I really enjoyed our conversations today, especially following the Lewis Blackman film, The biggest concept I struggled with throughout the day was the issue of efficiency vs thoroughness. I felt this was relevant to almost every issue we discussed, though only mentioned a couple times. Many of the practices we discussed are not performed because of the issue of efficiency; either students/residents don’t have enough time or they do not want to appear to be an inefficient team member.
For example, take the simple concept of just listening to your patient and gathering a history. As a third year medical student, I am only following 3-4 patients, and can spend a good amount of time gathering a thorough history. I try not to interrupt patients and I ask about every symptom I can possibly think of, go check uptodate, and come back and ask about more symptoms that can help with my differential. I ask clarifying questions and restate/summarize a lot of what patients tell me to be sure I’ve got their story right. I try to be as thorough as possible to ensure I have every detail right. Countless times, I’ve gone to interview a patient with an intern and they have to leave 15 minutes into the history because that is all the time they have, and they need to move on to see their other patients for the sake of efficiency. Because my workload is significantly smaller, I get the freedom to be thorough and spend another 30 minutes with the patient. It is true that patients have seen me as their doctor, but that is simply because I have the ability to spend so much more time with the patients I follow. When I look ahead to my future as an intern when I am managing 2-3 times as many patients as I do now, I know that this type of thoroughness is not sustainable. It would simply be impossible. So, while we talk about how it is extremely important to listen to your patients, I think its important we mention the reason that we often don’t – we just simply don’t have the time.
Another area where this comes up is going up the chain of command. One of the biggest barriers to calling for guidance is that you do not want to be seen as a needy team member because of something you should be able manage on your own. In other words, being extremely thorough and notifying your seniors about every small issue would make you look like an inefficient member of your team – and not incorrectly so! You’d be slowing down your own work but also that of your seniors/attendings. Understanding where the line is drawn is a clear gray zone that takes a lot of clinical judgement, and I can see how this is an area where patient safety is on the line.
I hope we get a chance to talk more about this issue, specifically maybe some strategies that residents/interns/nurses have for being both thorough and efficient providers, so that they can avoid burnout.