"The Road Less Traveled"

I've always liked the poem "The Road Less Traveled" by Robert Frost.  It's an easy poem to like, as Frost's message is simple and profound at the same time.  You've probably heard it before - it's the one that ends with:

Two roads diverged in a yellow wood, and I - 

I took the one less traveled by,

And that has made all the difference.

I was thinking of this poem when I reviewed a study published in the journal Management Science by Diswas S. KC, Maryam Kouchaki, Bradley Staats, and Francesca Gino.  I think you will understand why in a moment, but for now, I want to focus on the specifics of the study.

The authors mentioned a quote by the founder of scientific management, Frederick Winslow Taylor, who I've mentioned a couple of times in past quotes (see in particular, "A Response to Medical Taylorism").  It's a curious quote for the topic that they researched (in my opinion, a quote from "The Road Less Traveled" would have been better), though I think I understand their intent:

"In the past the man has been first; in the future the system must be first.  This in no sense, however, implies that great men are not needed.  On the contrary, the first object of any good system must be that of developing first-class men."

They briefly talk about the role of Taylor's scientific management in improving operations, particularly in manufacturing.  However, they also emphasize that the field of operations management, with its traditional focus on inanimate objects (e.g., machines, inventory) has too long neglected the importance of people and process.  I wholeheartedly agree - people and process are incredibly important to the success of an organization, and the health care industry, which is the subject of this particular study, is proof of that concept.  

The authors first discuss what is currently known on this topic.  For example, a previous study found that radiologists typically read and interpret films that they expect to finish quickly first, before moving on to the films that may take longer to read and interpret.  Unfortunately, by doing so they actually spend more time in the long run, taking longer to finish reading through a batch of films than it otherwise should have taken.  

There are three proposed reasons for why individuals choose to do easier tasks first when they encounter high levels of workload.  First, according to something called the "goal gradient hypothesis", our motivation increases as we near the achievement of our goal.  For example, customers at a coffee shop who are given a free coffee card with 2 out of 12 stamps already punched in will fill the rest of their card quicker than those customers who are given a card with no stamps already punched.  Two studies (see "Slow first, fast later" and "The efficiency of slacking off") found that health care providers work faster near the end of their shift.  Second, completing work makes people feel good.  There is something quite satisfying about finishing our "To Do List".  Third, individuals may prioritize the things that they can finish quickly because they believe that it may shorten the overall time it takes to finish all of their work.  

The authors first studied patient flow through a busy metropolitan emergency department over a 2 year period, involving just over 90,000 total patient encounters.  Consistent with prior research, they found that physicians are more likely to pick up easier patients (as opposed to a difficult one) when their workload is higher.  In other words, when the emergency department is busy, providers will choose to see the easiest patients first (assuming patients have been triaged appropriately - emergency departments always prioritize care of the sickest patients before anyone else).  True to form, these patients had a shorter length of stay in the emergency department, so the individual physicians' short-term productivity actually improved.  However, the long-term productivity (in terms of the total number of patients any one provider can see during her or his shift) actually got worse!  

The authors next conducted a number of laboratory studies (using undergraduate students as study subjects) to help identify the reasons why individuals prioritize easier tasks when they get busier.  They again demonstrated the short-term productivity gain and long-term productivity loss found in the real-world setting of the busy emergency department.  They also found that, in general, as individuals experience higher workloads, they prioritize simple and easy tasks because it gives them a sense of goal achievement (call it the "completion high").  

It's great to see a study that uses health care as a model - usually it's the other way around, in that those of us working in health care have to adapt practices studied and proven in other industries.  In addition, the implications of a task prioritization that results in a short-term gain at the expense of a long-term loss is of significant interest, both within and outside the health care industry.  It will be interesting to see additional studies on this topic.  For now then, it seems that taking "the road less traveled" (in this context, choosing to prioritize the more difficult tasks over the simpler ones first) is better in the long-run (remember my post "Eat that frog!").