For fifteen years of practice, I have undoubtedly followed my organization’s standard process for patient flow. After all, I had been ‘flow mapped’ and “measured cycle time” by a team of managers with Toyota-like precision, so I just assumed this must be the most efficient way to run a medical practice.
You know the routine I’m talking about. The patient arrives at the check-in window to check in and sits down to wait. A medical assistant (MA) arrives with a chart, calls the patient’s name, and leads them into the clinical area. First stop: the dreaded scale for a weight. Next, in the examination room for vital signs: blood pressure, pulse and temperature. Now the MA bombards the patient with questions, furiously typing into an electronic system for the next five to ten minutes – or more, according to the historian. Many of these questions will turn out to be completely irrelevant, already on file or repeated by the doctor. Finally, the AM leaves the patient alone in the exam room to wait (and sometimes wait, and wait) until the doctor finally rushes in.
Ah! This is the big moment, and in my opinion, where the magic happens. Doctor and patient sit together and have what appears to be a simple conversation to the casual observer. As the patient talks about their concerns, the physician digs deeper, asking relevant questions that have been honed through years of practice in the history taking. During this interviewing process, the physician will use open-ended questions, strive to build patient confidence, and apply advanced techniques such as motivational interviewing to help guide the patient toward optimal health. The doctor not only asks about physical complaints, but also addresses wellness issues, such as making sure the proper drug tests have been ordered. After an exam and medical plan have been determined, the doctor leaves the exam room to rush to the next patient, leaving an MA to complete orders and escort the patient to the payment area.
If this orchestrated ballet works perfectly, the patient is out of the office in about an hour, including perhaps 15 minutes spent with the doctor. Administrators and workflow experts assure physicians that this type of streamlining leads to the most efficient visit and “patient experience.” After all, it takes a team to care for patients these days!
Or does it?
Imagine a different scenario. The patient arrives at the practice, registers and is seated. Their own doctor arrives at the waiting room door, recognizes their longtime patient, smiles at him, and waves him into the office.
Stay with me.
The doctor then walks the patient down the hall to the exam room, chatting and building rapport. Both enter the examination room, take their seats and continue to discuss for a few moments. The patient has overcome his surprise at seeing the doctor so quickly and is now relaxed and at ease, entering the historical part of the visit without the usual irritation or even anger of waiting or repeating answers to the same questions. again and again. Empathy and trust now sufficiently established, the physician opens the patient’s chart and proceeds directly to obtaining the patient’s history, updating relevant clinical details along the way.
Now I’m about to get even more radical with you.
Imagine that once the anamnesis has been taken, the doctor obtains its own vital signs.
It’s shocking, I know, and counterintuitive to everything the sigma-lean-Toyota folks have told us about task shifting. But doesn’t that make so much more sense?
First, the patient has been seated for approximately ten minutes, which ensures a more accurate blood pressure reading than that taken immediately after the patient enters the office. It also helps patients avoid weighing anxiety and stigma. Although it is essential to obtain weight as an indicator of health, we know that the scale can be emotionally taxing for some patients. Explaining to a scale-averse patient why they are getting their weight or allowing them to stand on the scale upside down to avoid seeing the number (a technique some patients with eating disorders use ) can improve their willpower. In many cases, patients who came into the office fearful of being weighed will jump on the scale when they realize that their doctor is supportive and nonjudgmental.
Second, obtaining vital signs after history is consistent with how physicians are trained to think. In a “SOAP” note format, the physical exam supplements the history in medical decision-making (unless, of course, the patient immediately appears unsteady when walking through the door). It allows the physician to decide whether additional vital signs such as temperature or pulse oximetry are indicated (perhaps not if the patient presents for follow-up depression, for example). readings that are easy to skip over when looking at a sheet of paper or a computer screen. We know that vital signs really are “vital”, and yet I can’t be the only doctor to admit that I got distracted by a patient’s multiple concerns and only noticed one abnormal reading vital signs as I took my notes later in the day. , requiring an urgent recall of the patient.
Probably the most important aspect of taking your own vital signs is that it allows the physician to have real hands-on experience with the patient. In a traditional busy office environment, patients can feel rushed and that “the doctor never even touched me”. Sometimes there is a good reason for this; perhaps the doctor didn’t get a chance to examine them because he spent too much time discussing them or because an examination was not medically necessary for that particular problem. Maybe the doctor did an abbreviated exam while talking to the patient, but the patient was too distracted to even notice. Taking their own vital signs allows the patient to truly feel a physical connection to their doctor, even if it’s only the minute or two it took you to apply a blood pressure cuff or help them step onto the scale.
Another way to get real hands-on experience is to consider performing your own phlebotomy. Although many physicians have not drawn blood since medical school or residency days, consider that phlebotomy is much less invasive than many other procedures we perform for our patients, and skills can be quickly refreshed after a few hours of observation and practice with an experienced phlebotomist (most labs are happy to offer this service). Blood sampling is also a satisfying way to wrap up your patient’s visit, bringing the visit to a natural conclusion.
Physicians may also find that they enjoy other clinical tasks usually relegated to assistants, such as administering vaccinations or performing EKGs, or may choose to hire an assistant to perform these tasks. After clinical work is complete, the final step is to perform clerical tasks, such as scheduling tests, procedures, and referrals, tracking medical records, and arranging a follow-up visit, which may be assigned to a non-clinical assistant. .
Results of this approach
Now I know that the idea of doing more hands-on clinical work as a doctor completely negates the last twenty years of practice management advice that has driven us to practice medicine on a production line to “see more patients.” . But patients are not machines. , and medical offices are not manufacturing plants. In fact, patients report more satisfaction with their office visit when the time they spend with the doctor “meets or exceeds their expectations”, and perform better when they feel a genuine connection with their doctor based on trust and mutual understanding. By cutting out the middleman, patients get exactly what they want and need: time with their doctor.
Physicians also benefit from this strategy. Happier patients are more member to medical plans, show improved self-management skills, and are less likely to sue for malpractice. Having fewer staff members can reduce the risk of data entry errors and increase team accountability. And believe it or not, taking your own history and vital signs can save you time, because one of the biggest bottlenecks in a doctor’s office, it is the time it takes to “house” the patients.
But can this strategy really save a practice money?
It depends. If the doctor’s job is to subsidize a C-suite of managers (the kind who pay high consulting fees to these office flow “experts”), probably not. But for a small practice where support staff salaries and benefits include the biggest part overhead, a reduction in staff can offset a decrease in the total number of office visits per day. Adding a scribe (virtual or in-person) to take notes during each visit can also allow a doctor to see more patients by reducing check-in time.
While implementing all of these measures may not be possible in your practice, consider what small changes you could make to allow you to spend more time with your patients. And if the vision I shared of being able to provide more direct clinical care to patients intrigues you, stay tuned for my next article on opening a direct care practice.
Rebekah Bernard MD is a family physician in Fort Myers, FL and author of How to Become a Rock Star Doctor and Physician Wellness: The Rock Star Physician’s Guide.