A Doctor Should Only Do Those Things That Only a Doctor Can Do

A Doctor Should Only Do Those Things That Only a Doctor Can Do

A doctor should only do those things that only a doctor can do. I heard those words during my second year of internal medicine residency during my gastroenterology rotation, and those words have always stuck with me.

This was 1987-88 and the use of computers in the medical office was far from routine. The attending physician I was rounding with was frustrated with one of his two partners who was spending an enormous time working out the bugs with the new computer system the gastroenterology practice just purchased. He was seeing fewer patients and doing fewer procedures (colonoscopies) as he fussed with the new computers.

The attending physician I was rounding with said, “He needs to be in the endoscopy lab where he can generate $500 plus an hour taking care of patients. We can pay some computer tech $75 an hour to get the computers up and running.” He then looked at me and said, A doctor should only do those things that only a doctor can do.

Before we go further let me share these quotes which I will repeat at the end of this article.

There is nothing so useless as doing efficiently that which should not be done at all.  Peter Drucker

Success has less to do with what we can get ourselves to do and more to do with keeping ourselves from doing what we shouldn’t.   Kenneth Cole

The advice from the gastroenterologist may be one of the best pieces of advice I have received. This advice gets to the core of understanding your essential functions. What skill do you have that separates you from all others? What skill(s) do you possess that are essential to your and your company’s success?  You should focus on those skills that separate you from others and this applies to everyone not just physicians. It applies to nurses, physical therapists, teachers, accountants, lawyers, IT people – everyone.

You should minimize performing tasks yourself that others can do for you. It’s called delegation. You should focus only on your essential function(s). And, the better you do that, the more successful you will be.

The fundamental problem in healthcare these days, I believe, is so few healthcare professionals spend the bulk of their time performing their most vital functions. Health care is being overrun and driven by legal, regulatory, and billing/coding concerns – not patient care – the essential function of healthcare professionals.

Below is what got me thinking about this topic.

Electronic Health Records

Focusing on one’s vital function has become increasingly difficult for physicians in this era of electronic health records (EHR). Recently, I read an article from the blog, KevinMD, which was posted on Facebook. The blog is sponsored by MedPage Today and receives quite a bit of traffic.

The article I read (which I can no longer find to link to) was written by a physician who discussed the inconveniences of using EHR focusing on how such systems have forced doctors to become clerical workers ordering their own tests, labs, and so on. He commented that doing such tasks takes away from the vital function of a physician – taking care of patients.

I skimmed the article and then jumped to the comments at the end of the article. By the time I saw this article, nearly 600 people commented on it many of whom were nurses that seemed to be employed by hospitals.

They called the physician “whiney” and more or less mocked him for finally having to do his work (ordering labs and tests) rather than delegating such mundane tasks to a nurse or medical assistant. In short, they were not close to feeling sorry for him. Some claimed that studies show there are fewer mistakes when physicians order the tests they want rather than having a nurse or medical assistant do it (more on that later).

Before EHR in the not so distance past, a physician would see a patient and then tell the nurse or medical assistant, “I want an x-ray of the right knee and send this synovial fluid for cell count, gram stain, and crystals. Also, get a CBC and sed rate on the patient. Thanks!”  (At least, I always say “thanks.”)

And, then onto see the next patient.

Nowadays, a physician will hunt and peck, click, and scroll through the EHR and order these tests personally. It is more time-consuming than you might imagine. Research shows that most tasks now take two to six times as long using an EHR system than with the old paper chart system.

Precious time is being spent performing tasks that do not require a medical degree. Physicians have become clerical workers and data entry personnel.

Physicians are the Rainmakers

I was surprised at how much grief this physician/author of the KevinMD articles was receiving from nurses who read the article and to me this example highlights the ignorance of most people who are employed. While they may know who signs their paychecks, most of them do not know who ultimately pays their salary. They don’t realize it is physicians who pay their salaries.

The nurses who commented negatively on the KevinMD article have no idea who butters their toast. I bet if you asked these nurses who pays them they will say “the hospital.” And, technically they are right, but it is the physicians who generate the revenue that pays their salary.

It is physician-generated revenue that pays the hospital CEO, too. If hospital employees understood this they would go out of their way to make sure physicians spent their time seeing patients. Patients have to be seen and cared for by a physician before any revenue is generated, and before salaries can be paid.

As physicians, we shy away from talking about the business side of medicine, but unless and until a physician sees a patient there is no revenue generated – for anybody.  And, the more patients a physician sees the more revenue there is to go around and support most of the entire healthcare system.

Where does the hospital get its money? Does the CEO of the hospital generate any revenue for the hospital? Does anyone within the multiple layers of administrative bureaucracy in hospitals generate revenue for the hospital? Does the chief financial officer generate any revenue for the hospital? The answer to all three of those questions is “no.” With rare exceptions, only physicians generate revenue for a hospital.

Physicians are the rainmakers even when they are employed physicians. As more and more physicians are being employed their importance to the financial well-being of the healthcare system is not fully appreciated. Employed physicians are being treated more and more like employees by both other employees (as evidenced by our nurses’ comments) and the hospital administration.

That is not wise, nor is it a good sign. The whole healthcare engine is fueled by physicians. Obstacles must be removed that prevent physicians from performing their vital functions.

Physicians should not be treated like “employees” even when they are. Name another type of employee in any industry that generates revenue that supports nearly the entire industry.

The EHR Obstacle

EHR is an obstacle. A huge obstacle. It does more than slow physicians down. (Yes, there are some good things about EHRs).  When I joined my current practice, Central Ohio Primary Care Physicians (COPCP) which is the largest physician-owned primary care practice in the country (360 physicians in 64 office locations), the group was in the process of switching to a new EHR system. Some physicians have had to reduce their patient load by 25% to 30% to accommodate the additional time it takes to navigate the EHR system.

If such a reduction happens across the board that means you need 25% to 30% more doctors to see “displaced patients” who cannot get in to see their previous doctor, not to mention the economic impact of generating 25% to 30% less revenue.

That reduction in patient load does not come with a 25% to 30% reduction in office expenses. The overhead stays the same. Our four-person practice within COPCP operates on an overhead of 45%. This means a 25% to 30% reduction in revenue is a 46% to 54% drop in physician income at a 45% overhead figure. Not insignificant. To offset that, some physicians have increased their patient loads but now spend their evenings (about an hour and a half based on studies) inputting information into the EHR from home.

There is little revenue that comes into a hospital or the healthcare system in general that is not ultimately generated by a physician or some other licensed provider. Only a physician can admit a patient to the hospital. Only a physician can order blood work and diagnostic studies.

Only a physician can prescribe medications or order an IV.  Only a physician can perform surgery or other invasive procedures. Nearly anything that generates revenue for a hospital is the result of a physician’s order or a physician’s action.

Now we can debate whether things should be that way or not. But, for now, that’s the way the system works. All other healthcare professionals exist because there are physicians. There are no physical therapists, no occupational therapists, no speech therapists, no nurses, no radiological technicians, and so on, without physicians.

Why is that? There would be no money to pay them – without physicians. Plus, these other professionals cannot treat patients unless referred by a physician (some exceptions).

All of these healthcare professionals play vital roles in patient care to be sure, and they are all indispensable. But, these professionals do not generate revenue or at least much revenue to generate a profit (physical therapists can charge for their services). And, guess what else? Without physicians drugs companies do not make money, insurance companies do not make money, manufacturers of medical supplies do not make money, and medical suppliers do not make money.

The whole healthcare system hinges on physicians. That’s why a doctor must perform only those tasks that only a doctor can do.  It is not a difficult concept to grasp but it is not being implemented.

It would seem most wise to enable physicians to spend their time – all of their time – engaged in their essential function. Taking care of patients. They should not be clicking orders in an EHR or transporting patients to the OR. Someone else can do that. Warren Buffett makes something like $7,000 an hour if not more. Do you think his company, Berkshire-Hathaway, wants him to type his letters of communication or book his appointments?

A physician should only do those things that only a physician can do… And, a nurse should only do things that only a nurse can do. 

I would not want to be a nurse. Much of their time is spent sitting and documenting rather than caring for patients. Much of their education is being wasted just like doctors on doing clerical and non-nursing tasks. They probably spend less time engaged in patient care than physicians. I can understand their frustration and not wanting to take on what they perceive as tasks a physician should do – but they don’t generate the revenue that floats the boat. That’s the difference.

The whole healthcare system is being overburdened by computer work (paperwork) and documentation. Every healthcare professional is spending less time performing their vital functions. And, it needs to change. The system is strangling itself.

Lost Time From EHR and Desk Work

For every hour physicians spend seeing patients they now spend two hours on EHR and desk work. You read that correctly. Here is the study. EHR and paperwork are colossal time suckers that rarely positively impact patient care. Maybe fewer errors are made if physicians personally order their tests, but how many errors are made, and what is the impact on quality of care when physicians only spend a third of their time with patients?

I suspect the errors that are made by spending less time with patients significantly outweigh the rather minor mistakes made by delegating lab and test ordering to nurses and medical assistants.

Digest this for a moment. Physicians go to college for four years, medical school for four years, then do a residency which is three to five years, and then a relatively high proportion do a fellowship that may last one to three years. They go through all that and now spend only a third of their time seeing patients and managing their care.

Physicians no longer spend meaningful time engaged in their most vital functions. If you are a CEO of a hospital why would you want to see your “most valuable employees” engaged in tasks that others can do? Some are beginning to ask themselves that question.

Imagine if doctors were free to see more patients. Fewer patients would burden the emergency rooms with non-emergent problems saving the system money. Patients would be seen sooner in physician offices when medical problems are more manageable and less costly – to just name a few benefits of not hampering physicians with clerical work.

Some hospital systems and larger private physician offices now provide scribes to shadow physicians into exam and hospital rooms to unload physicians of these non-physician functions. These scribes do the required work in the EHR and the physician reviews it. But, those scribes cost money and they do not always “pay for themselves” by enabling physicians to see more patients.

A physician should only do those things that only a physician can do. And, you should only do those things that only you can do and do better than anyone else in your organization ….. as much as possible.

Know Your Vital Function

As I write this I am taking an online program to improve one’s productivity and the major focus has been on limiting your work day to only your vital function, removing distractions (social media), and focusing on just one task rather than multi-tasking. So this KevinMD article that led me to write this article was very timely for me.

In an upcoming article, I will share some of what I have learned about increasing work productivity and will cite examples of individuals who have become extraordinarily successful by simply focusing on their one or two vital functions.

Those who perform only their vital function become ultra-successful. The ultra-successful do not perform tasks below their pay scale.

Know your vital function. Focus on your vital function. For physicians, it is seeing patients.

REMEMBER:

There is nothing so useless as doing efficiently that which should not be done at all.                           Peter Drucker

Success has less to do with what we can get ourselves to do and more to do with keeping ourselves from doing what we shouldn’t.   Kenneth Cole