MPA, Virginia Commonwealth University School of Medicine, PO Box 980019, Richmond, VA 23298-0019; e-mail, medmond@vcu.edu.

Ann Intern Med. 2010;153(12):845-846. doi:10.7326/0003-4819-153-12-201012210-00288
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Frederick Winslow Taylor was a mechanical engineer who, in the late 19th century, became known for his time-and-motion studies. These analyses formed the basis for the field of scientific management, and his recommendations altered manufacturing processes for maximal efficiency. Iconically symbolized by the stopwatch, he was later criticized for his paternalistic views that workers needed to be taught the most efficient approach to their tasks and that they were generally incapable of independent thinking. Subsequently, more enlightened management scholars have demonstrated that efficiency and productivity are not necessarily synonymous.

I recently completed a 2-week stint as an attending physician on the internal medicine ward service, an assignment that I have dutifully completed twice yearly for the past 2 decades. I have always looked forward to spending time with the residents and students, despite the heavy demands of medically and socially complicated urban, poor patients and even though, as a subspecialist, my knowledge of general medicine isn't what it used to be. But, for many reasons, neither is the entire inpatient medicine experience. It's increasingly stressful, much less fun, and exhausting. Changes on the inpatient medicine wards have been unfolding over the past several years, but recently these changes hit me hard.

Those of you who trained in the last century, as I did, will recall that the team room was the nerve center for managing the group of patients to whom you were assigned. It was a hub of activity that contained a large table where the housestaff reviewed thick paper charts, wrote their history and physicals, ate meals, and all the while shared the stories of their lives and their patients' illnesses. It was strewn with EKGs, x-rays, photocopies of journal articles stained with coffee, and a worn edition of Harrison's Textbook of Internal Medicine. You could walk into the team room at any time and immediately sense activity, observing multiple interactions among residents, students, and attending physicians.

Now, fast-forward to the modern-day team room: It still has a table, which if not physically then certainly figuratively much smaller and generally devoid of clutter. All of the action now occurs in the periphery of the room at a bank of computers where the housestaff sit nearly all of their working hours facing the wall. The room is silent except for the rhythmic clicking of multiple keyboards.

The marked changes in the way we conduct our business in teaching hospitals have been driven by advances in technology that have improved the process of care and allowed us to focus on more important tasks than tracking down the paper chart to insert a note or spending needless time in the radiology film room with a clerk attempting in vain to find the x-rays that we need. The constant focus on patient throughput has also had an impact. But the biggest changes have been driven by the rules of the ACGME on resident work hours and their rigid enforcement.

Every resident now has an invisible but heavy stopwatch sitting on their shoulder, ticking loudly, constantly reminding them that their task list still has many unchecked items as time slips away. This clock has transformed our approach to care. Everything that occurs in the course of the day must pass the test of whether it consistently adds value. If it doesn't, it has been eliminated. Although we work in a field where this cost–benefit calculus usually pays off, this is not absolute—and the difference is what has traditionally separated the average physician from the excellent.

Inside and outside the team room, everything has become streamlined; witness the history and physical that today's residents perform. Many elements that were considered an integral part of the work-up by yesterday's standard have been sacrificed because their yield is generally too low to accept the drag on efficiency. The casualties include the funduscopic and otoscopic exams, as well as most of the neurologic exam. Accordingly, patients' expectations have also changed. My patients frequently tell me that they have never had such a complete exam, and I recently provided a second opinion for a new outpatient who nicely questioned me as to why I was looking in her ears when her problem was infection of the arm. The social history also has been scaled back to include only those aspects that might impact “dispo”: Does the patient have a home, and is there a caregiver to assist on discharge from the hospital?

Before enforcement of the 80-hour workweek rule, residents would simply work longer in response to any unforeseen event, such as a patient's sudden deterioration, or a planned event that took longer than expected. Part of the maturation process for young physicians was coming to terms with the daily unpredictability and lack of control associated with caring for acutely ill inpatients. However, the ability to stretch the day to accommodate the complexities of care has ended, and strict departure times have clearly added to the stress that our current house officers face daily.

The ticking stopwatch has also limited the levity, banter, and humor (albeit often dark) that permeated the team room of my day. There's no time for that. I feel guilty if I ask the residents questions about themselves or what they did over the weekend as they type (and they are always typing), because I'm distracting them and using precious time. So I find that I don't know them very well as people, and I suspect that they don't know each other very well, either. To assuage my guilt, I engage in tasks to make the residents more efficient, such as calling consultants who are taking too long to respond to our request for an evaluation that can't be done as an outpatient. One of my colleagues, a master clinician and superb attending physician, says that he now feels guilty when he attempts to teach, because he can see the look of fright in the residents' eyes as they wonder how the teaching session will impact their time.

On the other hand, I do find that the residents are better rested, less cynical, and generally more knowledgeable—although less experienced—than I was at their stage of training. I attribute this to increased time spent away from the hospital and maintenance of a healthier lifestyle.

I suspect that some of my angst is actually sentimental longing for a time that's passed. But when I think back on the aspects of internal medicine that drew me in as a student, it was the internists' unrushed, careful approach to the patient; their attention to detail; how they interacted with their colleagues and students; and, above all, the time they spent discussing interesting cases that left an indelible impression on me. As a resident, I took comfort in the elasticity of time that allowed me to fully experience my duties as a young physician still learning medicine's art and science while emulating my role models. Now, as an attending, finding all of the time-saving measures necessary in the course of the day to get the residents out of the hospital before the clock strikes has been a painful transition. In the process of this daily race, I think we have sucked out much of the joy that brought us to internal medicine in the first place.

The ACGME has succeeded. This train is finally running on time. Frederick Taylor would, indeed, be very proud.

Michael B. Edmond, MD, MPH, MPA

Virginia Commonwealth University School of Medicine

Richmond, VA 23298-0019





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