In our second installment, we explored variables within Dr. PBO's control that might reduce the unpleasant aspects of his job. Assuming he has adjusted those within his control, let's talk about he might go about becoming (apologies to Seinfeld fans) a master outside his domain.
Dr. PBO's scenario already has one great advantage: he is a business owner, an increasingly rare advantage in the world of corporate medicine. Might there be a way to allow him to preserve his ownership stake while still reducing those aspects of the job that create the greatest aggravation?
This really a two-part question. What will enable him to cut back clinically? Will he like the job more by doing less of it?
This final installment will focus on ideas that allow Dr. PBO to cut back via one of two tactics.
Tactic One: Become So Valuable They'll Let You Cut Back To Keep You
First, he can redefine his role within the group as a mover and shaker who improves life for his practice partners so greatly that they will gladly reduce his clinical time in exchange for appointing him group administrator (if he finds ways to make everyone more money, they'll cut him some slack).
I belong to a group where folks who feel strongly about a particular issue roll up their sleeves and get the job done to everyone's benefit. Not surprisingly, those agents of change who demonstrate a repeated capacity for improving group practice conditions collectively are those individuals the group often recognizes by conferring formal administrative stipends.
Find aspects of the work that your colleagues would agree are rate-limiting steps in patient care or provider happiness, and devise ways to make them function better for everyone. One real world example is a friend whose husband was appalled at how her emergency medicine residency program schedule could not accommodate their ability to take a one week vacation together, even with months of advance notice. He studied the rotations, devised an alternate scheduling arrangement, and made his case to the chief residents in charge of scheduling. His wife's residency ultimately adopted the new schedule because it allowed everyone to schedule one week vacations.
Reduce Call Burden
Avid readers (here's looking at you, blood relatives) might recall an ophthalmologist who found himself in a similar predicament with respect to intolerably growing call burden. Instead of revisiting that post, I'll urge Dr. PBO to review the link to see if any of the strategies resonate.
A market strategy can be very effective in allocating call, night or weekend shifts assuming the number of group partners is sufficiently large. If taking call pays really well, those who opt out are perceived to be paying dearly for the privilege, and those who shoulder the burden feel fairly remunerated for the inconvenience, a market solution has the best chance of overcoming objections about fairness.
Optimize Administrative And Clerical Tasks
As an emergency physician, I have no direct oversight in the nurses, techs and unit secretaries whom I depend on every day. On the rare occasions I am assigned a less than ideal team, I recall a children's book refrain from when my kids were younger: You get what you get and you don't get upset.
I've been extremely fortunate that our hospital is able to recruit top talent for the most part. Having said that, I envy Dr. PBO's ability to hire his own staff. Finding a talented office manager who can efficiently secure necessary supplies, negotiate discounts, manage human resources and make your life easier is critical.
I state this in order to begin from a reference point of gratitude. Dr. PBO chooses the quality of personnel he surrounds himself with. He can staff up in order to increase efficiency.
I've worked in community emergency departments where the techs set up laceration trays, irrigate wounds, preselect the proper size sterile gloves for the treating physician and have local anesthetic ready at the bedside. I've also worked in county hospitals where physicians perform all of these tasks. It's no surprise the former saw (and billed for) a greater volume of patients with better efficiency.
If Dr. PBO collaborates with his practice partners in identifying the rate-limiting steps in the office caused by insufficient (or inefficient) personnel and sets in motion correctives, he sets himself up for a smoother ride. A periodic kaizen exercise that engages office staff as well as providers can lead to continuous quality improvement and cumulative gains in throughput as well as reduced friction for the care Dr. PBO provides.
We already mentioned scribes as one option to reduce Dr. PBO's personal clerical burden. Another hack might be to get a virtual assistant to organize his life and calendar outside of his clinical commitments.
Maximize Reimbursement For The Work You Perform
A friend of my wife's from training once sheepishly related that it was not until his second year as a plastic surgeon in private practice that he discovered he was only billing for a single breast each time to reconstructed a pair. Many physicians who don't pay attention to billing end up inadvertently writing off their version of the 50% off discount.
No one teaches you how to get properly reimbursed for the work you do. Sure, the dreadful electronic medical record (EMR) creates documents intended to justify billing more than to enhance patient care, but this does not mean that Dr. PBO's practice is not overlooking remuneration they are legally due for work performed.
A business-savvy office manager or interested partner might conduct audits of a few months of charts to see if billing is reaching its full potential. Is a sloppy partner's documentation leaving money on the table? Might an in-house billing specialist who is not detail-oriented be doing the same?
Solicit bids from outside medical billing agencies (who often conduct their own audits) to see if there is a large discrepancy between what you currently earn and your group's potential revenues.
Tactic Two: Create A New Policy Enabling Owners To Practice Part-Time
Alternately, Dr. PBO can propose policy changes that allow him to cut back.
Variables that require changes in group policy take time, on the order of 1-2 years to achieve buy-in and take effect. These are solutions for those who have time to invest, not for those at the end of their wits who need immediate action.
I've explored this topic previously in a prior post and a podcast interview, but the basic steps remain clear:
Tailor Your Message To The Audience
Since not all physicians struggle with burnout, Dr. PBO's colleagues may not understand the desperation it breeds. Even among colleagues I considered close friends, when I confided my burnout I often encountered people whose advice consisted of sayings like:
- You just need to step up
- Get over it
- Compartmentalize it
- You just don't want to practice medicine anymore
- Medicine has no place for you if you can't work at this pace
When I proposed a policy change that would allow individual physicians in my group to specify their desired shift load, it would have been a hard sell if I'd billed it as a solution to my individual burnout. By making the message about becoming an even more family-friendly group where parenting could co-exist with work, the message rang true for a majority since our group consists of mostly working parents.
Dr. PBO needs to accomplish his goal in a way that has the greatest resonance for the broadest swath of the votes he hopes to secure.
Make A Withdrawal From The Bank Of Goodwill
Dr. PBO has a track record of being the person we all want on our team: always willing to overbook his clinic for a patient who needs to be seen, always saying yes to taking on a new patient. As his colleague, I'd feel a sense of gratitude for having such a team player for so many years. The key is that Dr. PBO frame his rationale to cut back for reasons I can understand and relate to.
Dr. PBO is struggling with burnout, but his partners may not be.
Dr. PBO also happens to have an ill family member that requires him to be present for more time than was necessary in the past. Dr. PBO's colleagues will certainly understand the ill family member justification. Thus, it would be reasonable for Dr. PBO to ask to reduce his clinical commitment based on his family member's need for increased assistance at home.
Both are entirely legitimate reasons to reduce clinical hours, but one will likely ensure broader appeal.
Take The Measure Of Your Partners Via Individual Phone Calls
Who will support your desire to cut back? Reach out to these folks and let them know your plans. When they express support, ask for their public endorsement at the time of your proposal.
Who thinks the system works fine as it exists and could feel threatened with your attempts to fix something they don't perceive as broken? Tailor your proposal to ensure this person's equilibrium is not disrupted by the changes you are proposing. Calling this contingent by phone individually to provide a soft pitch of you proposal and gauge their response can improve your odds of success by discovering points of concern and collaborating on a satisfactory ways of addressing those concerns which can be incorporated into your proposal to help cement support among this faction.
Who will oppose you or try to present you as the weak link in the partnership? This is probably the most important faction to reach out to in advance, as they will be your most vocal opponents. What can you do to protect yourself from their predicted objections?
An advance call to this delegation can help in a couple of ways. First, by providing advance notice no one will feel ambushed, which will help to reduce the risk of knee-jerk emotional responses in the moment.
Second, you show respect for someone when you ask for their expertise. A brief summary of the proposed changes accompanied by a solicitation for assistance in making the proposal more palatable might gain buy-in from the biggest skeptics, or help you detect that they are not opposed to your proposal in its entirety but simply to a facet you can eliminate to garner their endorsement. For example, someone might be strongly opposed to your suggesting a market solution to weekends, but have no objection to your proposing a market solution to night shifts.
People may feel passionately about issues that defy logic. If you can't persuade, accommodate their objections in your proposal provided it meets your needs.
Keep Your Proposal Narrowly Focused On Solving Your Problem
Beware that skeptics may try to hijack your proposal in an attempt to address their own hot-button agenda items.
A polite response should convey:
- you are trying to address a single narrow problem, not fix every problem simultaneously
- encouragement that they ought to do as you are doing to perform the substantial legwork in order to take the lead on their own separate proposal
- gratitude for considering something so important to your long-term happiness
This is usually sufficient to remove the expectation that you will be solving their problem.
This concludes the 3 part series on suggestions for how Dr. PBO can cut back going forward. I look forward to any comments that can build on these suggestions or point out strategies I omitted!
Comments 3
Great advice CD and a well done 3 part series.
There is a lot of great information that all of us can incorporate to make our medical practice more tolerable and hopefully reduce if not eliminate burnout.
I hope that there is a follow up post in the future of what Dr. PBO ended up doing and if it was successful or not.
Interesting article. Back in the day our group tried to develop some flexibility. We were small 7 physicians no CRNA’s and we all did our own anesthesia. Some members of the group decided we needed to hire nurses but of course none of them were responsible for the day to day management. Nurses are a mixed bag. They get paid by the hour and expect that 8 hour limit not be violated or else you get to pay 1 1/2 time. If you can manage 3 nurses the economics work out, 2 nurses it does not, 4 nurses gets to be dangerous. The other problem is the surgeons expected their anesthesia to be physicians, so the first incident can cause big PR problems. You can see adding nurses can be advantageous. Properly applied there is a little more money to be made, but there are pretty severe boundaries that come with that extra dough and wrongly applied can wind up costing you in the end.
So what’s the point? You need to understand all the moving parts when you start messing with the system. If you’re not the administrator of the group it’s quite likely you don’t understand the moving parts, the idiosyncrasies of the players and your bright idea may actually unwind everything. When you propose a change if you haven’t thought it through and through and sought external input for the analysis and support in the group you’re going nowhere. If you can craft a plan between several group members that is solid, typically a few are against and a few are indifferent, however some groups are wound up tighter than a tic effectively always at war internally. Making systemic changes in those groups can blow things up. The hot heads leave and now you’re left understaffed and more over worked, even if the change was the right thing to do.
Author
Interesting point about CRNAs, as I’d often wondered why they weren’t more widely adopted. There’s a level of pragmatism involved in any proposal that is essential to churn out the sausage without burning down the kitchen.