This is the second in a series of three articles by Dike Drummond, MD, a Mayo-trained family physician, author, speaker and trainer on physician burnout. On Sept. 28, he will lead a five-hour workshop in Indianapolis to help physicians rediscover their joy in medicine. Sign up at www.ismanet.org/HappyMD.

   PREVENT PHYSICIAN BURNOUT - PART 2   

7 ways to lower practice stress and get home sooner 

By Dike Drummond MD 
CEO, www.TheHappyMD.com

In article one of this three-part series, we discussed the causes, effects and pathophysiology of burnout. If you have not read that article, available online, it is important you do so soon. The tools that follow are not nearly as effective if you don’t 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. Article three will focus on tools to build and maintain your energy and life balance.
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 they 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.

A perpetual balancing act

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, to maintain balance, you must measure 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 EMRs.

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 when the last patient leaves your office and you get home – with your charts done.

Each tool is a potential component of your personal burnout prevention strategy. You may be using some of these already. 

Focus on action

Do not get overwhelmed here.

This is a list article. As you read, take note of the tools that seem simplest to implement or seem most attractive to you. As you read down the list, your job is to pick just one to get started. I will be giving you implementation pointers at the end of the article. 

Focus on taking action.

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 and the next one, part three, and actively look for one tool in each article that you can begin to practice ASAP. Ready? Let’s begin. 

FOUR ELECTRONIC MEDICAL RECORD (EMR) TOOLS

Let’s start with four EMR strategy components we have tested and found effective in the real world.

1. Move from being a hater to a power user
Notice your attitude. Do you suspect that 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 EMRs are ever going to go away? No. 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 not obvious, since to stand up and announce that you like the EMR system 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 any. 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 say “stop” when they do some keystroke combination that magically completes a chart note. Take notes. Ask how they did that. Pick up two or three tools you can use. Before you leave, ask if you may have their templates. They always say yes. 

Two or three sessions later, you’ll be 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 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: longer is not better.

3. Broken-record moment automation: Documentation
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 the desktop, how much of it would have been produced by free typing into the chart? If your answer is more than 30 percent, 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 14th 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 broken-record moment is a golden leverage point to get home sooner. It marks an opportunity to automate. Use this process: 

• As you notice BRMs, 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 broken-record moments into simple keystroke combinations, and you will 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 you are 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. Broken-record moment automation: Patient education
You will find another category of broken-record moments (BRMs) in the patient education side of your practice. Your little voice will point out, “This is the 13th time I have said the same thing to a patient this week.” 

Once again, step one is to make a list of all these moments. Write them down. Then, decide how you will take care of this patient education going forward. There are four main methods:

• 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 or medical assistant in charge of keeping them stocked.
• Video. Record videos of you doing your best teaching on your BRM subjects. Load them onto cheap tablet computers your nurse or medical assistant can give to patients to review at the end of each visit. You can also upload them to YouTube.com and give patients the URL or embed them in your patient portal for patients to watch in your office or at home.
• Delegation. Train your staff to take over the broken record from you.
• A combination of the above, for example, a handout with a video link.

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

6. 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 twice-a-day huddle in your practice, you are getting home later than you need to.

Here are the basics of a huddle. 

• Allot six minutes before each of the two halves of your day.
• Include all members of your patient flow team, such as your receptionist, whoever rooms your patients and the float nurse.
• Make it a stand-up meeting. Go to them. Do not make them come to your office.
• Make sure someone has the schedule for the upcoming half-day in hand. Review the schedule together.
• Troubleshoot the patients on the schedule already. Know who is sick or upset, who has special needs and 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 that a printer is down or you have just run out of flu vaccine.

Huddle power tips:

• Check in with your team. Ask everyone how they are doing. 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.
• Say thank you. Acknowledge and thank the members of your team for anything they have done in the past 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 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. Anytime 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. Take this breath together and invite any stress or worry or tension out with your exhalation.

7. Batch processing
Doctors are a lot like dogs in some ways. If a dog is sitting on the porch and I get its attention by throwing a tennis ball, the dog can’t not chase it. It 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 request for an urgent one and chase it, just like the dog with the tennis ball. Add in test results, phone messages and 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. Stop it. 

The solution is batch processing.

Take all the tasks that are not urgent, put them into piles, or batches, and run the batches 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 went in this basket, test results went in that one when they returned, and so on.

In a standard office day with a morning and an afternoon 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 is done before you go home.

EMRs make this a little different, because these non-urgent tasks often pop up as alerts on your tablet, laptop or desktop screen. These prompts are equally enticing to our dog-like “fetch” mechanism and are 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 but must be done before the day is over – that we can put to batches and do all at once, twice a day?” Add their suggestions to the list. 
Now, pick one item on the list and design a batch process. Consider:

• 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?

Here is an example process: Your nurse screens all lab results as they come in and, between patients, alerts you to any abnormal values. All labs are batched in a lab folder in your EMR, which you run and process at 11:30 am and 4:30 pm.

Batch Processing Power Tips

• 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 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 act

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 only 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 seems 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 that you can’t see when you are in the room with a patient.

Do not read this article and fail to act, or you will have missed a chance to step out of Einstein’s insanity trap. It is time to build your burnout prevention strategy.

Everything you need to do that is here in article two of this three-part series. 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 health care organizations. He is the creator of the FREE Burnout Prevention MATRIX Report with more than 235 ways to prevent physician burnout.