Balancing – Not a New Act

The concept of “work-life balance” seems newer to the field of medicine, which trails many other professions that have already incorporated creative and flexible options for work with the advent of telecommuting. Still, this term has been present now in medical circles for long enough that to suggest otherwise would be to appear out-of-touch…which is just what anesthesiologist Dr. Karen Sibert did recently when she wrote a New York Times Op-Ed suggesting that female physicians who worked part-time were doing a disservice to US healthcare system and not fulfilling a moral obligation to their patients.

Many physicians responded quickly and critically to the article in comments, tweets, and blogs. Some valid points were raised, including ones asserting that “balanced” physicians are better physicians and others that pointed out that the article placed an inordinate amount of blame for the current – and future – shortage of primary care doctors on female physicians who work less than full-time.

Putting aside the fact that the definitions of full- and part-time work are somewhat arbitrary (variable across employers, professions, and countries) the truth about work-life balance is that it is actually not a new concept. In fact, I would argue that Dr. Sibert, who completed her training in the 1980s and raised four children while working full-time as an anesthesiologist had it. It was just one that worked for her.

In its purest definition, work-life balance has always been present in some form or another. What changes over time – individually and societally – is the value of the items being measured on the scale.

 This is not to say that there are no seemingly unbalanced situations out there (like an older doctor I knew who was in the office till 8 or 9pm almost every night). But wouldn’t I be assigning my own value system to the variables in his equation for balance? That older physician’s iteration of work-life balance worked for him and his wife. If it didn’t, things would shift at some point, similar to the law of conservation of energy in physics. Today’s “work-life balance” is a representation of a definite societal shift in the value of the items being measured (work and life and let’s add in happiness, as if it was work-life-happiness balance).

Has medicine failed to provide enough $, stuff, and status to motivate full-time work?” asked one physician on Twitter.

A poignant conversation on Twitter briefly touched on some other potential factors that might be fuelling a trend of physicians desiring part-time work (which is not limited to female doctors or physician-parents, by the way). Whenever one looks at a career or job, there is a measurement of the trade-offs (benefits, commute, status, compensation, hours, prospects for advancement). Almost every one of us does this, irrespective of profession/job. It might be possible that, in the case of the field of medicine, interests outside of practicing medicine have gained value or the rewards of practicing medicine have diminished. Or both.

Based on my discussions with other primary care doctors, it appears primary care is following the law of diminishing returns or, in the case of physician burnout, even the law of negative returns. With a compensation model that favors proceduralists, an increasing workload to keep up overhead, a sense of dispensability from some employers and the public, anti-doctor sentiment (which is witnessed in social circles despite the presence of physicians in them), and monthly debt repayments equivalent to a mortgage for some, it wouldn’t be hard to imagine that some primary care physicians – a subset of a group of bright individuals who tends to delay happiness for the sake of training – might feel quite disheartened early on in their careers and seek some balance in the form of outside interests, including being more engaged in family life.

Medicine – when practiced within a certain frame of mind – is a field that is almost second to none in its ability to provide satisfaction. But, as in any demanding profession, there are definite trade-offs. “Work-life balance” is just a prettier way to describe it.

*For the record, I am a full-time primary care physician and really do enjoy working as an internist. I have worked no less than 90% of full-time and although no one can predict the future, I intend to continue to work full-time as long as I am emotionally, physically, and psychologically able to provide excellent care. I say this because I once had a glimpse of a place where there was potential harm in working full-time under certain circumstances. And that – rather than a decision by any physician to work part-time – is what is unfair and even dangerous to patients.

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**photo by Renjith Krishnan (freedigitalphots.net)

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A Health-Related Art Exhibit in Philadelphia

If you happen to be in the Philadelphia area between now and the end of July 2011, check out a unique exhibit of historical health advertising from the late 19th-early 20th century at the Philadelphia Museum of Art. Today’s New York Times Science article, “Spoonfuls of Medicine, Marketed for Centuries” has a couple great links. One link provides a slide show of a few of the posters being displayed. The other is a link to a video showing an animation of a piece of German artwork described below:

But the star of the show may be the single image intended neither to cajole nor to terrify but to educate and amuse. The five-volume anatomy and physiology textbook that the German physician Fritz Kahn brought out in the 1920s was illustrated with a poster-size folding color plate depicting “Man as Industrial Palace,” a work that combines the Lilliputian charms of “Where’s Waldo?,” Willy Wonka’s factory, the world’s best dollhouse and a really good pinball game.

– Abigail Zuger

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The Evolution of My White Coat

The significance and use of the white coat has been a topic of late. Most recently (and eerily coincidental to my drafting this post) there was a piece on Get Better Health about it. Thus, my post can be seen, perhaps, as an extension of those recent commentaries as I present some opinions from the “crowd” compiled by informally polling Twitter and Facebook regarding the question: Should doctors wear white coats?

Results on Facebook (total number of responses = 15):

Yes – 27%

No – 33%

It depends – 40% (unfortunately, those who responded with this answer did not provide further explanation, which would have been interesting)

Results on Twitter (instead of their Twitter handles, the parentheses indicate their background for reference):

(psychiatrist) Id say most psychiatrists typically avoid #whitecoats in the hospital setting as well, need to balance inherent power dynamic

(pediatrician) #whitecoats less about power more about pockets to hold stuff…and the things are dang dirty too like ties
More than docs wear white coats– often one in white coat is NOT a doc:)

(other) not at #hopkins. we have a 25-yr + tradition of white coats for many reasons, not least is de-stigmatizing psych. yes based on healer’s status assoc. w/ successful psychotherapy outcomes (Frank’s Persuasion & Healing) & white coats with status

(chiropractic magazine) It’s nice to see doctors wear #whitecoats or scrubs – some professional garment, to preserve

(a consultant to healthcare industry) All about 1st impressions & ppl r different. I don’t like cuz separates me from Doc. Many seniors do cuz they expect separation.

(a med student) Yes, I think it shows professionalism, not to mention there are pockets for holding things. 🙂
Yes, some patients only know it is a Dr they are talking to based on the coat. And some docs are bad with intros.

(unknown) IMO, #whitecoats show #professionalism which is sorely lacking these days.

(an RN) no but found the hospital experience to be daunting without identity….vulnerable time for those involved.

The white coat has its detractors. Apparently a Twitter conversation was devoted to the characterization of those who wear it as as egotistical or snobbish. There could be some – albeit rare, in my opinion – truth to that. An unfortunate example of this would be one medical student I knew who proclaimed that he loved being in medical school because he was surrounded by doctors in white coats, “like gods.” I kid you not. I was disgusted by that remark and it was evident he was not in medicine for the “right” reasons. But that is not the norm. Furthermore, the use of the white coat is not restricted to physicians. It has also been a uniform for lab techs, aestheticians, barbers, dentists, and Clinique salespeople at the department store counter.

Another reason that the white coat has been losing its appeal is for the same reason physician neck ties have been scrutinized in recent years – potential transmission of bacteria. This issue is referenced in a recent post by Dr. Westby Fisher and presents a quandary.

As for me, the white coat has had different meanings over time:

In medical school – It was a short coat, which looked a little silly, really. But it held a  library (before smartphones) and some tools. It was my identifier that said to patients “I am not a doctor, but I am not a random stranger. I am here to learn.”

In residency – it was a longer coat. It was my identifier that said, “Though I look young and I am a woman, I am a doctor.  And ,yes, I am the one writing your orders. No, I will not get a doctor. I am the doctor and I am practicing in real-time to be an attending. It is very important for me to get this role down.” It also kept me warm and held snacks and notes and patient checklists, and more tools. I had to wash it on my own – frequently. It got pretty tattered by the end. It was a frequent cause of neck pain.

Currently – My white coat holds my pen, stethoscope, cellphone, and some business cards. It seems to be 10 pounds lighter than it used to be. It keeps my clothes clean during potentially messy procedures. In a funny way, I feel it holds me accountable to every patient I see. Hopefully it relays experience, professionalism, and provides some reassurance to new patients that he/she is in well-trained hands even though I don’t have a head of grey hair yet.

Now, I have tried going without the white coat, but, invariably, I forget my stethoscope or need my cell phone. Or someone says, “You look too young to be a doctor” – is that the glaucoma talking? – at which point, I want to run to get it and say, “See? I am not too young. I spent many years training. You can trust me.”

In sum, I think the most notable features of the white coat are that it provides efficiency and protection and a reminder of my role as physician to educate and treat my patients as best as I can and to be as professional as I can. One particularly inspiring view can be found in a transcript of a speech given by Mary L. Brandt, MD during a “white coat ceremony.” She says to the bright-eyed medical students “You are putting [on] a coat of candor, of sincerity, of openness, of kindness and of self-care.” Physicians should read it whenever they need a reminder of what that white coat represents.

But, the white coat as a status symbol? Perhaps, but only for those patients and doctors who perceive it as such. But this is not the case for me. I am only too happy to take it off before I leave the clinic.

Never Let Them See You Sweat

One workday a few years ago, I had to be at a semi-formal family function by a certain time. Of course, of all clinic days, this one was even more hectic: multiple consultant phone calls, phone messages marked with “red flags,” letters that – for some reason – needed to be written on the day requested, and not one, but two people needed to go to the ER (one via ambulance). I drove as fast as legally possible to get to my relative’s house. Without having had a break to even go to the bathroom, it was difficult to sit in traffic. 

I got there eventually and was greeted with a slight reprimand for being late. OK. I expected that. But I didn’t expect the comment that followed. “What do doctors do, anyway? They spend just a few minutes with patients. Otherwise, all I see them do is talk to each other in the hallway.”

Leave it to family or close friends to push you off of your high horse (irrespective of whether you are on one or not). Not too long before this, there was a suggestion by an administrator of our clinic that we should increase the number of patients we see since recent changes in our EMR should have improved our efficiency. These two events made me wonder: Exactly how much time do I actually spend involved in patient care outside of seeing them? 

So, for the next few weeks, I used an online stopwatch and closely monitored my daily activities, recording how much time I spent on “indirect care,” including, but not limited to:
– refills
– patient questions on the phone
– phone messages
– reviewing consultant notes
– talking to consultants on the phone
– documenting/charting
– reviewing outside records
– filling out forms, including insurance authorizations and nursing home documents

(all of these tasks can require research into the respective patient’s chart)

Before you read on, if you are a patient, can you guess how much time this adds up to? If you are a physician, do you know exactly how much time this takes you? Have you ever tried to measure it? 

The answer for me:

4 to 4.5 hours a day. 

To clarify, I was the second most “efficient” physician in that moderate-sized practice, if not THE most efficient. And I was shocked by this number. I imagine that it would take 5-6 hours for docs who were not as efficient.

I do it despite the lack of reimbursement for the majority of these tasks. After all, it’s part of the overall care of my patients. You might not see such generosity, however, from other productivity-based-paper-pen-and-brain careers that lack fancy tools or equipment (accounting, law). What’s more, when nurses were phased out of primary care clinics, we lost some of the help with administrative tasks and some of the minor, more straightforward clinical work. Instead, primary care doctors were asked to “do more, in less time, with less help, and with less reimbursement.” It’s a part of medicine we often try to hide – rather than fix – and the part that medical students tend to avoid. That being said, I continue to practice in primary care because I still strongly believe in its purpose and I believe I am helping others… at least until a candid remark about physician “laziness” shocks me into the reality of a completely different perception out there.

While I work diligently to take care of other patients in between actual patient visits, I also work hard to give each person I physically see the amount of time needed to have him/her be heard and to be thorough. Though it sounds pseudo-therapeutic on some days, there is no such thing as a three-martini lunch, only a three-minute lunch. So, if I do happen to have the time to talk to a colleague, it is a nice reprieve. But twiddling my thumbs I most certainly am not. And, quite often, I think and worry about some of my sicker patients long after the clinic has closed….