Thursday, September 23, 2010

Three-Ring Circus Clinic

Two tigers leaping through burning rings of fire at circus

When I was a little girl, attending the circus was the highlight event of the year. I remember looking forward to it each year – perhaps because it was something fun, and each year something new. Never the same show twice. Very busy behind the scenes, yet at the same time, quite organized and appearing smooth on the surface.

In the same way, the clinic can be a truly hectic scene. But with me as Ring Master, I was able to magically eventually learn to conduct my three rings of fire for a much smoother overall show, with spotlight on the dedicated patients, meticulous staff, and me with my super chic top hat.

I have to admit that there have been days in which I have magically seen up to nineteen patients in one half day. However, I wouldn’t say that I am proud of that, or that it went smoothly. That is how many patients the average physician sees in one full day. But, I did learn greatly from the experience. I was forced to learn how to become very efficient. It’s survival of the fittest. If you aren’t efficient, you can easily become prey to your tigers and lions when seeing this many patients a day.

It was a gradual learning process, one that included some trial and error. But I have learned a few magic tricks to make my days run smoother. Here is what I learned as the clinic Ring Master, which may perhaps be helpful for others who put on a similar show:

Practice Your Magic Tricks: Review the patient chart thoroughly before you walk into the exam room. First of all, it’s too distracting to review the chart when the patient is talking to me. Second, I may be construed as “rude” by the patient while doing so. I need to refresh my memory and review pertinent details of the patient’s case. I write all over the progress note and come up with their diagnosis list and my plan for them before I even walk in. For instance, if I have a diabetic that comes in for headaches, I come up with a plan for their diabetes – retinal photo, diabetic foot exam, and a pneumonia vaccine that they are overdue for. I write this in the chart. Then I walk in and address the patient’s concerns about the headache, and at the end take care of their diabetes. Reviewing and writing in the chart before I walk in saves me a lot of time, and gives an idea of how I want to manage my time with the patient knowing that they need other items addressed besides their headache. In this way, I am prepared to show off my magic tricks before I perform for my audience.

Aim for the Cirque De Soleil: I train my medical assistants (MA) and aim for the best show. We have an occasional shifting of MA’s in my clinic. That means that every once in a while, there’s a new MA that needs to be trained on how I expect them to room my patients. Therefore, I have made a list of how I would like the patients to be roomed based on their symptoms. For instance, every patient with chest pain gets an EKG. Every patient with burning with urination gets a “urine dip” test. Every patient with a breast complaint needs to be dressed in a special gown for examination. This saves me time since I have these items completed before I even see the patient. I may even make a “pocket version” of this list and dispense one to each new medical assistant. My MA’s are then the elite of all performers.

Construct the Stage and Props Meticulously: Take Photos of Rooms. When I have to leave the exam room to look for a band-aid, or goodness forbid a pap smear speculum in the middle of performing a gynecological exam, this wastes a lot of time (not to mention is also quite a disturbing experience for my patients). Rooms should be stocked frequently, and with items that I personally use frequently. Simply telling the staff to “stock the room” is not sufficient. Stock the room with what? One trick I learned is to create the ideal exam room myself, and then take photos of each cabinet, drawer, and tray. I then printed those photos and labeled each item in the photos. These photos were placed in a central location that the staff grabbed to take with them when stocking the rooms. And the stage is ready for show!

Print Your Show Itineraries: Keep a stack of commonly used forms and handouts in the exam rooms. This saves me time; I no longer have to walk out of the exam room to fetch the handout from my office and return to dispense it to my patients. Every seat is prepared with an itinerary.

The Ring Leader Calls the Shots: Delegate. Seeing this many patients a day, I am not able to respond to every patient message or request. I am not able to call every patient with their normal lab results. I delegate a lot to my very-efficient staff. This delegation has truly been key to running a successfully busy clinic. As Ring Leader, I call the shots and put on the show.

Now, let the show begin!  Lights!


Dreaming again said...

My least favorite (and happens at one particular office every 3 months like clock work)
start the appt
meds you take? list given
Alleriges? Latex
You're allergic to latex?
Are you sure?
Who told you were allergic to latex.
Well the first was a nurse who noticed a reaction. I didn't believe her so I didn't limit my exposure. The second was an ER doctor. I thought he had th tournaquit on too tight/too long so I ignored him too.
The third was a dermatologist ...who then had me go off several of my meds so he could do lab work ...where I tested positive in regards to latex.
The fourth was a gynocologist that I forgot to tell ... 'nuff said.
The fifth was an ER doc I was too sick to tell.

Do you need more? cause there is more ... like the dermatologist that had done the lab work,but his nurse forgot, I forgot and when he came into remove the melanoma found pretty red (and swollen) fingertips imprints (welts) where she'd touched my face.

So every three months we have this conversation about the fact that I'm truly, not just experiencially, but proven by lab work that I'm allergic to latex.

20 min later, doc is done, he's ordered lab and she pulls out the latex gloves & equipment to draw my blood. When I remind her that it must be latex free, she in a snotty voice says "well you should have let me know at the beginning before I pulled all this out of my box"

The first 4 times it was funny ... it's now going on 4 times a year for ... well... I'm almost 46 and it started at 40 .... soooooooooo way too long for to not have caught on.

Dinah said...

Hi, thought you'd like to know I referenced you.

Minqi said...

Good, I will save this one too.
how about have MA put down the med list? will it be more or less efficient?

Jill of All Trades, MD said...

Dreaming Again, OMG -- that's a lot to take! :)

Minqi, i think it would save time, but you may need to train them to write "BID" "TID" etc.. to be more complete (i often find they just write the name and dose, but skip the sig) :)

Michelle W said...

Thanks for providing a bit of sunshine in a Grand Rounds that's mostly about grousing: the grousing is funny and therapeutic, but it's nice to seem some contranst. I especially like the comparison to show business. One of my favorite SprintNextel commercials was the one where the film crew planned a wedding: as somone who's been a stagehand, I've often wondered if things would be simpler if you just had a stage manager to organize things and make sure everyone was synchronized.

stargirl65 said...

I love your photo idea. Also a great idea is how/what you want everything laid out for a pap smear/abscess I and D/ other procedure. Set out everything you want and where you want things then take the phot so they will set it up properly in the future.

Jill of All Trades, MD said...

Michelle and Stargirl, glad you found the post useful/enjoyable! Thanks so much for your comments! Stargirl, i did do that for my minor surgery "tray" and it worked out great! Thanks for the tip :)

Carrie said...

Hi, Jill!

I'm a CMA and would love to know the "list" you give your new MAs. I am always searching for ways to maximize efficiency for our staff and this sounds like it would be a great addition.

Jill of All Trades, MD said...

Hi, Carrie! Here is that "list" you asked me about:

Hope it's helpful for ya!