“The important task rarely must be done today, or even this week. … But the urgent task calls for instant action. … The momentary appeal of these tasks seems irresistible and important, and they devour our energy. But in the light of time’s perspective, their deceptive prominence fades; with a sense of loss we recall the vital tasks we pushed aside. We realize we’ve become slaves to the tyranny of the urgent.” 1
A few months ago, on one of my presidential travels, I met a young hospitalist who was overwhelmed. Thirty-year-old Emily had finished her residency in a good program just six months before. She had been a good resident, even winning an award as Resident of the Year. She was married with a young child at home and had recently moved to a new city, which was about 500 miles from her and her husband’s families. Her husband was staying at home to care for their child. They had chosen to move to this city because of its ideal climate and abundance of outdoor activities. The city had several HM opportunities, and Emily had chosen the one with the largest, most mature program. Everything seemed perfect at the start of her new job, but within a few months, she was overwhelmed, which led her to thoughts of quitting or moving to a program across the city to improve her lot.
One could naturally think that this was just a hospitalist in transition, from residency to attending. She was dealing with a lot of professional and personal issues, and maybe she had just not found her groove yet. And this was certainly true. Professionally, she was dealing with about a 20-patient-a-day workload. She had volunteered for two hospital committees and was serving as a physician champion for a UTI bundle the hospital was rolling out. The program was not short-staffed, but it did foster a culture of finishing your work before going home, and Emily was consistently staying one or two hours beyond her eight- to 12-hour shifts.
When I asked her about the specifics of her HM program, she had few complaints. The program had several night hospitalists, so she was grateful for the lack of night call. They also had fellows from an academic medical center helping with weekend admissions, so weekend call was once every six weeks. The monthly hours required by the program were reasonable. She got along with the group and hospital leadership; her salary was competitive and, in fact, guaranteed the first two years. At that time, she would graduate to a modified-productivity system based on a combination of work RVUs and quality metrics.
Yet Emily clearly was overwhelmed and contemplating a resignation.
As I talked with her, I started working through the differential diagnosis like any physician would. Knowing that the source of many hospitalist issues is the program itself, I worked through the various pillars of hospitalist satisfaction as demonstrated in SHM’s white paper on career satisfaction: reward/recognition, workload schedule, community/environment, and autonomy control.2 There seemed to be minor issues in some of the areas but nothing significant.
I then jumped to job fit and attempted to get a rough estimate of job control. Once again, minor issues. Emily did not appear to have a major disconnect between her desire for control and the control she currently had in her work.
So, being the persistent diagnostician, I asked her what she thought she needed. She immediately said, “Six more hours in a day!” And then, as I talked with her some more, the problem became apparent. She was a victim of what Charles Hummel described in 1967 as the “Tyranny of the Urgent.”1
Hummel was not the first to describe being overwhelmed by the small things of the day, nor will he be the last. Steven Covey, David Allen, and many others have made entire careers describing effective time-management techniques to control the small things. The core problem is that each of us starts the day with a plan, but we are sidetracked by many small tasks. At a given moment, the tasks appear to need an inconsequential amount of our time; however, they add up to significant amounts of time over the course of a day. Thus, we are detracted from accomplishing the core plan for the day—or the week or the month.
Hummel, a Christian writer, is not for everyone, but his discussion about the delirious enticement of completing a task that is thrown in front you was extremely insightful. I particularly like his reference to the demands and interruptions of the telephone. And Hummel was writing about this before e-mail, cell phones, televisions in public places, and instant messaging were prevalent.
On one hand, HM is perfectly synergistic with the tyranny of the urgent. Patients don’t get sick on a schedule. Codes and RRT calls occur suddenly. Families arrive at the hospital and can’t be ignored. Admissions and consults sprout up and orders need to be written. The list goes on.
As hospitalists, we must seek to prioritize what is important. We must actively choose to do this one thing rather than the million other tasks thrown at us. I am not saying to ignore patient care, but take a careful look at what you can control.
As I talked with Emily, I discovered she constantly checked her e-mail throughout the day, even on days she wasn’t working. She never sat down and took a lunch, even for 20 minutes. She hadn’t taken a family vacation, even for a short weekend, mainly because of what she described as work demands. She also told me that she enjoyed reading novels but had not read a single book since starting her new job.
As I spoke with Emily, I pointed out some of the things she was telling me. Soon, she started to slow down and think a little. I coached her to limit herself in the next two years to one quality improvement activity or committee. I also suggested she simply use the next two professional years to learn how to become an attending. I told her to read and continue to become comfortable with decision-making as a hospitalist—all else professionally should take a back seat.
Personally, I coached her to eliminate some of the daily distractions, specifically the overuse of her e-mail. I suggested she ask the nurses to avoid interrupting her when she is writing a note; take a regular lunch with a colleague; leave work on time.
In the end, each of us needs to decide what is important and discover how we should spend our time. Of course, we need to fix the practice issues so HM can thrive, but each of us needs to do a personal assessment, discover (or maybe rediscover) what is important, budget our time, and follow through. If we do, we will all be better off.
Thank you for allowing me to serve as your president. TH
Dr. Cawley is SHM president.
1. Hummel, Charles E. Tyranny of the Urgent. Downers Grove, Ill.: Intervarsity Press; 1967.
2. A challenge for a new specialty: a white paper on hospitalist career satisfaction. SHM Web site. Available at: www.hospitalmedicine.org/AM/Template.cfm?Section=White_Papers&Template=/CM/ContentDisplay.cfm&ContentID=14631. Accessed March 2, 2009.