Are Physicians Managers or Makers?

In my serendipitous wanderings, I ran across this article Maker’s schedules, Manager’s schedules.  Paul Graham, the author and a founder of Y Combinator describes schedules in two forms. The first is

“The manager's schedule is … embodied in the traditional appointment book, with each day cut into one-hour intervals. …When you use time that way, it's merely a practical problem to meet with someone. Find an open slot in your schedule, book them, and you're done. Most powerful people are on the manager's schedule. It's the schedule of command.”

In fact, this is the typical office hours schedule, appointments broken into 15-minute blocks, perhaps with a lunch break, maybe not. Usually, the front of the house staff (a restaurant term for those with direct contact with the patron, our receptionist, nurse or mid-level provider) has set the stage for our arrival, vital signs, chief complaint, medication changes all duly noted and entered into the EHR. All the is left to do is see our patient and manage their care. And if you are like all the rest of us, that fictional account of how the day progresses is lost somewhere during the first hour or two when a problem arises. The underlying reason is that a maker’s schedule intervenes. Here is Graham’s description of maker’s schedules.

“But there's another way of using time that's common among people who make things, like programmers and writers. They generally prefer to use time in units of half a day at least. You can't write or program well in units of an hour. That's barely enough time to get started.”

What throws off that efficient manager’s schedule is the need for us to create a moment for ourselves and our patients; typically when we might be discussing and deciding on treatment options that carry significant risk and benefit. Or when we recognize the need for that conversation, the one about putting your affairs in order, or that we have no further ways to manage or treat a situation. The times when we are called upon to be physicians, to be makers, rather than managers.

Graham is quite clear, “Each type of schedule works fine by itself. Problems arise when they meet.” We call those problems by many names; physician burnout comes to mind. This clash of schedules also cheats doctors and their patients of the opportunity to deeply engage, interact, to provide an opportunity to provide a healing moment that benefits both parties – sustaining the patient, reinvigorating the physician. There is more to why maker’s and managerial schedules clash.

“If I know the afternoon is going to be broken up, I'm slightly less likely to start something ambitious in the morning. … And ambitious projects are, by definition, close to the limits of your capacity.”

But here is the thing. All of our EHRs, all of the scheduling software we purchase is for a manager, divvying out 15 minutes increments of our time as if we were simply health managers. If we are to return to our roots as health makers, then we need to take control of our schedules. We can try to manually reduce the time required to get into the proper frame of mind by clustering like type of appointments together; you know routine visits in one cluster, meetings to review results and make decisions in another, addressing long-term issues in a third. Or we might insist that our vendors start putting some of that vaunted ‘artificial’ intelligence into our schedulers, become smarter to reflect and perhaps separate our manager schedules from that our maker schedules. Then the machines of automation will be assisting rather than leading us. It seems like such a simple thing, a scheduling program. Unless we are more demanding of the tools created to help us, we are at risk of our scheduling programs making us first managers and then providers, rather than the makers we truly are.