I recently read Dr. Jerome Groopman’s marvelous 2007 book, How Doctors Think. His book caused me to refocus on the importance of “time” as we consider the complexities of healthcare, and look for solutions that will promote our quest for the Triple Aim. The book came out a dozen years ago, but it’s core messages are clear and remain true today. The link above is to a New York Times review written at the time of publication by Michael Crichton. It is sad to note that Crichton died of a rapidly progressive cancer the year after he wrote the review.
Crichton celebrates in his review how Groopman accurately presents and discusses as the focus of the book the errors in reasoning that physicians make. Groopman was writing five years before Daniel Kahneman wrote his amazing book presenting the fundamentals of behavioral economics, Thinking Fast and Slow, but Groopman’s appreciation of the Nobel Prize winning work of Kahneman and his research partner, Amos Tversky, and its application to medical practice is masterfully demonstrated through interesting clinical stories and interviews. Crichton retells some of Groopman’s vignettes in the review as he underlines how deftly Groopman describes the biases we bring to practice and how the “heuristics” that we use to move quickly through our over filled schedules impact how we treat patients. Crichton summarizes much of the book in one paragraph:
Groopman powerfully conveys the complexity of the physician’s role, the anxiety and uncertainty that dog his every step, the difficulties that arise in understanding patients, eliciting their stories, making a diagnosis. One of the messages of “How Doctors Think” is that patients need to be active participants in their care; and without question the best physicians encourage, and even demand, the involvement of patients. Yet a paradox lies at the heart of Groopman’s subject: although the medical profession has long recognized that doctors communicate poorly with patients, physicians receive little training to improve that interaction. Historically, medical education has regarded communication skills with an indifference that approaches contempt. It’s unscientific, it’s hand-holding, it’s bedside manner. Yet it’s clearly important.
Further on he writes:
…he is critical of much of the thinking now in vogue. Today’s physicians are increasingly encouraged to behave as if they were computers, and to reason from flowcharts and algorithms. This is intended to produce better diagnoses and fewer errors; it is also embraced by insurance companies, who use it to decide which tests and treatments to approve. This approach can be useful for “run-of-the-mill diagnosis and treatment — distinguishing strep throat from viral pharyngitis, for example,” Groopman writes. But for difficult cases he finds it limiting and dehumanizing.
The recurrent issue in the book is how doctors must intuitively go through their day making “snap” decisions when appropriate while simultaneously fighting the business of healthcare to find the time to adequately question the patient and reflect on the patient’s problem when reflexive heuristics are inappropriate. Finding the time to be with the patient and to think about the patient is the challenge. The implication is that it is the demand of insurers, other payers, and medical managers for increasing efficiency and faster throughput that is robbing us of the adequate time to practice thoughtfully. One is left with the realization that time is the common denominator of our collective distress.
You may wonder: “Why did Michael Crichton write this review? What does he know about healthcare?” You may remember Crichton as a writer of amazing books that became thrilling movies like the Andromeda Strain or Jurassic Park. You may not know that Crichton was also a 1968 graduate of Harvard Medical School or that he was a keen observer of the issues of healthcare delivery and the doctor patient relationship. Crichton was a keen observer of medical practice and a critic as well as a “futurist” of the state of medical practice in the late 60s.
He published a book, Five Patients, in 1970 about his experience as a Harvard Medical student at the Massachusetts General Hospital. Five Patients was republished in 1994 by Crichton with additional comments about the interval changes over 25 years and the cost of care at that time. I read Five Patients in 1970 in the midst of my medical school clinical rotations. It had a profound effect on me at the time. The first Five Patients link is to the 1970 NYT review of the book. It is worthy of your attention because the reviewer comments on Crichton’s observations about the challenges of care in the late sixties. What is startling is how apt Crichton’s description of the issues he saw at the MGH would be for much of what we experience today. Before I give you a quote from the article I should show you the disclaimer attached to the 1970 review from the Times.
About the Archive
This is a digitized version of an article from The Times’s print archive, before the start of online publication in 1996. To preserve these articles as they originally appeared, The Times does not alter, edit or update them.
Occasionally the digitization process introduces transcription errors or other problems. Please send reports of such problems to archive_feedback@nytimes.com.
That disclaimer is important since the quote that I am lifting for your perusal has an obvious and regrettable “transcription error.” Here is the quote:
Crichton discusses the problems of rising cost of hospitalization in general and in teaching hospitals in particular; the high cost of personnel is the crux of the matter. He points to problems over demands to treat more people, but also to carry individualized…
That’s it. After “Individualized” what comes next? The sentence ends without a period and the next paragraph begins:
I am less optimistic than Crichton about possibilities of using audiovisual methods for care of patients in remote areas. Many, however — myself included — share his conviction about the role of computers in clinical decision‐making, which he views as one of the most important soon ‐to ‐be developed techniques.
I assume that what is missing from the incomplete sentence would have completed the thought something like this:
He points to problems over demands to treat more people, but also to carry individualized [care to each patient.]
If so, that is the same complaint that Groopman underlines forty years later, and is still true today, now fifty years later. Clinicians have been asked for a long time to see more and more patients while simultaneously providing individualized care for each patient. There is a tension between “safe patient centered care” and “efficient and effective.” It is a tension that must be one of the core drivers of what we recognize as “burnout.” It is a tension that is a function of “time,” the commodity that is always in short supply. Indeed one of the six domains of quality is that care should be “timely.” The challenge of “time” to our system of care is further enhanced by the necessity of expanding the system to care for another 10% of the population. A system that is inherently inequitable, socially tiered, too expensive, makes too many errors in its current mode of operation, and is emotionally destroying its professionals will not easily accommodate an expansion of its capacity without reengineering and further investment.
In a post a couple of weeks ago, I confessed to having harbored negative feelings about Dr. Groopman. Those feelings arise from my own sense, perhaps an incorrect interpretation, of his writing as containing scattered comments that seem to suggest that physicians have an ethical obligation to disregard demands for efficiency that compromise their time to think about patients. His most straightforward expression of this core idea was in an article that was published in the New England Journal of Medicine in January 2016 and co authored with his wife, Dr. Pamela Hartzband, an endocrinologist, entitled “Medical Taylorism.”
They begin the article by referring to Frederick Taylor who was an early twentieth century efficiency expert. Taylor wrote a book, The Principles of Scientific Management, that summed up his methodologies and thinking. Taylor’s work transformed production processes in many industries and was a forerunner to the thinking of Deming and Juran, and the evolution of Lean and other processes of continuous improvement. Taylor’s pioneering work in applying engineering principles to the work done on the factory floor was instrumental in the creation and development of the branch of engineering that is now known as industrial engineering. Don Berwick has emphasized this work in the evolution of his thinking on quality and safety. There is a direct line from Crossing the Quality Chasm and the Triple Aim back to the work of Taylor. It is ironic to me that Dr. Groopman’s book, How Doctors Think, and The Triple Aim both came to us in 2007, and shortly thereafter in 2009, President Obama began the work on the ACA which was signed into law in 2010.
The Groopman/Hartzband article was a specific pushback against the use of Lean and other methods of continuous improvement to promote the six domains of quality: patient centeredness, safety, efficiency, effectiveness, timeliness, and equity. I have bolded references to time.
They write in their article:
Open-ended interviews, vital for obtaining accurate clinical information and understanding patients’ mindsets, have become almost impossible, given the limited time allotted for visits — often only 15 to 20 minutes. Instead, patients are frequently given checklists in an effort to streamline the interaction and save precious minutes. The EHR was supposed to save time, but surveys of nurses and doctors show that it has increased the clinical workload and, more important, taken time and attention away from patients.
Physicians sense that the clock is always ticking, and patients are feeling the effect. One of our patients recently told us that when she came in for a yearly “wellness visit,” she had jotted down a few questions so she wouldn’t forget to ask them. She was upset and frustrated when she didn’t get the chance: her physician told her there was no time for her questions because a standardized list had to be addressed — she’d need to schedule a separate visit to discuss her concerns.
Groopman and Hartzband gave faint praise to some aspects of “Taylorism” but quickly found fault with the application of continuous improvement processes to healthcare because they considered its focus on efficiency and waste reduction to be potential encroachments on the practice autonomy of physicians. They perceived the search for “best practices,” or standardized approaches to clinical problems to improve the cost and quality of care as a potential encroachment on the “time” doctors have to be with patients and think. They wrote:
To be sure, certain aspects of medicine have benefited from Taylor’s principles. Strict adherence to standardized protocols has reduced hospital-acquired infections, and timely care of patients with stroke or myocardial infarction has saved lives. It may be possible to find one best way in such areas. But this aim cannot be generalized to all of medicine, least of all to such cognitive tasks as eliciting an accurate history, synthesizing clinical and laboratory data to make a diagnosis, and weighing the risks and benefits of a given treatment for an individual patient. Good thinking takes time, and the time pressure of Taylorism creates a fertile field for the sorts of cognitive errors that result in medical mistakes. Moreover, rushed clinicians are likely to take actions that ignore patients’ preferences.
Time is always a concern in practice. As I look back on my years in the office and hospital, I realize that the only time I had enough time was during my weekends on call. There was a choice. I could attack my rounding responsibilities with focus on getting finished as soon as possible so I could return home with the hope that my beeper would remain silent, or I could look at a quiet Sunday morning as an opportunity to spend uninterrupted time at a patient’s bedside and get deep into their chart looking for clues and insights that I had not observed during the rush of the week.
“Time” is the denominator of efficiency. It is also sweet to be able to disregard it as I did on those slow Sundays at the hospital. Efficiency is essentially production per unit of time. Value is a concept of cost and quality. Time is a determinant of both cost and quality. I totally agree with the contention of Groopman and Hartzband that the individual is the highest priority of professionalism. But that focus on the individual must be balanced by a sense of equity for all individuals in the population. What I fear is that a singular focus on the individual without consideration of that focus on the whole of the population will ultimately damage the doctor/patient relationship that Groopman and Hartzband want to protect. It is trite to say that no man is an island, but it is true that in healthcare we are increasingly interdependent. My great grandfather, a country doctor in rural North Carolina, practiced in an era when he was all that the patient had. I practiced in an era when the success of the care I provided required a dependency on systems that went far beyond my “black bag” or the four walls of my office.
I both agree and disagree with Groopman and Hartzband when they write:
We believe that the standardization integral to Taylorism and the Toyota manufacturing process cannot be applied to many vital aspects of medicine. If patients were cars, we would all be used cars of different years and models, with different and often multiple problems, many of which had previously been repaired by various mechanics. Moreover, those cars would all communicate in different languages and express individual preferences regarding when, how, and even whether they wanted to be fixed. The inescapable truth of medicine is that patients are genetically, physiologically, psychologically, and culturally diverse. It’s no wonder that experts disagree about the best ways to diagnose and treat many medical conditions, including hypertension, hyperlipidemia, and cancer, among others.
What they fail to realize is that the science of continuous improvement and the promise of automation of some tasks in the routine of practice delivery represents the only way we can ever extend the benefits of care to everyone, and that the cost of care for those who now do have access is accelerating at an unsustainable rate. For physicians to withdraw to their offices and demand that they not be bothered with the responsibility of helping to create a new organization of care will guarantee that we will continue to see the cost of care rise and that acceptable access to services will be available to fewer and fewer people.
I totally accept the challenge that the one of the primary objectives of our continuing efforts to transform our system of care should be to preserve more time for direct contact between patients and clinicians at critical moments in the course of diagnosing the origins of illness. Clinicians need to have the time to answer questions and give emotional support to those who are suffering. But underneath that challenge is the reality that “time” is an essential resource that determines sustainability and access. We have no chance of ever providing quality care for everyone if we just accept the push back of their final paragraph:
Medical Taylorism began with good intentions — to improve patient safety and care. But we think it has gone too far. To continue to train excellent physicians and give patients the care they want and deserve, we must reject its blanket application…We need to recognize where efficiency and standardization efforts are appropriate and where they are not. Good medical care takes time, and there is no one best way to treat many disorders. When it comes to medicine, Taylor was wrong: “man” must be first, not the system.
My response is “yes..but, we must do both.” We must continue to search for efficiency and effectiveness that will promote equity in care for everyone through an economically sustainable system while we endeavor to preserve the time to practice compassionately and effectively. I am drawn once again to the wisdom of Robert Ebert from 1965. What we must do is to recognize his wisdom that:
“The existing deficiencies in health care cannot be corrected simply by supplying more personnel, more facilities and more money. These problems can only be solved by organizing the personnel, facilities and financing into a conceptual framework and operating system that will provide optimally for the health needs of the population.”
To protect time for better patient care we must all recognize that change is essential, and that the methodologies of continuous improvement to enable the effective integration of the benefits of technology into practice and care delivery are our best chance of protecting the time Dr. Groopman asserts is necessary to protect the quality of care. It sounds crude to say that time is money, but it is. Time is also essential to patient management and provider health, well being, and professional satisfaction. We all need to be willing participants in the collective efforts to be good stewards of time and of all of the resources needed for better practice in pursuit of the Triple Aim.
