time-saving methods for physicians [PODCAST]

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Endocrinologist Michael Morkos discusses his article “Mastering the artwork of environment friendly affected person encounters: ideas for physicians.” Michael shares sensible methods for optimizing the affected person encounter to boost each effectivity and affected person satisfaction. He delves into efficient documentation methods, emphasizing the significance of sustaining eye contact whereas touch-typing within the examination room, and adapting clinic setups with adjustable carts and laptops. Michael explains his system for ordering future labs throughout visits in lab-heavy specialties like endocrinology, making certain all mandatory information is obtainable for follow-up appointments. He additionally outlines his streamlined EHR workflow, together with pre-charting, side-by-side overview of out of doors information, and clear affected person communication throughout the go to. Michael highlights how these strategies allow him to finish all notes and fees by the tip of the day, considerably lowering after-hours work and contributing to burnout prevention.

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Transcript

Kevin Pho: Hello, and welcome to the present. Subscribe at KevinMD.com/podcast. At this time, we welcome Michael Morkos. He’s an endocrinologist and the writer of the e book, No Work After Hours: Instruments to Preserve a Nice, Environment friendly, and Productive Clinic With out Work Earlier than or After Hours. There’s an excerpt from that e book on KevinMD. Michael, welcome to the present.

Michael Morkos: Thanks a lot, Kevin, for having me immediately.

Kevin Pho: Simply briefly share your story and journey, and discuss what led you to jot down this e book within the first place.

Michael Morkos: I take into consideration these coming to drugs as considered one of two paths: drugs or surgical procedure. In drugs, we take satisfaction in having long-term relationships with our sufferers, and we take satisfaction as nicely in having lengthy encounters and taking good care of no matter a affected person wants in between visits as nicely. I discovered that I used to be combating a number of work earlier than and after hours, with a unending in-basket and telephone calls and lengthy encounters, and having to complete charts and notes after hours. I used to be not very keen to depart drugs and search for different careers, so the query was: how can we make it an environment friendly course of whereas sustaining glorious outcomes?

Kevin Pho: Great. And such as you, I’m in a cognitive specialty, inner drugs. I do main care, and the story that you simply share resonates with a number of us. You will have what’s referred to as pajama time, the place it’s important to end your charts late into the night. I’m considering listening to a few of your ideas. In your excerpt, you discuss ideas for physicians in mastering the artwork of environment friendly affected person encounters. Simply share that article and discuss it for individuals who haven’t had an opportunity to learn it.

Michael Morkos: Within the few ideas that I shared within the article, the dream that I had was: how can I begin on time and end on time? No pre-charting, no work after I depart the clinic. So I pre-chart earlier than I see the affected person. After which how can I end the notice, the entire orders, labs, imaging research, and prescriptions throughout the encounter?

By the point the affected person leaves, I’m finished with all of that, together with my notice and the cost. The affected person is finished, I’m finished. The subsequent affected person is finished. By 4:00 PM, I’m finished with 4:00 PM. I depart. I don’t have any work after that.

Michael Morkos: For the proposal I had within the documentation, you’ve got other ways to do it. Some like dictation, so that they’re going to complete the encounter and go after that and dictate their notice, which implies the encounter now could be longer. Some are extra environment friendly in that they write within the affected person encounter, however the issue will get to be that they face the pc display. They aren’t sustaining eye contact, so the sufferers will not be joyful, they’re not glad, they usually don’t really feel heard. If we aren’t sustaining eye contact, I can’t really feel that you simply’re listening to me or respecting my presence.

And a few will depend on AI, which will get to be very attention-grabbing and really useful. What I discovered is an issue with AI, or no matter AI mannequin is getting used, is that they generate paragraphs. They don’t have bullet factors, or a minimum of to this point. And I suppose being obsessive with my notice, and I prefer it in a sure method, AI doesn’t suffice, or a minimum of to this point, the place I’m.

So the proposal I had is to have the doctor have a cart with a laptop computer. When a affected person is available in, I’m going to deliver that cart down. I’m going to face the affected person. The pc goes to be at a decrease degree, and whereas the affected person is speaking, I’m touch-typing, so I’m sustaining eye contact and I’m ending every thing. Then, by the tip, within the evaluation and plan, I write out loud what I’m writing because the evaluation and plan and within the directions. So when the affected person leaves, they’ve written directions with every thing I stated, and my notice is finished as nicely.

Kevin Pho: So how lengthy have you ever been utilizing this technique for?

Michael Morkos: Six years now.

Kevin Pho: And how briskly do you sort? As a result of I can think about should you touch-type your whole notice, together with the historical past of current sickness and the evaluation and plan, typically even if you’re going through and speaking to the affected person, it’s important to sort fairly shortly to get that finished in actual time.

Michael Morkos: And in addition, I write much less, so I don’t write lengthy paragraphs. After I realized touch-typing, that was whereas making ready for the medical abilities examination for the united statesM.L.E., so I didn’t have it rising up. Again then, I used to be touch-typing 15 to twenty phrases per minute. Proper now, I am going anyplace from 50 to 80 phrases per minute.

Kevin Pho: After which after the affected person leaves, your whole notice is full? You don’t need to do any modifying or proofreading afterwards?

Michael Morkos: No, I’m finished. Really, the affected person leaves and I’m finished. It’s a rising and studying curve, which is attention-grabbing that I monitor. You understand, you get these reviews from HR on how lengthy the affected person visits are. I suppose the one who benefited probably the most from the books I wrote is me, as a result of I can see that my velocity within the go to, whereas sustaining nice medical outcomes and nice affected person satisfaction, after all, is growing. The affected person visits are shrinking.

My documentation is quicker. My orders… I imply, the 2 different issues that I talked about are orders and EHR workflow. I suppose I’ve a pc engineer in my coronary heart. That’s why I just like the EHR a lot. Having order panels as a substitute of trying to find every single order each single time with each affected person made my life far sooner. Adjusting my workflow and seeing what my workflow is and adjusting the EHR to be the quickest for what I do made an enormous distinction in rushing up my talents and allowed me to see extra sufferers whereas nonetheless ending on time.

In my follow, we had 20-minute slots for established sufferers and 40 minutes for brand new sufferers. I discovered that I’m ending seeing the affected person in 5 to 10 minutes and I’m simply sitting, doing nothing. So I used to be ready so as to add extra sufferers whereas not overloading myself.

Kevin Pho: And I feel the bottom line is the ergonomics of your workplace go to. You talked about a cart the place I assume you’ve got a laptop computer, and you’ve got the display positioned in a method the place you are able to do the touch-typing but in addition preserve eye contact with the affected person. You’re going through the affected person as you’re typing out your notice.

Kevin Pho: Discuss to me about AI scribes, as a result of that’s all the craze now, proper? It’s marketed as an answer the place clinicians can cut back their cognitive load and preserve eye contact with the affected person. Full disclosure right here, this podcast is sponsored by considered one of these techniques, the Microsoft Dragon Copilot. You talked about that you simply had an expertise with an AI scribe, however the notes that it generated weren’t to your customization.

Michael Morkos: AI, I consider, has an awesome function. We’re so completely different, and a few of us have abilities that others don’t have. For somebody who’s slammed and much behind in every thing, it could provide an awesome answer. However I discovered that for the notes from my colleagues, I don’t learn paragraphs. I can’t; I don’t have time for that. I would like bullet factors or very brief paragraphs. AI proper now provides you with longer paragraphs.

The opposite factor is, typically the dialogue consists of a number of social points as nicely. Now, some techniques are sensible sufficient to extract the social issues and convey solely the medical. It could be helpful within the HPI, that’s for certain. However in my evaluation and plan, which is a very powerful factor, I’ve a system which I feel is logical. I begin with: what are the presenting signs and indicators? What’s the workup, together with labs and imaging research? After which, what’s my evaluation of that? Finally, I am going to the therapy.

And within the therapy additionally, you handle hypothyroidism, proper? On a regular basis. So how I love to do it’s, in October 2023, I began with 100 micrograms. It led to a TSH of 4.5. So in January of the next 12 months, I went to 125 micrograms. It went to a TSH of 1.0. We continued that, after which out of the blue, the affected person gained 30 kilos, so now the TSH is seven. So now, in October of 2024, I adjusted to 175 micrograms and see the outcome. In simply briefing that notice, I can inform what I did initially and the way issues are going. AI won’t try this.

You see my level? So how can I make it temporary? How can I make it very environment friendly? I can’t go to the older notes. I’ve every thing finished. Can we’ve collaboration? Completely. Can I decide and select what to place in and what to not? Completely.

Now, in my subsequent visits, I find yourself having the entire prior historical past that’s related below “preliminary historical past.” So preliminary historical past is all the time copy and paste, after which I’ve an interval historical past that will get to be one to 2 traces: what occurred for the reason that final go to? And my evaluation and plan is copy and paste, and I simply tweak. So I really don’t spend a number of time. Issues get to be very quick.

Kevin Pho: What recommendation do you’ve got for physicians who aren’t correct and quick touch-typers? As a result of it feels like your system relies on the truth that one is an correct and quick typer. Plenty of physicians aren’t. What sort of suggestions do you’ve got for them?

Michael Morkos: For them, there are two ways in which we often go. The primary is the simpler method, which is figure sensible, not onerous. After which there’s the tougher method, which is figure onerous. I really like working onerous in a wise method.

I really like growing new abilities that I didn’t have earlier than in the event that they’re going to take me in the suitable path. Studying to touch-type takes time. I imply, it took me possibly 20 minutes every single day for a month, not investing hours and hours, however it’s a talent that may go a great distance.

Should you can’t touch-type, AI might be nice for the preliminary historical past, however in the entire subsequent visits, we really don’t want that. The interval historical past is only one to 2 traces. The tweaks within the evaluation and plan don’t take time. However growing a system the place we are able to get extra environment friendly whereas being simpler and going through the affected person, not giving the affected person our again as a result of the one who designed the room put the pc towards the wall, can simply go a great distance.

Kevin Pho: You additionally talked about that if you do the evaluation and plan, you’re doing it in actual time and speaking it out with the affected person as you’re typing it. I really like that transparency. Inform us among the benefits of doing it that method.

Michael Morkos: The primary benefit is having no surprises with the sufferers. Now, after the Cures Act got here out, the entire sufferers have entry to their notes. What I might hate probably the most is the affected person coming again to me saying, “You didn’t point out that,” or, “This was inaccurate,” or, “It was shocking to me.” So once I write it out loud with the affected person, I inform them, “I’ve no secrets and techniques. That’s what I’m writing. That’s what you’re going to learn.”

It additionally establishes that relationship of engagement and involvement. “That is my evaluation of your scenario, and you probably have one thing to argue towards, let me know proper now and we are able to focus on it. And that’s what we’re going to do as nicely. That is the follow-up.” I simply really feel that it brings them to be energetic of their well being.

Kevin Pho: Now, this excerpt and the following tips are out of your bigger e book, No Work After Hours: Instruments to Preserve a Nice, Environment friendly, and Productive Clinic With out Work Earlier than or After Hours. Inform us another key ideas that you simply’ve written within the e book.

Michael Morkos: Affected person satisfaction was an enormous, large problem. Once we be taught drugs rising up, you solely concentrate on the medication half and how one can be an efficient clinician, which is extraordinarily essential. However then after you permit and are working in a well being care system, they’re often going to speak to you in three conditions, and you’ll right me right here.

• Primary: you’ve got poor affected person satisfaction scores. As a result of if you’re doing nicely, they won’t discuss to you about that.
• Quantity two: they’re going to speak to you about your income. Identical deal from them: “You’re a nice clinician, however you aren’t making sufficient. So that you both see extra sufferers or we’re going to chop again in your fee.”
• And quantity three: your high quality metrics. You didn’t meet your high quality metrics, after which your high quality cash, if that is a part of your productiveness, goes to get lowered.

That is after they discuss to you. Very hardly ever are they going to let you know, “You didn’t prescribe the suitable diuretic,” or, “You gave a medication that induced uncomfortable side effects.” Often not, as a result of we be taught our medication nicely.

So for affected person satisfaction, the query is: how are you going to obtain good affected person satisfaction? The simpler method for a lot of clinicians is to spend longer visits and chat in regards to the canine, the boat, the brand new automobile, and no matter initiatives sufferers have of their lives. However what I felt deep in my coronary heart is that this isn’t the place for that. The medical go to is just not the place for social issues. Now, it’s good to know the sufferers, I’m not saying no, however this isn’t the place for extended social discussions.

That is once I dug deep. How can I obtain nice affected person satisfaction whereas being environment friendly and productive? Possibly I didn’t share this with you, however my second e book that got here after that was Doctor Income Secrets and techniques. So how are you going to be productive as nicely whereas attaining all of that?

That is what I discovered. It’s very attention-grabbing that there are fundamental human abilities that we want, like sustaining eye contact. It’s big. If I’m speaking to my son and he isn’t trying me within the eyes, I’m going to really feel he’s not respecting that dialogue. The second is the smile. We get overwhelmed by many issues, however should you stroll in and simply have a smile in your face that you simply preserve by the go to, primary, you’re going to really feel happier. Quantity two, the affected person goes to really feel welcome. Quantity three is having good listening abilities.

Normally, we have a tendency to leap to conclusions. I suppose that’s what we get to be taught, proper? How briskly in a multiple-choice query are you able to learn and are available to the conclusion? That conclusion is true. Primary human abilities can go a great distance.

Kevin Pho: It feels like widespread sense, however typically when physicians are below a lot strain, such as you stated—not solely from the medication itself however from directors with these three pillars of strain with affected person satisfaction, income, and high quality metrics—they typically neglect these fundamental abilities within the examination room.

Michael Morkos: And we have to remind ourselves on a regular basis of that idea of regression to the imply, that we are inclined to regress after some time. I keep in mind on my telephone display, I had issues written right down to remind me every single day. Each time I regarded on the telephone, it could say, “Don’t neglect to smile,” “Don’t neglect to take care of eye contact,” till they turned habits that I do with each single encounter.

Kevin Pho: And typically I discover that affected person satisfaction means various things to completely different sufferers. For one, some sufferers might like their docs speaking about social points that will or might not be related to the encounter itself. For different sufferers, satisfaction could also be only a clinician being on time, being temporary, and never spending extra time within the physician’s workplace go to. As a result of let’s face it, sufferers typically have higher issues to do than being in a physician’s workplace. So in my expertise, I discover that for affected person satisfaction, it’s important to gauge what values are essential to that particular person affected person and sort of tailor your strategy to every one.

Michael Morkos: Completely. I suppose I’ve a psychologist in my coronary heart as nicely, and it’s attention-grabbing if you examine completely different character traits and what works with every. A part of what we do is we’re leaders, proper? We’re leaders in our clinic and within the affected person encounter. Am I the chief, or is the affected person the chief? I really like the thought of getting a sort of co-pilot, but it surely will get to be me, the doctor, being the chief of the encounter.

Some sufferers don’t thoughts spending two hours chatting, proper? I’ve to succeed in that center floor. I might love to listen to the chats to an extent, after which we’re going to circle again. In my thoughts is, the affected person is right here for, let’s say, diabetes. How is the A1C doing? The place are we going to get with their Graves’ illness, thyroid nodule, thyroid most cancers, or pituitary illness? So I’ve that medical half, after which we’ve the social half, and I’ve to know when it’s affordable to simply shift gears and return to the medical half with out hurting the affected person and with out me spending hours, which I can’t do.

Kevin Pho: Now, what about these physicians who’re simply utterly overwhelmed? They’re chronically behind, they need to spend hours after the clinic catching up on their notes, they usually’re burned out and considering of leaving drugs completely. What could be your single greatest tip to assist these many, many physicians that I hear about?

Michael Morkos: I’m going to have a query first: did you select that specialty out of affection and fervour? As a result of many physicians didn’t. Many didn’t. I suppose my third e book that’s behind my thoughts is, how do you select properly? I suppose it’s going to harm, however I’ll say it: some physicians go after cash, others go after way of life. When the choice is just not based mostly on ardour, they’re going to get what they need, hopefully, however to not the most effective extent. After which they’re going to get burnt out.

Now, let’s say that you’re the place you’ve got your ardour. Be humble sufficient to open your thoughts and be taught new abilities and put the effort and time into studying them. As a result of these are abilities we’ve to be taught, like how one can be environment friendly with the EHR. We get very resistant with inertia. I’m part of an enormous follow. I discuss to many physicians. I suppose our satisfaction and ego get in the best way of studying, however once I humble myself and say, “I don’t know every thing, and there is a chance to be taught and develop,” it will probably take you a great distance. Those that do the most effective are the most effective disciples who go to be taught and develop.

Kevin Pho: We’re speaking to Michael Morkos. He’s an endocrinologist and he’s the writer of the e book, No Work After Hours: Instruments to Preserve a Nice, Environment friendly, and Productive Clinic With out Work Earlier than or After Hours. There’s an excerpt from that e book on KevinMD. Michael, let’s finish with some take-home messages that you simply want to depart with the KevinMD viewers.

Michael Morkos: The one message that may make the entire distinction is having good boundaries. Having good boundaries first with your self, saying, “No, that is sufficient. I want to vary.” Having a superb boundary with the affected person, saying, “I can’t focus on ends in between visits. Let’s have one other go to.” Having good boundaries with the employees and with the management, and good boundaries in saying, “I can’t do it alone. Let me get additional assist and attempt to refine my abilities.” This could take you a great distance.

Kevin Pho: Michael, thanks a lot for sharing your perspective and perception, and thanks once more for approaching the present.

Michael Morkos: Thanks a lot, Kevin, for having me immediately. I respect you.