A senior doctor known across the country came to me to talk about managing his time. We spent the day on something else. What it costs to be the person everybody needs and how a man can lose the reason he became a doctor while practicing more medicine than ever.
He came to our session an hour late. He apologised twice, sat down, and told me in one sentence why. A patient he had operated on eleven days earlier had died that morning. He had been with the family. Then he asked whether we could get started, because he had a clinic at five.
He wanted to talk about managing his time.
He is a doctor most people in this country could name. Senior, respected, the man you are relieved to be referred to. He is also in trouble, though nobody around him would use that word and neither would he.
What the corridor sees
If you have waited to see a consultant, you know the experience from the other side. You were given six o’clock. He arrives at eight. The room is full of people who have taken leave from work and brought an elderly parent who cannot sit comfortably for that long. When your turn finally comes you get seven minutes and his phone rings twice during them.
You pay at the counter on the way out. In the car somebody does the arithmetic out loud. Forty patients, that fee, four nights a week. The number is large and it settles a view of the profession many of us are quietly ready to believe.
I have been in those corridors as a patient’s son. The impatience is real and I am not going to pretend I have never felt it. My father is at the ICU as I write this note. His state is such, that only God can help him to come home. Yet, I write as I sit outside the ICU on some of my thoughts about a consultant I coached some months previously. Hope it helps to have a healthy conversation of sides I haven’t seen.
What the corridor cannot see
Here is the same evening from the other chair.
Before the clinic he did a ward round, two procedures and a conversation with a family about a scan result. He has not eaten since half past six. In his pocket is a phone that will ring at two o’clock tonight and he will take it, because the alternative is a registrar deciding alone.
The patient in front of him is the thirty-eighth person of the day who needs something from him that only he can give. Before each one he does something that nobody in the waiting room notices, because it happens behind the face. He puts away the last consultation and arranges himself for this one. He has done that thirty-seven times already. By eight o’clock it is no longer free.
“He was not late because he had no respect for our time. He was late because somebody else’s father had needed him more than we did.”
The Medscape burnout report published this year found something that stayed with me. Most doctors who are struggling deal with it alone. Nearly three quarters say it has damaged their closest relationships. They tell their own patients to seek help early, then hold themselves to a standard they would never impose on anyone else.
The trap is that the money and the duty point the same way
A consultant in Sri Lanka earns modestly from his state appointment and substantially from private practice conducted before and after those hours. Income is therefore a direct function of volume. Every additional patient is more money, which is the obvious part. Every additional patient is also somebody who genuinely needs a doctor and has waited weeks to see one, which is the part that makes this so difficult to solve.
This is why the usual advice fails. Tell a businessman to take fewer meetings and he weighs it against profit. Tell this man to see fewer patients and he weighs it against a woman with a lump in her breast who would otherwise wait until March. There is no version of restraint that does not feel to him like both a pay cut and an abandonment.
The hospital does not help him, for a straightforward reason. His name fills the appointment book. The institution has every reason to extend his lists and none to protect his recovery. His family has grown into the income, as has a wider circle who assume, as people do about doctors, that there is always more.
Nobody in that arrangement is a villain. That is precisely what makes it so hard to interrupt.
The question he answered too quickly
I asked him how many patients he could see in an evening and still be the doctor he had set out to be.
He answered in under two seconds. Twenty-two. No hesitation, no working it out. He had known that number for years and had never once said it aloud.
Then I asked what the list had been the previous evening. Forty-one.
We sat with the gap between those two numbers for a while. It is my experience that the most useful thing a coach can do at such a moment is nothing at all.
“How many patients can you see in an evening and still be the doctor you set out to be? He answered in under two seconds. He had known the number for years.”
When he spoke again he did not talk about money or hours. He said he could tell me exactly which patients he had rushed. Not roughly. Exactly. He could remember the ones he had moved along, the questions he had not invited, the times he had reached for the prescription pad a minute earlier than he should have.
A man who has been practising for three decades knows the difference between the medicine he performs and the medicine he intended to practise. He carries that difference home every night and it does not go anywhere.
The forty-first patient is not seeing the same doctor as the fourth
A boundary sounds like a personal indulgence when you describe it in the language of balance and self care. Described accurately, it is a clinical control. The doctor who reaches the end of a forty-one patient list is not the same physician who started it. His attention has thinned. His curiosity has gone. He is pattern matching rather than examining, and pattern matching is how experienced clinicians miss things.
Put plainly, the twenty-third patient onwards is receiving a diminished doctor at full price. He knew that better than I did. What he had never done was give himself permission to treat it as a professional standard rather than a personal weakness.
“A boundary is not self indulgence. It is the last piece of clinical equipment protecting the patient at the end of the list.”
What he changed and what it cost him
He capped the evening list at twenty-eight, on the way to twenty-two, because he was honest enough to say that going straight there would collapse. He put a fifteen minute gap in the middle of the clinic and told the desk it was not available for overflow. He asked the hospital to stop adding names after the list closed, which required one uncomfortable conversation with an administrator who had assumed for years that he would absorb whatever arrived.
He also did something small that I think about often. He told the desk to give waiting patients the truth about delays, in one sentence, rather than the usual line about the doctor being on his way. The complaints did not stop. They changed character, which is not nothing.
The financial part was the hardest and we spent two sessions on it. He had been earning against an unexamined assumption of what was required. When he actually worked out what his family needed, the figure was materially lower than the figure he had been chasing. That is a common finding in this work and it never stops surprising the person who does the sum.
It cost him money. I want to state that plainly rather than tidy it away, because any doctor reading this will know at once whether I am being honest with him. He earns less than he did. He has decided what the difference was buying and concluded that he was paying too much for it.
For the people in the waiting room
Almost none of this is visible from the corridor, which is where the resentment gets manufactured.
The man who kept you waiting two hours may have spent forty minutes of them telling a family something they will remember for the rest of their lives. He may have taken a decision at three o’clock this morning that he is still turning over. He may be seeing your father at the end of a day in which he has already been the person everybody needed, thirty-seven times.
None of that excuses genuine indifference, which exists in medicine as in every profession. It does mean that the arithmetic we do in the car park is usually wrong and that we are reading exhaustion as arrogance.
If you are a doctor reading this, the question I would put to you is the one I put to him.
What is the number at which you are still the physician you meant to become?
You already know it. The only question is whether you will ever say it out loud to somebody who can help you hold the line.
The care that patients want is not produced by a doctor who has nothing left. It is produced by a doctor who has protected enough of himself to still be present at eight o’clock in the evening for a stranger who is frightened.
It begins, as it always does, with a professional deciding what he will not trade away, and then holding it when everybody around him has an excellent reason why he should.
Wishing you a week in which you are treated with care and in which you extend some to the person treating you.
– Niroshan Silva, MCC.
