At my current place of work, administrators and my clinical bosses are very obsessed with how I spend each hour of my day.
Each clinical activity I perform, whether it be a half-day in clinic, or a week managing the inpatient consultation service, or the ICU, is assigned a certain number of hours. I also receive a certain percent of my effort (think in the 10-20% range) which is reserved for various administrative duties and titles, which I suppose some might argue is generous that I receive it at all. For the math-inclined who want to see hard numbers: a five-day stretch in the ICU is credited at 12 hours per day, for a total of a 60-hour week. A half-day of seeing patients in pulmonary clinic is credited for five hours. The supposed net of my clinical and administrative assignments are broken down to average a 40-hour workweek over a 52 week year.
Where the system breaks down for me, are for tasks that I have labelled as taking “infinity time,” meaning the task can easily expand to exceed the number of hours that I’m given credit for, and theoretically expand to fill all my free time, hence “infinity.”
A classic clinical example, is what happens in the outpatient setting. While I receive ~30 minutes credit to handle one clinic appointment (which is meant to encompass time on preparation for the visit by reviewing the chart and any relevant studies before hand, actually seeing the patient, documenting the clinical encounter into the medical record, and any inter-visit care that occurs), it’s very rare for the care of that patient to be confined to that unrealistic time frame. At the very least, the patient might arrive late to their appointment, pushing my clinical schedule behind by that amount of time, since our clinical policy mandates me to see pretty much every patient regardless of their time of arrival. Moreover, many of my patients have complicated pulmonary disease processes, which necessitate significant amounts of time coordinating with other providers, which can take place over days and weeks of additional conversations. Many of my patients are extremely disenfranchised (non-English speaking or have poor medical literacy), and since many of my patients are dealing with serious illness (eg advanced lung disease or possible lung cancer), I often will take it upon myself to make sure that patient’s follow up on the plan of care. This usually involves helping them make subsequent testing appointments, making sure that they have followed up on those appointments (our health system is so stretched then that our clinical support staff have next to no bandwidth to provide provider support beyond the most basic functions such as doing intake vitals and setting up internal appointments), interpreting new test and imaging results, making follow up conversations over the phone to discuss results, and next steps for care (often through an interpreter, which adds additional time to each call).
In addition to this, new results flood into my inbox on a daily basis, as well as new messages from patients asking me for advice whenever something new comes up. Since most of my patients do not speak English and do not know how to follow up on their results or use emerging formats like “MyChart,” and I firmly believe every patient likes to hear the results of their tests, whether normal and definitely if abnormal, it means additional time tacked onto whatever clinical responsibilities I have to call them. Since I am a pulmonologist, my patients also like to call me to let me know every time they have a cough or an upper respiratory infection.
For me, this outpatient inbox and follow up, has come to take up what I call “infinity time.” I received 30 minutes of credit for the care I provided, but in reality, I may have taken up to 10 hours of time coordinating various aspects of their medical care plan over the next several months (this is compounded by the fact that my clinic is so full and my availability is so limited that I do not have the luxury of scheduling frequent follow up visits which would at least block off another 30 minutes of time for care; the end result is that all this work becomes inter-visit care that I simply shift it to my off-hours and personal time so that I can ensure things are moving forward for my high acuity patients). I have deep sympathy and admiration for my colleagues in primary care for this reason.
In the ICU, an example of “infinity time” is night call. In a 5-day week of ICU coverage, I am credited for 60 hours of work for a presumed 7AM-7PM schedule. However, if I am on night-call for one or more of our system hospitals, on a typical week I may be called anytime at home, including in the dead of night. On any given week, I anticipate that I will woken up between the hours of 11PM – 6 AM at least 2-3 evenings (sometimes multiple calls per night), to help provide guidance on management of patients, and answer questions big and small. This may result in sheer exhaustion due to the number of sleepless nights, however this is accounted for in none of the formulas that are plugged into account for how I have spent my time.
Unfortunately, most critical care set-ups require night coverage of some variety, whether it be hospital or home based. By my math, providing 24 hour ICU coverage should equal to 24 hours over a 5 day week, or 120 hours of theoretical work. However, by administrator math, even though I was not permitted to sleep for 2-3 nights of that stretch, I only performed 60 hours of work. Home-based ICU coverage is very poorly credited, if at all, and I deeply envy specialties that are shift based, such as anesthesiology and emergency medicine, where hours worked equals hours credited, and “infinity time” situations seem more limited.
The Sunday prior to joining service also gets marred- usually with some form of sign out (which at the minimum for me usually involves pre-reading the chart for patients I’m assuming care over and reading a sign-out email, or other times includes a long phone call to have a “warm” handoff between providers. This effectively turns a day off (or a weekend day for normal people) into a low acuity, partial work day. It always feels like my personal time is never my own anymore, and work’s tentacles find way to encroach on more and more of my time, energy, and emotional/mental space.
Other examples of “infinity time” relate educational endeavors and other administrative activities. I am frequently asked to provide educational curriculum for various groups within the health system, whether it be trainees, other physicians, nursing, or respiratory therapists. As anyone knows, creating high quality educational content, tailored to each learner, takes a not insignificant amount of time. I happen to be a meticulous planner of teaching material and have always received positive feedback about how I teach. Being neither a genius nor a gifted public speaker, however, any success I have represents the hours of preparation that I have poured into the project. A 40 minute presentation might take me 30-40 hours to prepare (yes, I’m pathetically slow!).
My fractional protected “administrative time,” is used as a thinly veiled threat against me, and is frequently invoked as a reason for why I can and should take on every request for every meeting, project, lecture, and committee. Another form of “infinity time.”
Given this, I find it ironic and hilarious (and demeaning and irritating) how often I am asked to account for how I have spent my time (at least monthly), and how frequently I am told that this-or-that doesn’t count for credit (meetings are “citizenship,” only the 40 minute lecture is credited, not the 40 hours of preparation), the implication being that I haven’t justified how I’ve spent my time and should be taking on more and more.
In my current practice, administrators have gone one step beyond by deciding unilaterally to assign a different time value to different clinical activities, in other words, making each clinical activity worth less time than it used to be credited. This new administrator math now means that in the next year, I will be assigned an excess of a hundred extra clinical hours per year.
It’s partly due to “infinity time” that I have decided not to continue with pulmonary medicine and an outpatient clinic practice, and that I am debating leaving academic medicine, although training future minds is one of the thrills of my career.
The thing is, none of us are guaranteed “infinity time” in this life. Being on the front lines of COVID and watching no less than hundreds of patients die before their time, along with the terrible tragedies I encounter on a daily basis in the ICU have made that abundantly clear.
I’m tired of doing work that requires infinity time and effort and leaves little room for me or anything else. As much as I’m proud of the work that I do, I want more for my life. Truly accepting that my time and energy are not infinite has forced me to examine the ways in which I worry that a career in medicine is competing with my ability to fulfill the equally (and frankly, more) important roles in my life as a daughter, sister, aunt, and Christian.