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“This is not what I signed up for.
Have you ever said this when you are rushing home 1.5 hours after the last patient left and you still haven’t finished all your charting? You grab a handful of forms to take home with you with the hopeful expectation that you will get them done tonight too. After you have done ‘enough’ to appear to be a present parent and prepared supper and said goodnight to the kids, that is.
You sink into the couch at the end of the household rush with the guilty constant ‘should be’ invading your every breath. I should be finishing my notes. I should go empty that inbox. I should tackle one or two of those forms. But your body feels heavy, and your couch entraps you with its soft embrace, you open Facebook and disappear.”
Sarah J. Smith is a family physician and can be reached at the Charting Coach.
She shares her story and discusses her KevinMD article, “You didn’t sign up for this. You don’t have to drown in the paperwork.”
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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.
Transcript
Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have Sarah Smith. She is a family physician in Canada and a life coach. She wrote the KevinMD article “You didn’t sign up for this. You don’t have to drown in the paperwork.” Sarah, welcome to the show.
Sarah J. Smith: Thank you so much, Kevin, for having me.
Kevin Pho: So we’ll get into your article in a little bit, but first off, can you share your story and your journey to where you are today?
Sarah J. Smith: Yeah. So I was a family physician for 15 years and still wasn’t able to get home with my charting done, and I was spending hours and hours in the evenings and weekends just doing my paperwork. I was looking for solutions, and at that time, the only people helping were people who were helping people leave medicine. And I really enjoy my job. I love my patients, and I thought that there must be a better way.
I’d asked mentors over the years how to get in control of my charting, and their answer was, “Come in on Sundays.” And I wasn’t happy with that answer either. And I found a general life coach who was able to help with any problem. I spent 18 months figuring out my charting problem, and the difference is amazing. Being able to have that certainty that after I finish the last patient, my charting’s done, I have my inbox able to be managed, and having my evenings and weekends free was such a major transformation and such a huge relief from the mental load.
Kevin Pho: Of course, what you’re describing is common not only in Canada but also in the United States as well. I’m a primary care internal medicine physician myself, and that story you told could apply to any one of us here in the United States. So before we get into your article, tell me a little about your practice.
Sarah J. Smith: Yeah. So I’m a rural physician. I have 1,400 people on my panel, and I also do emergency ER shifts. I’m doing that tonight, a 16-hour shift. Inpatients, long-term care, palliative care, lodge patients, the whole everything that goes with rural practice other than obstetrics and anesthetics. So, yeah, practicing physician here.
Kevin Pho: And do all the places that you practice in, whether it’s in your long-term care facilities, your clinic, or the emergency room, are they all electronic medical records?
Sarah J. Smith: No, we’re still paper charts on the wards and in emergency and in long-term care. So it’s a mixture.
Kevin Pho: Yeah, OK. All right, so let’s talk about your KevinMD article. It’s titled “You didn’t sign up for this. You don’t have to drown in the paperwork.” Now, for those who didn’t read the article, can you just walk my audience through it and share the story of why you decided to share it?
Sarah J. Smith: I wanted to let physicians know that this is a common experience for them. There are options for helping you manage your clinical day and getting transformation in your clinical day. There are physician coaches now available who can help walk you through changes in your clinical day, but just even knowing that change is possible can be helpful for some physicians.
So physicians are often describing to me six to 30 hours of charting after patient encounter time: the time they spend with patients, and then again the same amount of time with the administration and paperwork. And their mental load is suffering because of it, and they’re wondering if they should walk away from medicine. It’s not something they really want to entertain, and they’re looking for alternatives. And that was what this article was about: just saying there are options. It isn’t just working on Sundays.
Kevin Pho: So please share some of the actionable tips that you write in this article that can help physicians get through the number of patients that they have to see.
Sarah J. Smith: Yeah. So the tipping point is wanting a change, like really having that determination: “I want this different.” And then making the steps towards how could you finish that chart after this patient if you wanted to? What could you start to do differently within your encounter and immediately after your encounter? What are the obstacles coming up for you that are getting that chart note done, and how is it possible if you wanted that solution for yourself?
Additionally, we look at leading the consultation, so actually in the room with the patient, the value that you’re giving. You can’t do 30-second medicine without giving yourself homework, right? So even if you say, “Yes, I’ll do that for you,” what you’re saying is, “I’ll do that later, in my own time.” And so it’s having that ability to help your patients understand the value you want to give them and that everything’s done at the end of the consultation.
And then even managing interruptions and distractions in your day and having protected time for your inboxes. A lot of physicians see this inbox as kind of random activity that happens to them. They’re not actually taking time to figure out how long do you spend doing inbox time? What does that look like over a week? As you task switch, you’re really becoming inefficient and adding time, and we’re looking for the minutes and seconds to help you get rid of that inbox. So if we find your best and most simple solutions for your inboxes, that is a way of getting through things faster and being more productive in your day. So finding all of those pieces gives you that 360 of your clinical day and helps bring transformation.
Kevin Pho: So walk me through a scenario. So I’m primary care, I’m in the States. I know you practice in Canada; there’s probably some differences between the two scenarios. But walk me through a typical scenario. What would that physician look like before implementing your tips, and what would that physician look like after?
Sarah J. Smith: OK, so before is kind of coming into clinic, maybe on time, maybe a little late. By lunchtime, they’ve maybe finished one or two charts. By the end of the day, they’ve finished maybe 20, maybe 50 percent of the charts, maybe not even. And then they’re spending hours and hours then finishing the charts, or they leave the charts. They do the urgent messages for an hour, hour and a half. They’re getting cranky and grumpy. They’re getting messaged by the family saying, “Where are you?” So they dash home, they do the family things, and then they’re either up until 11 or 1 or 2 in the morning, or they go to bed because they’re exhausted, and then at 3 a.m. they get this little wake-up that says, “Hey, you should be charting. Get up and chart.” And then they spend three till six in the morning sitting at their computer, cold and grumpy, doing their charts.
So that’s a before-after. So physicians have often dropped their patient rate down to three an hour or two an hour just to try and keep up, and they’re still not keeping up, and they’re now really frustrated because they’re earning less money. So when we start working with them, we’re working out how do you see the patient and do the chart, see the patient, do the chart, see the patient, do the chart? So at four, when they’re seeing their last patient, all their charting is done.
Additionally, they’ve put into place strategies for inboxes, so their inbox is done, and they have a strategy for knowing, “What do I need to do right now before I leave? And then I’ll be coming back to whatever’s left at my next scheduled protected time for my inbox.” So they’re going home, having supper, walking in hours earlier. In fact, the family, like, the jaw-dropping “What are you doing at home? Did you quit?” has been a common experience, and physicians saying to me, “What do I do with myself now? I have all this time. I don’t know what to do. This is weird. It feels weird.”
Kevin Pho: So one of the things that I talk about on my show and on my blog is, of course, physician burnout in the United States. Studies say that it’s approaching 50 percent, and this is even before the pandemic. What’s the situation with burnout like in Canada, and can you share some of the experiences that you’ve talked to when you’re coaching other Canadian physicians?
Sarah J. Smith: Yeah. So I coach both Canadian and U.S. physicians, and they’re all having very similar experiences. Electronic medical records have not made things easier. In fact, it’s added a lot easier ways of patients communicating with you constantly, the ability to leave you messages constantly. So that administration burden, the interruptions, distractions, things that are stopping you getting your work done, are contributing to burnout. So I think that I would expect burnout would be much higher than 50 percent in the physicians that I look after, who are having troubles with, you know, they’re not even off when they get home. They’re always, “I should be doing this. I should be doing that.”
Kevin Pho: Yeah. So let’s talk about electronic medical records, and one of the biggest complaints that I see is that they force you to have all these click boxes to check, and sometimes it even takes longer documenting on an electronic medical record than it does on a paper record. What are some tips that you could share specifically addressing the cumbersome electronic medical record systems that physicians are faced with today?
Sarah J. Smith: Yeah. So when we have 17 clicks to re-prescribe a medication, there’s nothing we can do about 17 clicks to re-prescribe a medication, or the fact that the EMRs are not set up so that you can easily find when the last mammogram was done. Despite all of that, we can still help you get to that point of getting your charting closed. So we have to work within a clunky dinosaur system of an EMR, and that frustration, all it’s doing is adding to your inefficiency. It’s just adding that burden of “I’m overwhelmed, I’m distracted, I’m anxious, I hate this, I’m not enjoying myself.” And that is further contributing to your not wanting to stay there and do it. You’re wanting to go find a snack or go talk to someone, and it’s contributing to further inefficiency.
So even when the EMR is difficult to use, we still want to work with your goals of “And I want to get it done anyway.” So it’s still finding the most simple solution, the fastest way to get this chart note done. What will that look like? Because it’s different for every physician, every EMR.
Kevin Pho: There are a lot of physicians who write comprehensive notes at home, or they dictate comprehensive notes. But sometimes I talk to physicians, if they have the chart right after seeing a patient, and they have to close it at a certain time, they sacrifice some of that comprehensiveness of the note. So can you speak to that balance and trade-off?
Sarah J. Smith: The note is specific to you. There are things you love to capture in the note. You may love to be comprehensive with your note. There are things that you need for the insurance and the billing and the diagnostic coding. There are the MRIs to order, the referral letters to be done. When we’re talking about closing the chart after every patient, we mean all of it, everything. And so now it is, how can I best help myself get that done? And it may not look like perfect sentence structure, but it does not have a compromise in the content of the note.
And so we really are focusing on “I want it done, I want it accurate,” and the most accurate is going to be right now, “and I want to have improved clinical decision-making,” which is freeing up my brain of all the other patients that I’ve seen today. So when you walk into the 12th patient of the day and all your charting’s done, you’re much more clinically available for that patient. You are focused and attentive and ready, and your best clinical reasoning brain turns up. You can listen to the story. You can kind of put all that together, that puzzle, and come up with your differentials a lot easier when you’ve taken out that burden of “Oh, I forgot Mary’s mammogram. Oh, I forgot that. I better not forget to do that script,” or whatever it is that you’ve still got floating around from earlier in the day.
Kevin Pho: We’re talking to Sarah Smith. She’s a family physician in Canada and a physician life coach. She wrote the KevinMD article “You didn’t sign up for this. You don’t have to drown in the paperwork.” Sarah, as you know, physicians have different levels of organization. There are some physicians who get all their messages done right away, but there are physicians who take days to close the chart. Speak to your experience in terms of how different physicians have different organizational levels. And can even the least organized physician be coached up to get their charts done on time after each patient visit?
Sarah J. Smith: So if you are determined enough to make a clinical change, you will be able to work within that goal of “I want this for myself.” So each physician who is coaching with me has their own goals. So they may not want to close charts after every patient, but they might want to. So I’ve worked with neurologists who have to dictate their charts. I’ve worked with pulmonologists who have to dictate their charts. I’ve worked with people who are using paper charts. They all have come in with that goal of “I want to get this improved.” Those 25 years in service who still can’t close their charts, they’re closing charts. So I think it is possible for all levels of physicians to learn at least an improved strategy for how to get this done. It’s possible even for you.
Kevin Pho: And what would you say are some of the biggest challenges physicians face when it comes to closing their charts, even after going through coaching sessions with you?
Sarah J. Smith: Yeah. So it is all of the common things that are obstacles for physicians: “I don’t want to make patients wait. What if I’m 20 minutes behind? I’m a slow typer. I have to deal with this stupid EMR.” Like, they are common to physicians, all of those questions. “Even though I have a scribe, and they’re no good, they’re not helping me.” Even with a scribe, getting your charting done after every patient requires some processing, helping that scribe figure out how you work and what you are looking for.
So it’s looking at what are the obstacles. So one of the physicians I coach came up with 139 reasons why this wouldn’t work, and she was closing charts within days. Like, the reasons why we can’t get our charting done as we go are common and not unique to every physician. And each of those obstacles, we just have to find out the strategy, and then you’ll be closing your charts.
Kevin Pho: So with that physician who brought up the 139 reasons why she couldn’t do it, what are some changes that she made in order to accomplish her goal?
Sarah J. Smith: Yeah. So she had that determination that leaving a patient waiting for two minutes wasn’t going to change her whole day, that it was going to be helpful for the patient, it wasn’t selfish for her to close the chart. I think that’s one of the big things. Physicians think that stopping here and closing the chart is selfish: “The only person who’s going to benefit is me.” That’s not true. We improve your clinical reasoning. We improve your ability to focus and stay in control of your clinical day.
How many things she tried to fit into that encounter, and having a strategy for what she might do differently if she wanted to. Now, not every physician is going to get patients to come back. Some people work within a model of care where they don’t want patients coming back every five minutes, that they only want to see them a couple of times a year. So that isn’t the strategy for every physician.
Changing how you’re charting: So what’s in your chart, and why? Who are you trying to make it perfect for? Why? Who’s judging you? And really being curious with those sorts of questions. Is typing in the room possible? If it is, how does it look? What are your objections to that? Is it the way your room is set up, and you’re not looking at your patient as you chart, and are there ways of managing that? Is it talking with your staff about setting the room up differently, so you’re not leaving the room every five minutes for the Pap light and the chaperone and the lidocaine and the syringes? Like, looking at all the inefficiencies in our workday.
So that whole 360 is thinking about how you do business, not just being in your business. So if you’re always going out to look for the ultrasound forms, can we have some of them in the room with you? Like, it can be simple things that save you minutes and seconds.
Kevin Pho: And my final question, Sarah: What’s your take-home message you want to leave with the KevinMD audience?
Sarah J. Smith: So I want you to know that the paperwork and drowning in your paperwork, there are things that can be done to help you improve your clinical day. And I think that can be night and day for physicians, that fear that “Maybe I just have to give up. Maybe I have to drop patient number. Maybe I have to move location.” Maybe not. Maybe that’s not what’s going to change the world for you, but maybe change is possible.
Kevin Pho: Yeah. And how can people reach you?
Sarah J. Smith: So they can find me at chartingcoach.ca. I have a Charting Champions program that physicians can use. It’s a lifetime access program to help you find your most simple strategies. So, yeah.
Kevin Pho: Well, thank you so much for sharing your time and insight, and thanks again for being on the show.
Sarah J. Smith: Thanks so much.
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