By GANESH ASAITHAMBI
In an episode of the sitcom How I Met Your Mom (HIMYM), Barney Stinson introduces a fictional phrase: attainable. The possimpible combines “attainable” and “unimaginable” and describes the extraordinary achievements by individuals who refuse to simply accept typical limits. In fashionable healthcare, the possimpible is not a joke; it has quietly change into 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 advanced affected person inhabitants. These expectations usually prolong past what present programs had been designed to accommodate. The gap between what the system can present and what sufferers want is more and more crammed 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 cellphone dialog takes longer than anticipated with questions on their cherished one’s prognosis and hesitancy about what to do subsequent with worry about what’s to come back. The doctor offers reassurance and steering. The doctor hangs up, solely to search out that observe dictations usually are not 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 every single day in American well being care.
These moments seem routine. Nonetheless, they mirror one thing extra consequential: healthcare has change into quietly depending on clinicians to stretch past the boundaries of the programs 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 steadily, coordinate extra advanced 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 way of extra effort. They keep later to complete notes. They return messages after scheduled hours. They soak up extra obligations when staffing is skinny. These actions are hardly ever framed as extraordinary. They’re described merely as professionalism. But professionalism shouldn’t require fixed overextension.
Burnout is steadily described as a disaster of resilience amongst clinicians. Nonetheless, it’s a disaster of system design. When organizations rely upon sustained discretionary effort simply to operate, exhaustion just isn’t an sudden failure. Slightly, 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 way of private sacrifice. Healthcare has at all times required moments of extraordinary effort. Emergencies and sophisticated diagnoses demand ability and dedication past routine observe. These moments are a part of the career’s identification. What’s new is the expectation that extraordinary effort happens every single day.
Sustainable programs can’t 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 hardly ever tried: an trustworthy accounting of the work that sustains the system. That accounting should start with making the invisible seen.
Healthcare has spent years attempting to unravel burnout that embody resilience coaching, wellness packages, and psychological well being sources. These efforts usually are not with out worth, however they share a typical assumption: that the issue lives contained in the clinician. In actual fact, the issue lives contained in the system during which we work, and the rationale it persists is easier 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 an alternative, it’s the work. It’s what fills the hole between what the system was designed to ship and what sufferers want. We can’t 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-Based mostly Costing (TDABC). The premise is easy: as an alternative of asking individuals to estimate how they spent their time, you measure it instantly. 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 functions deal with process prices, care pathway effectivity, and provide change optimization. The methodology was used to search out hidden prices in programs and was hardly ever used to search out hidden labor inside them. That is the hole value closing.
If TDABC was utilized not simply to what will get billed, however to the total scope of what clinicians really do, together with every part 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 depends upon invisible effort, who’s carrying it, and the way a lot of it exists. You can’t employees what can’t see. You can’t redesign what has by no means been measured. The methodology exists, however we’ve got merely not pointed it on this path.
AI has entered the dialog as a possible reply; nevertheless, 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 report knowledge already data when notes are accomplished, when messages are despatched, and what time of day the work occurs. Exercise seize know-how 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 information exists; it’s merely not getting used to ask the correct query. As a substitute of utilizing that knowledge to watch clinicians, well being programs might use it to diagnose themselves. The patterns of after-midnight observe completion just isn’t a efficiency problem; reasonably it’s a system sign.
As soon as invisible labor turns into seen, the downstream penalties usually are not difficult. Staffing fashions may be constructed round what clinicians really do, not simply what will get billed. Workflow redesign has an proof base as an alternative 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 programs don’t win as a result of they do extra. They win as a result of they do the fundamentals with consistency. Pirkle has stated, “Boring excellence beats good chaos each time.” When fundamentals are unreliable, no technique deck on the earth will prevent. When a system fails, it’s hardly ever a failure of effort, it’s as an alternative a failure of reliability.
That’s exactly what the possimpible has obscured. Healthcare has mistaken good chaos—the day by day heroics of a workforce absorbing what damaged programs can’t—for prime efficiency. Good chaos just isn’t excessive efficiency; it’s a warning. Healthcare has at all times produced moments of real heroism: the resuscitation that ought to not have labored, the analysis made on intuition after every part else failed, or the clinician who stayed as a result of leaving was simply not an choice. These moments are actual. They’re a part of what attracts individuals to this work. They need to be acknowledged as extraordinary.
Nonetheless, they don’t seem to be extraordinary after they occur every single day earlier than lunchtime. As Ted Mosby reminds Barney in HIMYM, “Each evening 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 depends upon them.
The possimpible was at all times 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 way of 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 eradicate heroism; it protects it. When programs are designed round what the work really requires, clinicians usually are not depleted by the routine. They arrive on the moments that actually demand every part they’ve with one thing left to offer.
Burnout is usually framed as a workforce problem: clinician wellbeing, retention, and or pipeline sustainability—these are all reliable, 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 way of worry and uncertainty. That dialog influenced what occurred subsequent. Whether or not the household understood the prognosis, whether or not they made an knowledgeable determination concerning the care plan, or whether or not the affected person went house with the correct 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’t show the total 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 just 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 occasions, readmission charges, mortality indices, size of keep. These metrics all mater, however they measure the output of a system, not the hassle that sustains it. A system that tracks outcomes with out monitoring the labor that produces them is flying with half its devices in the dead of night. It’s time to flip the lights on.
Ganesh Asaithambi, MD, MBA, MS, is a Minnesota-based stroke neurologist working at Alllina Well being
