Part II: Prevent Physician Burnout: 8 Ways to Lower Practice Stress and Get Home Sooner

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 and your desired quality of life on the other.

Dilemmas are very common in health care. 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 EMR.

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 our 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 comb through this article and part three actively looking for one tool in each article you can begin to practice ASAP. Ready? Let’s begin.

A Five-Part EMR Strategy

Here are five EMR strategy components we have tested and found effective in the real world.

1) From Hater to Power User

Notice your attitude. Do you feel your EMR 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 EMR 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 EMR 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 EMR 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 two to three 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.

2) 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 are writing in the chart is not supporting your billing code, covering your “legal part” or helping the next provider in the chain, don’t put it in your note.

Do not write the great American novel. You do not need complete sentences, or perfect spelling, you never need to touch the semicolon key, and remember that longer is not better.

3) Use the Software

The use of EMR 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, “OMG! 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 home sooner. It marks an opportunity to automate. Use this process:

• As you notice BRM, just write them down. Make a list.

• Once a week, take one off the list and template it. Ask I.T. or your Power User friend to help if you need to.

The templating process will only take 30 minutes or so. Here is the power.

• How many times do you need to make a template?

• For how long can you use that template?

In a month you will have transformed four BRM into simple keystroke combinations and be getting home sooner.

4) Team Documentation

You are programmed to be a Lone Ranger superhero perfectionist. 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 at the apex of the care team and the one who gives the orders, your staff will not usually butt in and tell you to 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 quickly?” Then be quiet and see what they say. This is way more effective than trying to figure it out yourself and giving them orders.

5) 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 you don’t have: 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.

• Get your administration to OK a risk-free scribe pilot in your practice.

• Run a detailed production and billing report for your last three months.

• Hire and implement a scribe in your practice. You pay all the costs. The scribe provides the manpower.

• Dial them in as well as you can over a three to six months period, until you feel you are working at maximum efficiency.

• Run another three-month production and billing report, now with your scribe.

• Prove you are now seeing more than enough patients to pay for the cost of the scribe.

• Ask your group to take over those payments. This is known as a “claw back.”

Broken Record Automation - Part II

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.

1) 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.

2) 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.com and give the patient the URL or mount them in your patient portal for the patient to watch in the office or at home.

3) Delegation

Train your people to take over the broken record from you.

4) Combination

A combination of the above, like a handout with a video link, etc.

Eliminating BRMs, in both documentation and patient education is one of the quickest ways to get home sooner.

The BID Huddle

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 BID huddle in your practice, you are getting home later than you need to.

Huddle Basics

• Six minutes twice a day before each of the two halves of your day.

• Include all members of your patient flow team. Receptionist, whoever rooms your patients, the float nurse.

• Stand-up meeting. You go to them. Do not make them come to your office.

• Make sure one of you has the schedule for the coming half day in hand. Review the schedule together and do two things.

• Trouble shoot the patients on the schedule already. Know who is sick or upset, who has special needs, who needs specific equipment or a special room.

• 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 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: Ask everyone how they are doing today? Get to know if there is anything going on here at work or in their personal lives that you need to know about, both good and bad. Know who’s child is sick and who’s 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 help you or the team do a better job. Praise early and often and be specific. “Thanks for your hard work, we really appreciate it.”

Delegate: 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.”

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 out breath.

Batch Processing

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 EMR 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 a 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. 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 our 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 a.m. and 4:30 p.m. That way the morning’s work is done before lunch and the afternoon’s work before you go home.

EMRs 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.

• Where will you collect the items to be batched? Is it a physical basket where you will put physical forms 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 the physician must get involved?

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 EMR which you run and process at 11:30 a.m. and 4:30 p.m.

Power Tip

Many EMR 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 IT to get these off your EMR face page. Have someone else screen these messages and alert you to the ones that actually demand your urgent attention. Sometimes you will find the alert box cannot be taken off the EMR face page. In that case you can still go old school.

Take a sticky note and trim it to the size that will cover the alert box. Stick it over that portion of your EMR screen and discipline yourself to peel it off and run the batch just twice a day.

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.

Biography

Dike Drummond, MD, is CEO of theHappyMD.com where he provides burnout prevention and leadership development coaching, training and consulting to individual physicians and health care organizations. He is the creator of the Burnout Prevention MATRIX Report with over 117 ways to prevent physician burnout.

Contact: dikedrummond@gmail.com

Reprinted with permission from Family Practice Management, American Academy of Family Physicians, September/October 2015.