I arrived at the hospital, white coat and stethoscope in hand. It was my first day as a doctor, and I was filled with a nervous mix of optimism and excitement.
I walked up to the medicine team room, entered the code on the door and introduced myself to the other residents — some of them newly minted doctors like me. I was about to receive handoff from the night team for the patients assigned to me. Years of school had led up to this point. I had dreamed about this moment. I was about to care for patients as a doctor for the first time.
That’s when the realities of practicing medicine hit me like a freight train.
My computer credentials didn’t work, so I couldn’t log on to the hospital’s system. As I waited on hold with the IT department, I tried to keep up with the handoff. I needed to learn about their conditions, medications and treatment plans. Labs were waiting to be followed up. Consults had to be placed.
My pager started going off. Questions piled in from nurses, case managers, social workers and other co-workers: Is this patient being discharged today? Can you sign this disability form? Have you placed that clinic referral yet?
I paused to collect myself and performed a ritual well known to physicians and other health-care providers. I grabbed a blank piece of paper, folded it in half and wrote down my patients’ names. Underneath each name, I began listing my checkboxes, or tasks for the day.
Before I knew it, we residents and the supervising physician were off to see patients. I had only just met some of the people whom we were going to be sending home. We wheeled computers with us, placing orders as we went from room to room. Still grappling with the unfamiliar electronic medical record used by the hospital, I could barely find the right buttons to click. The list of checkboxes on my folded paper grew and grew.
Later in the day, we all slumped back to the team room. Discharge summaries needed to be signed. Progress notes had to be written. Families wanted updates. My fellow residents and I typed away at our computers, phones to our ears, pagers ringing out.
My first day as a doctor was overwhelming, to say the least.
While medical school introduces budding physicians to the science of disease and treatment, residency trains us how to care for patients within the labyrinth of the U.S. health-care system. We have to learn how to work within hospitals and clinics with the goal of becoming independent practitioners. We come face to face with the gritty realities of insurance coverage and electronic medical records. The bureaucracy of providing patient care in many ways defines how we learn to practice.
In medical school, clinical medicine often comes down to “Drug A treats Condition Z.” During residency, we learn that A treats Z if you can figure out how to order A in the computer, you document why you chose A in your note, the hospital approves the choice of A, insurance covers A, the patient can afford A’s co-pay, you sent the prescription for A to the right pharmacy, the patient actually picks up A from the pharmacy, and you coordinate follow-up appointments to see if A is helping the patient.
As my first year of residency has gone by, I’ve become increasingly aware of how much time we dedicate to the administrative side of medicine — and the very real costs for up-and-coming physicians. I can write a comprehensive hospital discharge summary, but I can hardly place an IV in a patient. I know what a prior authorization form looks like, but I don’t know what my patients’ pills look like. I often spend 12 busy hours in the hospital but less than a few hours with my patients.
Often, it seems that administrative skills have begun to outweigh the human connection necessary between caregivers and patients.
Of course, some of these concerns are magnified during residency training. In academic medical centers, much of the grunt work of patient care, from placing orders to writing notes, falls upon residents.
But in other ways, young doctors are just scratching the surface of the health-care bureaucracy. As residents, we’re often shielded from the complexity of medical billing. We don’t yet have to grapple with establishing our own practices, maintaining staff, hospital contracts or malpractice insurance.
This is a broader problem in American medicine. A study published in 2013 found that internal medical interns spent 40 percent of their time on computers. Residents often spend more than four hours per day on documentation and electronic charting, according to several studies. A 2010 review of studies suggests hospital physicians on average spend less than one-fourth of their time directly caring for patients. In a study released last year, researchers found that doctors in clinics spent nearly two hours on desk work for every one hour with patients.
All this paperwork is straining physicians. A nationwide study found that more than 90 percent of medical residents felt the amount of required documentation in patient care was too much. In a 2016 survey of more than 6,000 doctors, half did not feel the level of clerical work in medicine was reasonable. Editorials in top journals across medicine have cited administrative workloads as part of the reason for the alarming rates of burnout in the profession.
When I look back on medical school, I remember sitting with patients for hours, chatting with them, learning about their lives. As medical students, we’re often given the time to do so, protected from the bureaucracies of medicine so we can spend time learning how to care for people. By comparison, as I reflect on my first year as a doctor, I cringe at how many days I spend sitting at computers, clicking away in windowless rooms, staring into screens, separated from patients.
But I’m also reminded of a recent column by a group of physicians. “The sound of medicine is not the click of a mouse. It is the human voice,” they wrote.
I find hope in those words. My days are measured by countless checkboxes, but whenever possible I try to add just a few more — I tell myself they’ll be worth it. Go to the bedside during free moments. Check in with my patients before going home. Stop by for those chats again, even if I’m tired and it’s late.
It’s been nearly a year since that first day in the hospital. Today, I’m far more efficient as a physician. My typing has sped up, and I have templates for virtually every kind of note. I can now find orders in the computer by muscle memory. I’ve learned how to admit patients into the hospital, transfer them between units, discharge them, refer them to specialists and follow up with them in clinic.
I’m becoming better at providing health care, but does that mean I’m better at taking care of patients?
Morris is a resident physician in psychiatry at the Stanford University School of Medicine.