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Posted by Ishani Ganguli October 14, 2011 08:00 AM
Never tell a medical resident that she doesnít work hard. In a 16 hour night on my current inpatient service, Iíll care for up to 24 patients on the hospital floor and admit up to five new ones: examine them, order their medications and laboratory tests, dig up their prior medical records, write several page notes about them, maybe extract fluid from their bellies or stick needles in their arteries to measure their oxygen levels. Iím lucky if I have a ten minute break to gulp down some leftover cafeteria food for dinner.
It doesnít seem fair, then, that the health care industry has had negative productivity growth for the past 20 years.
But it has, argue Bob Kocher and Nikhil R. Sahni (who is my fiancť, incidentally) in a Perspective published in this weekís New England Journal of Medicine. (Really, honey, if you think I should spend less time watching Gossip Girl, you donít have to tell me via an internationally distributed journal.)
The majority of our nationís health care dollars is spent on labor wages, they write. And even as the quantity of health care jobs grows in the face of our faltering economy, each of us in the industry is getting less and less done (productivity is measured as volume of activity per unit of cost).
Yes, quality is not the same as productivity, and certain aspects of better quality care - like spending time with patientsí families and ensuring safety - canít always be subsumed under the productivity umbrella, as they duly note. But I buy it. The trend is unmistakable.
I certainly donít have to look far to find examples of inefficiencies (what Nikhil and Bob would call low-value tasks) in my job as an intern Ė tasks, in other words, that donít require a medical degree:
At 6:30 each morning, Iím one of two or three interns scrambling to find the green binders in which nurses scribble down each patientís vital signs so that we can re-scribble them onto our stack of progress notes for the day.
I fill out a paper form to request an interventional radiology procedure for a patient, fax the form, and call down to the secretary manning the fax machine to confirm that she received the form and will schedule the procedure.
A very capable nurse calls me over to ďpushĒ an anti-clotting fluid into a patientís chest tube because floor rules require a doctor to do this job.
There are examples in every hospital: One resident friend in San Francisco cites completing disability paperwork and finding primary care doctors for patients who are leaving the hospital. Another in New York City gripes about drawing blood for routine labwork, transporting patients to their procedures, and restocking equipment.
Itís no wonder weíre so unproductive (and compared to regular doctors and nurses, residents are cheap labor).
As Nikhil and Bob write, we should address this problem not by cutting wages or decreasing jobs, but by reshuffling the responsibilities and rules for doctors, nurses, physician assistants, physical therapists, and other health care workers to take better advantage of their particular skills and training. Of course, better information technology would help as well (I hear MGH is piloting a trial of electronically-recorded vital signs (!) that may soon fan out across the hospital).
At the innovative primary care clinic where I work, the Ambulatory Practice of the Future, one of our goals is to ensure that every member of the health care team functions at the top of his or her training. Our medical assistant sees my patients before I do. She takes their vital signs, asks them about their most recent colonoscopy or mammogram, and begins to record their medical histories. When she passes the baton to me, I focus on pelvic exams and diagnostic dilemmas. For patients struggling to lose weight, our health coach helps brainstorm exercise and diet strategies. Our medical secretary schedules follow up appointments and arranges for referrals. Iím pretty lucky - this clinic is far from the norm.
It will be an enormous challenge to change those norms in established practices and hospitals, to ask health care professionals to work differently. But in the spirit of supporting economic growth (and better serving our patients), all of us in health care need to do what we do best.
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