Sunday, May 02, 2010

Susan Mackie tells us the value of DNKs

Dr. Amy Ship writes:

"Hats off to Dr. Susan Mackie, whose lucid, thoughtful, powerful essay "The Value of DNKs" is published in this week's New England Journal of Medicine.

"We are lucky to have her and her voice!"

Some excerpts:

DNK (pronounced "dink" and always uttered wistfully by the residents in my program) is the abbreviation that appears on our online schedule when a patient "did not keep" an appointment. DNKs obviously represent suboptimal care for the DNKing patients, as well as a financial loss for the practice. But as residents, we have all been guilty of hoping for DNKs in our schedule. I had always thought of this desire as a sign of laziness, but on that day, I began to suspect that the reason I felt I was a good doctor was largely the result of my two DNKs. DNKs create time. Time allows us to build relationships. And what is primary care about if not relationships?

. . . As I progress in my career, pressures to improve the quality of the care I provide will inevitably grow, as will my patients' expectations. Less certain is what will happen to the amount of time I can devote to the care of each patient. Enthusiastically, and perhaps naively, I have mentioned to my mentors that I look forward to a future in which I will be able to share responsibilities with nurse practitioners and physician's assistants in such a way that my appointments with patients will be fewer, more thorough, and more satisfying for everyone involved. None of the experienced physicians I've talked to have confidently embraced this vision. Perhaps they have seen too many changes for the worse to believe that a change for the better is possible.

. . . I firmly believe that adequate time — not simply perceived time, but real time — is an indispensable component of our encounters with patients if we are to be good doctors. How sufficient time can be most effectively incorporated into the structure of primary care delivery, given its payment constraints and expectations of quality, should be the subject of ongoing research, as new policies are codified. In the meantime, I will continue to take guilty pleasure from DNKs.

1 comment:

e-Patient Dave said...

A few months ago I had the chance to visit with Amy Ship, between two other meetings at BID. This was just after she'd received the compassionate care award.

Funny: me, one of the most online people you'll meet, and Amy who knows nothing of social media - all she knows is she wants to take care of patients. And I'm all wrapped up in policy stuff these days, and she just wants to take care of patients.

But we were completely aligned on this: let's find everything that gets in the way of clinicians & patients doing healthcare together, and get rid of it.

btw, Dr. Susan Mackie's vision of proper time allocation among the different team members echos one of Lean's principles, as I learned in Alice Lee's lean workshop at BID. The principle is that as much as possible, everyone should work at the top of their pay grade. It's part of the Lean principle of respect for people and their potential.