Monday, December 16, 2013

Two types of "scut work"

When I was an acting Medicine intern in Manhattan's Bellevue Hospital at the turn of the century, all employees who provided the hospital's "ancillary services" went home between the hours of 5 PM and 8 AM. It was the job of the on-call interns to fill in. If a patient needed a stat blood draw or IV line replacement in the middle of the night, his nurse paged the intern to do it. If I wanted a vial of blood to reach the lab before the morning, the only way to accomplish this was to carry it there myself. If a patient needed an urgent x-ray or CT scan, I personally navigated his or her stretcher from room to elevator and through the corridors to Radiology. (Even during daytime hours, this was often the most efficient way to complete this task.) In those days when x-rays and scans were actually printed on sheets of transparent plastic and stored in file folders, it was also the intern's job to hunt down images needed for morning rounds.

Generations of doctors-in-training have given the name "scut work" to these kinds of tedious, often disagreeable chores that do not require a doctor's degree but are nonetheless essential to patient care. More than a decade later, interns and residents continue to toil at similar unrewarding tasks in hospitals all over the U.S. and around the world.

But scut has evolved in the era of electronic medical records to mean more than late-night blood draws and transporting patients and medical records. Scut work is now performed by physicians with decades of post-residency experience, at all hours, in outpatient and inpatient practice. It goes by important-sounding names: "Stage 2 Meaningful Use" or "NCQA Certified Patient Centered Medical Home." Specific tasks involve clicking through endless series of drop-down boxes to document smoking cessation counseling, order flu shots and age-appropriate cancer screenings, and record transitions of care and receipt of referral notes. These are all things that I would have documented in a free-text or dictated note, but must now jump through electronic hoops to get credit from private and public payers who believe that primary care patients will ultimately benefit from all this clicking even as it distracts my and my colleagues' attention away from the real work of doctoring.

In a recent editorial in Annals of Internal Medicine, Drs. Christine Sinsky and John Beasley argue that "texting while doctoring" is a potential patient safety hazard:

In clinics across the country we have observed patients send signals of depression, disagreement, and lack of understanding and have witnessed kind, compassionate, and well-intended physicians missing these signals while they multitask. These physicians are concentrating not only on the patient but on typing the history, checking boxes, performing order entry, and other electronic tasks. ... Computerized order entry displaces to the physician clerical tasks once performed by others, increasing time commitment and cognitive interruptions.

The authors suggest that supporting team-based care models that rely on non-physicians to do the bulk of documentation may still save the physician-patient interaction. But this is unlikely to happen if physicians are required by federal regulators to type in orders themselves, or if new payment schemes do not rapidly supplant fee-for-service and render current billing templates obsolete.

In contrast, Dr. Diane Chang describes old-school scut work in JAMA's "A Piece of My Mind" as "the physical, backbreaking, day-to-day work of taking care of another person." She shares scenes of doctors, nurses, aides, and other health workers debriding infected ulcers, cleaning up vomit and feces, feeding and bathing and changing beds. "Acts of caring are sacred: feeding the sick and old, cleaning them, and tending to their wounds are in some ways as intimate as you can get with another body," she writes. "In performing these acts, we bear witness to people naked and infirm, at the beginning of life or at the very end, or at the most vulnerable moments in their lives."

I don't want to go back to my days of doing scut at Bellevue. I am not nostalgic about trying repeatedly to place an 18-gauge IV in a patient with no palpable veins at four in the morning, or replacing a delirious patient's nasogastric tube for the fifth time in as many hours because he kept pulling it out. But at least that kind of scut, unlike the tedious tasks involved in electronic documentation, was work that was meaningful to patients.