When I was eight years old, I remember being excited about having a USB drive to save my favourite games from my cousin’s computer.
I took as many as I could but to my horror and despair when I got home the games wouldn’t work. I asked my cousin if she could fix them.
She explained that I had opened each game folder and only copied the individual file I had to click on to launch the game, ignoring the other files. I saw them as clutter. I didn’t realise they allowed the game to run and I didn’t appreciate their vital role behind the scenes.
Years later, I find myself thinking of this analogy a lot as a doctor. Only recently, I was speaking with a colleague who eloquently put into words what I had experienced but struggled to articulate for a long time. Medicine has become ‘taskified’. Complex decisions and processes about patient care are reduced to fragmented tasks, which can be ticked off a job list, taking away the fundamental role of the doctor in synthesising, understanding and making judgement calls around patients’ care.
In addition, for doctors in the early stages of training, when complex processes are boiled down to a list of bullet points, it becomes easy to see how the work of a doctor on the ward can be replaced by non-doctors. Anyone can request a repeat troponin, fill out a painstakingly long ‘refer-a-patient’ form for a just-to-be-safe query, or call a specialist to ask a handed-down question about a patient they have neither seen nor examined. These are but a few examples of jobs resident doctors are tasked with and in many cases are being outsourced to non-doctor AHPs (allied health professionals).
I am reminded of a time when I was asked by an AHP to chase a cardiology referral for a patient admitted under the surgical team. I was not given any clinical context for why the referral had been sought, just that it was something they hadn’t gotten to doing during the day and therefore became my job to tick off.
Admittedly, I found myself annoyed this job had fallen on my shoulders when I didn’t know the patient, didn’t understand the query and was already incredibly busy. However, reading through the notes written by the requesting doctor, I quickly came to see the clinical reasoning. The way it was handed over to me reflected how a complex and potentially critical clinical issue was reduced in the morning ward round to another job on a list – ‘call cardiology’. It’s not difficult to see the dangers of this.
The pressure on the NHS mean doctors are often not given the time or support to develop clinical decision-making skills. Instead, they are expected to complete a series of tasks without experiencing how they tie together to complete a picture. The unique ability of doctors to build on their foundational knowledge of physiology, anatomy, biochemistry and pathology – and apply this to patients in front of them – is not only being eroded but is fundamentally attacked by the ‘taskification’ of medicine.
We are treating the role of the doctor as I once looked at the computer screen in front of me as a child. We separate patient care into small tasks to be completed in the most efficient way, ignoring the ‘behind-the-scenes’ role of doctors’ training. The cardiology referral was seen as an isolated administrative task, the underlying understanding required to appreciate its urgency was clutter; it was ignored.
Knowledge held by doctors of cardiac pathology, positive and negative predictive values of symptoms in a patient of a certain age and the ability to interpret subtle ECG changes was not required to pick up a phone and ask a question of a cardiology colleague, so it was assumed that having that knowledge was not required. In fact, having that knowledge made a doctor overqualified for the simple task of picking up a phone.
Doctors subconsciously build on their knowledge of clinical sciences, their prior experiences treating patients with similar conditions and their understanding of the limits of normal and abnormal physiology, in completing these small ‘tasks’.
By treating the years invested in training doctors as background noise – distracting and unnecessary – we are robbing doctors of the opportunity to appreciate how seemingly small tasks fit into patients’ trajectories and we prevent doctors from building their own personal inventory of cases and clinical trajectories. How long will it take us to realise, just like I did as a child many years ago, that dismissing the foundational pillars that work behind the scenes will lead to the task simply not working?
Mennatallah Yakoub is a core trainee 1 in general surgery from London