Matt Morgan: “Just to let you know”—flattened hierarchy brings steep demands

Matt Morgan discusses the gradual increase in volume of mental workload that doctors have to deal with

“I just wanted to let you know that you may get a call later about a sick patient on the ward,” said the junior doctor by phone.

“Um, OK then. Let us know if we can help,” I said.

As I walked through the intensive care unit, a junior nurse showed me a blood gas result.

“Just to let you know, the potassium is a bit low.”

“Oh yes, have you got some prescribed?” I asked.

“Yes thanks” said the nurse.

“Oh, ok then, thanks.”

Medicine has gone through a revolution over the last one hundred years from a self-serving doctor-centric model to patient-centred care with shared decision making. Accompanying this change has been a gradual flattening of hierarchy where today I have as many referrals from doctors fresh from medical school as from consultant colleagues. Whilst this has brought many benefits, it also brings harms. These harms that are not always obvious or immediate, but include a gradual increase in volume of mental workload. Whilst this may not outweigh the benefits of this change, it needs to be recognised and mitigated.

As discussed in my last blog, “The Ward Round is Broken,” the quality of decisions made by individuals degrade considerably after around 200 per day. This is true not only in medicine, but even in other sectors including differential judicial outcomes according to time of day. Remarkably, the gravity of these decisions seem to matter little. Even deciding whether to have a Flat White or an Americano during your 12 hour on-call is chalked up by your mental machinery. Now you only have 199 good decisions left. In fact, decisions do not even have to be made to be counted. It is sufficient for your unconscious mind to weigh and balance options even in the absence of an outcome. The very fact that I know there is a sick patient out there or an abnormal potassium level may adversely affect my ability to make a difficult patient care decision many hours later.

As a new consultant, I still sometimes feel uncomfortable deferring certain tasks to others. These include prescribing drugs, requesting investigations, and doing practical procedures. Sometimes, it may even take longer to ask others than to do them myself. On many occasions I do them. However, when I do not, this is not because I view them as menial or unimportant. Quite the opposite. Instead, I need a way to protect my cognitive faculties from being flooded with tasks that others can perform often better than myself. In turn, this leaves me with my 199 good decisions that can be used in situations where I am best placed to do so.

It can be helpful to have pre-warning about sick patients or potential admissions. This is especially true when bed capacity is an issue, as is the case most days. However, this cognitive noise again distorts and consumes facilities that are sadly finite. The next time you start a conversation with “just to let you know,” consider whether this is one of those 199 things that needs to be said. Please leave me with at least one spare decision for the coffee. Today is definitely a flat white day.

Matt Morgan is an intensive care consultant, scientist, computer programmer, teacher and geek interested in machine learning, medical education and public engagement. Twitter: @dr_mattmorgan

Competing interests: I have spoken at a number of education events for which standard travel expenses have been reimbursed. I received a research grant from Heath Research Wales and the Medical Research Council in 2016. I am paid as the lead clinical editor for BMJ’s onExamination.