บทถอดความฉบับเต็มของ Doctors, Stop Charting After Hours: Dr. Sarah Smith, The Charting Coach

months I had this same problem of I was there after, after the last patient left for hours and hours, I just going home without the work being done. I was then working in those evenings and weekends. And it was when my big kid was in grade 10 and I was listening to him have a conversation with dad about going to uni in two years that I, my heart just sank and I realized, wow, I've been their mom and a doctor since, you know, he's now grade 10 and I still haven't figured this out, what's wrong with me, Because I thought it was a me. Well, I thought it was definitely a me problem because it followed me from Australia to Canada. And then I'm like, well, will I ever figure this out? And I had no idea how to figure figure out this problem. It was completely impossible. I had not been given any other way of doing medicine. And this was my life and I was done with it. I was resenting it fully by that stage. 5 00:03:53.000 --> 00:04:06.000 Well, I feel like it's something that's become so normalized in medicine. You know, people almost think, okay, I can't avoid this. So do you think now is it really unavoidable? 6 00:04:06.000 --> 00:06:00.000 So I do believe that many of our systems are not looking after doctors OR clinicians. So one, our EMRs, EHRs are not designed for us. They're designed for being able to track what we're doing in a day and to be able to hold a lot of information about patients. But it takes so many steps to be able to do something within that emr. And even finding information back out of that EMR is not well looked after for us. So. So that's part of the problem is it's not set up for us. Secondly, especially since COVID But I know many physicians in the US were already managing massive mychart inboxes, so they've got that direct patient to doctor conversation happening. A lot of the physicians didn't have that happen until the COVID times in Canada, for instance. So this was going from something that never existed, which was patient direct to doctor questions started to become a bigger feature of. And if we don't start to notice the ask on us, we are always, always asked to do more. They never ever. I've never, not once in my career ever heard of a doctor who somebody comes up to them and says, hey, can you see a third less patients tomorrow? Can we, you know, do your inboxes for you for the next week. Like never. But we'll get asked, can you cover Sally's inbox for the next week, next month? Can you pick up so and so shifts they're sick today? We'll get asked to do more. And so it becomes important that we notice what we're being asked to do and we have strategy on how we do it. So that inbox can be light or heavy, depending on how we've been taught or learned to approach it. And the same number of items can look very different for humans if we're not taught strategy. 7 00:06:00.000 --> 00:06:27.000 I think that is so true and I love hearing you say that. It's being able to set those boundaries and have that right communication.

So tell us, what are some tips and strategies that you found that you've deployed? I know we're going to get in here more about what you're, what you're doing to help with the charting, but tell us what, what have you just found works? Being a practicing physician or clinician and then kind of pushing back. 8 00:06:27.000 --> 00:09:29.000 Yeah. So we know that direct patient to doctor is not. Or clinician is not ideal because often the questions coming to the physician are not physician questions, like, can I get an earlier appointment? That's not a question you need to be answering. It's not for you. So starting to think about who else is in my team. Who else can be doing this? Who else is looking at this ahead of me? A lot of physicians will have a nurse, an MA or somebody looking at those messages before they're passed on to you. And so sometimes I hear a lot, but my nurses are busy too. I'm like, yeah, but when you have them read it and then action it to you, and you have to read it and action it back to them, then they're doing work twice anyway, and they've already had to read it to assign it to you. And therefore, if we give them a step, a permission step for some of those things to be automatically deferred to the other person. Back to please rebook this. We now remove some of them out of your inbox. So starting to be curious, who's available, who can help me with this? Now, some of you will say, there's no one, it's just me. In which case we just need shortcuts for you. But just be wise before you say that, really be curious. Is that true? Is there anyone else in my team? Can we start having conversations about what it looks like to be just deferring everything on and not having some think because the nurses Have a lot of stuff skills and they can do some of that high level thinking for us. We can permission give for even some of the items will reduce the things on your. Secondly, it can. So we had an example. One of my physicians recently came to me and she counted her items. She'd done 1200 items in a week. Well, yeah, that's in addition to patient care. Yeah, right. And this was overwhelming and unsustainable. Now it took us a number of weeks and we looked at everything she was doing about her inbox and you'll have some places, some administrative organizations who really want to push the patient portal, they want patients using this. But it's up to you how you approach that. You can't stop them having this angle at patients, but you can certainly stop the tennis that happens the back and forward of these messages with your approach. So she would ask for clarification from the patient and the patient would write back. Now that's creating another item in her inbox rather than that defer to well, I can't look at your rash in a patient portal message. I need to see it to do good quality patient care. And so saying this is a great question for our next appointment and getting that patient in now that requires systems to be able to create

room for that patient coming in. But it's important that she's not spending three paragraphs trying to figure out what sort of rash it is. That's not good clinical care. 9 00:09:29.000 --> 00:09:59.000 Well, that, that is great advice. And I think it's something that, like you're saying sometimes is a learned behavior because you want to take on everything and you think, okay, I don't want to push anything off. But with, by doing so, you're, you're really, you know, almost burdening yourself with too much work. And so I love that advice. And I wanted to also ask you because I know you talk a lot about, you know, what are some habits that kind of quietly create this documentation backlog throughout the day? 10 00:09:59.000 --> 00:10:46.000 Okay, so habits during the day, look, they're everywhere. Because habits, like you said, are learned behaviors that we have practiced over possibly decades. And so to intervene, the first step is noticing what am I doing. So the noticing isn't the fun part because we often want to judge ourselves so badly. An example, I notice that at 10:30 I'm running half an hour behind. Now you'll have this sinking pit in your stomach when you realize that. But rather than to pay attention to the sinking pit in your stomach, I want you to say, I wonder why and start to notice what's happening that's creating that result? Because there is the place that we can intervene. So I wonder why. Well, I rushed in at five past eight. My first patient starts at eight. 11 00:10:46.000 --> 00:10:47.000 Why? 12 00:10:47.000 --> 00:12:27.000 Well, I had this dread and anxiety in the morning. I didn't want to get out of bed. And then my lunch took three minutes extra to, you know, organize because I hadn't blah, blah, blah. And there'll be reasons, right? So we dash in the door at five minutes past the hour, the door gets unlocked at eight. So the patient couldn't even be in a room for 8 o' clock even if you wanted them to. And that five minute delay of getting started now compounds. But you looking at yourself saying, I'm a terrible doctor because I'm running X number of minutes behind. And you, you didn't even create some of those minutes. You were sitting around waiting for somebody to put someone in a room or someone to get weighed in or someone to get measured. So it's important to start the noticing. It can look like the words we use in, in an encounter can add to those minutes too. How are you today? Cost you five minutes. Five minutes rather than a professional and friendly, what are we doing today? Can shave minutes off your encounter time. We're only given X number of minutes with a patient, whether we've chosen that or we've been given that appointment length because physicians and clinicians work in environments where they either choosing that or they're being given that. We can help you run on time by the noticing. What minutes am I given? If I understand that the encounter includes all of the aspects of the encounter, any referrals that need doing, all the orders and the notes now, how will I approach that time? Because if we just what are we doing today? And we get the list from the patient and we try and figure it all out and then an hour later we're like, oh, no, I only had 15 minutes. 13 00:12:27.000 --> 00:13:11.000 And I know there's that time squeeze. And I know that that's something that you kind of feel like, okay, the clock is ticking, here we go. And so I know that there's a lot that sometimes can be done in advance. Like I've just, you know, I. Sometimes patients can answer questionnaires in advance. And like you're saying, how do you kind of lead that first intro can guide and save. Save a lot of time. So I think that's a really practical tip for everybody. And is there something in terms of, I know you were talking about inbox, like what, what do you recommend? Or what have you seen work for other physicians do the. Is it best to tackle it first thing at ongoing throughout the day, at the end of the day, what strategies have you seen work there? 14 00:13:11.000 --> 00:16:02.000 Yeah, it's important because we're rarely given protected inbox time. Rarely. Like, we do see models of that happening some places, like you'll be given an hour admin time or you'll be given whatever, but most don't. And so now we know there's a time requirement for this in basket, and I'd love to have that. So whatever you spend, like, if it takes me three hours to do my inbox, I'd love it to take an hour and a half. And that can be possible to say, how long does it take me? And then how can I make that half? That's a great question to ask your brain. But now, when are we going to do this work? So what is available? What is that protected time? Because the last thing we want to do is do it between patients. We come out of that room, we open the inbox, we hit the first item, we look at it and say, well, I don't have time to figure that out right now. And we close it again. And now we're doing that inbox twice or more for each item. So we want to set aside some time. It'll look different for you by day, by week, but we need to really say, where are my moments of time where I have time for that? So it could look like you've got 20 minutes in the middle of the day. It could look like I've got 10 minutes before I see the first patient. And then the last question you want to ask yourself is, where should I start? Because we've just used up that initiation energy. So we need a plan. So I'll give you an example. I would get script refill requests, and I said yes to doing them. I wanted to do them outside of a patient encounter. For me, it worked at the time. But if I did not get that to the chemist or the pharmacist by lunchtime, I got a second reminder. Now I have two things in my inbox for the same problem. Now I've just doubled my inbox. No, thank you. So I would hit those script refills first thing. I then realized I would open it up. I'd see what pharmacy, what thing that they

wanted for that patient. Then I'd have to go to a different screen. And then I have to remember, hang on a minute, what chemist was that again? And I'd go back to. And I was toggling between pages. Well, that wastes time. What do I need? I need two screens. So it's starting to be aware of what is taking me time because all the minutes and seconds count. What do I need? Starting to ask that question. What do I need to make this faster, easier and done. I might need to have helped myself. So if I have put into the free text box why they're on this medication, it helps me decide how often I need to monitor it. So if I've written rosuvastatin, primary prevention diabetic has a different level of monitoring than post demi. So that already saves me time too. When I go to do that script refill, I'm not then saying, are they up to date with their lipid profile? 15 00:16:02.000 --> 00:16:19.000 Love that advice. Now tell us. I know we talk about AI scribes and you know, documentation tools. They are becoming more common. Are you seeing this help solve problems? Some of this, you know, problems with, with just time management. 16 00:16:19.000 --> 00:17:40.000 That's a great question for some of the physicians I look after. This is the missing piece of the jigsaw and they are thriving with that extra little hand. For others, they're using it as a tool to hurt themselves with. And that's. This is what I mean. They use it in the encounter and then they say, well, the note is done somewhere in the Ethereum, so they leave it to later. Now they've created a brand new work list of items to do later. Wonderful. In addition, Most of the AIs are still hallucinating, so you have to read through it for accuracy. Then you're reading it in somebody else's language because it's rarely looks like something that you would create yourself with the language that you would use in the format that you would do it. So now you have to read fully to look for error to understand what happened. And when you see that note next time, when you're going into the patient encounter, it's not your writing. So now you have to read it to be able to figure out what was going on last time. So it's actually time, time, time. So if we're going to use AI, we still need I see the patient, I close the chart. How am I going to end the AI, read it for accuracy, edit if needed, and close the chart before I move to the next patient. Otherwise all I'm doing is creating myself yet another inbox. No thanks. 17 00:17:40.000 --> 00:17:45.000 Another workflow. Write another workflow. 18 00:17:45.000 --> 00:18:45.000 Let's write another list to figure out. Plus some AIs will kick it out after 30 days. It's lost Forever. So some physicians aren't getting to it within that 30 days. So now they've got zero about that encounter when they go to do that chart note for some of the physicians who are really behind in their backlog. So a couple of possibilities. One is I leave myself a mental hook at the top. My little concise summary if I'm going to use AI. So something quick that I can have a look at next time I'm in the patient chart so I don't have to read through everything. Some of them have better processes on the back end so they can start to look and sound like you. And some of them you can put templates in as well so it can be closer to the format that you're used to reading things in. So when you're looking for an AI, you're looking for a really high level processor, something that's highly editable. So it's a little bit more familiar to you when you're looking at that note later and don't leave it till later. Don't give yourself a brand new inbox of things to do. That's not fair. 19 00:18:45.000 --> 00:18:48.000 Are there any that you particularly like, Dr. Smith? 20 00:18:48.000 --> 00:18:53.000 No, none that I can tell you are amazing. None. None of them. 21 00:18:53.000 --> 00:19:28.000 So we're getting there. Let's the whole, whole trends with AI is we're, we're getting there. Well, I appreciate that. Well, tell us now. I know obviously this is something you've studied a lot. So with, you know, the after hours charting and all of the documentation, how correlated is that with physician burnout? If you see somebody that's able to break that cycle, do we see them rebound in terms of, you know, their work life balance and just being overall more happy while they're practicing? 22 00:19:28.000 --> 00:21:52.000 Yeah. So we've studied the physicians who came through charting champions and we saw a statistical significance in improved quality of life, reduced burnout, reduced time working after hours, improved job satisfaction. And then also they weren't seeing less patients. So this was able to get that work done without dropping numbers of patients in a day, which I think was really important for them to see because they were worried that I was going to tell them to just half the patients they see in a day. And I can tell you some of the physicians who've come into my world have halved the patients and it hasn't helped because they just expand the appointment to include all of the time and their habits of leaving it to later continue. And plus we've generated more items in that appointment. So we've now got more items to do later in the inbox. So it's really important that we understand the time working outside the room is really contributing to our job dissatisfaction. It's giving us a whole second job that's typically unpaid. So we're doing all that paperwork. Administrative burden, typically not generating dollars for you. You've earned the dollars in the room. Now you're diluting your income. You're using up your required time for rest and recovery of your brain so that your executive function can be restored and optimized by tomorrow morning to help your decision making. So we end up vicious cycle of tired. That's harder to do the work. So we want to defer the work. So then we're having to do the work later. Then we can't rest and

recover. And we can understand this is not a now a me problem, it's an us problem. If my colleague is here three hours after shift, they're having less time to recover. They're more likely to want to leave. And so that's not helping physician retention. And that's really important that we understand this is not just about me and my suffering. It's about us and our retention. Because if you leave, I have to do double and I don't want that. And so it's about looking after each other and noticing, hey, I noticed that you're still here when I leave at night. What's going on? Can we help you? Is there anything that we can do to get you out of here on time? Like as we start to do that for each other, it's wonderful. We see this in emergency departments, hospitalists and clinic staff. If they're starting to watch each other and say, your administrative and charting is important. If you're not getting to it, how can we help you? And starting to be curious about what do they need to be successful. 23 00:21:52.000 --> 00:22:03.000 I think that is a perfect segue into. If you have any advice for healthcare leaders, what would you recommend for reducing physician burnout? 24 00:22:03.000 --> 00:23:55.000 Yeah, I think listening, watching what's happening with your physicians and listening to what they're saying. Remove any patient to doctor direct contact. We don't get that with our dentist or our lawyer or why would we do it to our doctors and clinicians like, and who is in the middle and what are they actually given permission to do on your behalf? I think the more we offload as we realize the patients want this, they want to be able to ask questions between appointments. How do we improve access for physicians? I see so many companies want to have our doctors fully booked six months in advance because they're worried it won't fill up. And the doctors are now having to approach that inbox in a way that I don't have an appointment for six months. So I've got to do this inside the inbox in a different way because I know I can't get them back in. And that's ridiculous. You can be half booked in the morning and be fully booked by afternoon. And those encounters are then so different because they're timely and necessary rather than the patient deciding, I need to be seen in so many weeks when that isn't necessarily the right person for that appointment that day. So starting to watch what's happening for the physician, see what the issues are in regards to emptying the in basket and access is a big deal. Looking at the teams that are supporting them and getting them to their highest level of ability to help you. So having the nurses have permission to do some of that inbox work ahead of the physicians, the permission giving to get that. Yep, that looks like a great question for a visit. Let's get you booked in. Rather than sending it on to the physician to have to then send it back saying, appointment please. They would be some of the places I would start and then listening. What do you need? I need two screens. My current workplace had me a second screen by that afternoon. 25 00:23:55.000 --> 00:23:57.000 We like that. 26 00:23:57.000 --> 00:23:58.000 We love that. 27 00:23:58.000 --> 00:23:59.000 What do you need? 28 00:23:59.000 --> 00:24:04.000 You might not know what you need, so you might need someone to come and sit and watch what you do and be like, I see that, blah, 29 00:24:04.000 --> 00:24:23.000 blah, blah, Right, right, right. How can we make more efficient? Well, that's great advice to the healthcare leaders that are listening and I want to give you the opportunity, if you could leave, you know, every physician listening with one message about reclaiming their time and building a more sustainable career, what would it be? 30 00:24:23.000 --> 00:25:37.000 I say it's possible. So it's possible to be having a different experience right now with the systems that are happening at you and to you, with the patient numbers that you have, with the inbox that you have, with the staff that you have, there are places where we can help you start to approach it differently. So if you're experiencing dread, anxiety, overwhelm, have no idea where to start, that's okay. Just the knowing it is possible to be having a different experience. What could I do today to look after me too? How could I start to do this in a different way? Asking your brain good questions and then going and finding the answers. So going and saying, how can I make this different? What is available for me to do this in a different way because I tell you we will do things on repeat day after day for decades. This was my lived experience. Nothing changes until you do and everything can change. Infinite possibilities if you want it. And I think that's just so important to hear that. It doesn't have to be like this. You have choice always. Even the way you start and end encounters or the way you handle your inbox items is always all up for negotiation when you want different. 31 00:25:37.000 --> 00:25:47.000 Great advice. Thank you so much, Dr. Seuss. Now tell our listeners how they can work with you and improve their work life balance and overall satisfaction. 32 00:25:47.000 --> 00:26:01.000 Yeah, I would love to be able to deep dive with your listeners. So we have Charting Champions program, which is a opportunity where you can come in and ask your direct questions that you don't understand my stuff. La la la. 33 00:26:01.000 --> 00:26:02.000 Right. 34 00:26:02.000 --> 00:26:18.000 That's what we do inside the Charting Champions program. We meet weekly so that members can come and ask questions or just listen in to other doctors figuring out their clinical day. You can find all that information at Charting Coach. And like you said at the beginning, my podcast, Free to Air is sustainable clinical medicine. 35 00:26:18.000 --> 00:26:38.000 Great resources and valuable tools for all of the providers that keep us all so healthy. And we want to give back and make sure that they're getting some time to enjoy their lives and be, you know, their best version of themselves. So thank you so much, Dr. Smith. Really appreciate your time on the Doc Lounge podcast today. 36 00:26:38.000 --> 00:26:39.000 Bye all. 37 00:26:39.000 --> 00:27:05.000 Thank you to all of our listeners. If you would like to be notified when new episodes air, make sure to hit that subscribe button. And a big thank you to Pacific Companies. Without you guys, this podcast would not be possible. If you would like to be a guest, Please go to www.pacificcompanies.com. thank. You.