Starting telehealth, and some thoughts on tasks vs. “thinking big thoughts”

After three months working on the inpatient psychiatry unit at UCSF (August – December), I switched to my six-month block of outpatient psychiatry at the SF VA hospital.  I still take call shifts at all three hospitals (UCSF, San Francisco General, and the VA), but now the bulk of my time is spent doing psychiatry by phone and video.  I’m told that the VA system converted its outpatient appointments to telehealth with remarkable speed last spring, in part because it already had a telehealth infrastructure in place (though for much lower volume) including its own video interface (called Veterans Video Connect).  Certainly this expansion of telehealth has allowed us to reach patients who might ordinarily have considerable difficulty coming to San Francisco for an appointment.

For the first time since before the pandemic started I am primarily working from home, and not commuting certainly feels like a luxury.  Another perk: I am far better hydrated than I used to be.  Thus far, I think I am enjoying outpatient work, even through telehealth. It’s too early for me to compare it with inpatient work, so the jury is still out on whether I see myself more as an inpatient or outpatient psychiatrist in future. That aside, I am also finally learning about the downsides of staring at a screen all day, and have wondered how many cumulative hours will be spent toggling audio sources and headphone/earbud connections between different applications.  

I do already miss the casual but fortifying in-person interactions that, during on-site work (which now that has to be distinguished from “work”), happen as a matter of course.  Throughout 2020, I felt lucky to still work on-site, making actual eye contact with patients and colleagues.  During our four months at the General last spring, the spacious resident workroom felt like a college dorm as we each faced a different direction on our computers, but shared commentary and chatter throughout the day, and we bolstered each other through the fear and uncertainty that the pandemic had brought.  By the summer, wearing a mask felt as normal as wearing my ID badge, and when we weren’t speed-walking around the hospital to see patients, my co-resident and I sat back to back in the consult workroom, frequently swiveling to update the whiteboard’s to-do list, reading messages off the pager, occasionally griping or sighing to each other.  In the fall, the inpatient unit sometimes created an illusion of normalcy: as I walked into the unit and interviewed patients I could, for brief moments, forget that we were in a global pandemic, though this illusion was interrupted by the spectre of COVID anytime someone coughed.  The co-resident working next door to me would regularly knock on my door to check in, and we turned the spacious hallway into our water cooler.  Now, these same coworkers are boxes in Zoom meetings or faceless bubbles in a text thread.  It’s not the same.

The past couple of weeks have felt tense, though fortunately I have a light month in terms of call shifts.  I need to sort out my clinic and schedule preferences for the entire PGY-3 year (July 2021 through June 2022).  For the first time in residency, we have some opportunities to choose sub-fields of psychiatry in which we want more training, and this planning task feels daunting.  Intellectually I know that the point of electives is to gain exposure to particular clinical areas, and so our elective experiences can help inform our future career interests.  On an emotional level I am thinking of this the other way around: I feel pressure to decide a priori what my career goals are, so that I can pick the electives that connect most clearly to those goals…but I’m not certain what those goals are. If anything, as I mentioned in my previous post, I feel increasingly aware of how much more I have to learn.

While this has been swirling around in my head, last week I found myself shifting rapidly between telehealth appointments with my patients, talking with a mentor about my academic priorities, didactic sessions during which I was simultaneously on the phone with IT (who was remotely installing some missing software on my work computer via a temperamental VPN connection), and reading news about the recent assaults against Asian-Americans in the Bay Area, including some elderly individuals who look like they could be my own relatives.  I felt the urge to cry several times but was also somehow physically unable to do so until two days ago, when I broke down fuming that I’d wasted half of a Saturday by watching old episodes of “The West Wing” instead of working on various projects that I hadn’t had time to get to during the week.  That cry was cathartic, as was the jog that I eventually persuaded myself to go on.

During my jog I listened to a podcast interview with Celeste Headlee, the author of Do Nothing: How to Break Away from Overworking, Overdoing, and Underliving. Headlee talked about on our society’s increasing prioritization of efficiency, which certainly rings true in that I’ve lost count of how many times I’ve said to an advisor or supervisor that I’m trying to work on being more “efficient” (generally meaning that I want to get faster at reviewing patient charts and writing clinical notes). The irony of listening to this interview while exercising (so efficient!), after I had berated myself for doing nothing during a weekend day during my residency training, was not lost on me.

The interview also mentioned the distinction between checking off checkboxes and doing work that actually moves us toward a goal and/or aligns with our values.  This continues to be a point of tension for me.  I will always be one of the first to stand up for the importance of task completion, and it matters to me that I am conscientious and organized in my work. Part of why I like inpatient work is that it is a complex dance between countless individuals in different roles and departments, whose individual efforts (and checkboxes) all weave together at a rapid clip.  It’s often the resident’s job to get a large number of tasks done in a small amount of time, tasks which are clearly necessary in order to move the patient’s care forward.  So we write the notes, order the labs, follow up the results, call the nurse, call the other team who paged about X, page someone else about Y, order the medications, get a page about the orders, change the orders, call someone to let them know we changed the orders.

As a medical student, learning to complete some of these tasks was a big part of each clinical rotation, and could provide plenty of gold stars, little dopaminergic reinforcements that could easily be interpreted as signs that I was a good fit for that particular specialty.  At some point during my third-year clerkships, though, I came to recognize that there was a difference between feeling satisfied by task completion and feeling satisfied (or intrigued) by the actual medicine that those tasks were intended to implement.  I had great experiences on many clerkships, but in the end what tipped me toward psychiatry was that nearly every day on that rotation, I felt a sense of fascination. Eventually, I expected to get good at checking off the checkboxes in my work.  I believed that once this happened, I would still need to be compelled by the particular type of doctoring in my specialty: getting to know that specialty’s patients, their backgrounds, and their clinical presentations; and thinking through the specialty’s range of diagnoses, differentials, and treatment options.

Sometime in the past six months, I think that transition happened for me. I got comfortable enough with the tasks that merely completing them stopped being anywhere near enough, that in order to feel satisfied with my work, I needed enough of the actual doctoring. I’ve been reassured, if not surprised, to find that even without the same amount of dopaminergic feedback from checking off my checkboxes, psychiatry definitely still feels like the right choice: it is still fascinating, even more so now that I’m 19 months into residency.  At the same time, I am also even more aware now that there are often so many tasks, and getting through them can be so burdensome at times, that what gets shortchanged is the actual doctoring, as well as the bandwidth for fascination and for what one of my attendings refers to as “thinking big thoughts.”  It is frustrating and even angering to realize that because the healthcare system sometimes requires me to perform so many tasks, time spent with a patient is often shortchanged. I doubt anyone ever went into residency thinking that they would have great work-life boundaries or plenty of free time in which to ponder, but I still chafe at the realization that often, time spent thinking deeply about how I am caring for a patient (or thinking about how we should be caring for our patients, or reading and learning so that I can better care for my patients) must be directly deducted from my own “time off.” 

I intentionally used quotations there because, as everyone else has already discovered but I am now discovering with telehealth, the boundary between work and life has only become more porous. I don’t have an answer for this tension yet, and I suspect it’s a challenge that will continue to be present throughout my training and afterward. I also suspect that as long as I have the good fortune of finding the core of my work fascinating, the answer may involve accepting a fluidity of boundaries. I’d like to accept that my efforts at efficiency and optimization drive me to try and optimize my so-called work-life balance, but that this optimum only exists as an unattainable abstract.