Between Patients: The Myth of Multitasking

I wrote this in 2017, when I was working with a simple EMR and when my practice had 15 minute visits. Years later, after adopting Epic, we never got over what was supposed to be a temporary slowing down to 30 minute visits while learning the new system. I have heard of practices where providers tell their patients that they’ll get 10 minutes face-to-face, so the doctor has enough time to work the computer, documenting the 10 minute encounter. And, still, there is a widespread expectation that many things can happen in the invisible space between patient visits. That whole premise is as counterproductive now as it was 8 years ago: Rapid task-switching is ineffective and inhuman.

Primary care doctors don’t usually have scheduled blocks of time to read incoming reports, refill prescriptions, answer messages or, what we are told the future will entail, manage their chronic disease populations. Instead, we are generally expected to do all those things “between patients”.

This involves doing a little bit of all those things in the invisible space between each fifteen minute visit, provided we can complete those visits, their documentation and any other work generated in those visits, in less than he fifteen minutes they were slotted for.

If we can’t capture (steal, really) enough time from our scheduled visits, we are still expected to somehow get that work done, but then on our own time. This results in most primary care doctors logging in to their EMRs from home after supper and on the weekends. Mismatched workloads and work schedule are a major source of professional burnout.

Compare this with air safety. Are airplanes scheduled to be in the air all the time, with refueling and maintenance squeezed in only if they happen to land ahead of schedule?

Quickly reviewing a couple of messages, a few lab results and some imaging reports, and then rushing in to see the next patient is an extremely inefficient and sometimes unsafe way of working.

I have likened this to jumping back and forth between baking a cake, balancing your checkbook and mowing the lawn. Normal people don’t work that way. Why do we expect doctors to?

Neuroscience teaches us that there is no such thing as multitasking. We really only do one thing at a time, and every time we switch from one task to another, we expend mental energy and brain glucose. Switching rapidly between tasks reportedly reduces usable IQ by ten points. Maybe doctors in general have IQ points to spare, but why organize our work that way on purpose?

MIT neuroscientist Earl Miller points out that juggling multiple plates floods the brain with cortisol (the stress hormone) and adrenalin (the fight or flight hormone), which prevents clear thought.

And those are the chemicals involved in burnout. In moderate doses, they are known to boost performance, but constant, low levels of them are the biochemical basis for burnout. We all know that.

My ideal way to work would be “protected” time for Results Review and Care Planning, and then, while another doctor does that, give me two medical assistants and double my number of exam rooms for efficient visits where I have already studied the charts and know better what I’m supposed to accomplish.

And, let me do slow visits grouped together, like physicals and wellness visits, and quick visits together, like sore throats, earches, rashes and knee pains. Slow and fast visits require different mindsets and skill sets. Again, comparing with everybody’s personal life, playing ping-pong or whack-a-mole interspersed with practicing yoga is very unintuitive an inefficient, at least as far as the yoga part goes.

Kind of like scheduled refueling and maintenance for aircraft…