All the President’s Mail

(A piece from 2015 foretells my current career switch)

Perhaps doctors should be more like the President.

After all, we also carry the ultimate responsibility for our constituents, even though we, too, have team members who do part of that work.

The way I understand things to work at the White House, those other team members collect, review and prioritize the information the President needs in order to manage his, and all our, business.

That is how things used to work in medicine, too, before computerization revolutionized our workflows: Nurses, medical assistants or secretaries would open the mail, gather the faxes, look over the lab and X-ray reports and put them on physicians’ desks in a certain order. Highly abnormal or time-sensitive information would be prioritized over routine “signature-needed” forms, and in my case, essentially normal reports on patients already scheduled to be seen within a few days wouldn’t even reach my eyes until the patient appointment.

Computers changed all that.

Now, most of the information goes straight to the doctors’ inboxes, unseen by other human eyes in the office. This is said to be faster. It is, to a degree, in the sense that the information leaves the laboratory or the X-ray department faster via their Internet connected computers. But in the typical medical office, we have now turned decision making doctors into frontline mail sorters and de facto bottlenecks of routine information.

The average doctor sees a different patient every fifteen minutes and the medical assistant rooms patients, takes vital signs, inputs visit information into the EMR and listens to voicemails, which are turned into physician emails. At the same time, the doctor’s electronic inbox is continually filling up with lab reports, X-ray results, consultation reports, electronic prescription refill requests, emails from case managers, and messages from counsellors and other care team members to please read and respond to their issues.

So when does the doctor check his or her inbox?

“Between patients”, is the way many people imagined this “system” to work. But, how much time do we have between all those back to back fifteen minute patient encounters? And how do we prioritize in those precious moments between the various types of new information waiting for our review?

Most EMRs color code “urgent” or abnormal reports, but when it comes to standard laboratory panels, “normal” patients statistically have 5% of their results outside the “normal range” without being sick, so the majority of Complete Blood Counts and Comprehensive Metabolic Profiles show up red, whether they contain panic values or just statistical noise. (See my post “The Red Blues“.)

Where does a doctor even begin a two minute dash through their overflowing virtual inbox?

By lunchtime, or after the last patient visit is over, we dive into the information that has been waiting all day, speedily delivered but bottle-necked for hours while we have been seeing patients.

Imagine if the White House IT Department instituted a similar workflow for the President: After a day of speeches, audiences with foreign dignitaries, ribbon cuttings and baby kissing, he has a few minutes before the State Dinner, and hastily types in his multiple passwords on the Executive Computer.

A hundred messages await. One of them contains information about hostile troup movements on our border, another a ransom demand from extremists threatening to blow up our embassy in a faraway land, but most of them are routine missives, reports and requests marked “urgent” in hopes of grabbing the President’s attention.

Is that any way to run a country? No, and any such proposal would surely be vetoed by the Commander in Chief. But that is exactly how information is managed in today’s medical office, on the frontlines of primary care.

Tick-tock, Doc! Three patients waiting, no more time for refills, emails or test results, urgent or not.

And stop reminiscing about having a secretary. Who do you think you are? The President??

(But of course, if you are the president of a mom-and-pop shop, you can and want to be more on the frontlines - that’s the difference between where I have worked in the past and where I will spend the rest of my career…gearing up to post about that in my PROGRESS NOTES category here on Substack!)