By GANESH ASAITHAMBI
In an episode of the sitcom How I Met Your Mother (HIMYM), Barney Stinson introduces a fictional phrase: possimpible. The possimpible combines “attainable” and “unimaginable” and describes the extraordinary achievements by individuals who refuse to just accept typical limits. In trendy healthcare, the possimpible is not a joke; it has quietly grow to be an expectation.
Clinicians are anticipated to offer care that’s safer, quicker, and extra compassionate regardless of rising administrative burdens, workforce shortages, and an more and more complicated affected person inhabitants. These expectations typically prolong past what present methods have been designed to accommodate. The space between what the system can present and what sufferers want is more and more stuffed by clinicians.
Image this instance on the finish of a clinician’s day. A doctor takes a seat to name a affected person’s household. The telephone dialog takes longer than anticipated with questions on their liked one’s prognosis and hesitancy about what to do subsequent with worry about what’s to come back. The doctor gives reassurance and steerage. The doctor hangs up, solely to search out that notice dictations aren’t full and messages are nonetheless unread. None of this exhibits up as productiveness, however it’s wanted to offer high quality care. There are literally thousands of eventualities like this that happen day by day in American well being care.
These moments seem routine. Nonetheless, they mirror one thing extra consequential: healthcare has grow to be quietly depending on clinicians to stretch past the boundaries of the methods they work inside.
This dependence has been normalized over time. Whereas healthcare organizations proceed to ask clinicians to do extra (doc extra totally, talk extra regularly, coordinate extra complicated care), precise workforce capability has remained stagnant. In response, clinicians have raised the capability of what’s attainable by working more durable.
Clinicians bridge this hole by extra effort. They keep later to complete notes. They return messages after scheduled hours. They take up extra obligations when staffing is skinny. These actions are not often framed as extraordinary. They’re described merely as professionalism. But professionalism shouldn’t require fixed overextension.
Burnout is regularly described as a disaster of resilience amongst clinicians. Nonetheless, it’s a disaster of system design. When organizations depend upon sustained discretionary effort simply to operate, exhaustion isn’t an surprising failure. Reasonably, it’s a predictable end result of a predictable design flaw. The possimpible describes this phenomenon completely. It represents the second when the unimaginable turns into achievable solely by private sacrifice. Healthcare has all the time required moments of extraordinary effort. Emergencies and complicated diagnoses demand ability and dedication past routine apply. These moments are a part of the career’s id. What’s new is the expectation that extraordinary effort happens day by day.
Sustainable methods can not rely indefinitely on particular person heroism. Over time, dependence on the possimpible erodes morale, reduces workforce stability, and finally threatens the standard of care itself. Addressing burnout requires greater than resilience coaching or symbolic gestures. It requires one thing healthcare has not often tried: an trustworthy accounting of the work that sustains the system. That accounting should start with making the invisible seen.
Healthcare has spent years making an attempt to resolve burnout that embrace resilience coaching, wellness applications, and psychological well being sources. These efforts aren’t with out worth, however they share a standard assumption: that the issue lives contained in the clinician. In actual fact, the issue lives contained in the system through which we work, and the explanation it persists is less complicated than most would admit: we’ve got by no means measured it.
The invisible labor of medical care doesn’t seem on any productiveness dashboard. It’s not captured in any staffing mannequin and generates no cost. But it isn’t peripheral to work; as a substitute, it’s the work. It’s what fills the hole between what the system was designed to ship and what sufferers want. We can not redesign what we’ve got by no means seen, and we’ve got by no means appeared.
Within the early 2000s, Kaplan and Anderson launched Time-Pushed Exercise-Primarily based Costing (TDABC). The premise is simple: as a substitute of asking individuals to estimate how they spent their time, you measure it immediately. You assign prices primarily based on precise time spent on precise actions, and what will get measured will get managed.
In healthcare, we’ve got barely adopted TDABC. Most purposes concentrate on process prices, care pathway effectivity, and provide change optimization. The methodology was used to search out hidden prices in methods and was not often used to search out hidden labor inside them. That is the hole price closing.
If TDABC was utilized not simply to what will get billed, however to the complete scope of what clinicians truly do, together with every thing that by no means creates a cost, the end result could be one thing healthcare has by no means had earlier than: an actual accounting of the place the system is determined by invisible effort, who’s carrying it, and the way a lot of it exists. You can not employees what can not see. You can not redesign what has by no means been measured. The methodology exists, however we’ve got merely not pointed it on this course.
AI has entered the dialog as a possible answer; nonetheless, framing AI as the answer misses the purpose. Healthcare doesn’t have a know-how deficit. Deploying AI right into a system that can’t see itself clearly doesn’t repair the system. It automates the dysfunction. AI is genuinely helpful however solely as an instrument. Ambient documentation instruments already seize clinician exercise in actual time. Digital medical document data already data when notes are accomplished, when messages are despatched, and what time of day the work occurs. Exercise seize technology already exists to trace the length and nature of medical duties with out including a single documentation burden to the clinician. That is the uncooked materials for TDABC to work. The info exists; it’s merely not getting used to ask the appropriate query. As an alternative of utilizing that knowledge to watch clinicians, well being methods may use it to diagnose themselves. The patterns of after-midnight notice completion isn’t a efficiency difficulty; somewhat it’s a system sign.
As soon as invisible labor turns into seen, the downstream penalties aren’t sophisticated. Staffing fashions might be constructed round what clinicians truly do, not simply what will get billed. Workflow redesign has an proof base as a substitute of anecdote. Management accountability turns into more durable to keep away from when the info exists, and fee reform, the slowest lever of all, lastly has one thing concrete to level to.
However there’s something extra basic at stake than operational effectivity. Excessive-performing methods don’t win as a result of they do extra. They win as a result of they do the fundamentals with consistency. Pirkle has mentioned, “Boring excellence beats sensible chaos each time.” When fundamentals are unreliable, no technique deck on the planet will prevent. When a system fails, it’s not often a failure of effort, it’s as a substitute a failure of reliability.
That’s exactly what the possimpible has obscured. Healthcare has mistaken sensible chaos—the every day heroics of a workforce absorbing what damaged methods can not—for prime efficiency. Sensible chaos isn’t excessive efficiency; it’s a warning. Healthcare has all the time produced moments of real heroism: the resuscitation that ought to not have labored, the prognosis made on intuition after every thing else failed, or the clinician who stayed as a result of leaving was simply not an possibility. These moments are actual. They’re a part of what attracts individuals to this work. They should be acknowledged as extraordinary.
Nonetheless, they don’t seem to be extraordinary once they occur day by day earlier than lunchtime. As Ted Mosby reminds Barney in HIMYM, “Each night time can’t be legendary. If all nights are legendary, no nights are legendary.” The identical is true in heroism in healthcare. When the extraordinary turns into the routine, it stops being a tribute to the individuals doing the work. It turns into an excuse for the system that is determined by them.
The possimpible was all the time meant to explain the uncommon and the exceptional. When a system is designed so poorly that the unimaginable is required simply to make it by a Tuesday, the possimpible stops being a celebration. It turns into the brand new regular, and no workforce can maintain a baseline constructed on distinctive.
Visibility doesn’t remove heroism; it protects it. When methods are designed round what the work truly requires, clinicians aren’t depleted by the routine. They arrive on the moments that actually demand every thing they’ve with one thing left to present.
Burnout is usually framed as a workforce difficulty: clinician wellbeing, retention, and or pipeline sustainability—these are all authentic, however they direct the results of invisible labor to the clinician. The extra uncomfortable actuality is that the results prolong to the affected person.
Recall the sooner case instance of the doctor who referred to as a affected person’s household on the finish of the workday. The doctor stayed on the road whereas a household labored by worry and uncertainty. That dialog influenced what occurred subsequent. Whether or not the household understood the prognosis, whether or not they made an knowledgeable choice in regards to the care plan, or whether or not the affected person went dwelling with the appropriate help or returned to the emergency division two weeks later. None of this exhibits up as a high quality metric.
That is the place the measurement hole turns into a affected person security hole. If invisible clinician effort is load bearing, and whether it is really influencing outcomes, then its absence has penalties that reach far past the clinician who selected to not make the identical name. We merely can not show the complete causal chain but, and never as a result of the connection doesn’t exist, however as a result of we’ve got by no means measured it.
The objective isn’t a healthcare system with out extraordinary effort. It’s a healthcare system that reserves it for extraordinary circumstances. The possimpible ought to stay attainable; it ought to simply not be required.
Healthcare has constructed total high quality infrastructures round measurable end result: door-to-needle instances, readmission charges, mortality indices, size of keep. These metrics all mater, however they measure the output of a system, not the trouble that sustains it. A system that tracks outcomes with out monitoring the labor that produces them is flying with half its devices at the hours of darkness. It’s time to flip the lights on.
Ganesh Asaithambi, MD, MBA, MS, is a Minnesota-based stroke neurologist working at Alllina Well being
