Christina Chase

PHILADELPHIA — Office-based physicians who maximize efficiency can see more patients per day without any loss of quality—in fact, smoother work flow can actually boost patient satisfaction, Dr. Mary S. Applegate said at the annual meeting of the American College of Physicians.

Improved efficiency can have “huge financial implications.” By saving 2 minutes per patient, physicians can see two more patients daily. At $50 per patient, this amounts to $10,000 more per year. Alternatively, doctors can choose to work a shorter day, going home about 45 minutes earlier instead of seeing those two extra patients, added Dr. Applegate, a family physician in a small group practice in rural Ohio.

One pressing reason to improve efficiency is the anticipated effect of pay for performance and other mandated initiatives. Physicians already have too much to do, and they need to find ways to protect their sanity if their workload actually escalates, she said. “In the end, we all don't want to become psych patients!”

In the past year, Dr. Applegate and her colleagues—two other physicians and two nurse-practitioners—looked critically at work flow and practice design to identify these strategies for enhancing time management:

▸ Delegate all “nondoctoring” tasks. Physicians should not spend their time on simple activities such as taking blood pressure, administering vaccinations, handling prescription refills, and filling out forms. Midlevel providers—nurse practitioners and physician assistants—can do a lot of these tasks. Designate a “queen of forms,” typically a nurse, who can fill in codes and dates; the physician may only need to sign. Save your time for diagnostic dilemmas and treatment failures, she suggested.

▸ Give staff clear instructions on handling common situations. Flowcharts work well and can empower paraprofessionals to manage various problems and tasks without consulting physicians.

▸ Cross-train your staff. Avoid situations where only one person knows how to do a certain task; when that person is out, work flow is disrupted. Staff members may be happier with more variety once they are comfortable with the new responsibilities, but “the transition sometimes can be difficult,” Dr. Applegate noted. To ease the transition, offer incentives to staff members willing to learn new things.

▸ Avoid routine phone calls. Although you may need to return calls to other physicians personally, a staff member can call patients back on routine matters. If bad news needs to be communicated to a patient, this should be done in person.

▸ Organize work space logically. Look at how the exam rooms, equipment, and inner offices are arranged and consider whether simple changes could streamline tasks that physicians and staff perform repeatedly. Simply moving a patient scale, or buying an extra one, might save snippets of time that can really add up. All exam rooms should be stocked with the same supplies and should be set up identically if possible.

▸ Listen to your patients. The patient interview will actually go faster if you do not interrupt. Patients talk for only about 60 seconds if they are not interrupted, she said. The patient feels heard, and clearer communications can lead to greater patient satisfaction. Make eye contact, sit down with the patient, and briefly touch the patient reassuringly or shake hands.

▸ Avoid batching of unpleasant or difficult tasks. Putting off work until later in the day when you're probably tired—and have forgotten some details about a patient encounter—can become “an unhealthy addiction,” Dr. Applegate said. One task that physicians often batch is writing notes in patient charts. The inefficiencies can add up when errors are made and patients are dissatisfied with their care down the line.

▸ Work in real time and get the job done. This is the opposite of batching: Stay focused and complete the entire patient encounter before that patient leaves. It is fine to look up information and even dictate in the exam room with the patient present. When some tasks unavoidably accumulate, set a rule that you will stop at regular intervals (for example, every two to four patients) to catch up before taking the next patient.

▸ Be a team player. Huddle with your staff for a few minutes every morning and afternoon to set a game plan and take control of the day before it controls you. This can help prevent glitches that would eat up valuable time. “Empower the staff to help you stay on time,” Dr. Applegate said.

▸ Take care of yourself. Balance work demands against personal time to avoid burnout. Physicians who neglect their needs for downtime and recreation are less productive and efficient. In extreme cases, this can lead to financial losses and even bankruptcy, she said.

▸ Embrace new technology. Use the available tools for billing, coding, and communications. Electronic medical records are not perfect and the transition can be painful—“It's like 3 months of pure hell”—but they are becoming a necessity. The need to log lab results for pay for performance is “the single best argument for an EMR,” she added.

The most important take-home message is to avoid batching difficult tasks, she emphasized. Get it done in real time. “It really does work!”

PHILADELPHIA — Office-based physicians who maximize efficiency can see more patients per day without any loss of quality—in fact, smoother work flow can actually boost patient satisfaction, Dr. Mary S. Applegate said at the annual meeting of the American College of Physicians.

Improved efficiency can have “huge financial implications.” By saving 2 minutes per patient, physicians can see two more patients daily. At $50 per patient, this amounts to $10,000 more per year. Alternatively, doctors can choose to work a shorter day, going home about 45 minutes earlier instead of seeing those two extra patients, added Dr. Applegate, a family physician in a small group practice in rural Ohio.

One pressing reason to improve efficiency is the anticipated effect of pay for performance and other mandated initiatives. Physicians already have too much to do, and they need to find ways to protect their sanity if their workload actually escalates, she said. “In the end, we all don't want to become psych patients!”

In the past year, Dr. Applegate and her colleagues—two other physicians and two nurse-practitioners—looked critically at work flow and practice design to identify these strategies for enhancing time management:

▸ Delegate all “nondoctoring” tasks. Physicians should not spend their time on simple activities such as taking blood pressure, administering vaccinations, handling prescription refills, and filling out forms. Midlevel providers—nurse practitioners and physician assistants—can do a lot of these tasks. Designate a “queen of forms,” typically a nurse, who can fill in codes and dates; the physician may only need to sign. Save your time for diagnostic dilemmas and treatment failures, she suggested.

▸ Give staff clear instructions on handling common situations. Flowcharts work well and can empower paraprofessionals to manage various problems and tasks without consulting physicians.

▸ Cross-train your staff. Avoid situations where only one person knows how to do a certain task; when that person is out, work flow is disrupted. Staff members may be happier with more variety once they are comfortable with the new responsibilities, but “the transition sometimes can be difficult,” Dr. Applegate noted. To ease the transition, offer incentives to staff members willing to learn new things.

▸ Avoid routine phone calls. Although you may need to return calls to other physicians personally, a staff member can call patients back on routine matters. If bad news needs to be communicated to a patient, this should be done in person.

▸ Organize work space logically. Look at how the exam rooms, equipment, and inner offices are arranged and consider whether simple changes could streamline tasks that physicians and staff perform repeatedly. Simply moving a patient scale, or buying an extra one, might save snippets of time that can really add up. All exam rooms should be stocked with the same supplies and should be set up identically if possible.

▸ Listen to your patients. The patient interview will actually go faster if you do not interrupt. Patients talk for only about 60 seconds if they are not interrupted, she said. The patient feels heard, and clearer communications can lead to greater patient satisfaction. Make eye contact, sit down with the patient, and briefly touch the patient reassuringly or shake hands.

▸ Avoid batching of unpleasant or difficult tasks. Putting off work until later in the day when you're probably tired—and have forgotten some details about a patient encounter—can become “an unhealthy addiction,” Dr. Applegate said. One task that physicians often batch is writing notes in patient charts. The inefficiencies can add up when errors are made and patients are dissatisfied with their care down the line.

▸ Work in real time and get the job done. This is the opposite of batching: Stay focused and complete the entire patient encounter before that patient leaves. It is fine to look up information and even dictate in the exam room with the patient present. When some tasks unavoidably accumulate, set a rule that you will stop at regular intervals (for example, every two to four patients) to catch up before taking the next patient.

▸ Be a team player. Huddle with your staff for a few minutes every morning and afternoon to set a game plan and take control of the day before it controls you. This can help prevent glitches that would eat up valuable time. “Empower the staff to help you stay on time,” Dr. Applegate said.

▸ Take care of yourself. Balance work demands against personal time to avoid burnout. Physicians who neglect their needs for downtime and recreation are less productive and efficient. In extreme cases, this can lead to financial losses and even bankruptcy, she said.

▸ Embrace new technology. Use the available tools for billing, coding, and communications. Electronic medical records are not perfect and the transition can be painful—“It's like 3 months of pure hell”—but they are becoming a necessity. The need to log lab results for pay for performance is “the single best argument for an EMR,” she added.

The most important take-home message is to avoid batching difficult tasks, she emphasized. Get it done in real time. “It really does work!”

PHILADELPHIA — Office-based physicians who maximize efficiency can see more patients per day without any loss of quality—in fact, smoother work flow can actually boost patient satisfaction, Dr. Mary S. Applegate said at the annual meeting of the American College of Physicians.

Improved efficiency can have “huge financial implications.” By saving 2 minutes per patient, physicians can see two more patients daily. At $50 per patient, this amounts to $10,000 more per year. Alternatively, doctors can choose to work a shorter day, going home about 45 minutes earlier instead of seeing those two extra patients, added Dr. Applegate, a family physician in a small group practice in rural Ohio.

One pressing reason to improve efficiency is the anticipated effect of pay for performance and other mandated initiatives. Physicians already have too much to do, and they need to find ways to protect their sanity if their workload actually escalates, she said. “In the end, we all don't want to become psych patients!”

In the past year, Dr. Applegate and her colleagues—two other physicians and two nurse-practitioners—looked critically at work flow and practice design to identify these strategies for enhancing time management:

▸ Delegate all “nondoctoring” tasks. Physicians should not spend their time on simple activities such as taking blood pressure, administering vaccinations, handling prescription refills, and filling out forms. Midlevel providers—nurse practitioners and physician assistants—can do a lot of these tasks. Designate a “queen of forms,” typically a nurse, who can fill in codes and dates; the physician may only need to sign. Save your time for diagnostic dilemmas and treatment failures, she suggested.

▸ Give staff clear instructions on handling common situations. Flowcharts work well and can empower paraprofessionals to manage various problems and tasks without consulting physicians.

▸ Cross-train your staff. Avoid situations where only one person knows how to do a certain task; when that person is out, work flow is disrupted. Staff members may be happier with more variety once they are comfortable with the new responsibilities, but “the transition sometimes can be difficult,” Dr. Applegate noted. To ease the transition, offer incentives to staff members willing to learn new things.

▸ Avoid routine phone calls. Although you may need to return calls to other physicians personally, a staff member can call patients back on routine matters. If bad news needs to be communicated to a patient, this should be done in person.

▸ Organize work space logically. Look at how the exam rooms, equipment, and inner offices are arranged and consider whether simple changes could streamline tasks that physicians and staff perform repeatedly. Simply moving a patient scale, or buying an extra one, might save snippets of time that can really add up. All exam rooms should be stocked with the same supplies and should be set up identically if possible.

▸ Listen to your patients. The patient interview will actually go faster if you do not interrupt. Patients talk for only about 60 seconds if they are not interrupted, she said. The patient feels heard, and clearer communications can lead to greater patient satisfaction. Make eye contact, sit down with the patient, and briefly touch the patient reassuringly or shake hands.

▸ Avoid batching of unpleasant or difficult tasks. Putting off work until later in the day when you're probably tired—and have forgotten some details about a patient encounter—can become “an unhealthy addiction,” Dr. Applegate said. One task that physicians often batch is writing notes in patient charts. The inefficiencies can add up when errors are made and patients are dissatisfied with their care down the line.

▸ Work in real time and get the job done. This is the opposite of batching: Stay focused and complete the entire patient encounter before that patient leaves. It is fine to look up information and even dictate in the exam room with the patient present. When some tasks unavoidably accumulate, set a rule that you will stop at regular intervals (for example, every two to four patients) to catch up before taking the next patient.

▸ Be a team player. Huddle with your staff for a few minutes every morning and afternoon to set a game plan and take control of the day before it controls you. This can help prevent glitches that would eat up valuable time. “Empower the staff to help you stay on time,” Dr. Applegate said.

▸ Take care of yourself. Balance work demands against personal time to avoid burnout. Physicians who neglect their needs for downtime and recreation are less productive and efficient. In extreme cases, this can lead to financial losses and even bankruptcy, she said.

▸ Embrace new technology. Use the available tools for billing, coding, and communications. Electronic medical records are not perfect and the transition can be painful—“It's like 3 months of pure hell”—but they are becoming a necessity. The need to log lab results for pay for performance is “the single best argument for an EMR,” she added.

The most important take-home message is to avoid batching difficult tasks, she emphasized. Get it done in real time. “It really does work!”

PHILADELPHIA — Office-based physicians who maximize efficiency can see more patients per day without any loss of quality—in fact, smoother workflow can actually boost patient satisfaction, Dr. Mary S. Applegate said at the annual meeting of the American College of Physicians.

Improved efficiency can have “huge financial implications.” By saving 2 minutes per patient, physicians can see two more patients daily. At $50 per patient, this amounts to $10,000 more per year. Alternatively, doctors can choose to work a shorter day, going home about 45 minutes earlier instead of seeing those two extra patients, added Dr. Applegate, a family physician in a small group practice in rural Ohio.

Dr. Applegate and her colleagues—two other physicians and two nurse practitioners—looked critically at workflow and practice design to identify these strategies for enhancing time management:

▸ Delegate all “nondoctoring” tasks. Physicians should not spend their time on simple activities such as taking blood pressure, administering vaccinations, handling prescription refills, and filling out forms. Midlevel providers—nurse practitioners and physician assistants—can do a lot of these tasks. Designate a “queen of forms,” typically a nurse, who can fill in codes and dates; the physician may only need to sign. Save your time for diagnostic dilemmas and treatment failures, she suggested.

▸ Give staff clear instructions on handling common situations. Flowcharts work well and can empower paraprofessionals to manage various problems and tasks without consulting physicians.

▸ Cross-train your staff. Avoid situations where only one person knows how to do a certain task; when that person is out, workflow is disrupted. Staff members may be happier with more variety once they are comfortable with the new responsibilities, but “the transition sometimes can be difficult,” Dr. Applegate noted. To ease the transition, offer incentives to staff members willing to learn new things.

▸ Organize work space logically. Look at how the exam rooms, equipment, and inner offices are arranged and consider whether simple changes could streamline tasks that physicians and staff perform repeatedly. Simply moving a patient scale, or buying an extra one, might save snippets of time that can really add up. All exam rooms should be stocked with the same supplies and should be set up identically if possible.

▸ Listen to your patients. The patient interview will actually go faster if you do not interrupt. Patients talk for only about 60 seconds if they are not interrupted, she said. The patient feels heard, and clearer communications can lead to greater patient satisfaction. Make eye contact, sit down with the patient, and briefly touch the patient reassuringly or shake hands.

▸ Avoid batching of unpleasant or difficult tasks. Putting off work until later in the day when you're probably tired—and have forgotten some details about a patient encounter—can become “an unhealthy addiction,” Dr. Applegate said. One task that physicians often batch is writing notes in patient charts. The inefficiencies can add up when errors are made and patients are dissatisfied with their care down the line. This is the most important take-home message. Get it done in real time. “It really does work!,” she said.

▸ Work in real time and get the job done. This is the opposite of batching: Stay focused and complete the entire patient encounter before that patient leaves. It is fine to look up information and even dictate in the exam room with the patient present. When some tasks unavoidably accumulate, set a rule that you will stop at regular intervals to catch up before taking the next patient.

▸ Be a team player. Huddle with your staff for a few minutes every morning and afternoon to set a game plan and take control of the day before it controls you. This can help prevent glitches that would eat up valuable time.

▸ Take care of yourself. Balance work demands against personal time to avoid burnout. Physicians who neglect their needs for downtime and recreation are less productive and efficient. In extreme cases, this can lead to financial losses and even bankruptcy, she said.

▸ Embrace and use new technology. Use the available tools for billing, coding, and communications. Electronic medical records are not perfect and the transition can be painful— “It's like 3 months of pure hell”—but they are becoming a necessity. The need to log lab results for pay for performance is “the single best argument for an EMR,” Dr. Applegate added.

PHILADELPHIA — Office-based physicians who maximize efficiency can see more patients per day without any loss of quality—in fact, smoother workflow can actually boost patient satisfaction, Dr. Mary S. Applegate said at the annual meeting of the American College of Physicians.

Improved efficiency can have “huge financial implications.” By saving 2 minutes per patient, physicians can see two more patients daily. At $50 per patient, this amounts to $10,000 more per year. Alternatively, doctors can choose to work a shorter day, going home about 45 minutes earlier instead of seeing those two extra patients, added Dr. Applegate, a family physician in a small group practice in rural Ohio.

Dr. Applegate and her colleagues—two other physicians and two nurse practitioners—looked critically at workflow and practice design to identify these strategies for enhancing time management:

▸ Delegate all “nondoctoring” tasks. Physicians should not spend their time on simple activities such as taking blood pressure, administering vaccinations, handling prescription refills, and filling out forms. Midlevel providers—nurse practitioners and physician assistants—can do a lot of these tasks. Designate a “queen of forms,” typically a nurse, who can fill in codes and dates; the physician may only need to sign. Save your time for diagnostic dilemmas and treatment failures, she suggested.

▸ Give staff clear instructions on handling common situations. Flowcharts work well and can empower paraprofessionals to manage various problems and tasks without consulting physicians.

▸ Cross-train your staff. Avoid situations where only one person knows how to do a certain task; when that person is out, workflow is disrupted. Staff members may be happier with more variety once they are comfortable with the new responsibilities, but “the transition sometimes can be difficult,” Dr. Applegate noted. To ease the transition, offer incentives to staff members willing to learn new things.

▸ Organize work space logically. Look at how the exam rooms, equipment, and inner offices are arranged and consider whether simple changes could streamline tasks that physicians and staff perform repeatedly. Simply moving a patient scale, or buying an extra one, might save snippets of time that can really add up. All exam rooms should be stocked with the same supplies and should be set up identically if possible.

▸ Listen to your patients. The patient interview will actually go faster if you do not interrupt. Patients talk for only about 60 seconds if they are not interrupted, she said. The patient feels heard, and clearer communications can lead to greater patient satisfaction. Make eye contact, sit down with the patient, and briefly touch the patient reassuringly or shake hands.

▸ Avoid batching of unpleasant or difficult tasks. Putting off work until later in the day when you're probably tired—and have forgotten some details about a patient encounter—can become “an unhealthy addiction,” Dr. Applegate said. One task that physicians often batch is writing notes in patient charts. The inefficiencies can add up when errors are made and patients are dissatisfied with their care down the line. This is the most important take-home message. Get it done in real time. “It really does work!,” she said.

▸ Work in real time and get the job done. This is the opposite of batching: Stay focused and complete the entire patient encounter before that patient leaves. It is fine to look up information and even dictate in the exam room with the patient present. When some tasks unavoidably accumulate, set a rule that you will stop at regular intervals to catch up before taking the next patient.

▸ Be a team player. Huddle with your staff for a few minutes every morning and afternoon to set a game plan and take control of the day before it controls you. This can help prevent glitches that would eat up valuable time.

▸ Take care of yourself. Balance work demands against personal time to avoid burnout. Physicians who neglect their needs for downtime and recreation are less productive and efficient. In extreme cases, this can lead to financial losses and even bankruptcy, she said.

▸ Embrace and use new technology. Use the available tools for billing, coding, and communications. Electronic medical records are not perfect and the transition can be painful— “It's like 3 months of pure hell”—but they are becoming a necessity. The need to log lab results for pay for performance is “the single best argument for an EMR,” Dr. Applegate added.

PHILADELPHIA — Office-based physicians who maximize efficiency can see more patients per day without any loss of quality—in fact, smoother workflow can actually boost patient satisfaction, Dr. Mary S. Applegate said at the annual meeting of the American College of Physicians.

Improved efficiency can have “huge financial implications.” By saving 2 minutes per patient, physicians can see two more patients daily. At $50 per patient, this amounts to $10,000 more per year. Alternatively, doctors can choose to work a shorter day, going home about 45 minutes earlier instead of seeing those two extra patients, added Dr. Applegate, a family physician in a small group practice in rural Ohio.

Dr. Applegate and her colleagues—two other physicians and two nurse practitioners—looked critically at workflow and practice design to identify these strategies for enhancing time management:

▸ Delegate all “nondoctoring” tasks. Physicians should not spend their time on simple activities such as taking blood pressure, administering vaccinations, handling prescription refills, and filling out forms. Midlevel providers—nurse practitioners and physician assistants—can do a lot of these tasks. Designate a “queen of forms,” typically a nurse, who can fill in codes and dates; the physician may only need to sign. Save your time for diagnostic dilemmas and treatment failures, she suggested.

▸ Give staff clear instructions on handling common situations. Flowcharts work well and can empower paraprofessionals to manage various problems and tasks without consulting physicians.

▸ Cross-train your staff. Avoid situations where only one person knows how to do a certain task; when that person is out, workflow is disrupted. Staff members may be happier with more variety once they are comfortable with the new responsibilities, but “the transition sometimes can be difficult,” Dr. Applegate noted. To ease the transition, offer incentives to staff members willing to learn new things.

▸ Organize work space logically. Look at how the exam rooms, equipment, and inner offices are arranged and consider whether simple changes could streamline tasks that physicians and staff perform repeatedly. Simply moving a patient scale, or buying an extra one, might save snippets of time that can really add up. All exam rooms should be stocked with the same supplies and should be set up identically if possible.

▸ Listen to your patients. The patient interview will actually go faster if you do not interrupt. Patients talk for only about 60 seconds if they are not interrupted, she said. The patient feels heard, and clearer communications can lead to greater patient satisfaction. Make eye contact, sit down with the patient, and briefly touch the patient reassuringly or shake hands.

▸ Avoid batching of unpleasant or difficult tasks. Putting off work until later in the day when you're probably tired—and have forgotten some details about a patient encounter—can become “an unhealthy addiction,” Dr. Applegate said. One task that physicians often batch is writing notes in patient charts. The inefficiencies can add up when errors are made and patients are dissatisfied with their care down the line. This is the most important take-home message. Get it done in real time. “It really does work!,” she said.

▸ Work in real time and get the job done. This is the opposite of batching: Stay focused and complete the entire patient encounter before that patient leaves. It is fine to look up information and even dictate in the exam room with the patient present. When some tasks unavoidably accumulate, set a rule that you will stop at regular intervals to catch up before taking the next patient.

▸ Be a team player. Huddle with your staff for a few minutes every morning and afternoon to set a game plan and take control of the day before it controls you. This can help prevent glitches that would eat up valuable time.

▸ Take care of yourself. Balance work demands against personal time to avoid burnout. Physicians who neglect their needs for downtime and recreation are less productive and efficient. In extreme cases, this can lead to financial losses and even bankruptcy, she said.

▸ Embrace and use new technology. Use the available tools for billing, coding, and communications. Electronic medical records are not perfect and the transition can be painful— “It's like 3 months of pure hell”—but they are becoming a necessity. The need to log lab results for pay for performance is “the single best argument for an EMR,” Dr. Applegate added.

PHILADELPHIA — Office-based physicians who maximize efficiency can see more patients per day without any loss of quality—in fact, smoother workflow can actually boost patient satisfaction, Dr. Mary S. Applegate said at the annual meeting of the American College of Physicians.

Improved efficiency can have “huge financial implications.” By saving 2 minutes per patient, physicians can see two more patients daily. At $50 per patient, this amounts to $10,000 more per year. Alternatively, doctors can choose to work a shorter day, going home about 45 minutes earlier instead of seeing those two extra patients, added Dr. Applegate, a family physician in a small group practice in rural Ohio.

One pressing reason to improve efficiency is the anticipated effect of pay for performance and other mandated initiatives. Physicians already have too much to do, and they need to find ways to protect their sanity if their workload actually escalates, she said. “In the end, we all don't want to become psych patients!”

In the past year, Dr. Applegate and her colleagues—two other physicians and two nurse practitioners—looked critically at workflow and practice design to identify these strategies for enhancing time management:

▸ Delegate all “nondoctoring” tasks. Physicians should not spend their time on simple activities such as taking blood pressure, administering vaccinations, handling prescription refills, and filling out forms. Midlevel providers—nurse practitioners and physician assistants—can do a lot of these tasks. Designate a “queen of forms,” typically a nurse, who can fill in codes and dates; the physician may only need to sign. Save your time for diagnostic dilemmas and treatment failures, Dr. Applegate suggested.

▸ Give staff clear instructions on handling common situations. Flowcharts work well and can empower paraprofessionals to manage various problems and tasks without consulting physicians.

▸ Cross-train your staff. Avoid situations where only one person knows how to do a certain task; when that person is out, workflow is disrupted. Staff members may be happier with more variety once they are comfortable with the new responsibilities, but “the transition sometimes can be difficult,” she noted. To ease the transition, offer incentives to staff members willing to learn new things.

▸ Avoid routine phone calls. Although you may need to return calls to other physicians personally, a staff member can call patients back on routine matters. If bad news needs to be communicated to a patient, this should be done in person.

▸ Organize work space logically. Look at how the exam rooms, equipment, and inner offices are arranged and consider whether simple changes could streamline tasks that physicians and staff perform repeatedly. Simply moving a patient scale, or buying an extra one, might save snippets of time that can really add up. All exam rooms should be stocked with the same supplies and should be set up identically if possible, Dr. Applegate said.

▸ Listen to your patients. The patient interview will actually go faster if you do not interrupt. Patients talk for only about 60 seconds if they are not interrupted, she said. The patient feels heard, and clearer communications can lead to greater patient satisfaction. Make eye contact, sit down with the patient, and briefly touch the patient reassuringly or shake hands.

▸ Avoid batching of unpleasant or difficult tasks. Putting off work until later in the day when you're probably tired—and have forgotten some details about a patient encounter—can become “an unhealthy addiction,” she said. One task that physicians often batch is writing notes in patient charts. The inefficiencies can add up when errors are made and patients are dissatisfied with their care down the line.

▸ Work in real time and get the job done. This is the opposite of batching: Stay focused and complete the entire patient encounter before that patient leaves. It is fine to look up information and even dictate in the exam room with the patient present. When some tasks unavoidably accumulate, set a rule that you will stop at regular intervals (for example, every two to four patients) to catch up before taking the next patient.

▸ Be a team player. Huddle with your staff for a few minutes every morning and afternoon to set a game plan and take control of the day before it controls you. This can help prevent glitches that would eat up valuable time. “Empower the staff to help you stay on time,” Dr. Applegate said.

▸ Take care of yourself. Balance work demands against personal time to avoid burnout. Physicians who neglect their needs for downtime and recreation are less productive and efficient. In extreme cases, this can lead to financial losses and even bankruptcy, she said.

▸ Embrace and use new technology. Use the available tools for billing, coding, and communications. Electronic medical records are not perfect and the transition can be painful—“It's like 3 months of pure hell”—but they are becoming a necessity. The need to log lab results for pay for performance is “the single best argument for an EMR,” Dr. Applegate added.

The most important take-home message is to avoid batching difficult tasks, she emphasized. Get it done in real time. “It really does work!”

PHILADELPHIA — Office-based physicians who maximize efficiency can see more patients per day without any loss of quality—in fact, smoother workflow can actually boost patient satisfaction, Dr. Mary S. Applegate said at the annual meeting of the American College of Physicians.

Improved efficiency can have “huge financial implications.” By saving 2 minutes per patient, physicians can see two more patients daily. At $50 per patient, this amounts to $10,000 more per year. Alternatively, doctors can choose to work a shorter day, going home about 45 minutes earlier instead of seeing those two extra patients, added Dr. Applegate, a family physician in a small group practice in rural Ohio.

One pressing reason to improve efficiency is the anticipated effect of pay for performance and other mandated initiatives. Physicians already have too much to do, and they need to find ways to protect their sanity if their workload actually escalates, she said. “In the end, we all don't want to become psych patients!”

In the past year, Dr. Applegate and her colleagues—two other physicians and two nurse practitioners—looked critically at workflow and practice design to identify these strategies for enhancing time management:

▸ Delegate all “nondoctoring” tasks. Physicians should not spend their time on simple activities such as taking blood pressure, administering vaccinations, handling prescription refills, and filling out forms. Midlevel providers—nurse practitioners and physician assistants—can do a lot of these tasks. Designate a “queen of forms,” typically a nurse, who can fill in codes and dates; the physician may only need to sign. Save your time for diagnostic dilemmas and treatment failures, Dr. Applegate suggested.

▸ Give staff clear instructions on handling common situations. Flowcharts work well and can empower paraprofessionals to manage various problems and tasks without consulting physicians.

▸ Cross-train your staff. Avoid situations where only one person knows how to do a certain task; when that person is out, workflow is disrupted. Staff members may be happier with more variety once they are comfortable with the new responsibilities, but “the transition sometimes can be difficult,” she noted. To ease the transition, offer incentives to staff members willing to learn new things.

▸ Avoid routine phone calls. Although you may need to return calls to other physicians personally, a staff member can call patients back on routine matters. If bad news needs to be communicated to a patient, this should be done in person.

▸ Organize work space logically. Look at how the exam rooms, equipment, and inner offices are arranged and consider whether simple changes could streamline tasks that physicians and staff perform repeatedly. Simply moving a patient scale, or buying an extra one, might save snippets of time that can really add up. All exam rooms should be stocked with the same supplies and should be set up identically if possible, Dr. Applegate said.

▸ Listen to your patients. The patient interview will actually go faster if you do not interrupt. Patients talk for only about 60 seconds if they are not interrupted, she said. The patient feels heard, and clearer communications can lead to greater patient satisfaction. Make eye contact, sit down with the patient, and briefly touch the patient reassuringly or shake hands.

▸ Avoid batching of unpleasant or difficult tasks. Putting off work until later in the day when you're probably tired—and have forgotten some details about a patient encounter—can become “an unhealthy addiction,” she said. One task that physicians often batch is writing notes in patient charts. The inefficiencies can add up when errors are made and patients are dissatisfied with their care down the line.

▸ Work in real time and get the job done. This is the opposite of batching: Stay focused and complete the entire patient encounter before that patient leaves. It is fine to look up information and even dictate in the exam room with the patient present. When some tasks unavoidably accumulate, set a rule that you will stop at regular intervals (for example, every two to four patients) to catch up before taking the next patient.

▸ Be a team player. Huddle with your staff for a few minutes every morning and afternoon to set a game plan and take control of the day before it controls you. This can help prevent glitches that would eat up valuable time. “Empower the staff to help you stay on time,” Dr. Applegate said.

▸ Take care of yourself. Balance work demands against personal time to avoid burnout. Physicians who neglect their needs for downtime and recreation are less productive and efficient. In extreme cases, this can lead to financial losses and even bankruptcy, she said.

▸ Embrace and use new technology. Use the available tools for billing, coding, and communications. Electronic medical records are not perfect and the transition can be painful—“It's like 3 months of pure hell”—but they are becoming a necessity. The need to log lab results for pay for performance is “the single best argument for an EMR,” Dr. Applegate added.

The most important take-home message is to avoid batching difficult tasks, she emphasized. Get it done in real time. “It really does work!”

PHILADELPHIA — Office-based physicians who maximize efficiency can see more patients per day without any loss of quality—in fact, smoother workflow can actually boost patient satisfaction, Dr. Mary S. Applegate said at the annual meeting of the American College of Physicians.

Improved efficiency can have “huge financial implications.” By saving 2 minutes per patient, physicians can see two more patients daily. At $50 per patient, this amounts to $10,000 more per year. Alternatively, doctors can choose to work a shorter day, going home about 45 minutes earlier instead of seeing those two extra patients, added Dr. Applegate, a family physician in a small group practice in rural Ohio.

One pressing reason to improve efficiency is the anticipated effect of pay for performance and other mandated initiatives. Physicians already have too much to do, and they need to find ways to protect their sanity if their workload actually escalates, she said. “In the end, we all don't want to become psych patients!”

In the past year, Dr. Applegate and her colleagues—two other physicians and two nurse practitioners—looked critically at workflow and practice design to identify these strategies for enhancing time management:

▸ Delegate all “nondoctoring” tasks. Physicians should not spend their time on simple activities such as taking blood pressure, administering vaccinations, handling prescription refills, and filling out forms. Midlevel providers—nurse practitioners and physician assistants—can do a lot of these tasks. Designate a “queen of forms,” typically a nurse, who can fill in codes and dates; the physician may only need to sign. Save your time for diagnostic dilemmas and treatment failures, Dr. Applegate suggested.

▸ Give staff clear instructions on handling common situations. Flowcharts work well and can empower paraprofessionals to manage various problems and tasks without consulting physicians.

▸ Cross-train your staff. Avoid situations where only one person knows how to do a certain task; when that person is out, workflow is disrupted. Staff members may be happier with more variety once they are comfortable with the new responsibilities, but “the transition sometimes can be difficult,” she noted. To ease the transition, offer incentives to staff members willing to learn new things.

▸ Avoid routine phone calls. Although you may need to return calls to other physicians personally, a staff member can call patients back on routine matters. If bad news needs to be communicated to a patient, this should be done in person.

▸ Organize work space logically. Look at how the exam rooms, equipment, and inner offices are arranged and consider whether simple changes could streamline tasks that physicians and staff perform repeatedly. Simply moving a patient scale, or buying an extra one, might save snippets of time that can really add up. All exam rooms should be stocked with the same supplies and should be set up identically if possible, Dr. Applegate said.

▸ Listen to your patients. The patient interview will actually go faster if you do not interrupt. Patients talk for only about 60 seconds if they are not interrupted, she said. The patient feels heard, and clearer communications can lead to greater patient satisfaction. Make eye contact, sit down with the patient, and briefly touch the patient reassuringly or shake hands.

▸ Avoid batching of unpleasant or difficult tasks. Putting off work until later in the day when you're probably tired—and have forgotten some details about a patient encounter—can become “an unhealthy addiction,” she said. One task that physicians often batch is writing notes in patient charts. The inefficiencies can add up when errors are made and patients are dissatisfied with their care down the line.

▸ Work in real time and get the job done. This is the opposite of batching: Stay focused and complete the entire patient encounter before that patient leaves. It is fine to look up information and even dictate in the exam room with the patient present. When some tasks unavoidably accumulate, set a rule that you will stop at regular intervals (for example, every two to four patients) to catch up before taking the next patient.

▸ Be a team player. Huddle with your staff for a few minutes every morning and afternoon to set a game plan and take control of the day before it controls you. This can help prevent glitches that would eat up valuable time. “Empower the staff to help you stay on time,” Dr. Applegate said.

▸ Take care of yourself. Balance work demands against personal time to avoid burnout. Physicians who neglect their needs for downtime and recreation are less productive and efficient. In extreme cases, this can lead to financial losses and even bankruptcy, she said.

▸ Embrace and use new technology. Use the available tools for billing, coding, and communications. Electronic medical records are not perfect and the transition can be painful—“It's like 3 months of pure hell”—but they are becoming a necessity. The need to log lab results for pay for performance is “the single best argument for an EMR,” Dr. Applegate added.

The most important take-home message is to avoid batching difficult tasks, she emphasized. Get it done in real time. “It really does work!”

PHILADELPHIA — Eight basic rules for making the rounds on older, hospitalized patients can help identify problems that the house staff may not focus on, Dr. Evelyn C. Granieri said at the annual meeting of the American College of Physicians.

It takes only 10 minutes to complete all eight assessments, said Dr. Granieri, a geriatrician at Columbia University, New York, who said she has been doing inpatient rounds almost daily for 17 years.

The eight rules are as follows:

1. Review all medications. Do this every day you visit the patient. Consider how changes in body weight and renal function may affect the appropriate dosage. “Older adults in the hospital are very dynamic in terms of their status,” she noted.

Also, keep in mind that medication changes are a major precipitant of delirium in older adults. On average, patients come into the hospital on about eight drugs and leave on about nine, but five of those medications are new, Dr. Granieri said.

The rate of cognitive impairment in hospitalized elderly over age 70 is as high as 75%, and so the discharge plan for medications needs to be “as simple as possible,” she said. Complex drug regimens are bound to fail, and may even precipitate an emergency department visit or rehospitalization. “Don't send patients home on b.i.d., t.i.d., and q.i.d. regimens. Try and do a q.d. or b.i.d. at the very most. This is very important,” she advised.

2. Perform a cognitive assessment. The best screening test is simply asking the patient to draw a clock showing a specific time. Give the instructions just once, and be ruthless in judging the results: “It's either right or it's wrong,” Dr. Granieri said. She related the story of a patient, who happened to be a practicing physician in his 70s, who drew and numbered the clock correctly but then added three hands pointing at 2, 4, and 5 and circled those numbers to indicate 2:45. As a physician, she said, “he had perfected the art of being vague.”

The clock test is a good early screen, but “it's not a diagnostic, it's an unmasking tool,” she noted. It's critical to unmask the impairment because a patient who can't draw a clock won't be able to take medications correctly or drive a car.

3. Look for pressure ulcers. Check the skin daily because a pressure ulcer can develop in as little as 2 hours. With the current shortage of hands-on nursing care, doing this screen faithfully has become even more crucial. On admission, 2%–10% of patients have pressure ulcers, but 10%–20% have them on discharge, she noted.

4. Check functional status. “One of the first things that I now do on frailer people, or people over the age of 75,” is immediately get a physical therapy and occupational therapy consult. This guarantees that the patient will get out of bed and be checked for ambulation. Also, the therapists often notice skin breakdown, incontinence, and inability to follow directions.

In bedridden patients, significant loss of muscle mass starts after 3 days, but it takes 9–12 days to begin rebuilding muscle with help from physical therapy.

But even without a consult, “you can look at them and see. You can tell if someone is getting out of bed. You can ask them to swing their legs around and stand,” she said.

5. Assess for gait dysfunction and fall risk. “It's incredible that many patients are discharged from the hospital without any test of their gait and ambulation,” Dr. Granieri said.

To prevent falls in the hospital, get rid of the Foley or Texas catheter. These are seldom needed but often overused, potentially causing falls as well as increasing the risk of urinary tract infections and resistant bacteria.

Little can be done to prevent falls in the hospital. “At the risk of sounding pessimistic, it's tough—there's no good answer.” A few environmental changes may help: Make sure that the beds are lowered, that there's enough light, and that each patient has a bedside commode.

6. Determine if your patient is eating and drinking. If a patient comes in malnourished, this can't be cured during a 5-day hospital stay. But during rounds, be sure the patient's food tray is close enough to reach, use a feeding program if available at the hospital, and check swallowing ability at least once (or be sure the nurse checks).

“Aspiration pneumonia—especially for people who are hospitalized who may be delirious or [have] cognitive impairment or infections—is deadly,” she noted.

Calorie counts are a waste of time, said Dr. Granieri, who used to be a dietitian and did many such counts herself. “If you think your patient is malnourished and they've lost weight, [they have]. Get them to eat by any means possible.”

For those who won't or can't eat, don't use tube feedings, she advised, “unless it's time limited, or unless they have only one organ system that's problematic.

“Tube feedings in people with dementia do not keep them alive longer,” but do increase complications. And studies have shown that people at the end of life don't feel hunger and thirst. “Once someone stops eating, that's it,” she said. It's important to talk with families early about the issue of tube feedings, she added.

7. Be sure patients have their glasses, hearing aids, and walking devices. If a patient isn't wearing glasses, chances are they're somewhere such as in a drawer, since almost all older people have visual impairment. A patient who uses a walker at home should have one in the hospital.

8. Use the team of clinicians available to you. Get consults, especially for home care. Take advantage of available services, such as physical therapy and nutrition services. Don't take care of a frail older patient alone, she emphasized.

Finally, keep in mind that all eight of these issues are interconnected. A patient with cognitive impairment cannot manage a complex medication schedule after discharge, and a patient who can't reach his glasses might not eat his meals. “Think in a matrix way, as opposed to a linear, or algorithmic, way,” Dr. Granieri advised.

PHILADELPHIA — Eight basic rules for making the rounds on older, hospitalized patients can help identify problems that the house staff may not focus on, Dr. Evelyn C. Granieri said at the annual meeting of the American College of Physicians.

It takes only 10 minutes to complete all eight assessments, said Dr. Granieri, a geriatrician at Columbia University, New York, who said she has been doing inpatient rounds almost daily for 17 years.

The eight rules are as follows:

1. Review all medications. Do this every day you visit the patient. Consider how changes in body weight and renal function may affect the appropriate dosage. “Older adults in the hospital are very dynamic in terms of their status,” she noted.

Also, keep in mind that medication changes are a major precipitant of delirium in older adults. On average, patients come into the hospital on about eight drugs and leave on about nine, but five of those medications are new, Dr. Granieri said.

The rate of cognitive impairment in hospitalized elderly over age 70 is as high as 75%, and so the discharge plan for medications needs to be “as simple as possible,” she said. Complex drug regimens are bound to fail, and may even precipitate an emergency department visit or rehospitalization. “Don't send patients home on b.i.d., t.i.d., and q.i.d. regimens. Try and do a q.d. or b.i.d. at the very most. This is very important,” she advised.

2. Perform a cognitive assessment. The best screening test is simply asking the patient to draw a clock showing a specific time. Give the instructions just once, and be ruthless in judging the results: “It's either right or it's wrong,” Dr. Granieri said. She related the story of a patient, who happened to be a practicing physician in his 70s, who drew and numbered the clock correctly but then added three hands pointing at 2, 4, and 5 and circled those numbers to indicate 2:45. As a physician, she said, “he had perfected the art of being vague.”

The clock test is a good early screen, but “it's not a diagnostic, it's an unmasking tool,” she noted. It's critical to unmask the impairment because a patient who can't draw a clock won't be able to take medications correctly or drive a car.

3. Look for pressure ulcers. Check the skin daily because a pressure ulcer can develop in as little as 2 hours. With the current shortage of hands-on nursing care, doing this screen faithfully has become even more crucial. On admission, 2%–10% of patients have pressure ulcers, but 10%–20% have them on discharge, she noted.

4. Check functional status. “One of the first things that I now do on frailer people, or people over the age of 75,” is immediately get a physical therapy and occupational therapy consult. This guarantees that the patient will get out of bed and be checked for ambulation. Also, the therapists often notice skin breakdown, incontinence, and inability to follow directions.

In bedridden patients, significant loss of muscle mass starts after 3 days, but it takes 9–12 days to begin rebuilding muscle with help from physical therapy.

But even without a consult, “you can look at them and see. You can tell if someone is getting out of bed. You can ask them to swing their legs around and stand,” she said.

5. Assess for gait dysfunction and fall risk. “It's incredible that many patients are discharged from the hospital without any test of their gait and ambulation,” Dr. Granieri said.

To prevent falls in the hospital, get rid of the Foley or Texas catheter. These are seldom needed but often overused, potentially causing falls as well as increasing the risk of urinary tract infections and resistant bacteria.

Little can be done to prevent falls in the hospital. “At the risk of sounding pessimistic, it's tough—there's no good answer.” A few environmental changes may help: Make sure that the beds are lowered, that there's enough light, and that each patient has a bedside commode.

6. Determine if your patient is eating and drinking. If a patient comes in malnourished, this can't be cured during a 5-day hospital stay. But during rounds, be sure the patient's food tray is close enough to reach, use a feeding program if available at the hospital, and check swallowing ability at least once (or be sure the nurse checks).

“Aspiration pneumonia—especially for people who are hospitalized who may be delirious or [have] cognitive impairment or infections—is deadly,” she noted.

Calorie counts are a waste of time, said Dr. Granieri, who used to be a dietitian and did many such counts herself. “If you think your patient is malnourished and they've lost weight, [they have]. Get them to eat by any means possible.”

For those who won't or can't eat, don't use tube feedings, she advised, “unless it's time limited, or unless they have only one organ system that's problematic.

“Tube feedings in people with dementia do not keep them alive longer,” but do increase complications. And studies have shown that people at the end of life don't feel hunger and thirst. “Once someone stops eating, that's it,” she said. It's important to talk with families early about the issue of tube feedings, she added.

7. Be sure patients have their glasses, hearing aids, and walking devices. If a patient isn't wearing glasses, chances are they're somewhere such as in a drawer, since almost all older people have visual impairment. A patient who uses a walker at home should have one in the hospital.

8. Use the team of clinicians available to you. Get consults, especially for home care. Take advantage of available services, such as physical therapy and nutrition services. Don't take care of a frail older patient alone, she emphasized.

Finally, keep in mind that all eight of these issues are interconnected. A patient with cognitive impairment cannot manage a complex medication schedule after discharge, and a patient who can't reach his glasses might not eat his meals. “Think in a matrix way, as opposed to a linear, or algorithmic, way,” Dr. Granieri advised.

PHILADELPHIA — Eight basic rules for making the rounds on older, hospitalized patients can help identify problems that the house staff may not focus on, Dr. Evelyn C. Granieri said at the annual meeting of the American College of Physicians.

It takes only 10 minutes to complete all eight assessments, said Dr. Granieri, a geriatrician at Columbia University, New York, who said she has been doing inpatient rounds almost daily for 17 years.

The eight rules are as follows:

1. Review all medications. Do this every day you visit the patient. Consider how changes in body weight and renal function may affect the appropriate dosage. “Older adults in the hospital are very dynamic in terms of their status,” she noted.

Also, keep in mind that medication changes are a major precipitant of delirium in older adults. On average, patients come into the hospital on about eight drugs and leave on about nine, but five of those medications are new, Dr. Granieri said.

The rate of cognitive impairment in hospitalized elderly over age 70 is as high as 75%, and so the discharge plan for medications needs to be “as simple as possible,” she said. Complex drug regimens are bound to fail, and may even precipitate an emergency department visit or rehospitalization. “Don't send patients home on b.i.d., t.i.d., and q.i.d. regimens. Try and do a q.d. or b.i.d. at the very most. This is very important,” she advised.

2. Perform a cognitive assessment. The best screening test is simply asking the patient to draw a clock showing a specific time. Give the instructions just once, and be ruthless in judging the results: “It's either right or it's wrong,” Dr. Granieri said. She related the story of a patient, who happened to be a practicing physician in his 70s, who drew and numbered the clock correctly but then added three hands pointing at 2, 4, and 5 and circled those numbers to indicate 2:45. As a physician, she said, “he had perfected the art of being vague.”

The clock test is a good early screen, but “it's not a diagnostic, it's an unmasking tool,” she noted. It's critical to unmask the impairment because a patient who can't draw a clock won't be able to take medications correctly or drive a car.

3. Look for pressure ulcers. Check the skin daily because a pressure ulcer can develop in as little as 2 hours. With the current shortage of hands-on nursing care, doing this screen faithfully has become even more crucial. On admission, 2%–10% of patients have pressure ulcers, but 10%–20% have them on discharge, she noted.

4. Check functional status. “One of the first things that I now do on frailer people, or people over the age of 75,” is immediately get a physical therapy and occupational therapy consult. This guarantees that the patient will get out of bed and be checked for ambulation. Also, the therapists often notice skin breakdown, incontinence, and inability to follow directions.

In bedridden patients, significant loss of muscle mass starts after 3 days, but it takes 9–12 days to begin rebuilding muscle with help from physical therapy.

But even without a consult, “you can look at them and see. You can tell if someone is getting out of bed. You can ask them to swing their legs around and stand,” she said.

5. Assess for gait dysfunction and fall risk. “It's incredible that many patients are discharged from the hospital without any test of their gait and ambulation,” Dr. Granieri said.

To prevent falls in the hospital, get rid of the Foley or Texas catheter. These are seldom needed but often overused, potentially causing falls as well as increasing the risk of urinary tract infections and resistant bacteria.

Little can be done to prevent falls in the hospital. “At the risk of sounding pessimistic, it's tough—there's no good answer.” A few environmental changes may help: Make sure that the beds are lowered, that there's enough light, and that each patient has a bedside commode.

6. Determine if your patient is eating and drinking. If a patient comes in malnourished, this can't be cured during a 5-day hospital stay. But during rounds, be sure the patient's food tray is close enough to reach, use a feeding program if available at the hospital, and check swallowing ability at least once (or be sure the nurse checks).

“Aspiration pneumonia—especially for people who are hospitalized who may be delirious or [have] cognitive impairment or infections—is deadly,” she noted.

Calorie counts are a waste of time, said Dr. Granieri, who used to be a dietitian and did many such counts herself. “If you think your patient is malnourished and they've lost weight, [they have]. Get them to eat by any means possible.”

For those who won't or can't eat, don't use tube feedings, she advised, “unless it's time limited, or unless they have only one organ system that's problematic.

“Tube feedings in people with dementia do not keep them alive longer,” but do increase complications. And studies have shown that people at the end of life don't feel hunger and thirst. “Once someone stops eating, that's it,” she said. It's important to talk with families early about the issue of tube feedings, she added.

7. Be sure patients have their glasses, hearing aids, and walking devices. If a patient isn't wearing glasses, chances are they're somewhere such as in a drawer, since almost all older people have visual impairment. A patient who uses a walker at home should have one in the hospital.

8. Use the team of clinicians available to you. Get consults, especially for home care. Take advantage of available services, such as physical therapy and nutrition services. Don't take care of a frail older patient alone, she emphasized.

Finally, keep in mind that all eight of these issues are interconnected. A patient with cognitive impairment cannot manage a complex medication schedule after discharge, and a patient who can't reach his glasses might not eat his meals. “Think in a matrix way, as opposed to a linear, or algorithmic, way,” Dr. Granieri advised.