Escape plans to save your clinical day

It’s almost noon and clinic is going well: patients show up mostly on time, pharmacy faxes haven’t started arriving and the EMR and wi-fi are holding up. At this rate you might even get (some) time for lunch. Then, as you wish your patient well and grab the doorknob, they blurt out:“Oh, I’ve also been getting chest pain when I walk.”And just like that, you are in clinical jail, left with imperfect options: Address the complaint and blow up your schedule, making your other patients wait and thus incur their anger and disappointment. Fire off a rushed referral and offload work to a colleague, jeopardizing that professional relationship and breaking the Golden Rule. Table the issue and hope the patient doesn’t have a catastrophic event; the patient leaves dissatisfied and will likely anonymously libel you online and/or complain to the college, further taking time you don’t have.While we’d like to think that clinical encounters are more like a dance than a battle, there is no denying that it sometimes it feels like a zero-sum game with the patient wanting more time and the doctor needing to move on to help others (or eat or go to the washroom). Having done this poorly more times that I’d care to admit, here are a few strategies to help avoid such no-win scenarios.Read: Dr. Eric Cadesky: Chart it: Every. Single. Time.Planning starts before the game begins: Coaches start preparing for the next game days or weeks in advance of the first pitch or puck drop. Similarly, a little bit of advance work can save time, so glance at the next day’s patient list to see if there’s anything more your staff need to prepare, like pap kits, or surgical or suture removal sets. If a patient is coming in to review a result, make sure that it’s available.Set the agenda: Before seeing the patient, take a few moments to be clear on your own agenda. Your EMR, properly updated, will tell you what needs to be done when, from A1C surveillance to cancer screening. When the patient arrives, ask “what are all the things you’d like to accomplish today?” The average patient has three complaints, so by triaging together you’ll set clear expectations and save time later. Feel free to remind patients of the time you have allotted and invite them to reschedule if there are more issues. I make liberal use of cues like: “I appreciate there’s a lot you’d like to discuss— what is most important in the 15 minutes you’ve scheduled today?” and “Those are a lot of issues, so please schedule another appointment so that we have the time needed to properly address them.”Say no, or nothing at all: There are several reasons why people want more of your time. Some are lonely. Some people think they’re doing us a favour by accumulating issues in The List. Some are reminded of other issues during the visit. Some are Cluster B and boundaries are an issue. (A colleague recounts that when he tried once to end a visit with a particular narcissist, he was met with the threat, “You can’t do that—I’m not done with you yet.”) Remind patients of the agenda you have set together and that they can schedule another appointment. Feel free not to take the bait when at the end of a visit a patient tosses you a “what do you really think of vaccines/the healthcare system/world events?” Tell them “it’s complicated” or that you can chat about it another time when, again, they can reschedule a visit. Rather than engage in time-consuming tug of wars, don’t pick up the rope in the first place.End like a birthday party: Birthday parties often wrap up with cake (something sweet) and a loot bag (something to take home.) Like a birthday, the end of a visit is something to celebrate, and like a birthday, you can end on a positive note and give patients something to take home. Take a few moments to review how an investigation has been furthered, a diagnosis made, a treatment updated, or another way that the patient’s situation has improved. Compliment them on coming in (especially if it was on time) and reinforce good decisions they are making. Send them an email link for exercises or an appropriate education article for them to read.Be good to yourself: Medicine is hard. Relationships are hard. Being sick is hard. Navigating all at the same time makes perfection unachievable, especially for high achievers. So, when you take the bait of a political comment or give into a doorknob complaint, allow yourself to be human. And then let me know how you did it.Clinical practice is challenging and there are many pressures on our time; planning, boundaries, and optimism can all help us as we help our patients.Dr. Cadesky is a full-service family doctor in Vancouver and the chief medical officer of Seymour Health. He can be followed @drcadesky on socials.

Escape plans to save your clinical day

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