Dear Patient And Your Loved Ones,
I am told of your sighs while you wait to see me in clinic. I get reports from clerks and nurses about you when you ask how much longer it will be because I am taking too long to get to you. I hear about your angry tone of voice that you sometimes use with our staff when you must blame someone for why you have been waiting for so long. It is not their fault. I ask that you be kind to them.
I see your eye rolls when I eventually knock on your door and walk in to talk with you because it is finally your turn. I hear the frustration in your voice when you address me after you’ve been sitting there for an extra twenty or thirty minutes . . . it was an extra hour and a half for some of my patients a few weeks ago.
Trust me, I do not think it is okay that you have to wait either. Honestly, I might be exasperated if I were you too. I have waited for doctor’s myself and it is terrible to have to wait. Why can’t doctors be on time? Is there a pandemic of lateness that is caught in medical school as easily as Covid??
I understand it is an even bigger problem if you are made to wait while you are feeling unwell because of your cancer or if you have side effects from your treatment that are causing you angst. I understand the high level of anxiety that comes with each passing minute while you wait to hear what your CT showed . . . is your cancer still behaving itself or is today the day I will tell you it is growing again? I understand you all have lives to get to and the last thing you want to be doing is waiting for me in a cancer centre.
I am sorry I am often late to get to you. There is rarely anything I can do about it though. Some people, like the son of one of my patients last week, might not believe me. Please know I am telling the truth.
Let me explain what it is that I am doing on my side of the clinic:
My job description states I have two half-day follow-up clinics in gastrointestinal (GI) oncology per week. In the cancer centre I work at, I am allotted specific clinic space. I do not decide the day of the week or whether my clinic runs in the morning or afternoon. I have been allotted Tuesday morning and Tuesday afternoon for the last few years. This means I must see all the patients I have with GI cancers on Tuesday. Even if I wanted to, I cannot easily see patients outside of this clinic space – other doctors are booked into the space during the rest of the week. All of the clinical space in our building is spoken for.
If you require blood work for treatment decisions, which is almost always the case, you are booked into a laboratory appointment for blood work one hour prior to your appointment time with me. You can choose to get this blood work outside of my building the day before. This allows you to not have to wait so long in our building on the day of your appointment with me. I do not know if this saves you time in the grand scheme of things because going somewhere else on a different day still takes time. If it does save time, it would not be that much.
Should you choose to get labs done in my building right before you see me, you are already in the building at least one hour prior to your scheduled appointment time with me. There is no way around this time commitment because at best, it takes forty-five to sixty minutes to get the results from your blood work back from the lab. I most often will need to see these lab results before I see you as they will direct our discussion. Please understand I have no control over laboratory staffing concerns which may delay your blood draw, how fast your blood work is processed, or if there are or aren’t problems with lab procedures or technology that will cause a delay in the availability of your results.
My clinic is divided into twenty-minute slots, meaning I am to see a patient ever twenty minutes from 8am until noon and from 1pm-5pm. I did not choose these time slots, they were chosen for me. The noon hour is reserved for “lunch” but anyone you ask will tell you that there is no lunch hour in my clinic. My nurse and I manage to scramble for some sustenance at some point in the day, but it is a rushed barely-chew-before-we-swallow-just-get-some-calories-in-so-we-don’t-fall-over kind of “lunch”.
A twenty-minute appointment slot might sound like ample time. Sometimes it is. Often it is not. Within those twenty minutes, you are weighed and brought into a clinic room to be assessed by my nurse who reviews a symptoms assessment form you filled out while you waited. My nurse then comes out of the room to report significant findings to me. I then have my visit with you. After we are finished talking, I come out of the room and have a flurry of things to do: I write chemotherapy orders where appropriate; click a bunch of boxes in our system to arrange for follow blood work, appointment times, next chemotherapy dates, and order any imaging that might be required; I fill out any forms that need filling out if I am ordering imaging or referrals to other physicians or services; I dictate a note which becomes part of your permanent health record and which acts as a communication tool for any other health care professionals that are involved in your care pathway. All of this must happen in twenty minutes for me to keep on time.
Now, this is all well and good if nothing is going “wrong”. Nothing going “wrong” means the lab is working properly and the blood work results are available an hour after your blood draw; you have no, or limited, side effects; you have not had a CT for monitoring purposes so a treatment plan modification is not required on this visit; you have had a CT but result is good news – your cancer is still responding; I don’t get interrupted by the other people buzzing around my work space wanting to ask me questions or tell me something about a patient I have already seen or soon will be seeing; or, I don’t get a page from an outside physician looking to talk to me about a patient we share. Yes, if nothing is “wrong” I might be able to get everything completed in the allotted twenty minutes.
But any number of things can derail the timing of my clinic and I can tell you something always does. There is rarely a smooth clinic where the stars align and every single one of you are doing perfectly well and don’t need any extra tender loving care. One, two, or more of these more difficult-to-deal with scenarios is the norm for my Tuesday clinics:
- Your blood work is delayed. I cannot have an informed conversation with you about the possibility of treatment if I don’t know what your blood counts are.
- You might have multiple complications with side effects. It takes time to sort through these, explain what is happening, come up with possible solutions, and make sure you know what the plan is going to be.
- I might have to give you bad news. Your CT shows your cancer is growing. I must spend time explaining the CT result and what it means. In many cases, I then have to tell you about a possible next option for treatment, the side effects of this treatment, and ensure you understand the pros and cons around your decision to proceed or not.
- We might need to have a goals of care discussion. At some point in your journey we need to discuss medical possibilities and impossibilities when faced with an incurable cancer and what should and should not be considered if your heart or lungs are being overwhelmed.
- We might need have to talk about death. This is not just a one sentence discussion.
- We might have to talk about discharge. If I have no treatment left to offer you, care is shifted to focus on pain and symptoms needs, which is done in the community by family physicians, homecare, and hospice facilities. This takes time to explain and discuss. Goodbyes with you are hard.
So, I fall behind.
Can you imagine if you and I had just spent fifteen minutes trying to sort through ameliorating the nausea and mouth sores you are experiencing from chemotherapy and me then telling you we would have to book another appointment in a five weeks, when I next have availability in my clinic, to discuss the results of the CT you had five days ago because we ran out of time today?
Can you imagine me walking into your room to tell you your cancer has grown and we have to change treatment plans but in the next breath I tell you I don’t have time to explain what the treatment plan entails because we spent fifteen minutes going through how you are doing and your CT report together?
Would it be okay with you if the last treatment we could try for your cancer has not worked and there is nothing left to try so I am discharging you but the buzzer to start the appointment time for my next patient just buzzed so I can’t get to your very important questions about hospice and dying?
I fall behind because I want to spend time with you. I have to sit across from you and say: Your cancer is growing. The chemo you are on is not working anymore. Here is the next treatment option. We are out of treatment options. You are dying.
It is important to me that you know each time I get jabbed in clinic by a sharp word or unkind look from you or your family member for running late, I get a little discouraged. When I am discouraged, I feel like I am doing a bad job. These feelings increase the chance of something called burnout. Running behind is not a reason for burnout on its own but it adds to the already heavy pressure of my job.
I promise you I do not fall behind purposefully. I promise you I am aware of the clock and how many people are waiting on me. I also promise you that when your time comes, I will do my very best to give you the time you need. I will be there for you but I also have to be there for my other patients.
With sincerity,
Jennifer Spratlin
Author Notes:
Physician burnout is a real thing. A recent publication authored by Louise Leger, entitled “The Burnout Drain”, cited patient aggression, workload, and paperwork as key factors in the increasingly stressed-out doctor phenomenon.(“The Medical Post”; April 2022; pages 13-14) Surveys across Canada consistently report physician burnout rates much higher than 50%. I can tell you we have measured burnout in my physician group. The percentage of both self-reported and quantitatively measured burnout is strikingly high among my peers. My colleagues and I are trying to do too much with too little – too little resources, space, treatment options, and perhaps worst of all, too little time.
This week I learned again that patients and their loved ones aren’t happy with me when I am late. This is not a new learning. What was new was the opportunity for me to re-frame my clinic tardiness. I let it get to me for a few days. I was pissed off that people were pissed off. But I recognized this piss off was accumulating points in my physician burnout column so I adjusted my thinking about the meaning behind my clinic running late.
What I have come to accept is that I will happily take the blame for being late if it means I am doing a good job for my patients. If I am late getting to the next patient because I had to go into detail about potential side effects of this last line of treatment, I am okay with that. If I am late because I had to help manage a patient’s pain so that we might have a chance of controlling it for the next few weeks, so be it. If I am late because I sat with a patient and answered their questions about how they might die, I will be proud of that. Those are wins in my job. It is a win even if it takes a little longer than twenty minutes.
This week I promised myself I will not change the way I practice oncology because of the time on a clock. This promise gives me a whole lot of points in the DO NOT burnout column as a medical oncologist. I’ll take that win.
