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.