Beating Burnout: Simple Tips to Make Patient Encounters More Efficient

Michael Morkos, MD, shares his recommendations for managing patients and their data as efficiently and stress-free as possible. He says that a few simple changes can make your day at the office run a lot easier and might even reduce the threat of burnout!

The patient encounter is the core of clinical physician practices. That’s why we went to medical school in the first place. The excitement and passion for seeing sick patients and helping them on their healing paths is a lofty ambition indeed.

One obvious skill set is to be a good clinician. However, there is a much-needed skill set that often gets overlooked and that is to have the ability to ensure an efficient workflow. Here, I would like to highlight some tips for documentation, placing orders, and optimizing the electronic health record (EHR) workflow. All of these can be challenging, but hopefully some of these tips can help you in your practice.

The Eyes Have It

Different physicians can have many different approaches to documentation. Here are some of the many I saw:

• Talking to the patient with eyes glued to the computer screen. Efficient? Yes. Pleasing bedside manner? Not so much. The satisfaction scores may need improvement, too. Continuous eye contact is critical.
• Talking to the patient throughout the visit and documenting afterward. While the patients are frequently happier, the physicians are usually behind with their documentation and might even postpone their notes till the end of the day, especially on busy days when they’re already behind. They will reason that patient care is more important than documentation.
• Dictating in front of the patient. Although efficient, I see it as a bit less professional and interferes with the basics of good communication.

Personally, if I don’t have all the details written down right away, I’ll forget them, which can be a big problem. I also like to have good communication with my patients. That’s why I love touch typing. I’ll talk to the patients and maintain eye contact while my hands are typing the notes. Sometimes, I need to look at my screen for a few seconds, like when placing orders or renewing medications. I’ll mention it, and I won’t be conversing at that point, but I make my best effort to maintain continuous eye contact during active discussions.

This workflow facilitates going to the clinic 5 to 10 minutes earlier and leaving when the last patient does. Isn’t it great? I almost always leave the office by that time with finished notes, charges, and a clean inbox.

Michael Morkos, MD, MS, MHI, ECNU

I requested an adjustable cart and a laptop in each clinic to achieve this. Sitting comfortably or standing in the exam rooms and facing the patient during clinical encounters would be optimal. Many room designs need to have the computer set up that way. Commonly, you’ll have to rotate your neck 45 to 180 degrees to face the patient while typing on the pre-installed desktop, which can be murder on your back.

Doctor’s Orders

Endocrinology is a lab-heavy specialty; I can only adjust many medication doses I manage based on lab results. Frequently, the results impact my questions during the patient’s visit. For example, if a patient had a recent TSH of 1.5, the visit would likely be straightforward, and I’d continue the present management. On the other hand, a previously controlled hypothyroid patient presenting with a TSH of 30 mcU/mL may cause me to ask many questions about supplements, compliance, tablet colors, medicine administration, weight changes, last refill, and so on.

Therefore, that’s why I order all the needed future labs during the patient’s visit, set the time for their visit, and clearly ask them to complete the labs before I see him or her again. I provide specific instructions on fasting status, time of the day, and how many days before the visit to get the tests completed based on what labs I’m getting: Collagen type I C-telopeptideand procollagen 1 intact N-terminal propeptide, bone turnover markers can take up to two weeks to get results at my institution, while TSH and free T4 will take less than 24 hours.

Thankfully, most of my patients follow my instructions, which makes life easier for all concerned. I’m happy to have all the needed data during the visit, ask all the relevant questions, and have a clear and detailed plan for the patient. This makes the patient happy, and he or she can leave my office with a clear plan of action.

EHR Workflow During the Encounter

By the time I enter a patient’s room, I have the old note (for existing patients) copied to a new note, and I have already selected the labs and parts of the imaging and pathology reports to include. I would also take snippets of the radiology images or insulin pump/continuous glucose monitor reports and include them in the note. As I talk to the patient, asking about the interim events and how they’re doing, I’ll fill that in the (Interval History) under the HPI.

I’ll review the outside records for the new patients before the visit. This was a tricky issue; previously, it was scanned in the chart, and reviewing it was difficult. Imagine being only able to see a page at a time; I couldn’t scroll through the pages, and it wouldn’t be easy to go back and forth with your notes in the EHR. I worked hard to update the protocol, educate the staff, and have them attached as PDFs that I can have side-by-side with the EHR note. You can easily adjust your screen size by pulling the title bar down and using any corner to resize it. I can scroll through the PDF on one half of the screen while having my note on the other half and typing or dictating directly before the visit.

Thankfully, most of my patients follow my instructions, which makes life easier for all concerned. I’m happy to have all the needed data during the visit, ask all the relevant questions, and have a clear and detailed plan for the patient. This makes the patient happy, and he or she can leave my office with a clear plan of action.

 I’ll usually maintain eye contact with the patient while touch-typing whatever is relevant as we go through their history. Next, I’ll edit the physical exam based on my findings, and then I usually stand by the patient’s side and show them what I have in the labs, imaging studies (frequently pulling the pictures), or glucose reports. The patients are usually eager to be involved in my data assessment and actively participate in the analysis and conclusions. It also makes it easier to agree on a shared plan.

Afterward, I edit the assessment and plan accordingly, then I’ll type while saying it out loud to the patient. I usually start by saying: “Let me tell you what I’ll write down. You can access it through the portal.” This way, they know that I’m not hiding anything. I usually write in the plan what I’ll copy and paste under patient instructions. I’ll order all the needed work-up to be done soon, if necessary, and before the upcoming follow-up visit, along with reconciling the medications. I’ll finalize the instructions afterward with all these details.

When the patient leaves, I’m ready to finalize the note, place the charge, and prepare for the next patient. This is the usual rule that I do almost all the time. By the time the last patient leaves, I’m done with all the notes and charges for that day. In between patients, I go through the inbox, messages, and results, and aim to finish them by that time.

This workflow facilitates going to the clinic 5 to 10 minutes earlier and leaving when the last patient does. Isn’t it great? I almost always leave the office by that time with finished notes, charges, and a clean inbox.

That’s why the clinic, especially an endocrinology clinic, is a beautiful practice with a low chance of burnout. Building an efficient practice is a learning curve, and it’s 100% worth it!

Morkos is codirector of the IUH Thyroid and Parathyroid Center, and assistant professor of clinic medicine in the Department of Endocrinology, Diabetes, and Metabolism at the Indiana University School of Medicine, in Indianapolis. An Endocrine Society member since 2015, he is an active member of the Society’s Early-Career Special Interest Group.