Teenage daughters can be ... challenging. I have two (ages 17 and 19), and let me be clear: I'm crazy about them. They are the best thing in my world. And they also drive me crazy. Many of you might understand that dichotomy. One thing I've learned is to enjoy any moment with them for what it is.
I had one of those moments the other day. I was upstairs in my office trying to catch up on work. You know the drill: finish up charts from the past week, start some pre-visit preparation for the upcoming week, answer emails, catch up on CME, and the like. I had hours of work in front of me.
My youngest walked into the room and said, “Dad, come downstairs and watch Apollo 13 with me. I want you to explain it to me.”
Moments. A moment to spend time with her. A moment to talk. A moment to teach.
“Absolutely!” I said as I quickly clicked “shutdown.”
For those who haven't seen the movie, Apollo 13 is a dramatic retelling of the fateful lunar mission that nearly ended in disaster. Thanks to some fantastic and heroic efforts by everyone involved — spoiler alert — the astronauts safely returned to Earth. (While the movie does take some artistic license, it's fairly true to the events that happened.1)
There's a scene in the movie, about halfway through, that I absolutely love. In the space capsule, there are canisters of lithium hydroxide (LiOH) that scrub carbon dioxide out of the air before it can build up to toxic levels. The problem is that the damaged spacecraft's scrubbers were only designed for two astronauts, yet there were three astronauts on board. Another canister of LiOH was available, but it was literally a square container that needed to fit into a round hole. Flight engineers gathered in a conference room at Mission Control in Houston. They dumped materials on the table identical to what was up in space, with a simple instruction: Use only the supplies found in the space capsule to somehow make a square container fit into a round hole. They couldn't go to the supply closet and get an extra piece of tape; they couldn't run to the store and buy another screwdriver. Use what you have, and fix the problem.
This is the challenge for many of us in primary care as well. How can we make our practices work more efficiently without adding resources, particularly staff? I don't know about you, but my practice faces two big headwinds when it comes to staffing: The cost of labor is going up, and the availability of labor is going down.
That said, we can make a compelling business case for increased staffing to support team-based care models in our practices (see the article by Kong, Bodenheimer, and Willard-Grace in this issue). I'm a big fan of team-based care, and I have experienced firsthand how value-based contracts done right can give us more resources in primary care. But at some point, more staffing isn't doable, and we have to work with what we have.
This is where efficient workflows and processes come into play. Yes, I know that getting people to change their behavior is challenging. Kotter might have eight steps of change management,2 but sometimes it feels like those steps are an escalator going in the wrong direction! But we can do this.
Over the many years I've been in practice, I have thought about that table at Mission Control, now tucked away somewhere in a back hallway. I've done a lot of work to optimize my practice, and still have a lot of work to do, but I always start at the same spot: How can I improve what I'm doing without adding any resources? It worked for the Apollo astronauts, and it's worked for me.
That moment with my 17-year-old daughter ended up lasting three hours. We watched the movie and talked and enjoyed ourselves. It was unplanned and unexpected and amazing. With the movie credits rolling, she said, “That was fun, Dad,” as she got up, went to her room, and shut the door.
It was a good day.