In Article One of this three-part series, we discussed the causes, effects, and pathophysiology of burnout. If you have not read that article, it is important you do so. The tools that follow are more effective if you understand the fundamental blind spots and conditioning of our medical education.
In this article, we will concentrate on methods to lower stress in your practice.
Before we begin, you must understand that burnout is not actually a problem. Let me explain.
Problems have solutions. When you apply a solution to a problem, what happens to the problem? It goes away … yes? So often physicians come to me asking, “What is the one thing I can do to lower my stress levels and make burnout go away?” Notice how this request presumes burnout is a problem that has a solution. When you can’t find that “one thing,” many doctors simply 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. You are “between the horns of a dilemma” taking specific actions every day, week, and month to maintain the balance you seek. You address a dilemma with a strategy, not a solution. By its nature, a strategy has multiple parts, and in order to maintain balance you have to be measuring how you are doing in some fashion.
The fundamental question at the heart of preventing burnout is this: “What is your burnout prevention strategy and how are you measuring your effectiveness?” The horns of the burnout dilemma are the amount of time and energy you put into your practice on one side and your ability to maintain a positive energy balance coupled with your desired quality of life on the other.
Dilemmas are very common in healthcare. Here are just a few examples: burnout, your compensation formula, the best care at the lowest cost, your call schedule, your accounts receivable, work-life balance, and EHRs.
From this point forward, we will be discussing tools to lower stress by increasing your efficiency at work and decreasing the time it takes to complete the tasks of your practice. One way to measure your effectiveness in this effort is to track the amount of time between your last patient leaving the office and you getting home – with your charts done.
Each tool is a potential component of your personal burnout prevention strategy. You may be utilizing some of these already. If so, make sure you read the Power Tips for that technique. As you read, take note of the tools that seem simplest to implement or feel most attractive to you. I will be giving you implementation pointers at the end of the article.
Remember, nothing changes unless you change your actions. This is an active learning process. If you read this article and do not change your actions, you remain trapped in Einstein’s insanity definition. I encourage you to comb through this article actively looking for one tool you can begin to practice ASAP. Ready? Let’s begin.
Here are five EHR strategy components we have tested and found effective in the real world.
a) From hater to power user
Notice your attitude. Do you feel your EHR program was written by the Devil himself in the fires of hell and his fingernails are digging into the backs of your hands every time you touch the keyboard? That is the definition of a hater. This attitude creates amazing avoidance behavior. You probably avoid your documentation until the end of the day and self-sabotage any attempts to improve your charting skills.
I have a simple question. Do you think the EHR is ever going to go away? Then this behavior is insanity. It destroys your ability to get home on time. Take a big breath and let it go.
Devote yourself to becoming a Power User instead. The first step is to find and study the Power Users around you. Typically they are hidden, since to stand up and announce you like the EHR is not a popular thing to do in most groups. Notice that these people are using the same software, seeing basically the same patients, and getting home on time. They know things you don’t.
Ask the nurses who the Power Users are. If you are solo, ask your EHR vendor to connect you to 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. Take notes. Ask how they did that. Pick up 2 – 3 tools you can use. Before you leave, ask if you can have their templates - they always say yes.
Two or three sessions later you are well on your way to becoming a Power User too. When the little hater voice comes up in your head, just say “Thank you for sharing,” and let it go.
b) Always and only document a minimal data set
There are three reasons to write a chart note: billing, medicolegal, and what I will call “continuity” – providing the next person who sees this patient with enough information that they can take over where you left off. If what you write in the chart does not support your billing code, cover your “legal part,” or help the next provider in the chain, don’t put it in your note.
c) Use the software
The use of 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 into a heap on your desktop … how much of it was produced by you free typing into the chart? If your answer is more than 30%, you are not as automated as you could be. The secret is to look for “Broken Record Moments” (BRMs).
This is when you notice, “This is the fourteenth time I have written the same note this week.” The typical reaction to a BRM is to become frustrated. Don’t stop there. Realize a BRM is a golden leverage point to get you home sooner. It marks an opportunity to automate. Use this process:
The template process will only take 30 minutes or so. Here is the power.
In a month you will have transformed four BMRs into simple keystroke combinations and be getting home sooner.
d) Team documentation
You are programmed to be a Lone Ranger superhero perfectionist. You are almost certainly doing too many of the charting chores yourself. 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 at the apex of the care team and the one who gives the orders, your staff will not usually suggest that you delegate a charting task to them.
Ask for help 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 efficiently?” Then be quiet and see what they say. This is much more effective than trying to figure it out yourself and giving them orders.
e) Hire a scribe in a risk free pilot project
Across the nation, physicians are pounding their administrator’s desks demanding a scribe. They always say, “If I had a scribe, I could see more patients.” I assure you the administrator is thinking, “Prove it.” You see, administrators have two concerns: money and manpower. For you to have a scribe, they have to come up with the money and the scribe. That is a risk for them.
Here is how you can get a scribe with a process I have never seen fail. Take all the risk yourself.
There are several national scribe companies. They will find, hire and train a scribe for you. All you pay is about $25/hour for their services. Try this...
You will find another category of BRMs in the patient education side of your practice. Your little voice will point out, “This is the thirteenth time I have said the same thing to a patient this week.”
Once again, step one is to make the list of all of these moments. Write them down. Then decide how you will address this teaching going forward. There are four main methods.
a) Written. Make patient handouts to cover the BRMs in your practice. Keep them stocked in an accordion file folder. Put them on pastel colored paper. Put your nurse/MA in charge of keeping them stocked.
b) Video. Record a video of you doing your best teaching on your BRM subjects. Load it onto a set of cheap tablet computers your nurse/MA gives to the patient to review at the conclusion of the visit. Or put them up on YouTube or load them in your patient portal for the patient to watch in the office or at home.
c) Delegation. Train your people to take over the BRM from you.
d) A combination of the above, like a handout with a video link, etc.
Document the method and source of patient education in the chart. Eliminating BRMs, in both documentation and patient education, is one of the quickest ways to get home sooner.
The BID team huddle is a time-honored method of preventing fires from breaking out in your day. If you are not routinely holding a huddle in your practice BID, you are getting home later than you need to.
a) Six minutes twice a day before each of the two halves of your day.
b) Include all members of your patient flow team. Receptionist, whomever rooms your patients, the float nurse.
c) Stand up meeting. You go to them. Do not make them come to your office.
d) Make sure one of you has the schedule for the coming half day in hand. Review the schedule together and do two things:
e) Address any other issues the team is facing in the next four hours - such as the printer is down or we just ran out of flu vaccine, etc.
Huddle power tips
Check in with your team
a) Ask each team member ‘how are you doing today?”
Get to know if there is anything going on 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.
b) Say thank you
Acknowledge and thank the members of your team for anything they have done in the last several days that helps you or the team do a better job. Praise early and often and be specific. “Thanks for your hard work, yesterday we accomplished all our charting before going home.”
c) Delegate appropriately and judiciously at the highest level of someone’s scope of practice.
Ask your team to be on the lookout for things you are doing as the doctor that they could take off your plate and complete instead. “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.” “Support” staff are meant to “support” physicians so the physicians can concentrate on patient care.
d) Clear and center the whole team
Invite your team to take a deep cleansing breath to become clear and centered before you start seeing patients ... you all take this breath together and invite any stress or worry or tension out with your exhale.
Doctors are a lot like dogs in some ways. If a dog is sitting on the porch and I get their attention by throwing a tennis ball … they can’t NOT chase it. They can’t resist.
With doctors … the tennis ball is a refill request that pops up on your EHR screen. It is not urgent or important and yet how often do you drop what you are doing to address it?
We mistake every action as an urgent one and chase them just like the dog and the tennis ball.
Add in test results, phone messages, referral paperwork … and your day is fractured 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.
The solution is batch processing. Batch processing is more efficient than continuously switching back and forth between tasks.
Take all the tasks that are non-urgent, put them into piles – batches- and run the batch twice a day at a time when you and your team can address them all at once. In the days of paper charts, we used to put out a basket for each task type. Refills go in this basket, test results go in that one when they return.
In a standard office day where you have an AM and PM schedule, some good times to do batch processing are 11:30 AM and 4:30 PM. That way the morning’s work is done before lunch and the afternoon’s work before you go home.
EHRs make this a little different because often these non-urgent tasks pop up as alerts on your tablet, laptop, or desktop screen. These prompts are equally enticing to our dog-like “fetch” mechanism and even more powerful time wasters.
Batch these too by NOT addressing them when they come in. Make a “virtual basket” that you run in a batch twice a day.
What can you batch in your practice?
Make a list of all the little things that interrupt your day repeatedly. As with your BRMs above, your first task is simply to make the list. Then bring in your team with a good question. “What tasks happen every day – things that are not urgent, yet have to be done before the day is over – that can we put in batches and do all at once, in batches twice a day?” Add their suggestions to the list as well.
Now pick one item on the list and design a batch process.
Example: Your nurse screens all lab results as they come in, alerting you to any abnormal values between patients. All labs are batched in a lab folder in your EHR for your review at 11:30 and 4:30.
Many EHR systems have a real time alert system on their face page telling you how many lab reports or emails or instant messages you have waiting. It is a nearly irresistible distraction and often a complete waste of time since the notice does not tell you about the urgency or importance of the alert.
Work with your EHR vendor to make sure the alerts are appropriate for your practice. Have someone else screen these messages and alert you to the ones that actually demand your urgent attention.
Time to pick a tool and take action.
It is easy to see 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. The key here is to pick just one and take just the first step. That is all. Once you take the first step, the second one will become clear as crystal.
Go ahead and pick one tool that feels like a good place to start. What is the smallest step you can take to implement it? I suggest you tell your team what you are up to and ask for their help right up front. They always have fresh ideas you can’t see when you are in the room with the patients.
DO NOT read this article and fail to take action or you will have missed a chance to step out of Einstein’s insanity trap. It is time to build your burnout prevention strategy.
In article three, we will focus on life balance tools that allow you to recharge your energy accounts and build more balance into your week.
Dike Drummond MD is CEO of theHappyMD.com where he provides burnout prevention and leadership development coaching, training and consulting to individual physicians and healthcare organizations. He will be presenting SVMIC’s live Risk Education seminars in 2019.
Dike Drummond, MD, is a Mayo-trained family doctor, professional coach, author, speaker and trainer whose sole professional focus since 2011 has been addressing the modern burnout epidemic in physicians. He is the CEO and Founder of TheHappyMD.com, where he receives 25,000 website visitors a month and hosts an online community of 18,305 physicians from 63 countries around the world. Dr. Drummond has over 2100 hours of one-on-one physician coaching experience and has trained over 25,000 doctors on behalf of over 134 corporate clients in the last three years.
Dike graduated from the Mayo Medical School in Rochester, Minnesota, in 1984 and completed his family practice residency at the Shasta Cascade Program in Redding, California in 1987.
Dr. Drummond practiced full spectrum family medicine for 11 years as a member of the Skagit Valley Medical Center in Mount Vernon, Washington. He was also the Chairman of the Executive Committee and Managed Care Medical Director for that organization.
In 1999, Dr. Drummond left his medical practice due to career-ending burnout. He became the COO of Superteams, LLC, providing leadership and facilitation training to Lean Six Sigma Black Belts in all branches of the US Military. He is a certified life and business coach with extensive experience in personal and business development with physicians and entrepreneurs over the last 17 years.
We're always just an email or phone call away.contact us