Sunday, August 16, 2015

My Doctor, The Juggler

The job of being a doctor can sometimes be like that of your favorite sidewalk juggler.  It used to be that a good ole family doctor would have to show up in the clinic for a couple of hours, make a few house calls, and be available if anyone needed him while he played a round of golf in the afternoon (really this is quite an exaggeration but it sets the tone).  In reality, most doctors today must compartmentalize their day, prioritize the patients from most sick to least sick, and then organize a plan of attack which then needs to be carried out with sniper-like precision (also a bit of an exaggeration for most doctors but if the shoe fits…).  Each day can be like a juggling act.  Despite perfect execution, a doctor still may have to call an audible when things don’t go as planned just like a juggler might have to do when a large wind gust arises or he/she mishandles a ball.  

I like the juggling analogy because the type of work each doctor does is different based on specialty, practice type, and patient population.  Some doctors juggle soft balls, others juggle crystal balls, and some tend to toss swords, chainsaws, or flaming torches.  Some juggle in padded rooms, others while walking a tightrope, and others in crowded areas full of women and children.  Real jugglers have to manage the crowds and other street performers like doctors have to deal with impatient patients and their competitors.  Both depend on being in the right place at the right time as much as their talent on some days.  

As a kid, I still remember seeing a juggler on the street managing six or eight flaming torches at a time.  He then caught them and changed them out to swords at which time he sent them hurling into the air and rotated them as if they were on a racetrack.  It seems to me that the job of juggling swords and flaming torches has some of the same perils as a neurosurgeon operating on a patient’s brain or a cardiac surgeon bypassing a person’s heart.  One slight mistake can lead to a waterfall of failure.  

Jesters and royal jugglers have been known to juggle their majesty’s crystal and glassware.  I would consider the medical equivalent to be an obstetrician catching babies or a pediatrician diagnosing an infant’s illness.  A plastic surgeon might also lay claim to this type of subject matter, although most doctors would agree that their craft is impressively delicate but the narcissism involved subtracts a point for style when compared to birthing and caring for the innocence of youth.  

The act of juggling can be as simple as tossing two balls in the air from hand to hand or as difficult as criss-crossing eight balls at a time.  Some doctors only work in a clinic, emergency room, or hospital and, therefore, have more of a two-ball juggle job.  That being said, different single venue situations can be as frenetic as some multi-site ones depending on patient acuity and volume.  Some doctors have an eight-ball rotation in which they bounce between a busy clinic, a procedural arena, and hospital/emergency department responsibilities.  Some primary care providers in small areas have the usual eight-ball motion but also have to deal with community expectations like neighbors knocking on the back door.  This would be the equivalent of the eight-ball rotation mixed with a bowling ball.  

Let me give you a real-life example of a multi-venue situation…I spend the first couple of hours of most days in the hospital rounding on inpatients, admitting ER patients, and following up on tests and procedures.  I can generally plan to get there early enough to see every patient and have a little bit of flex time without running late.  Not all doctors have this luxury as some are tethered to multiple hospitals and/or a high volume of patients admitted during each day.  The juggling occurs when you arrive and have several unexpected admissions and/or a really sick patient who needs twice or three times the amount of attention than you expected.  

Once finished in the hospital (around 7 or 8 am), I then usually spend the rest of my day evenly split between procedures and clinic, and then at the end of the day I go back to the hospital to take care of new patients and consults as well as discharges that need to happen prior to going home.  It sounds easy…four hours doing procedures (most of my procedures are scheduled as an hour each) and four hours in clinic.  Not so fast, my friend.

To break down each venue, realize that every clinic, procedural area, and hospital function differently.  No site is the same but there are some generalities that can be formed about each.  Clinic seems to be the most misunderstood portion of a doctor’s life when considered by the lay public.  Patients often become frustrated with clinic wait times as they expect their doctor to arrive on-time to clinic and to be seen in a straightaway manner as if there is no other priority.  What most do not realize is that the clinic schedule is only the first hurdle in the triathlon of a doctor’s day.  Assuming I get through with my hospital rounds on time and start my procedures on time with no interruptions, emergencies, or unexpected waylays, I usually arrive to clinic and am greeted by my nurses who inform me that one or more patients had called and needed to be seen urgently.  A good doctor’s clinic is usually pretty full in the first place and these add-ons are necessary for excellent patient care but devastating to a schedule.  I often will inhale lunch just before walking into the first room and then sink into my groove in clinic, bouncing from room to room, usually distracted and delayed by the various nursing calls from the hospital or the ten minutes on hold with the ER as they alert me to the arrival of my next admission.  

If I am lucky, I am able to keep up with the phone calls, electronic medical record, and patient load.  The biggest issue in clinic for me (which is so hard for the outsider patient to understand) occurs when a followup visit scheduled to take ten minutes takes forty-five minutes.  These “special” visits often involve true illness(es) like chest pain or congestive heart failure but can also be non-urgent delays.  One of the most common delays occurs due to a patient’s reaction to a piece of medical news that is exaggerated due to depression, anxiety, or current situation in life.  I usually have one patient cry all the way through their twenty-five minute visit per day and another patient per day will spend fifteen minutes telling me about his or her financial/marital/familial/religious woes that are not absolutely medically necessary but impossible to avoid.  There is no way to judge or plan for these delays, and thus a doctor is left to juggle the remaining patient’s anger and unhappiness while still trying to provide good care.  

Often times, clinic wait times are ridiculous due to emergencies related to non-clinic issues.  A partner will call occasionally to ask for advice or assistance with a difficult procedure…a patient will code or get into trouble in the hospital…a friend of a friend of a friend will become sick and need phone advice relayed via your spouse or mother (usually a twenty minute conversation)…an emergency will come into the ER which takes precedence over the more stable clinic patients (this is the equivalent of the juggler taking a sword to the chest as it usually blows up the clinic schedule)…a technology issue will arise in which the electronic medical record is slow or not working at all and will slow things down…a nurse will get sick during clinic and have to go home, leaving an understaffed clinic…and the excuses go on and on.  

This rant has covered most of the reasons why being a doctor is similar to being a juggler, but is by no means a comprehensive list.  We haven’t even considered the “business” side of medicine in which a doctor is forced to juggle insurance companies and their insane preauthorization requests, mounds of paperwork, hospital administrators, frivolous lawsuits, competition between other groups/doctors/etc, and a whole host of other issues.  We haven’t pondered the governmental regulations that are being enforced to make the practice of medicine about as messy as juggling ice cream cones in the dead of summer.  We don’t have time to mull over the quality metrics that all doctors are supposed to achieve yet seem to change on a daily basis.  I would be remiss if I didn’t mention that most doctors juggle the strains and stresses of their job with their responsibilities as a spouse or significant other, parent, sibling, and friend.  

In a way, all jobs have a juggling component and so I want to make it clear that this is not a plea for sympathy or respect.  My hope in this story was to give an insight into my profession’s challenges so that the lay public might understand the different scenarios which affect a doctor’s ability to meet their expectations.  Some days are flawless and others are littered with dropped swords.  

Written by David Jones, MD- owner/blogger at, a physician peer ratings website.  

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