Observations Letter from New England

Staying ahead of getting behind: reflections on “scarcity”

BMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g2634 (Published 10 April 2014) Cite this as: BMJ 2014;348:g2634
  1. David Loxterkamp, medical director
  1. 1Seaport Community Health Center, Belfast, ME 04915, USA
  1. david.loxterkamp{at}gmail.com

No one is busier or needs more bandwidth than a generalist physician

You ramble into the exam room 45 minutes late. The patient is startled, annoyed, but you apologize and ask how you could help. He reaches for a crumpled list and begins a rambling oratory that you are clearly no longer listening to. Slumping on your stool, you stare at a computer screen that displays the “quality measures” you must address today. And so the stage is set . . .

We have all been there. We will be there later today: hurried, behind, distracted by everything except the one question the patient doesn’t know he needs answered today. Our problem is scarcity of time—if only we had enough to do today’s work well.

A new book by Sendhil Mullainathan and Eldar Shafir1 explores the costs of feeling perpetually behind. Scarcity: Why Having Too Little Means So Much begins as a study about poverty and why people who are poor stay poor. The authors cite numerous laboratory experiments and field studies that elucidate the decision making process of people perpetually on the financial margin. When faced with a money crisis, their choices are predictably short sighted and impulsive.

The authors define scarcity as the condition of “having less than you feel you need.” Scarcity rivets our attention and in so doing narrows our capacity to simultaneously contemplate other priorities and downstream consequences. Scarcity, the authors contend, taxes our mental “bandwidth,” or fluid intelligence. Thus, it makes us less insightful, forward thinking, and self controlled.

Mullainathan and Shafir did not set out to defend the poor. Their agenda was to further a science of scarcity, one that encompasses loneliness, dieting, addiction, sleep deprivation, lack of money, and—for our purpose—crammed schedules.

When resources are scarce, people “tunnel”; they ignore everything but the pressing need. Tunneling has been shown to lower IQ test scores by 13 or 14 points, enough to drop a person from one intelligence category to another. It doesn’t destroy brain cells; it impairs our capacity to use them. Insidiously, it slows down our mental processing like a computer with insufficient RAM. It enables impulsive decision making that satisfies our immediate needs to the detriment of long term goals.

No one is busier or needs more bandwidth than a generalist physician. Because we are busy, patients wait to see us—and they use waiting time to pad their problem list. This sets up a cascade of predictable events:

To really listen to the patient’s problems takes time, so we run behind. And because there are no breaks in our schedule, we fall farther behind. And we find it impossible to catch up during the next appointment for the person who has waited an hour to be heard.

Within the confines of a 20 minute visit we are expected to frame the chief complaint and execute a plan. Is the problem urgent or serious? Is it an isolated concern or part of a syndrome, exaggerated or minimized, real or imagined, or even the real reason they needed to see us today? Is it a problem that medicine can properly solve? Does it lie within our scope of practice or should we refer?

So we burn our bandwidth by unwrapping bandages before the wound is fully exposed. We listen for problems we can easily fix, discarding others that are too vague or deeply buried in a belabored explanation. We push our agenda, ignoring theirs. We close the visit with a prescription, test, or referral, knowing that taking five minutes to read or make a telephone call might save the patient an unnecessary expense.

We hire assistants to do the work we can’t complete, allowing our diagnostic acumen to be hijacked by checklists and “chief complaints” that are framed by those with less training or familiarity with the patient. We race on without documenting our office notes, aware that they will be less accurate and take more time to complete later.

With so much to worry about, we focus on quality measures that our paycheck depends upon. Such measures are important, but they are not why the patient came to see us today. Under the tick of the merciless clock, we work less efficiently, less creatively, less comprehensively. Our mind slows and narrows. We ultimately forfeit what our patients need most: patience, compassion, deep understanding, wider scope, and the gift of human relationship.

The authors describe a study on workplace innovation in which time was singled out as the most important missing ingredient—“unstructured time . . . time to play, time to gaze out the window, time to read and react.”1 To eliminate scarcity, the first step is to create “slack”—a buffer for the unexpected but predictable crises that vex our lives. Office inefficiency must be seen as a system flaw rather than individual failure. Freedom is the reward for fixing the flaw: freedom from shortsighted error, freedom to learn from experience, freedom to respond creatively to our repetitive mistakes, freedom to enjoy our work and pass that joy along to our students and patients.

Practice redesign movements like Direct Primary Care and the Patient Centered Medical Home (PCMH) in the US address bottlenecks of time. But doctors must find solutions that allow us to care for more than just those who can afford it or who are complex enough to be worthy of our attention. Patients deserve a doctor who has time to listen, care about them, and offer hope for the problems they believe are worthy. Every doctor deserves that too.


Cite this as: BMJ 2014;348:g2634


  • Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

  • Provenance and peer review: Commissioned; not externally peer reviewed.


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