It’s Friday night, and I just finished up another long day of virtual meetings ending with one where I failed to explain something that I believe to be obvious, so I’m opening a bottle of wine and reflecting.
How did this become standard practice?
Clinicians in pretty much every hospital in the country use paper lists to manage their work tasks as they round on and care for patients. The unrecognized reality is that although EHRs have helped in areas, they have not fixed this part of our workflows. We still heavily rely on paper, and it is simply not good enough. It is static and siloed, trapped in scrub pockets and on clipboards, leading to delays in care and mis-communications. And yet when I present an alternative – a team-based shared rounding and task list platform – it can be hard for people to connect the dots to see the advantages. Why isn’t it more obvious?
Often when I show clinicians the advantages of going electronic, they have a hard time getting it. Even though I’ve shown them quotes from people who swear by it, or usage graphs that show high, consistent engagement. Even though they admit to using Google Sheets (not HIPAA compliant) so they can access their lists off from home, or worse, that it often stays outdated because it is hard to edit on the phone. Why not use a (HIPAA compliant) purpose built tool for clinicians instead? Just like developers use JIRA and builders use electronic GANT charts?
But there is significant resistance to change. Rather than simply declaring “resistance is futile” and moving on, this blog is about my reflections on why we in the medical profession tend to be resistant to process change…even when it’s for the better.
Clinicians are overworked…and getting busier
The average clinician works 12 hour shifts or longer, often 80 hours a week (if they are lucky) or more, and have a constant feeling of “doing everything they can to get through the day.” Now add the stress of having peoples’ lives in your hands. Every decision, every action carries a significant weight. Not just in that moment, but often, for many days to come. It is *very* hard in our environment to introduce a new idea. If something is working – even if it is not exactly working well – it seems easier to keep doing what we know how to do, than to learn a new way to do it. There simply isn’t time to stop and ask “is there a better way?” So we stick to what we are taught….because “this is the ONLY way.”
Hierarchy
In business, structures have flattened, but in medicine, a very strict hierarchy is still in place. This means that even if an intern or medical student (typically more open minded when it comes to process and technology change) wants to try something new, they are often forced to stick to doing things the way their seniors ask them to….which is how they in turn were forced to do it when they were interns. This leads to very slow cultural change – exacerbated in programs with longer training programs and thus longer “cultural memory.”
Subjects not systems
Unfortunately, we do not teach the value of systems and process improvement early enough in medical training…if at all. It’s not surprising really, when there is only so much people can learn in a short period of time. And of course, we need to learn vast amounts of clinical medicine, pathophys etc. However, I am more and more convinced that we must incorporate systems and process improvement education into medical education alongside other core competencies. Clinical workflows are only becoming more complicated, and the use of technology will only increase. We must teach students, trainees and attendings how to recognize and mitigate safety and efficiency risks early and often.
Transparency vs. privacy
In the business world, transparency has become the word of the decade. Be transparent with your employees and they will be motivated. Be transparent with your clients so they know what to expect. But in medicine, being transparent with your lists & signouts feels uncomfortable. Even being transparent between teams, let alone across disciplines is rare. They are “my notes.” We want to keep them close, until we’re ready to share. But in reality, it’s not just about us and our work…it is about the patient. And what the collective WE need to get done to take care of them. Whether that is the attending, the resident, the nurse, the therapist or the social worker. But, later is simply not good enough. When we work as team, we all need to know what you’re thinking, when you are thinking it. Transparency is only going to become more and more important in medicine. We have made great strides with sharing progress notes with patients and their families. It’s time to bring this change to our colleagues as well, sharing our plans and changes in management in real time.
We have been burned by technology too many times
I have heard people say “clinicians hate technology.” This is simply not true. Clinicians usually love technology! We just hate poorly designed technology. Which unfortunately is what we have all come to expect in the clinical setting. Much of the technology clinicians have been asked (ahem…forced!) to use, are clunky, hard to use and deeply unintuitive. Tech has transformed our lives outside the hospital. But the minute we step through the doors into the clinical world, we timewarp back to the 80s, where paper is a bandaid to help us manage poorly designed systems. Or at least, systems designed for the business of healthcare, instead of the delivery of it. Perhaps then, it is not surprising that when someone like me shows up with a new tech solution, regardless of how well designed and loved, there is significant disbelief that it can really be “that good.”
Conclusion
Now that I’ve made a serious dent in this bottle of wine, it is pretty clear to me why the residents today didn’t get it when I explained the obvious (my bad). But my mission remains the same – to break through the final frontier. To explore strange new workflows. To seek out new tech and new collaborations. To boldly go where no doctor has gone before! 😉
Or at least to save a few trees and stop wasting so much paper.