Millions of people follow the teachings of Marie Kondo, a Japanese lifestyle guru who believes that by properly simplifying and organizing our homes, we can create a life of serenity and inspiration. People are enamored with her "KonMari" method of going through their belongings and keeping only those things that “spark joy,” as she infamously says — feeling that if they can only get rid of the excess stuff in their lives, they can get rid of the excess stress.
What has led to the excess stress in our lives as clinician? Aside from the obvious emotional strain of taking care of sick and dying patients, doctors routinely deal with long work hours and high stakes decision-making. This is nothing new. So why did 43.9% of clinicians in the United States surveyed by the American Medical Association have at least one symptom of burnout in 2017?
I would argue that one major problem is that we’re buried in an overwhelming number of work tasks, which distract us from face-to-face time with our patients and interfere with time with our families and friends as our work spills over into home time. Every minute, minor distraction, extra few steps, taken in isolation, is no big deal. But now we’re spending up two-thirds of our time in charting and paperwork alone. All of these tasks add to our cognitive load and leads to mental exhaustion, frustration, and compromised decision-making.
Cognitive load refers to how much of our working memory is being used for a task. It correlates to our perceived mental effort. When we are gathering new information, we process that information through working memory. Existing knowledge is retrieved through working memory as well. We have a limited bandwidth of working memory available for novel information. When we are distracted by unnecessary information, our ability to integrate consider or learn new information becomes limited. This has direct implications on our ability to effectively practice medicine.
Clinicians carry a heavy intrinsic cognitive load due to the complex nature of practicing medicine. Higher complexity of material being processed takes up more of our working memory than a straight-forward medical problem or procedure. This weight can be reduced by experience and training, making more of the issues we come across as straightforward. As the number of Americans over age 65 doubles from 40.5 million in 2010 to 89 million in 2050, in conjunction with the number of patients having one or more chronic diseases continuing to rise, we will face more patient encounters that require a heavier intrinsic cognitive load.
Extraneous cognitive load is that imposed by how information or a task is organized (like going to three different locations to gather the materials you need to place a chest tube). As extraneous load increases, the amount of working memory available to attend to the complex information about your patient at hand is reduced (hence we create a chest tube kit).
Over the years, the number of extraneous tasks being placed upon the shoulders of the clinician has grown such that the extraneous cognitive load is the size of a bus. Much of this cognitive burden comes in the form of excessive amounts of poorly-organized electronic medical information; increased number of doctor-dependent tasks like lab ordering; increased hospital cutbacks on ancillary staff; and more issues. Clinicians are answering phones, sending their own pages, and answering patient call bells, to name a few examples of burdens then placed onto them. While each individual task seems small, a study in 2000 showed that ED clinicians were interrupted an average of once every 6 minutes. Even worse, every 8.5 minutes, there was an interruption which required the clinician to switch their attention from the task at hand to a new task. If that clinician was engaged in a complex cognitive task, like considering what to do next to take care of a patient, it takes almost three times longer to effectively return to that task than if it were a simple task, like entering a computerized order.
When the Centers for Medicare and Medicaid Services decided in 2015 that administrators were no longer allowed to enter medication, laboratory or diagnostic imaging orders on behalf of clinicians, and hospitals decided to cut back on front desk administrative staff or staff who stock the clinical areas, I doubt they expected that the extraneous cognitive load on clinicians could serve to increase the risk of errors.
Arguably, cognitive load leads to clinician burnout. Burnout is defined as: (1) physical and emotional exhaustion despite attempting to rest; (2) depersonalization, manifesting as dysfunctional coping mechanisms, cynicism, sarcasm, and compassion fatigue; (3) an objective and/or subjective lack of efficacy. A study published in JAMA found that on average, about half (or 46%) of U.S. clinicians are burned out.
Studies have shown that a large contributor to clinician burnout is the emotional strain of the work as well as cognitive overload. Given a person’s capacity for cognitive load is fixed, solutions to clinician burnout should focus on external factors related to a clinician’s work flow.
Studies have shown that people suffering from burnout have a dampened neurophysiologic response when exposed to stimuli meant to evoke emotion. Clinically, they experience emotional exhaustion and cynicism from emotional blunting. Additionally, clinicians who are approaching burnout may have symptoms similar to that of depression or deterioration in their quality or quantity of work. Various surveys may be used to measure the level of burnout, like the widely recognized Maslach Burnout Inventory.
While many interventions have been directed toward improving our ability to cope with the emotional strain of our job, we cannot ignore the need to address how the rising cognitive load imposed upon physicians as a result of poor coordination between regulatory agencies creating various mandates, growing amounts of clinical data that is becoming more onerous to document and sift through, and loss of support staff due to shrinking healthcare budgets.
So, how can we KonMari our cognitive load? We cannot change the overall health care system we work in (not quickly or easily, in any case), so we must think about how we can make a difference to clinicians today. We can work locally to improve our own work situations and make the best of what we have been given.
We need to think critically about how we can optimize our work flow using inspiration from Marie Kondo by doing an assessment of our current work flow. Going through our “belongings”, so to speak, and keeping only those that contribute meaningfully to our work. Some things may not need to be included in our work flow and can be discarded completely, redistributed to other staff or be addressed by optimizing our work environment. Some things may need to be better optimized, like how we set up and use our EMR.
Consider taking inventory of how clinicians are spending their day by shadowing one for a few hours and ask yourself:
1. How is the clinician wasting her time?
How much time is spent on tasks not directly related to practicing medicine and can it be delegated to someone else? Does she spend a lot of time looking for supplies? Is she making phone calls that could be made by someone else?
2. How often is the clinician being interrupted?
Who is interrupting the clinician and why? Can you train and/or empower other staff to take on some of the interruptions to off-load the clinician? Can issues resulting in an interruption be prioritized or addressed during a period of downtime?
3. Is the clinician maximizing efficient use of the EMR?
Is he spending a lot of time looking for the proper electronic orders that could be improved with adjustments in the EMR build? Is he using the clinician-to-clinician communication tools available to him and if not, why not? Can patient data be better organized to suit the individual physician? Can clinician notes be pre-populated with the proper information? Does the clinicians need a scribe to document patient visits?
Cognitive load is an important variable to consider when thinking about how we can reduce clinician burn out and improve patient care. We need to find ways to reduce cognitive burdens on clinician. How can you KonMari your cognitive load?
Irene Tien, MD is a board-certified emergency medicine and pediatric emergency medicine physician who has been striving for 22 years to cultivate her empathy and provide the best medical care she can for her patients. She runs the blog titled My Doctor Friend.
Dr. Tien is a 2018–2019 Doximity Author.
Image by Lightspring / Shutterstock
