What is a Clinician's Role?
As technology evolves, we need to ask, ‘what's the job of a doctor or advanced practitioner?’
This sounds like a crazy question. But it isn’t. What does a doctor do? What’s my job with my patients?
I got to thinking about what I do on a daily basis. Some of what I do is transactional — Simple stuff with clear end-points. Some of it involves critical conversations and deeper kinds of thinking, planning, and translating.
Breaking my job down into different roles
So I made a list of the things I do. And here’s what I came up with.
Find. I look for and find things. This is the discovery of problems during physical exam and endoscopy. Usually these are things a parent didn’t know about when they came to see me. They’re discoveries that solve a child’s problem.
Do. Transactions. These are medicine’s well-defined encounters with clear endpoints. Changing a gastrostomy tube, removing a polyp, pulling a button battery from a toddler’s esophagus, or stretching a stricture. Increasingly encounters of all kinds in healthcare are being shaped as transactions when they probably shouldn’t be (and why we won’t see Genius Bars in healthcare anytime soon).
Identify patterns. So much of clinical medicine is the identification of patterns. It’s the ‘seeing’ part of medicine. I look for things I’ve seen 10 thousand times. More importantly I look for the thing that doesn’t look like the others.
Connect. The patterns come from connection. This is the job of taking bits and pieces of information and putting them together. This usually involves taking elements of a patient’s story, applying wisdom and experience and then offering a really educated guess about what’s happening.
Translate. I can find connect things or identify concerning patterns but if it doesn’t get across to my parents on their level, it’s worthless. Often I take something that I find (or they find) and translate what it means, or why it may be meaningless. Why it’s relevant, irrelevant or just plain funny. This is the reassurance piece. The translation piece of what we do is growing as patients do more on their own and as diagnostics become more technical.
Negotiate. This is the built in element of shared decision making. Negotiation is a huge part of the clinical encounter, especially with parents. They may want something that may not be in the best interest of their child, but I have to respect their values and interests and find a path forward.
Show. For me, a huge part of translation is showing. I do this visually on my whiteboards. If I can’t show I can’t treat. For me, visual communication is at the heart of what I do.
Tweak and adjust. Parents of medically complex children know their kids better than I do. They know their rhythms and patterns. This is my ‘sherpa’ role where I offer insight to make the journey safer. New onset retching with g-tube bolus feeds in a child with cerebral palsy… ‘Okay, let’s do this…’
Respond. Tweaking is effectively response and reaction to changes in my patients. Routine labs show an unexpected bump in creatinine (a measure of kidney function) and we have to decide what it means and how to proceed. Alot of chronic and primary care is responding and reacting to changes in the status quo.
That’s a lot of jobs. So it’s easy to see why someone could be confused.
Most of these things are done in combination – all of it is experimental and continuous depending on the the parent I’m working with. Some people call the ability to succeed with these more ambiguous parts of patient care the art of medicine. Or they use the tired characterization of bedside manner.
We tend to pigeon hole certain specialties with particular jobs. If you know a surgeon, you may think, ’she’s all transaction — just perform surgery and go home. She fixes things.’ But the greatest surgeons cross into all of these tasks when treating problems that have no black-and-white surgical cure.
Understanding our role at any given moment of the day is important in order to effectively bridge the doctor-patient divide. Because patients often expect something different than what we think we need to deliver.
How do we train when we don’t know a clinician’s role?
How do you teach someone to do this? I’m not sure. It’s complicated when we can’t identify what our job is.
Most of this I taught myself. Some of it is ingrained social intelligence with a think layer of experience and creativity. Medical training gave me the background to begin to learn all of this. After my training I had to unlearn alot. My best skills have come from watching other great clinicians do these things (without really knowing that they’re doing them). Other skills have come from feedback from the tens of thousands of parents I have worked with.
Identifying a clinician’s role may be our future’s biggest challenge
As technology evolves in healthcare we have to continue to ask, ‘what is the job of a doctor or advanced practitioner?’ And how is it changing? How do we need to evolve to both stay satisfied and meet the needs of our patients? And when it comes to the medical school or APP admission process, how do we select for the best humans given the job?
Of course, all of this is changing by the year.
And as medicine becomes more industrialized we have to remember that some of the most important things that we do can’t be reduced to a process. Take another look at that list — there isn’t much there that can be operationalized or turned over to an algorithm.
Health systems have to re-architect our view of clinical work and support professionals in ways that enable them to function in a changing environment. Clinical work needs to be redefined in a way that capitalizes on human strengths. And this isn’t about scale, process and volume. It’s about configuring the clinical space to allow clinicians like me to do what we do best.
If you’re a physician or advanced provider, what do you ‘do’ that isn’t on the list? Let me know in the comments.
What about SUPPORT? Sometimes that is all I can do -- empathize (or whatever the latest buzz word is that means I get their concerns and their pain) and acknowledge where they are in their journey. In primary care we do a lot of that.
Medicine is evolving rapidly, with the teaching still stuck in the archaic hierarchy model, where it is passed down through that structure. Learning never stops. I have learned more from self-education and curiosity, combined with my 1.5 years of practice, than in my 14 years of structured education combined.
With the hyper-specialization of healthcare and the exponential rise in the knowledge of modern medicine, the greatest loss I feel is to the patient. In my primary care practice, I see patients who are seeing 6 specialists. Still, nobody is communicating with each other, and in many instances, I see we do more harm than good, despite our best intentions. One of the reasons for choosing primary care for me, was to see them as a whole body, and not a system of different organs. That made me realize, how so many things are connected, not just physiologically but in terms of the interactions, and with their mental well being. I love how you have separated the different aspects of medicine, in these tiny chunks of cognition, but also how you defined the roles we still play in our patient's lives, without underestimating their importance.
However, I do feel, sometimes, we fail to connect these dots, which ideally should be a job of an internist, but at this point, has become more of a referral center for specialties, which has led to its demise in terms of a specialty. We need better generalists, than more specialists, is what I am trying to say. That starts by really teaching the process of "How to think", rather than memorizing a bunch of useless facts. I think with ChatGPT, there is a case to be made for helping us be more creative in terms of explaining complex concepts into simple ones, but also make a case for having healthy debates about what's important, and whats not in medicine.
I leave by quoting the great William Osler “The good physician treats the disease; the great physician treats the patient who has the disease.” All his quotes have stood the test of time, and again. At the end, you are just helping people.