Being a doctor is, apparently, a noble, fulfilling, humanitarian, interesting profession. Many dream of joining the medical fraternity – a selected group of modern angels, superheroes, gods of life and death, who dart silently along hospital corridors in their white coats, like clouds in the sky during windy weather. Swinging stethoscopes around necks, batteries of pens in pockets, name tags pinned to chests plus other tools of trade attached here and there (torches, tourniquets, tape meters, handbooks, smartphones, chocolate bars, fizzy drinks) add to the mystery of those creatures and boost public respect.
Surely, all doctors think about is the next case: diagnosis, optimal prescription, maybe an operation. Undoubtedly, their tense faces signify concern about patients, worry about the initiated therapies’ outcomes, care about sick, injured or the otherwise troubled (labouring mothers; snoring husbands; climacteric wives; victims of nature who cry for more pouty lips etc.). Certainly, constant restlessness of medics affirms sufferers – their saviours rush to assist instantaneously. Right?
All doctors agonize about is paperwork, at least in South African government health facilities. Therefore they dash, look petrified and kill stress with caffeine, nicotine or high-carbohydrate foods. Their meek smiles, detected occasionally through the fog of exhaustion, are involuntary reflexes that have roots in subconscious – displaying amiability somehow proves professionalism, calling, sensitivity and attention, i.e. those traits of character, which the white-coated champions strive for, but which the merciless bureaucracy slowly squishes.
Doctors spend up to 80% of their time on administration around any patient (up to 6 hours on an average 8-hour day, up to 18 hours during 24-hour call!). Looking for and filling in forms, finishing up case histories, making phone calls, browsing lazily loading databases to find lab results, waiting for responses, booking auxiliary services (X-ray, ultrasound, ambulance, blood transfusion etc.), running to emergency cupboards to fetch medications – the list goes on and on… Some of such chores comprise indeed the medics’ responsibility, although the gross majority of them should never occupy their mind, especially writing down useless information and completing redundant documents.
Two habits have become the beloved standard:
- Introducing separate sheets for any medical process, even minor. That requires one to re-entry data, already available elsewhere, into “unique forms uniquely designed for unique procedures”. Incredibly, the same fact could be repeated in 3, 4 or more places, which indicates how many hours are wasted on silly copying.
- Whenever a client pays a visit to the hospital, the attending practitioner must describe (by hand) the complaints, findings and recommendations. Nothing really improper with it, however the authorities insist on creating “detailed notes” (without defining what the vague term means), so the doctor can achieve a magic status of “legally untouchable”. This fear-mongering gives rise to compilation of essays – not constructive summaries – full of duplicated, worthless, obvious, yesterday’s news. “Pregnant 26 years old female coming for a routine check-up to the Antenatal Clinic” – announces the first line, like it could be a pregnant male, or the age could change unexpectedly, or the scheduled follow-up could become a complete surprise, or an expecting mom could seek assessment by an ophthalmologist. The same happens during ward rounds – every day an almost identical story is put on paper, with little alterations, thus one can read that the same individual of the same weight rests in the same bed with the same problem. Results (typical observations like blood pressure, temperature, pulse rate, urine output etc. plus laboratory tests’ findings) are painstakingly transcribed into the “detailed notes” from other graphs or tables (the figures are already there, marked down on the supplementary, beautifully drafted charts, yet it is not enough). Nurses scribble equally elaborate comments between the doctors’ pieces and add, of course, matching results. By the end, the patient’s folder reminds one of a maniac’s journal, with each page containing information recollected to the dot in dozens of calligraphy styles
Where is that madness coming from? Well, from three sources:
- National or provincial nerve centres that shelter government officials. They manufacture general policies for all health facilities. Many of their directives pertain to standards of documentation, which are transmitted to executors, who reside in smaller (but similarly comfortable and clean) regional bunkers. Those local enforcers, armed with orders from the top, attack hospitals and clinics.
- Administrators of hospitals and clinics study the incoming instructions and whip inferiors to obey.
- Clinical head of departments, who have already undergone transmutation from doctors into quasi-managers (although they have no managerial, administrative or organisational neither education nor flair) support the upper echelons of rulers and vehemently collaborate in whipping.
The received commands are regurgitated until a fresh document is born: checklist to tick, table to populate, sheet to cram with data. As the obedience must be secured, superiors issue a regulation, which forces workers to use the new piece of paper. The whole process has its sophisticated name: implementation.
Furthermore, representatives of any of the above levels can independently concoct standing orders, protocols, standing operating procedures, forms to be filled or similar. They never turn for opinion to people best suited to evaluate the proposed changes – to employees.
But why do they do it? Why do those watchdogs avalanche their most precious assets – doctors and nurses – with stationery, instead of letting them perform what they are trained to do? Firstly, the overseers confuse the quality of work with the quantity of “detailed notes” (the only service aspect they have faculty to estimate). Secondly, they need to justify their jobs and protect cosy appointments somehow – they prove their importance by a steady production of regulations plus stationery, which subsequently gives reasons to produce more regulations (amendments to previous regulations, or regulations regulating current regulations) plus stationary (revisions of the earlier stationery versions).
The self-propelling bureaucratic madness instigates absurdity as follows (just a few examples):
- Instructions pinned to the board: “Policy to display policies on this policy board”.
- Forms that hold material duplicated from other comparable forms.
- Sisters pre-preparing details on special sheets for clerks, who then capture those details into computer databases (2-step ceremony to accomplish 1-step task).
- Describing patients destined for admission in 4 places (no substantial differences between each description).
Over-regulating – in any industry – clearly signals a system collapse. The concerned authorities – in order to gain public belief that “something is being done” about service delivery – introduce more and more measures to control those who are toiling on the frontlines. Such “corrective” or “enhancing” actions inevitably cause more paperwork for the employees, thus diminishing greatly their attentiveness, satisfaction and effectiveness, but increasing exhaustion, disappointment and irritation. Excessive monitoring sucks out the essence of good health care, as the focus is shifted from the sick ones onto meaningless administration. The doctors’ frustration translates into annoyance with innocent patients, since each patient triggers off tonnes of secretarial errands.
Consecutively, supervisors look for remedies to modify doctors’ conduct from obnoxious to pleasant – new rules follow, now policing the mischievous medics’ behaviour. “Patient Centred Care” initiative is cooked up – a fantastic tool to robotize manners of disobedient doctors and sisters, who have mysteriously forgotten about their mission (and passion) to concentrate on the wellbeing of patients. Apparently, an overburdened, fatigued and discontented practitioner should smile, show empathy, explicate calmly everything to the treated client, maybe even crack a few jokes. Equally idiotic would be to introduce a “Cure Centred Medicine” or “Speeding Centred Car Races” schemes. The initiative, of course, is propped with a brand-new checklist plus scrutinising team (nominated guards walking around, inspecting how everybody acts, berating naughty individuals, grimacing in disapproval, reporting out-of-line demeanours).
An oppressive, communist little state flourishes.
Let’s spell out some facts to our dear desk-jockeys, who for some reason cannot grasp the obvious.
- In many instances, you outsource doctors and nurses to manage the hospital, whereas it is your job to manage. By creating standing operating procedures, forms, registers etc. you literally pass certain duties on professionals, who should be busy with utilising their skills to save lives. They are not there to fill in inventories for your statistics, to resolve shortages of beds not prevented by you, to record similar data in dozens of places to comply with your requirements. By stealth, you absolve yourself from your basic responsibility, which is to minimise administrative burden placed on those whose employment guarantees your posts (not the other way around).
- Here are the major factors contributing to the pitiable service delivery and patients’ displeasure: overcrowding of health facilities, poor socio-economic conditions in the country, financial constraints, contracting a doctor to labour minimum 56 hours per week (sometimes in up to 30-hour nonstop shifts), morphing consultants into pencil-pushers, taking up to 80% of health workers’ time for dealing with red tape, wasting money on recruiting more bureaucratic personnel. You cannot clean such a mess with extorting more control over already strained to the limits medics, but by attending to the above predicaments. If you find yourself mumbling that “it is out of our control”, resign from your positions, as plainly you are not suited to contest the core problems.
- The system that you have devised will be attracting staff with certain predispositions, so-called “system-lovers”, but repelling those who prefer “hands-on” approach. In effect the most proficient professionals will keep running away (to private sector or overseas), leaving you with less clinically capable doctors, who compensate scarcity of expertise with “detailed notes” and who form a circle of system-defenders (they need to provide evidence of their loyalty, aptitude or otherwise value to the organisation, so they harass others to abide by paper laws). This easily predictable situation will further deteriorate quality of service or teaching. Also, it will build atmosphere of confusion, tension and growing exasperation, especially due to unequal distribution of true work – setup not conducive to the development of professional behaviour. Unequivocally, you are accountable for designing an environment in which medical staff is happy, therefore pressurising doctors to be nice towards patients in constructed by you hell signifies how masterfully you transfer blame for your incompetence, detachment from reality and incapacities in logical thinking onto those whom you should serve.
- You terrorise health staff with visions of legal consequences when data is not copied many times in countless documents. Nothing better confirms how clever you are in misdirecting debates: from scrutinising inadequacy of dictated by you routines, to legends about attorneys hunting insufficiently replicated information. It is mandatory to record all pertinent facts, however it is ludicrous to record the same facts many times. You spread culture of defensive medicine – a conviction that multiplied annotations attest perfect medical management. That practice only clatters patients’ folders, prolongs periods of looking for pertinent information in the heaps of paper, prompts mistakes. Serial copying of previous findings affirms belief in those findings, seeds doubt about individual judgment, distorts clinical picture, leads to wrong interventions. Medics, driven by utter fear, protect themselves against some unspecified punishment by frantic writing, without explicit concept of legally valid notes. It is your duty to make the process of capturing data easy for doctors and nurses and in such a way, that not a single detail will be repeated twice. Here is one million dollar idea for you: computers. Those modern machines can collect, record, feed, store, retrieve, display, print or send anything you wish, and in any format you wish (text, graphic, photo, voice, video, database). For your convenience, the smart devices will also clone information as many times as you wish on: local hard drive, portable hard drive, smartphone, in-house server, remote server or cloud. They are definitely far cheaper to run and maintain than your Stone Age methods, plus far greener, far friendlier to use, far more accurate.
- Do you see that? Do you see how you rob health professionals of the critical to their performance aspects? Aspects like: establishing a relationship with the patient, confidence, training by seniors on the floor, utilising proficiently acquired skills, rest, satisfaction… Can you figure out how effective it would be to reduce doctors’ administrative duties to maximum 20% of their time? Can you imagine that this new paradigm would allow you to decrease the inhumane requirement of minimum 56 hours of work per week (which constitutes slavery, increases potential of errors, ruins private lives, deteriorates health and contributes to many other problems) to 40-46 hours?
It is outrageous that in the 21st century, when we are surrounded by helpful technology, growing crowds of quasi-managers impede progress and then look for causes of poor healthcare, whereas they are the cause.
Doctors, nurses and patients suffer…
In all fairness, some guidelines are helpful – the art rests in rooting out the obstructive ones. Currently, the obstructive ones prevail.