Becoming Faster At Seeing patients – Making It Easier On Yourself
I recently got my 2015 fourth quarter performance numbers, I did quite well in patient turnaround time as well as patient satisfaction scores. In this post I want to talk about a few techniques I use to see patients efficiently, safely, and timely while providing good customer care.
I cringe when using the term ‘customer care’ but I’m intelligent enough to recognize that this is the direction medicine is going. Disagree with me if you like, but most of what we do to patients and for patients is not really changing their outcome much which has made it even more vital that the medical field markets its services to the consumer. Through the advertisements that the pharmaceutical companies run, despite their inaccuracies, we have been able to make patients think that they do indeed need us in order to maintain their health.
In a society that has embraced the Starbucks culture, speed and efficiency are the cornerstone of success. It’s about delivering consistent and perfect customer care, right here, right now. People get mini heart attacks having to wait too long in line, they will have a shit-fit if their mocha-latte isn’t exactly what they asked for. And even I find myself frustrated when a webpage doesn’t load at the speed that I think it should.
I am good at what I do because I can embrace this big picture. I know the major players in management, I know what numbers they are measuring and I recognize the variables that could hinder my performance. I’m not working trying to deliver perfect healthcare… that almost makes me chuckle thinking about it; if I did that I would be out of a job within a few months.
I recognize that a patient who comes to the urgent care, paying the higher fees and willing to wait around for their same-day appointment is doing so mostly for the convenience. A secondary factor might be that they are worried about a sign/symptom and don’t think they can wait for the primary care doctors, while not being sick enough to brave the emergency department.
Completely an erroneous conclusion, my timely entrance into the exam room is viewed by the patient as my level of competence. My confidence and just a touch of that God-like complex puts the patient at ease. A well-placed smile with really good listening skills without interrupting the patient makes me seem caring. My body language, head position and right amount of eye-contact assure that the patient knows they have my undivided attention.
This completes the ‘courting’ phase. They are sizing me up, figuring out whether I’m competent. The meek patient will act super submissive and hope that I take enough charge without dominating them. The confrontational patient will try to dominate me but at the same time know exactly when to pull back once they fail to do so. The malingering patient will try to control me and hope that I avoid eye contact, and they will respect me for not calling them out but at the same time not playing the sucker.
So, the meek, the aggressive, the malingering, these are 90% of the patients I see. I have a method to deal with all of them which is also about 90% effective. Based on the Pareto Principle, I am the most efficient if I deal with this larger percentage and then deal with the rest on the fly.
I shadowed a sport orthopedist in my group once, someone I grew up with, a very intelligent and technical doctor. But man, that dude was struggling in clinic, not able to get a word in, not able to establish a caring dominance, to the point of drowning in the first 2 patient visits. I stepped in and gave him a couple of pointers, and just like a brilliant specialist he absorbed that immediately, implemented it and holy shit, what a difference. He wrote to me a week later saying what a difference I made. Yes, I’m tooting my own horn, let me have my moment of glory.
I’ll delve into the specifics of dealing with various personality types in a later post. I want to address 2 other issues that I believe can slow down and render a good clinician ineffective. I will start out by saying that you should know you are a good clinician, whether you are specialist, hospitalist, urgentologist or dermatologist. We are so over-prepared in the US medical schooling system that unless you just plain don’t give a shit, you have all the knowledge and/or tools needed to be a good clinician. Therefore, for most of us the clinical aspect is the easiest, it’s the rest of the shit we deal with that this post is written for.
The 2 other limiting factors are your staff and the ancillary services. Staff would be the MA, LVN, RN, xray tech, lab tech, specialists on the phone or front desk people. The ancillary services would be laboratory, imaging, patient transport, space availability, pharmacy and scheduling. These do overlap quite a bit but understanding them will help you stay afloat and it will increase your efficiency by at least 50%. More importantly it will make your job easier by a factor of 2.
Staff – They Can Negate All Your Hard Work
If you are working with slow staff on a particular day it is best to not assign them too many tasks. I go as far as to tell them to only vital a patient and room them. I don’t want them to get a chief complaint, I don’t care for the patient to be ungowned, and I don’t care for any procedure trays to be set up. No, I’m not encouraging weak staff. If I am inclined I will then show them how quickly I set up my own procedure tray so they can learn, which works only if I show them more than once, or I will let their team-leader know about my staff’s inefficiency and make sure it’s addressed. Plenty of times I will even pull my own patients from the waiting room… sometimes this is just the right kind of shit-stirring that needs to happen for the staff member to step up.Super busy day in the urgent care, not a single nurse to be found anywhere to relay orders to.
If it’s a crazy busy day with a lot of demand on the staff I will not add more to their workload, it will only bite me in the ass. Three IV fluids already running? I will PO challenge my patient. Two patients in monitored beds? The next patient needing monitoring will be sent off to the hospital. It is better to divert a patient to the ED/Hospital than slow down your patient flow and the entire system in the urgent care.
Furthermore, I will discharge my own patient, it’s the best way to close the loop on the entire visit. I don’t want my patient asking some vague question to my MA who will then have to track me down to ask that question of me, Chinese whisper style. This will keep the patient in the room longer, which means I have one less room to work out of, which means that my MA is not rooming patients because she is looking for me instead. Sure, you might get stuck with “How do I call to schedule this follow-up appointment?” “Where do I go to pick up this sinus rinse kit, how much is it?” But it’s still better to answer these yourself unless you have a stellar nursing staff that day.
It’s easy as a doc to get lazy in the monotony that is your day. Who wants to go draw up the same lidocaine, in the same syringe, always finding the alcohol pad drawer empty, grabbing the same gloves and walking back to the patient room with your loot. However, if you get into the habit of doing a lot of this yourself then your self-sufficiency will become a huge commodity. Which staff is gonna complain about you when they know you are self-sufficient? Run with this, do more yourself, and soon you will see the more competent staff will be drawn to you, they will fight to work with you and they will weirdly make it their mission to have you do less of the monotonous work.
Ancillary Services – An Easier Beast To Tame
Enough about staff, let’s talk about the ancillary services. You sent a patient off for an x-ray or lab test and the receiving department is slammed. Think outside of the box, think on your feet. Why are they slammed? Is it because their phlebotomist called out sick or is it because the x-ray tech is also stuck doing EKG’s today so they can’t focus on performing imaging. You can get this info from your nurses usually, nurses have an incredible ability to see the big picture which is why they do a better job than doctors running a clinic/hospital floor. So, have your nursing staff do the EKG’s that day, have your nurses draw up the blood and send it over to the lab who has enough lab techs to process the blood. Or, remember that you as a clinician have the ability to change your judgement call. If you are getting that CBC just in case so you can sleep better at night, fuck it, skip it, go with your instinct and go with your next move.
You may not know why but same days will feel especially draining. Is it because of higher acuity? Possibly, but very rarely does acuity change. Your decreased confidence that day, your skewed perception, your indecisiveness is more likely to blame. It’s okay, you are gonna have those days. Did the bus just drop off a bunch of asshole patients? No, you’re having a shitty day because your underwear is riding too high. First, recognize that you are having an off day, that every case is seeming complicated, nothing is straight forward.
Your instincts aren’t serving you well, remember the basics, go back down to technique. It’s like when you play a sport, you’re just not feeling it that day. Every move that used to come naturally, you have to think a lot about. Get your technique down, write the case out on a piece of paper if you have to, type the case out and write out a plan/DDx/assessment before making a decision about what to do next with the patient. You will see how quickly you can gain your flow back this way. On such off-days I get the HPI, do the full exam and then excuse myself either with an excuse or tell the patient that I will have to go think about the next step – it works just fine for me.
However, sometimes it’s your front desk staff who are all having a shitty day, pissing the patients off which means the patient will unload that crap right on your freshly shaven face as soon as you step into the exam room. Learn to defuse the situation and if you are in the position to say something go up to the front desk and ask if something is wrong? “Yes! Our damn system is down and we can’t look up anyone’s co-pays and the patients are getting pissed at us!” This is when you reach into your wallet and take out your credit card, order food for the front desk and again, if you are in a position to say so, have them not collect co-pays that day and tell the patient that they will be billed for this visit.
Think on your feet and outside of the box… show the staff that you feel their pain. They view you as infallible, they think that your work is easy, sometimes they need a little hang-hug from you.
What makes me stand out in the urgent care is that I am highly efficient at triaging patients, coming across as caring, not wasting time in the exam room, I am decisive and I make the patient feel cared for. I always have a smile on my face and I joke around with the staff in an appropriate manner. Am I among the top physicians providing quality of care? Interestingly I don’t know of any metrics for this in our organization. We do internal audits and I haven’t had any bad outcomes/cases.
I know shitty clinicians with no adverse outcomes and I know amazing clinicians who have had 1-2 terrible, sad outcomes. I have certainly had my misses, things that I could have done better to ease suffering and cases I’ve followed where, had I been a little more vigilant and thorough, I would have prevented a negative outcome.
How can I capitalize on these positive attributes? If I can consistently be in the highest percentiles as far as efficiency, quality of care and patient satisfaction scores then I can market myself as a consultant for various medical groups. Many Primary Care offices like adding Urgency Care to their practice in order to generate more revenue, but they can get bogged down due to inefficiency.
I could also use my skills and move up higher in a leadership role. I did just that, taking on a medical director role a few months ago. I’m proud to say that my medical group tends to advance people who are skilled at what they do, not those who are good at puckering up someone’s ass.
If I can develop better organization skills I could write an online course which clinicians can take to help them improve their efficiency and speed. I could market that to various urgent cares as well as my own medical group.