Efficient.
An obsession of modern medicine.
“I think it’ll be more efficient if we do it like this,” I pointed out.
“We’re not here to be efficient. We’re here to be effective.”
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While I can’t recall the exact topic or question in mind, I can still picture the scene of this conversation with a mentor. We were in his sunny office, surrounded by piles of paper charts, shelves of medical books, and pictures of his family: the typical office of a family doctor.
“We’re not here to be efficient. We’re here to be effective.”
The words stung a little because I realized I had been wrong to prioritize efficiency. But it was the good kind of sting. The sting of correction and redirection. The sting of learning.
The memory of that conversation has redirected me again and again throughout medical training in a system that emphasizes efficiency, often at the cost of genuine, meaningful care.
Efficiency vs. Effectiveness in Medicine
To be efficient is to produce results with little or no waste. While perhaps great for engineering, efficiency has little role in human relationships. And in medicine (particularly family medicine and “primary” care), efficiency has been over-emphasized to the point of patient harm.
“The most common unintended consequences of performance management [i.e., efficiency measures] identified in the literature were …administrative burden, insensitivity, reduced morale, and systemic dysfunction.”
There has even been the proposal to study different types of medical efficiency, offering more names for the same basic problem as if renaming it will solve the issue: an overemphasis on efficiency in healthcare.
A clear example of this is seen on a population level with value-based care initiatives [i.e., financial incentives for health systems]. If at the end of the year, patients meeting criteria for certain screenings have undergone these tests, health systems or practices are awarded or not penalized financially. While of course this will benefit some patients, it will also inevitably harm others.
As a more specific example, consider the mass-ordering of mammograms by healthcare systems. Yes, it is more efficient than having 1:1 appointments with each patient. And yes, it will cause harm to those for whom the risks actually outweigh the benefits of this test, such as those patients who are not expected to live beyond 10 more years. In those remaining years of life, they may now be subjected to breast biopsies and even treatment which may negatively impact the quality of life with the time they have left.
This is efficient harm.
Efficiency can also be seen running the show in office-based, insurance-driven care. Because clinics are reimbursed largely based on the volume of patients seen (i.e., more patients seen in a day = more money), clinics are incentivized to see more and more patients. The 5- and 15-minute visit was born.
The number of primary care visits has increased astronomically ***. Some might argue this has made shorter visits necessary, so more patients can be cared for.
However, shorter visit length has been associated with an increased risk of antibiotic prescribing, decreased preventative care and diagnoses, among other harms. We’re seeing more patients, but are we caring for them? We are efficient in 5-15 minutes. But, more importantly, are we effective?
The product in insurance-based healthcare systems is “patients evaluated and treated” with waste being largely a function of time: time to room the patient, time seeing the patient, time ordering tests, time charting, and time answering messages. Studies have demonstrated that more (not less) time with the patient not only increases patient satisfaction, but physician professional satisfaction as well. A study noted it takes an average of 15 minutes to prescribe a new medication with the inherent discussion regarding the risks, benefits, and alternatives - and that didn’t include the time it took to room that patient, catch up on the patient’s dog, or form the agenda for the visit. In offices that only have 15-minute visits, are patients missing out on informed consent in the name of efficiency? It seems almost inevitable when time is viewed as a measure of efficiency, of waste.
Of course, it is worth noting that these adverse effects of efficiency are often unintended consequences. Most physicians mean well. Administrators, too, often attempt to turn up efficiency in the name of “caring for more patients.” Unintended or not, these are just some of the consequences of prioritizing efficiency in healthcare.
An Efficient Machine
Efficiency in healthcare can trickle down into the personal lives of physicians as well.
During training, I would find myself calculating estimated visit times over and over every day, trying to find time to care for patients and maybe get a lunch break.
“If I get to clinic 15 minutes earlier, I could start earlier and then if I can manage to help Mrs. Jones in 10 minutes, I could spend 20 minutes with Mr. Jones. He could use the extra time. And if I start pending my orders now, I might have a 20-minute break for lunch.”
On and on, ad nauseam. Not an uncommon experience for the average family doctor in a healthcare system.
But this over-emphasis on efficiency actually began even earlier in my medical training, as it does for many others. In medical school, efficiency became a priority not only in the clinic, but in nearly all facets of life. It sounds a bit laughable now, but going to the grocery store even became a study in efficiency: if I went in the morning, there would be no lines to wait in; and if I wrote my list by grocery aisle, I wouldn’t have to go down aisles more than once which would save me a few minutes, etc., etc.. When studying, I would set my timer for 50 minutes, taking a 10-minute break every hour before repeating for hours on end (also known as the Pomodoro technique). My non-medical roommate even began to refer to me as “a machine” for all my gold-star efficiency.
As physicians, an over-emphasis on efficiency not only impacts our work schedule or lives, but often trickles into our personal lives as well. I applied the principle of efficiency in the name of rest. I consistently took 1 day off from studying per week during the first two years of medical school. These are two of the most intense, concentrated years of studying when becoming a physician. But, honestly, this day off was more in the name of efficiency than any solid understanding of rest and Sabbath [which I plan to write more about soon]. The reason: if I took a day off, I could study longer and more intensely on the other six days. I could be more efficient in the week ahead. It was efficiency masquerading as self-care.
Reclaiming Time: An Answer to the Over-Emphasis of Efficiency
While some level of efficiency and discipline is helpful and even valued (and often rewarded), it can be easy for it to go too far as we have seen. An over-emphasis on efficiency harms patients and harms physicians.
Efficiency has become something I am still sometimes learning to de-emphasize in my own life and clinical practice. But the rewards are many:
A sinus surgery cancelled for lack of sinus infections
A child who now sleeps in his own bed and through the night
A woman who can dance when just getting out of a chair was a struggle
These are stories of effectiveness in medicine. What an honor to get to give the gift of time and presence and be a part of these stories of healing.
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I’m grateful the words of my mentor came to my mind again towards the end of training. While I had learned to be efficient, I knew that my spirit was calling for a deeper relationship with my patients. One that wasn’t so focused on the efficiency of time, but on being effective in helping them find healing.
And that’s why I started my own direct primary care practice, and am so passionate about helping other physicians become independent: so we can take our time back and decide how to use it effectively for our patients.
Because at the end of the day, we cannot make time, or move time, or buy time.
We can only choose how to use it.
And I choose to be effective.
“Many people experience time as an unruly mess that is often out of control. We need time, as if God has not allotted to us all that we are meant to have. We make time, as if we had the power to create it. We steal time, as if we could add more to our lives. We spend and use time, as if it really were a commodity.”
― Dan B. Allender, Sabbath: The Ancient Practices