Efficiency and humanism in clinic
7/29/15
Jennifer K. Phillips, MD
Associate Professor at UNM department of
Family and Community Medicine
Be heart based
• The culture of medicine struggles to maintain
the health of its citizens; I think those of us in
health care should strive to be different and
change the culture from the inside – for our
patients and ourselves!
• “A heart based organization is open to
idealists and those who seek to serve others”
• Culture of respect makes things better, safer
and more healing- better quality and safety
Why efficiency?
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Work smarter not harder
There is too much to be done to waste time
Access to care
There is not enough of us to go around
Work life balance
No money- No mission
• We have a mission to serve the health care needs
and improve the health of New Mexicans
• 15th century French proverb, “To cure--sometimes; to heal---often; to comfort---always”.
• “Empathy is innovation, and sensitivity to others
is a huge catalyst for creativity. People who really
devote themselves to studying the human
condition often uncover important underserved
markets.”- Athena doctrine
Start your day off right
• Set your intention for the day
• Arrive on time or early
• Huddle with your MA and/or nurse- are there any
things that will take more time? Procedures? Special
requests from any one?
• Look at pre-work
• Limited patient look up- don’t waste too much time on
this- they may not come
• Have your MA contact patients who don’t show to
reschedule appropriately. Your MA may ask you.
Help things to go well
• Remember “Compassion, patience and
simplicity.”
• Don’t make things too hard
• Try simple before employing complex
• Don’t be afraid of what might be going on
• It is totally OK when you don’t know the
answer… patients appreciate your honesty
Be a problem solver
• Patients come with a problem- we help them
sort it out
• Every day is different
• Be comfortable with all the uncertainty
• There are mysteries
Don’t judge the patients- it wastes
time
• Some people have a broken leg, some people
have a broken head
• Help them move forward to their next stepwhatever it is
• At least half of our job is listening and
reassurance
• Connect in whatever time you have
• Be in service, “what can I do for you today?”
Accept that there is light and dark
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People are poor and sick and tired
Don’t expect it to be any other way
Being poor often makes people sick
You became a doctor to take care of sick
people
• This is the way it is
• “Do not be content dealing only with the
effects of injustice and poverty”
Be a good team player
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Be nice
Be patient
Have fun
Help out- we are all in this together
Don’t waste time with gossip and hard
feelings
• Be flexible and easily adaptable- think
“Bamboo not Oak”
Help everyone to work at the top of
their license
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Delegate appropriate things
Let your team help you
Let your team help your patients
Your patients will do better with a team to help themdon’t be a hero
• Don’t work harder than the patient- meet them where
they are
• MAs and Nurses love their job more when involved in
patient care
• It takes a village- we are all equals but different pieces
of the puzzle
Develop a flow
• Parallel process with your MA at the start of
your visit- start computer, small talk with pt
• People care about how you are “being” -not
as much what you say or what you do
• Open computer- use EMR in the room with pt
• Studies show patients are only bothered by
EMR if their provider is bothered
• Don’t let it bother you
The flow
• Vitals are Vital!
• Chief complaint- why are they here?
• Make a mental list of 3-4 things to address;
some yours, some theirs
• Connect with the patient
• Therapeutic relationship is give and take
• Long term relationship- work in progress
Meaningful Use
• Update Problem List
• Do Medication Reconciliation- what are they
actually taking? Have them bring their meds
• E-prescribe new meds or changes- connect to dx
• Make sure MA updates allergies in EMR
• Check Health Care Maintenance tab- your MA
may have already given vaccines, done foot exam,
and checked POC HgA1C – let them help!
Finish up
• Make plans for problems with: referrals, med
changes, behavior plans, coaching, nurse f/u,
order labs, social work, CHW, etc
• Teach back- “what do you understand about how
we are going to change that?”
• Present to attending as you go or every few! Have
a plan- but they can help
• Do your billing- no level 2s!!
• Most visits are level 3 or 4 (attending sees pt) or
V-codes (preventive med)
Document Now- as you go!
• Don’t save it until the end of day
• Dictate, Dynamic note, template, powernote, dragon,
m-page
• Batching wastes time- up to 20-60 min for every 4 hrs
• LEAN processing used in Toyota and other
manufacturing since the 1990s
• They found that when you batch you build cars with
more errors and you wasted time
• When you wait to dictate or document you end up
with a product that is not as good and you spend more
time making it- people can wait for a little bit- you will
have more free attention to give them
Other Tips for efficiency
• Do not make small talk during peak work time
• Slow is fast- be prepared for procedures- have
everything you need
• Delegate set up and clean up- but don’t make a
mess either
• Notes should be SOAP notes that ‘tell a story’
with key parts- but not full H and P’s- simple
• Don’t be distracted and don’t distract… Focus
your attention
• Good enough is good enough
Gifts of Imperfection
• Don’t expect perfection from yourself or othersyou WILL be disappointed
• “Better done than perfect.”- Sheryl Sandberg
• Communicate well
• Ask questions
• ¾ of life is organization the rest is fate
• Prioritize- Who is dying? Who is bleeding? Who
is sick? Who can wait? Not everything can
happen at once--- patients understand
Don’t worry
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Keep thoughts focused
Keep the end goal in mind
Don’t sweat the small stuff
Do the best you can and move forward
Nothing is perfect
Take pride in your work and how you are learning
all the time
• Remember everything is transitory- hard days in
clinic too will pass- sometimes the goal is just to
make it out alive for patient and provider