It was 6:30 pm. I had been in the office for 11 hours, and had been done with seeing patients for one hour. At my left hand was a pile of papers, each one representing a patient I had seen that day. At my right hand was a smaller stack, representing the notes I had already written. As I finished each note I would move the paper from the left hand pile to the right hand pile.
Who was next in line? A man I had diagnosed with Parkinson disease that morning. I spent about an hour with this man gathering his medical history and current symptoms, examining him, and then landing a life-changing diagnosis on him like a ton of bricks. Now it was time to document the encounter. What were his reflexes? And which arm was it that didn’t swing during the gait exam? For the life of me, I couldn’t remember.
Just then my phone rang. It was my wife.
“Hey! How’s my man?” she asked, trying to sound positive.
“OK,” I said, not really trying to sound positive. “I saw 11 patients today, and I still have 7 notes to write.”
“Yikes! How long is that going to take?”
I did some quick math. Figure 10-15 minutes per note, and it could easily be an hour and a half. “Uhhh … It will be a while,” I said. “At least an hour.”
“Well, we’re starting dinner without you then.”
I got home after 8:00 that night. Dinner was put away, and scripture time was over. The younger kids were already asleep. My only consolation was the fact that it was Thursday, and that I had every Friday off. Without that light at the end of every tunnel I could not have made it through the week.
One day I had the idea to study my own efficiency. I made a spreadsheet and started collecting the following data points each day in clinic:
- Number of patients seen in clinic
- Time I finished with last appointment
- Time I walked out the door to go home
- Wrap-up time (the difference between the previous two points, calculated by the spreadsheet)
It didn’t take me very long to realize that the wrap-up time correlated closely with another data point that I soon started tracking:
- Number of notes left to write at the end of the clinic day
The more notes left to write, the longer it took me to wrap up and leave the clinic. That was the bottleneck, the rate-limiting step. The spreadsheet had revealed my biggest weakness, my worst inefficiency. But it didn’t tell me what to do about it.
After about two months of trying different things and getting no traction with them, I vented my frustration to one of the other doctors at my practice. “I get to the end of an already long day, and I’m staring at 6 or 7 notes to write,” I said. “And I can’t just dig in and write them. I have to unwind a little, go to the bathroom, get something to eat, read a news article, or something. But all of that just sets me back another half hour! I can’t seem to make a dent in it.”
“I write my notes between patients,” he said.
I looked at him with surprise and interest. “Really? Always?”
“Yeah, pretty much,” he said. “I do a lot of it in the room with the patient.” He described how he uses dictation software to write the note, and he often will print a copy and hand it to the patient as they are leaving.
“But what about when you are running behind schedule?” I asked.
“I make the next patient wait. It only takes a few minutes to write the note, and it saves you a lot of time later. It makes your notes better, too.”
I was intrigued. Could I really take the time to do something to help myself while I made the next patient wait? It sounded so foreign to my programming — where the patient always comes first — and yet it was so logical and simple.
“I think I’m gonna try that,” I said.
And I did! Here is what happened over the next few months as I learned how to force myself to write each note immediately after seeing the patient:
The graph shows the raw data of how many notes I had left to write at the end of each day. In the early data it was not unusual to have as many as 5 or more notes left to write at the end of the day. I started the intervention at about day 60, and within a month I had figured out how to get all of my notes written by the end of the work day, every day.
I had to make several workflow changes during those 30 days. My old habit was to do a lot of typing in the room during the interview with the patient, recording their history of present illness (or “HPI” in doctor lingo). Over time I settled into a new pattern of taking sparse handwritten notes during the encounter and then using dictation software to record the HPI back in my office. This turned out to have several advantages for me. First, because I am not a quick typist it is faster to use dictation software. Second, the computer is less distracting during the visit and I can give the patient better eye contact. Third, the HPI has a better logical flow when recorded after the big picture is obtained, because most people don’t describe their illness in a way that makes it easy to document concisely in real time.
Did I fall behind schedule because I was taking the time to write notes during the day? No. Actually I did better at staying on schedule because I was thinking more about efficiency. And it is true that writing notes between seeing patients is faster than writing them at the end of the day, because everything is fresh in your mind and you don’t have to muster as much motivation.
And guess what I started doing at lunch time instead of trying to write all of the morning’s notes? Eating lunch! And reading a book! And writing blog posts! And with my extra time at home I recorded music, went running, and played with my kids. I simply couldn’t believe how much happier I was at work and at home by improving this one inefficiency.
Eventually I also learned how to work through my message log during the day so that I didn’t have so much stuff in my inbox at the end of clinic. As I stayed on schedule more and more and left the office at a sane hour day after day, I started to tell my medical assistant and scheduler to fill up more of the holes in my schedule. Over time my average number of patients per day increased, so that I was seeing more patients while spending less time in clinic and more time at home.
We only have so much time every day. Finding ways to use our time more efficiently while doing the things we have to do will allow us to spend more of our time doing the things we want to do. Like with any stewardship, if you are a wise manager of your time you will be rewarded with more of it.
Your inefficiency may be different from mine, and I don’t intend this post to be a one-size-fits-all solution. The general principles can be applied to many different situations:
- Become aware of how you are spending your time.
- Identify the biggest opportunities for improvement.
- Reach out to others for ideas and help.
- Be willing to try new ways of organizing your work.
- Track your progress so you can recognize and celebrate improvement.
Have you had a similar experience? What did you do to improve your time management? How did your efforts pay off? What are you still struggling with? Let us know in the comments below.
Part 6 of a medical education memoir: Adventures and lessons from my first years in practice