Shadowing reveals more efficient ways to practice medicine

Sara Berg
Senior Staff Writer
AMA Wire
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While many health care organizations are offering ways for physicians and other health professionals to cut stress through activities such as meditation or yoga, a health system in western Washington state has started a program that aims to find and address the root causes of physician frustrations with their days and nights in practice.

MultiCare Health System (MHS) recently created the Provider Wellness Program (PWP), which serves physicians and advanced practice providers. The goal is to address the environmental factors that can lead to burnout over time.

Headquartered in Tacoma, Washington, MHS is composed of seven, medium-sized community hospitals and employs more than 850 health professionals. Stagnant scores of “provider engagement” within their medical group as well greater evidence of physician burnout nationwide drove MHS to act, according to practice optimization consultant Ellie Rajcevich.

In the first couple months of the program, MHS program consultants have shared the program with hundreds of providers and leaders throughout the organization and have shadowed more than 15 physicians. One key change is to help offload non-physician work to other staff. The shadowing has revealed that, at too many practices, a lot of work that is being done by physicians can be completed by other health care team members.

“In doing some physician observations, I’ve seen doctors place orders for mammograms or colonoscopies, which are things you know—based on the patient’s age and the dates of the previous tests—when they need to have those done,” Rajcevich told AMA Wire®. “Instead of having the doctor take the couple minutes to make those orders, someone else can do that and then the doctor doesn’t have to worry about it.”

A large bulk of work is also associated with the in-basket which, depending on the type of electronic health records (EHR) system being used, can include messages from patients, test results, or basic questions and requests from a nursing home or referring provider. Often, that in-basket can place a significant workload on the physician, but these tasks can often be triaged or handled by other members of the health care team.

“When we’re shadowing, we will ask the doctor if there is a reason why they don’t want someone else to do the work,” Rajcevich said. “And they usually say ‘Oh, I just do it.’ So we help coach them on other ways to complete it.”

Learn better times to complete work

Patient visits are associated with a large bulk of work, including the completion of charts or reviewing the in-basket. Physicians tackle their work in different ways, but the PWP works to help improve workflow by problem-solving pain points and coaching them through a solution to test.

“We’ve worked with a couple doctors that like to wait until the end of the clinic day to review their notes before signing off on them,” Rajcevich said. “They are often doing that late at night when their families are asleep. They rush home to spend time with their family and then plug back into work from nine to midnight, sometimes two in the morning. They’re working long hours and it’s making them unhappy. It’s not sustainable over the long run.”

Rajcevich recommends that physicians plug into different kinds of work at various parts of the day, depending on whether they need other people to be involved. For a provider who likes to review their notes at the end of the day, Rajcevich and her colleagues advise that providers do the work in the early-morning hours before clinic opens instead of burning the midnight oil.

“We’re not suggesting people change what they like to do, but maybe doing it differently can help buy some time back into their day,” Rajcevich said. “It’s coaching people through some of that and helping them see different opportunities in their current workflow with a fresh set of eyes.”

Let someone else do the typing

A pilot program was created prior to the development of the PWP that incorporated a medical assistant (MA) scribe model in a family medicine practice. This is the model described in the “Team Documentation” STEPS Forward™ module offered by the AMA, said Rajcevich.

Through this model, the MA will room the patients, pend orders and medication refills and do a quick handoff with the doctor. While the physician sees the patient, the medical assistant will scribe the visit with the doctor. At the end of the visit, the MA wraps everything up, gives the patient the after visit summary and ensures that follow-up instructions are understood.

“The doctors are finding that they are closing their charts more promptly and they are done with all their documentation at the end of the day,” said Rajcevich. “They feel like they have a better work-life balance, more efficiency and are happier in general.”

Medical assistants have also said they know more about the patient because they are there for the entire visit which allows them to answer questions and perform better follow up.  Furthermore, they have acquired a holistic understanding and better appreciation for the workflow of all team members, not just their own.

“We feel it is a win across the board so far and we are continuing to work with them,” she said.

Gaining mastery of the EHR

Some physicians are exceptional in their use of the EHR—they are fast and know how to set things up so that it works well for them. Then there are physicians that don’t know what they don’t know, said Rajcevich.

“These physicians might know that something is clunky or frustrating, but they don’t know that they can make it better or how it can be better, or if there is a way to reduce the time they are spending doing something over the course of the day or week,” she said.

Epic offers a way for MHS to identify what some of the biggest opportunities are with physicians and their teams. This can include whether they are spending a lot of time in orders or in their in-basket, or their notes are two times the length of their partners and don’t need to be that long. By identifying these opportunities, Epic trainers for MHS can help physicians update preferences to reflect the care they are providing their patients while also reducing the number of clicks needed to complete tasks.

MHS has three certified Epic trainers to train new providers as part of their onboarding to MHS, shadow the provider in clinic and perform one-on-one coaching sessions. After learning how the providers work with the EHR, the trainers can offer insight about what potential opportunities are available to help, and how it might complement any recommendations developed during collaboration with the PWP practice optimization consultants.

The level of engagement or involvement provided will depend on the wants and needs of the provider. Some physicians are shadowed only once and MHS will follow up later to see how things are going.

“If they want us to really get in there with them, then we are happy to do that,” Rajcevich said. “If they want us to shadow them one time and get some feedback, then that is fine too. We follow the lead of the physicians and the teams we’re working with.”

By participating in the program, physicians can see more patients because there will be less work that falls to one person associated with each visit. With more team members sharing the workload appropriately, physicians achieve a more efficient work day and experience a better work-life balance. 

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Comments

How novel and refreshing! Instead of offering the physician a self-help program of mindfulness, yoga, etc (i.e. implying the physician is the problem), one administration sought the factual system problems underpinning physician burnout. It appears that health system began to deeply LISTEN to physician frustrations and seek redress; the outcome aims to permit physicians to play at the top of their license, i.e. more medicine & less computer & clerical work. Keep it going...
This kind of thing can be a Wolf in Sheep's clothing. Many of us in group hospital based practices are frequently asked to participate in "consultant based activities" . The consultants and management usually laud the results while the physicians have yet another burden. Many of us are tired of the attitude that "physician burn out" reflects poor time and activity management on the parts of physicians. In my opinion the AMA is not representing physicians well in regard to this topic. I would like to see the AMA change the framing of this. The term 'Physician Burnout' itself implies a flaw in the physician rather than the system. Physicians are being overburdened by a system that is top heavy in administration and administrative activities. Underpayment, burdensome EMR, arcane Coding, you name it. Rather than fighting the fight the AMA looks for ways to SELL us solutions while patting our hands telling us don't worry we have your back.
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