In article one of this three-part series, we discussed the causes, effects, and pathophysiology of physician burnout, and we learned that it affects an estimated one in three physicians at any given time. (See “Physician Burnout: Its Origin, Symptoms, and Five Main Causes,” FPM, September/October 2015.) We also learned that each of us has an “energy account,” much like a bank account, and burnout occurs when there is a negative balance over time. To avoid burnout, we have to 1) increase our energy deposits by creating balance in our lives or 2) decrease our energy withdrawals by reducing stress.
In this article, we will concentrate on the latter – methods to avoid burnout by lowering stress in your practice. (See “Series overview.”)
In this three-part article series, we will explore the following:
Part 1: Burnout's symptoms and causes,
Part 2: Proven methods to lower physician stress levels (this article),
Improving the work life of physicians to help them avoid burnout is such an important goal that researchers are now calling it the “fourth aim” of health care, next to improving population health, enhancing the patient experience, and reducing costs.1 Clearly, it's a big deal.
First, an important distinction
I would like you to consider that burnout is not actually a problem. Let me explain.
Problems have solutions. When you apply a solution, the problem goes away. Physicians often ask me, “What is the one thing I can do to lower my stress levels and make burnout go away?” Notice how this question presumes burnout is a problem that has a solution. When they can't find that “one thing” to solve the problem, many doctors slide back into their old work habits and give up on the possibility that things could be different.
In reality, burnout is a dilemma. It does not have a solution, because it is not a problem in the first place.
Dilemmas are perpetual balancing acts that require perpetual action. You address a dilemma with an ongoing strategy, not a onetime solution. A successful strategy to lower practice stress and get home sooner will often contain three to five components.
This article offers you eight potential strategy components. Each is focused on increasing your efficiency at work. As you read on, make a note of the one that seems most useful to you. This can be the tool you implement first. You can measure your effectiveness in this effort by tracking the amount of time between your last patient leaving the office and you getting home – with your charts done.
The methods presented below have been tested in the real world by hundreds of physicians like you in my burnout coaching practice. In reality, there are many more practice efficiency tools than you see here. These are the ones my clients have found most useful as first steps. They are not a substitute for system-level changes (see “A word to leaders”). And there's a bonus tip in the video available with the online version of this article (see “The universal upset patient protocol”).
Ready? Let's begin.
VIDEO: THE UNIVERSAL UPSET PATIENT PROTOCOL
Dr. Drummond describes a method for reducing the stress of dealing with upset and angry patients.
1. Move from EHR hater to power user
When using your electronic health record (EHR) this week, notice your attitude. Do you feel that your EHR program was written by the devil himself in the fires of hell? Do you find yourself tensing up when you sit down to type? Do you often complain about your EHR to others and say things like “It won't let me do [fill in the blank]”? If so, you might be an EHR hater. This attitude leads to avoidance behavior, such as avoiding documentation until the end of the day, which can sabotage any attempts to improve your charting skills and get home on time.
EHRs are evolving, but they are not going to go away, so hating them isn't an effective strategy. In fact, it wastes your energy. Instead, devote yourself to becoming a power user. The first step is to find and study the power users around you. They are the ones using the same software, seeing basically the same patients, and getting home on time with a lot less frustration. They know things you don't.
If you need help identifying a power user, ask your nurses who the power users are. If you practice solo, ask your EHR vendor to connect you with one. Ask if you can watch them chart – they always say yes. Then sit right behind them while they are at the computer and get ready to yell “Stop!” when they do some keystroke combination that magically completes a chart note. Ask how they did that. Take notes. Pick up two to three tips you can use. Before you leave, ask if you can have their templates – they always say yes. Two or three of these power-user training sessions later, you will be well on your way to becoming a power user too.
A WORD TO LEADERS
With physician burnout at epidemic levels, we cannot assume that it is merely an individual physician's problem that needs to be remedied on an individual level. System-level changes are also required if we want to reverse this trend. Frustration and discouragement are at all-time highs, and the physicians in your organization need your leadership and support. We have to address both the internal and external causes of burnout if we want to heal our profession.
As you read this article, identify the leadership strategies and organizational changes you can make. Ask yourself if your administration actively seeks out and values physician input into processes and workflows. If your physicians are not stepping up and participating in the design of the workplace, ask yourself why. How can you help your organization find a balance between business principles and clinical system designs that works for both sides of the organization? This is not easy work, but it must be done.
2. Document the minimally necessary data set
There are three reasons to write a chart note: billing, medicolegal, and continuity. If what you are writing in the chart is not supporting your billing code, covering your “legal part,” or helping the next provider take over where you left off with this patient, it probably doesn't need to be in your note.
This is not to say that your notes should be void of the patient narrative. By all means, chart well, but do not write the great American novel. You do not need to use complete sentences and should never touch the semicolon key. Longer is not necessarily better.
3. Use EHR software to automate what you can
EHR software is meant to semi-automate your chart notes through the use of templates. Here is a test: If you piled up all your documentation from a week onto your desk, how much of it did you produce by free typing into the chart? If your answer is more than 30 percent, you are not as automated as you could be. The secret is to look for “broken record moments.”
A broken record moment is when you notice, “This is the fourteenth time I have written the same note this week.” The typical reaction to a broken record moment is to become frustrated, but don't stop there. This is a golden opportunity to automate and get home sooner. Here is the process:
As you notice these moments, write them down. Make a list.
Once a week, take one item off the list and template it. Ask an IT person or your power user friend for help if you need it.
The templating process will take about 30 minutes or so. In a month, you will have transformed four frustrating broken record moments into simple keystroke combinations.
4. Make documentation a team sport
If you have superhero, perfectionist, or lone ranger tendencies like most of us physicians, you are almost certainly doing too many of the charting chores yourself. Realize that all documentation is team documentation. You don't have to do it all. However, if you want your team to help, you will have to ask them. Because of your position, staff may not feel comfortable initiating this discussion.
Ask your staff for help with documentation in an open-ended way and see how they respond. It could sound like this: “Hey everyone, I am working on ways for us to become more efficient at charting. We are a team, and all of us are in the chart at some point. What are your ideas about how we can share the work more effectively so I can get from patient to patient more quickly?” Then be quiet and see what they say. This is much more effective than trying to figure it all out yourself and giving them orders.
Some groups have had success allowing medical assistants (MAs) to document key portions of the visit on their own (including the chief complaint, review of systems, and past medical, family, and social history) and then act as a scribe recording the history of present illness once the provider is in the room.2 Experiment, and see what documentation efficiencies your team can find.
5. Pilot the use of a scribe
I often hear physicians complaining that their administrators won't allow them to have a scribe. “If only I had a scribe, I could be more efficient and see more patients,” they say. The administrator is thinking, “Prove it.” For you to have a scribe, the administrator has to come up with the money and the scribe. That is a risk.
One way to get past this hurdle is to pilot the use of a scribe, perhaps even agreeing to take all the risk yourself initially. There are several national scribe companies that will find, hire, and train a scribe for you. You pay about $25 per hour for the scribe's services. The process would look like this:
Get your administration to OK a scribe pilot in your practice. Run a detailed production and billing report for your last three months. Hire and implement a scribe. After a three- to six-month period, when you feel you and your scribe are working at maximum efficiency, run another three-month production and billing report. If the data proves that you are now seeing more than enough patients to pay for the cost of the scribe, ask your group to make it permanent.
6. Look for additional broken record moments
In method #3, we discussed broken record moments in your documentation that can be addressed with automation. Another category of broken record moments is patient education. If you listen, your internal voice will point out, “This is the thirteenth time I have said this same thing to a patient this week.”
Once again, step one is to make a list of all these moments. Write them down. Then decide how you will handle this teaching going forward. There are four main methods:
Written materials. Make (or find) patient handouts to cover the broken record moments in your practice. Print them on colored paper. Keep them stocked in an accordion file folder in your exam rooms. Put your nurse or MA in charge of keeping them stocked.
Videos. Record videos of you doing your best teaching on your broken record subjects (or find ones you like online). Load them onto a cheap tablet computer that your nurse or MA can give to the patient to review at the conclusion of the visit. Or put them on the Internet at YouTube.com and give the patient the link, or post them in your patient portal for the patient to watch in the office or at home.
Delegation. For situations that require face-to-face education, train your staff to handle these broken record moments.
Combination. Combine any or all of the above methods as needed to save you time, such as having your nurse give a patient an educational handout with a link to a video on the same topic.
7. Huddle with your team
The team huddle is a time-honored method of preventing fires from breaking out in your day by anticipating needs and problems. Some experts recommend a once-a-day huddle,3 but I have found it more effective to huddle twice a day.
Here are the basics:
Meet for six minutes before each session (morning and afternoon).
Include all members of your patient flow team: your receptionist, whoever rooms your patients, the float nurse, etc.
Make it a stand-up meeting. This keeps it short.
Go to your team. Do not make them come to your office for this meeting.
Make sure one of you has the schedule in hand, so you can review it together and do two things: 1) Troubleshoot the patients on the schedule; know who is sick or upset, who has special needs, and who needs specific equipment or a special room, and 2) Let your team know what to do with any open appointment slots; know when your next available appointment is.
Address any other issues the team might be facing in the next four hours, such as “the printer is down” or “we just ran out of flu vaccine.”
A huddle can reduce your stress by increasing your team's efficiency and reducing the feeling of chaos in your day. (See “Huddle power tips” for more ideas.)
HUDDLE POWER TIPS
To make your team huddles even more effective, try the following tips:
Ask everyone how they are doing today. Find out if there is anything going on either at work or in their personal lives that you need to know about, both good and bad. Know whose child is sick and whose child just got a college scholarship.
Say thank you. Acknowledge and thank the members of your team for anything they have done in the last several days that helped you or the team do a better job. Praise early and often and be specific.
Delegate. Encourage your team to be on the lookout for things you are doing as the doctor that they could take off your plate. For example: “We are a team. Caring for patients and completing the documentation are team activities. We share the load. Any time you see something you could do instead of me, something that would help the team be more effective, please bring that idea to the next huddle.”
Clear and center the whole team. Invite your team to take a deep cleansing breath and become centered before you start seeing patients.
8. Embrace batch processing
Have you ever noticed that, if a dog is sitting on the porch and you get his attention by throwing a tennis ball, he cannot not chase it?
With doctors, the tennis ball is that message your nurse just placed on your desk or that popped up on your EHR screen – a refill request, test result, referral paperwork, telephone message, etc. Even when it is not urgent or important, how often do you drop what you are doing to address it?
This activity fractures your day into a hundred pieces for one simple reason. You are taking care of these items one at a time and allowing them to interrupt your patient flow.
One solution is batch processing. Take all the tasks that are nonurgent, put them into piles (you may have to do this virtually for EHR messages), and process the batch twice a day at a time when you and our team can address them all at once. In a standard office day where you have a morning and afternoon schedule, some good times to do batch processing are 11:30 a.m. and 4:30 p.m. That way, the morning's work is done before lunch and the afternoon's work is done before you go home.
To identify what you should batch, make a list of all the little things that interrupt your day repeatedly. Then ask for your teams' input: “What tasks happen every day – things that are not urgent yet have to be done before the day is over – that we can put in batches and do all at once, twice a day?” Pick one item from the list and design a batch process. You'll have to decide the following:
Where will you collect the items to be batched? Is it a physical basket where you will put forms or messages, or a virtual basket that will hold emails or test results?
Who is doing the batch processing – you or one of your team members?
What are the screening criteria that mean you as the physician must get involved?
Here's an example: Your nurse screens all lab results as they come in, alerting you between patients to any abnormal values. All lab results are batched in a lab folder in your EHR, which you process at 11:30 a.m. and 4:30 p.m.
Pick an idea and take action
It is easy to read an article like this one, with multiple suggestions for practice changes, and get completely overwhelmed. Your brain naturally focuses on how you can implement them all at once, which is impossible, so you end up doing nothing.
The key is to pick just one idea and take the first step. That is all. Once you take the first step, the second one will become clearer.
So go ahead and pick one idea that feels like a good place to start. What is the smallest step you can take to implement it? Tell your team what you are up to, and ask for their help up front. They likely will have fresh ideas you can't see because you are busy in the exam room seeing patients.
Join me in a couple months for article three, where we will wrap up this series by focusing on life balance tools that allow you to recharge your energy accounts and build more balance into your week.