If you have ever had your morning hijacked by an alarm clock that failed to wake you, an “urgent” matter that greeted you at the office, or a morning meeting that went too long, leaving you hopelessly behind schedule for the day, you know how important those early hours can be. How we start the day can set the tone for how we function the rest of the day.
Research suggests that our mental energy and willpower are limited each day and can quickly become drained by too many choices and decisions.1,2 A morning routine that varies as little as possible may help prevent decision fatigue, setting you up to be more focused and productive the rest of the day.
You probably have a personal morning routine that you have settled into over the years (for example, make the bed, go for a run, and grab a cup of coffee – black). But do you have a professional morning routine? Could you be more deliberate about how you start your workday, with the goal of making each day more productive, efficient, and even enjoyable?
Although there isn't an evidence base pointing to the perfect morning routine in a medical practice, this article presents seven best practices that have helped other physicians. They might just inspire you to examine and refine how you start your workday.
1. Start “on time”
We all know that starting on time is vital to a successful day, but it's often easier said than done. How do you get yourself and everyone you work with to arrive on time and ready to see the first patient?
First, it helps to be clear about what “on time” means for the various positions in your group. For physicians, does it mean one hour before the first patient visit, 30 minutes before, or five minutes before? The answer depends on the particulars of your practice.
Dale Block, MD, CPE, a family physician in Mason, Ohio, follows the same office routine every morning, and his critical first step is, “I get to the office early, well before my first patient at 8 a.m.”
This gives him ample time to prepare for the day ahead. (More about that later.)
For Lynn Ho, MD, a family physician in North Kingstown, R.I., “It helps to arrive 15 to 30 minutes before the first patient.”
She uses the time primarily to “relieve the pressure buildup of overnight faxes, prescription requests, and emails,” she says, so she has a clean slate when the first patient arrives.
Arriving to work a few minutes early is sufficient for Christine A. Sinsky, MD, FACP, an internist in Dubuque, Iowa, and vice president of professional satisfaction for the American Medical Association. “It gives you time to center yourself and connect with your team,” she says.
But “on time” looks a bit different for Douglas Iliff, MD, a family physician in Topeka, Kan. “My first patient is always at 8:30, and I always show up at 8:45 to pick up my stethoscope and pen and head for the exam room just as the nurse has finished the check-in,” he says. “It's kind of like ‘just-in-time’ inventory control.”
What makes this work for Iliff is that he has a high-functioning, small staff that communicates well, and they have worked together for many years. They don't need a lot of “pre-game” to their day because “we've worked together so long everybody knows their job and our patients, and we're going to be talking all day every day anyway,” says Iliff.
Regardless of how your practice chooses to define “on time,” the real test is whether you and your staff are ready, not hustling to get ready, when the first patient arrives.
If certain members of the team are chronically late, you may need to meet with them privately, find out what is causing the problem, encourage them to examine their personal morning routine, and then hold them accountable.3
2. Create a meeting-free, interruption-free zone
In a popular TED talk, author and entrepreneur Jason Fried purported that one of the biggest obstacles to workplace productivity is too many interruptions, specifically meetings and managers checking in on their employees.4 His solution – “no-talk Thursdays” – wouldn't be doable in a medical practice, but the overall principle can be helpful.
Imagine if, in the first moments of the workday, you and your staff didn't gather at the water cooler but instead gave each other some space, no meetings, just uninterrupted time to prepare for the day.
If you aren't in a position to propose such a thing, perhaps you could arrive at the office 15 minutes before anyone else and create this time for yourself. Or create a few minutes of solitude at home, on the train, or at your favorite coffee shop before arriving at the office.
What should you do during this time? See below.
3. Perform an “intellectual mise-en-place”
A good habit at the start of the day is to conduct a brief planning session – an “intellectual mise-en-place.”5 Chefs use this technique, translated “everything in its place,” to look over a recipe and assemble all the tools and ingredients in the right measurements before they begin cooking. It creates order, calm, and efficiency.
In the same way, Ryan Neuhofel, DO, MPH, a family physician in Lawrence, Kan., sets aside time each morning to look over his schedule and prepare for what's ahead so he doesn't spend the day in reactive mode. “After warming up the Keurig machine, I start my morning in clinic by reviewing the day's scheduled visits,” he says. “Regardless of reason for visit, I review each person's history to make sure everything with known chronic and preventive care is up-to-date. With more complex presenting problems, I often start a preliminary visit note with some questions and space for answers. I have found this 10- to 20-minute morning preparation keeps me from being overwhelmed later in the day as new stuff arises.”
Block has a similar routine. “I go through all faxes that came through to the office the night before. I also go into my EHR inbox and work through results and patient emails. This way my CMA has work lined up so she can start her day,” he says.
“I then go through my schedule and prepare for the patients. For example, I get procedure consents filled out and ready for patient signature right after I review informed consent before the procedure starts. I look at the kids on the schedule for well-child care and try to determine their immunization needs. I also fill out any forms in advance so I am more efficient with patient care, like getting worker's compensation forms filled out as much as possible before the patient appointment,” he says.
In contrast, Sinsky starts the morning by focusing on just the next patient. “Some physicians like to review the whole day's patients at once. I like to review each patient just before I go in the room, so the information is fresh,” she says. “The main point is to not walk into the room and then try to remember who the patient is and reconstruct what they are here for. By reviewing outside the room you can spend the first golden minutes making eye contact, sharing a brief social conversation, and developing trust.”
The key pieces of information are “the last note and the social notes you might tuck away in the EHR,” says Sinsky.
In addition to prepping for the day's immediate tasks, it's wise to take a moment to look ahead on your calendar, says Jennifer Brull, MD, a family physician in Plainville, Kan. “Calendaring on a weekly basis helps me see issues that might come up or conflicts, and I can rearrange in a proactive fashion,” she says.
4. Eat a frog
Mark Twain is credited with saying, “Eat a live frog first thing in the morning, and nothing worse will happen to you the rest of the day.”6 In other words, if you have an important task that is challenging or likely to be procrastinated, tackle it early in the day.
For Brull, hospital rounds have the potential to derail her day if she isn't careful, so she completes them early. “Playing catch-up is always tough,” she says, “so I give myself enough time each morning to finish hospital rounds before trying to start clinic.”
With rounds completed, she can focus more clearly on the rest of her practice.
Another common “frog” is exercise, which many people put off until later in the day only to find that they've run out of time or energy. But there's a vital reason for doing it early, besides all the health benefits, says Brull: “I exercise before work so I feel accomplished.”
Instead of spending all day dreading it, she gets a psychological win for the day.
Other potential frogs might be a difficult phone call you need to make, an electronic health record template you need to create, or a staff member whose behavior you need to address. Whatever it is, consider putting that frog out of its misery before lunch.
5. Plan ahead to enjoy something
To counter that frog you're going to eat, make sure your day also includes something you enjoy.
Lynn Ho wastes no time in doing this. “I cycle, or sometimes run, the 4.5 miles to work,” she says. “We live in the Northeast in coastal Rhode Island, and biking or running past all the little salt ponds is a treat. In the summer, I pass giant pink lotuses waving in their pond. And on a very bracing day where the wind chill brings the temperature below 10 degrees, I am reminded that survival is a blessing to count.”
If you aren't that disciplined, a helpful technique is to put something positive on your daily to-do list. Author Donald Miller recommends identifying the following items before your workday begins:
“If I could live today over again I'd ____.” The idea here is to fast-forward to the end of the day and imagine what you wish you had done (e.g., give each patient my full attention, speak up for what I need, call my dad), and then make sure you do it.
“Things I get to enjoy today.” This could be anything from a latté to dinner with a friend to attending your kid's soccer game.
Writing these things down, and even saving them in a journal for future reference, “will keep you from getting caught up in trivial problems and will allow you to focus more on what really matters,” writes Miller.7
Another aspect of this is to practice gratitude each day. “On your way into work, think about all of the things you are grateful for,” says Sinsky. “The day goes better if you start in a positive frame of mind.”
6. Huddle with your staff
A team huddle is not a staff meeting. It is a brief, stand-up conversation that allows you to simply “check in with nursing and other staff on potential problems and plan for the day,” says Brull.
For example, your team might review the schedule and identify potential no-shows, times when you could squeeze in an acute visit, or patients who will require additional supplies or equipment in the exam room. “It's an opportunity for everyone to learn about unique challenges and needs for the day,” says Sinsky.
(For more on huddles, see “Huddles: Improve Office Efficiency in Mere Minutes,” FPM, June 2007.)
For Block, the huddle is the final step in his morning routine, but it isn't just for addressing the day's appointments. “The very last thing I do is huddle with my staff and run through today's schedule. But we also share with each other anything personal that we want to share,” he says. “It builds collegiality and teamwork.”
7. Start the night before
Having a pile of unfinished work on your desk from the previous day is no way to start a new day. Instead, it's a good habit to tie up loose ends – phone calls, emails, and so on – before you end the current workday. The goal isn't “inbox zero,” but you don't want “inbox 5,000” either.8
“The most important thing I recommend is to stay at the office if possible until all of today's work is done including charting,” says Block. “That way, you begin fresh every morning to start a new day. I try to never leave any charting hanging unless it is necessary, like waiting for pathology on a surgical procedure I performed in the office that day.”
Although it's not always possible to finish all of today's work today, make it a goal to at least “start the day with your charts caught up,” says Brull.
You can also enlist your staff to help you get a jump on tomorrow. “Have someone on your team review tomorrow's charts today and highlight any significant abnormalities, like an unexpected abnormal CT scan or a patient in for hospital follow up,” says Sinsky. “It gives you a chance to review these records, discuss findings with other physicians, and be fully ready for the patient.”
Finding what works
Having an effective morning routine is a win-win-win strategy. It makes the day go better for staff, for patients, and for doctors. “This process has worked for me for years and improves my efficiency and effectiveness,” says Block. “It has brought me great joy in being a family physician.”
If your morning routine isn't working for you, don't be afraid to admit it and try something new.
But whatever you do, don't forget the coffee.