Access Doesn’t Guarantee Value

Our obsession with inputs is breaking our ability to care

This started with a LinkedIn post a couple of weeks back that generated a lot of discussion. I thought I would build it out. As always, I work these things through on paper (or my iPad) to help me understand what I think.

I hope it has some value for you.

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Access is medicine’s latest sacred cow.

We like to believe that more inbound channels create better care. But that’s magical thinking.

First it was the telephone.

Then it was the pager

After that was the car phone, the cell phone, and the smart phone.

Then it was email and MyChart.

Then Epic staff messages. And now Secure Chat.

During the early days of Twitter Chicago cardiologist and activist Wes Fisher predicted this run on our attention and called it time creep.

And every EHR feature rollout brings more of it.

Access is not the product

I think alot of the discussion about access is really a fantasy of what could be. We believe that if we create more tools for getting to us, high touch care will follow. And honestly, our intentions are good.

We want to believe that the doctor’s always there. Ready and waiting. But doctors shouldn’t be accessible to their patients all the time. I’m always suspect of the friend who claims they can call their doctor’s cell phone any hour of the day.

Maybe I’m the outlier, but I don’t want to make decisions with my cardiologist after her second glass of Pinot Noir on Saturday night.

To be our best we need a clean inputs. Good signal. And we need time away.

But access only gives you a channel. It’s connection that creates the opportunity for change — the potential to be heard, understood, and helped in a way that moves care forward. That’s where access can bring value.

So access without value is a suitcase word.

The 21st century Cures Rule gave us access to notes. But as we’ve seen, the access is only as good as the note itself.

The physics of physician bandwidth

A doctor’s ability to connect is limited by attention, workload, emotional state and a variety of other human variables. This isn’t a tech issue. It’s a design issue — and a human one.

Doctors work in what I call the zero-sum medical day. Essentially, there are only so many hours in the day to handle stuff.

The problem isn’t access itself — it’s that every new access point is launched without asking: What will this replace? Where will this time come from?

So we obsess over access like it’s the point. But access is like electricity — essential, but meaningless on its own.

A fully charged MacBook doesn’t write the novel. It just makes it possible.

Technology creates the space for change. We have to show up and do the rest.

Until we treat attention like the scarce clinical resource it is, we’ll keep mistaking access channels for care.

This is one of my favorite peer-review pieces on the subject from The New England Journal of Medicine on the ecology of attention:

One of the most important factors at play in the clinical environment is the apparent tension between availability and attention. Clinicians rightly value availability to our colleagues, our multidisciplinary teams, and especially our patients. But we propose that shallow availability — or “reachability” — can often be a barrier to the type of deep, interpersonal availability that is most essential. Reachability is attractive in the short term: it allows clinicians to provide and receive instant feedback, and it appears, on a small scale, to improve efficiency by reducing barriers to communication. But frequency of communication is a questionable surrogate for quality of communication.