During my medicine rotation, I had a patient who was bilingual and needed an MRI. He insisted that we talk to each other in English, even though his native language was Portuguese. I started asking him questions from a safety screening and consent form.
“Do you have a pacemaker, defibrillator, or any wires in your body?” I said.
He hesitated before answering. “Uh, I don’t think so.”
The questions got a little more complicated, yet he refused a translator. As it took longer and longer for him to answer, and all the other tasks I needed to do continued to pile up, I told him I was going to get him a form in Portuguese. He relented, I faxed the completed form over to the imaging department, and then I stood at the machine, waiting for the confirmation.
Filling and faxing forms, confirming prescriptions, requesting medical records — these tasks rob me of time I could be thinking about how to treat my patients, yet I do them because they need to get done and more senior residents tell us we need to do them as part of our job. It’s called “scut work” and it’s the target of some reform efforts led by people who think it contributes to burnout.
“You didn’t graduate from medical school to stand by a fax machine,” said my supervising physician. Yet as an intern, I spend a lot of time doing things that don’t really advance my medical education, things that other people in the hospital hierarchy are paid to do.
As a doctor, I’m training to be at the top of the hierarchy, but I also want to be a team player. I told my attending that I tolerate these tasks because I feel uncomfortable dumping menial tasks on other people.
It feels elitist, I said, and not collegial.
”It’s not dumping,” she replied, “it’s delegation.”
All hospital personnel have responsibilities towards patient care, she said. Doctors, however, have responsibilities that nurses don’t, and nurses can do things that nursing assistants can’t. Everyone has a different role to play, and while I may be able to trade places with a staff member who has a more limited scope of practice, they cannot trade places with me.
She called this “practicing at the top of your license,” putting your mind and time to the best possible use in diagnosing and caring for patients — doing those things that my medical school training has prepared me for. Support staff, she said, are there to do the rest.
It’s a lesson she said she learned in residency when her attending caught her hovering by a fax machine, too.
At Boston Medical Center, the Committee of Interns and Residents, a resident union, has been successful in helping residents delegate some of these tasks. For example, unit coordinators or medical secretaries are now responsible for obtaining outside medical records instead of residents. The committee is also investigating more efficient ways to complete MRI safety screenings and work with pharmacy technicians to complete medication reconciliations.
After that conversation with my attending, I thought about all the time as a doctor I spent getting patients water, or looking for pillows, or helping them walk to the restroom. I thought about my Brazilian patient and how the time I spent filling out a piece of paperwork with him put me so far behind on other important tasks: calling in consults, following up on labs, and finalizing discharges for patients to nursing facilities with ambulance transportation. Those were my duties as a doctor. The pillows and water, I did because I wanted to be helpful. In the long run, I realize that I may have been doing both myself and the patient a disservice.
While I’m rarely asked by the staff at my hospital to do non-physician tasks, I wondered why I felt uncomfortable passing along these patient requests. I’ve realized that many female physicians are similarly conflicted, and when they set boundaries, they often face unfair consequences.
I’d heard that nurses at another Boston hospital often asked female surgical residents to help do non-physician tasks like repositioning patients. When these residents declined to help, they were seen as unprofessional and complaints were filed. Noticing a disproportionate number of complaints against his female residents, a senior doctor investigated the issue and it led to a staff meeting where he highlighted the gendered discrepancy in these requests. He and the residents called for a culture change and reminder to each member of their role in patient care.
While it may seem like these tasks are no big deal, time is a precious commodity. Five minutes here and five minutes there can add up to less time spent with my patients, or even snowball into extra work. I only have four years to practice medicine with the support and structure inherent in a residency training program. I want to take advantage of it.
That conversation with my attending changed me. Since then, I’ve been working on respectfully asserting myself with patients, and sometimes gently reminding them of my role in patient care — that I am their doctor. Now when they ask me to fetch them milk or sugar, instead of saying yes, I say, yes, let me get someone to do that for you.
Dr. Jennifer Okwerekwu is a first-year resident in the adult psychiatry training program at Cambridge Health Alliance. You can read more of her columns here.
I read the piece very carefully and learned from it thank You!
I also read the comments and two things became very clear to me (I was aware, but still, cristal clear now!)
1.Doctors are VERY aware of their position as team leaders and expect that each member of their team does their job accordingly!
2.Nurses and other team members are “oblivious” to their responsibilities; “being commandeered” being one of them!
Darlings it’s called ‘ORDER’ not if “it pleases your Royal Highness, it’s a request!”…
Being part of a multidisciplanary structure means you are being lead by someone,well, that someone happens to be “A” doctor!
If you were doing your military service and the leader told you to do JOUR JOB would you tell them come and do it for you?! AND if they don’t (which they won’t because daa it’s not their job!) would you say that they are inhuman??! Because they ARE doing their job LEADING??!
If you aren’t able of being part of this kind of structure than you can do anything else and PLEASE STOP filling the spot that somebody would dream to be in!
And STOP b…ing about NOT being ABLE to do it!
And that has nothing to do to with “EXPERIENCE” you either CAN follow orders or you CAN’T!
THAT’S PLAIN SIMPLE!
Well, based on the comments I can see that although your point is very valid, others have abused the staff probably using the above logic. I agree with what you’re saying. It’s correct.
To the obviously bitter nurses commenting, I’m sorry some docs were apparently messy and abusive, maybe elitist? They were wrong to do so. However, you’re being short sighted with your comments and your lack of ability to put yourself in her shoes is showing. A physician’s job is different than yours and yes, we should all work together, but the physician is ultimately responsible for that patient so they do lead the team. The team would work a lot better if staff would help them be better leaders, not resist and undermine them or suggest they do their job AND your job. That’s childish and it doesn’t help the humility you claim to promote.
Those “other people” are paid to clean up. If there’s stuff for “other people to clean up” it means those charged with cleaning up are not doing their jobs. Tell them to get back to work or hire someone else
Well said, Dr. Okwerekwu–and thanks for the shout out to us over at BMC!
We wrote a piece (http://www.wbur.org/commonhealth/2016/02/16/residents-hours-scut-work) about a year ago, before the ACGME changed its duty hour regulations, saying that we need to be focusing on *what* residents do with their time, not just how much time they spend at work. We hope that as the ACGME starts looking at working environments and resident wellness that these issues are brought to the forefront.
In the past year, we have made so much progress working with the hospital to improve our training while also making BMC an even better place for our patients–we work hard to find solutions where everybody wins.
Residency is a period of just a few years of training before we’re expected to go out into the world and take care of patient’s independently. I’m sure all of our patients would appreciate it if we had spent our time learning, doing procedures, talking with patients and families, and learning to be an independent physician rather than spending our time on the phone making appointments, running blood samples down to the lab, or faxing other facilities.
Good Article, and good commentary on functioning as a resident in a hospital. The military has a regimented hierarchy that teaches leaders the tasks that should be delegated at each level. Advancing through this hierarchy makes this knowledge part of the organizational culture. It’s clear the same thing does not happen in medicine. Perhaps some leadership classes taught as a part of a broader medical education could help solve this problem. Doctors are inherently leaders in medical care…..But it doesn’t mean they have developed leadership skills.
Astute observation, Jeremy. Once I learned the military concept of “positional authority”, I was able to function much more effectively as a physician. Unfortunately, as you point out, this concept is not well understood in our medical culture. The commenters who show contempt for delegation of responsibilities wouldn’t last a day in the military or a team-based health care structure.
How did the Portuguese patient ever make it past the intake person at the front desk without a translator your highness?…just asking. I ‘m with FransBevy on this one. The day of a doctor being omnipotent is over. As a teacher I have to do jobs which many consider not part of my pay grade either. If I didn’t do them, they wouldn’t get done. It’s what being part of a team is about.
Please, cut the baloney.
What she means is that she leaves a mess (paper, charts, coffee cups, medical supplies, etc..) for others to clean up.
spoken from 30 years as a nurse
Thank you for explaining this in a thoughtful and humble way. I always thought that many doctors used their position to abuse the role they obtained in the hierarchy. This explanation better explains the rationale behind why doctors refer many simple requests to subordinates.
Welcome to the practice of medical care as a factory line. It’s one thing to gain greater efficiency by staffing a busy practice/department such that care givers don’t loose precious face time with patients hovering over a fax machine; its an entirely different thing to redirect patients’ request for aid or information to a more “appropriate” level in the hierarchy. As a previous commenter mentioned – how dehumanizing. Patients become sources of inappropriate demands and irritations rather than the vulnerable human beings they are (and no my feelings on this point would not change were the healthcare professional a man vs. a woman). There is something profoundly broken with a medical system that demands such a decoupling of empathy with “care giving”.
Congratulations. You have learned to de-humanize yourself. Simple kindness to a patient in need keeps you humbly human and takes much less time than finding someone else to do it. I learned this early in my career and it always feels right to connect with both patients and the nurses in this way. I suspect you will learn this over time as well.
Yes. And you just might pick up that vital piece of information about thd patient as you bring that water or help reposition. Patients are more likely to reveal themselves in unguarded moments.
Irene, that is an incredibly myopic and sexist view. Excellent patient care is now delivered in teams and the idea of the physician as the commander-in-chief is being eroded. The team approach leads to humility and connection with members of the team. When roles are clearly outlined, delegation of tasks is not mistaken for lack of humanity. It’s also hogwash that operating at the top of one’s license results in disconnection from patients. Each moment I wait at the fax machine is time taken away from my time with the patients. Patients are clever and have a keen appreciation for a high functioning team. They don’t mistake delegation for belittlement.
I say that your comment is sexist because I’m confident that you wouldn’t make the same criticism if the author were a man. Women who understand the importance of efficient delegation of tasks are seen as “cold”, “bossy”, and other words that are not fit to print here.
If you don’t believe me, I invite you to visit my community health center and observe one of our five teams in our “pods”. We are as patient centered as it gets. We don’t just give lip service to “PCMH”.
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