Fixed-schedule productivity versus the illusion of control

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Fixed-schedule productivity versus the illusion of control

Will I make it home for dinner tonight? For my kid’s soccer game? For that family gathering right after my shift is supposed to finish? How many notes will be left to bring home? Paperworking and messages are just piling up again…

Have you wondered, how can I get everything done and get home in time? Or are my expectations and goals matching reality? Are there things I could change to work towards those goals? Are you caught in a showdown between getting things done, helping with the never-ending needs and requests around you? If you have asked these questions yourself, or if you have had someone else in your life asking them of you, please read on.

Fixed-Schedule Productivity

Previously, I covered concepts from Cal Newport’s book Deep Work, examining focused work and craftsmanship, aligning priorities and actions, and ultimately supporting your larger goals and purpose as a physician.

Here, I will revisit Newport’s work and examine another aspect called fixed-schedule productivity. We will proceed to look at our attention and distraction - Squirrel! - then opportunities for batching and productivity gains in clinical workflows. And yet, by holding these topics up to closer scrutiny, we will examine whether fixed-schedule productivity is truly achievable or if it is just a mirage.

In Academia…

So, in Deep Work, Newport describes fixed-schedule productivity from the perspective of a professor in academia. Just as in medicine, academia is filled with competing expectations, all vying for focused attention. And yet, with only so much time, the work typically spills out of normal time to the evenings and weekends. He committed to not doing work things, email in particular, after five-thirty PM. Then Newport looked back at what other productivity strategies needed to happen to make that goal a reality.

In this analysis of both his and another academic’s habits, he notes a laser focus on the research and scholarly output. These are the things needed to move forward on his professional goals. He acknowledges the importance of managing his own time, planning for deadlines in advance, and mindful, more intentional use of email and other communications, so that the “shallow work” does not consume all the time and attention.

In Medicine…

Sounds a lot like my prior discussions of priorities and goals, where I talked about not attending every meeting to which I am invited weighing new opportunities against those priorities. Why does this matter so much? Because in the spirit of fixed-schedule productivity, I want to be able to go home by a certain time, a reasonable time, any time. And yet, in medicine, what gets in the way of that? Is fixed-schedule productivity just a pipe dream for academics like Newport?

Let’s take a look at what gets in the way. First, oh wait, what were we talking about again? Yes, what gets in the way, distraction. Sure, there is checking my email again after I went on to find the number for the community resource, the check of my messages at lunch that somehow lands me checking the news. Not that those are necessarily bad, just that I end up spending more time on something else that I was not intending to.

Attention Residue

Newport also references a concept from Sophie Leroy’s 2009 article entitled “Why is it so hard to do my work? The challenge of attention residue when switching between work tasks”. Leroy’s analysis concludes that switching from one task to another leaves workers thinking about what they were just doing, but she goes on, “Time pressure while finishing a prior task is needed to disengage from the first task.” She posits that the lack of time pressure to finish leaves room for the person to keep thinking about what else could have happened, rather than getting to a sufficient answer and moving forward.

Reflecting on these conclusions, it makes sense because it resonates true with every day experience in medicine. “Being present where you are”, focused and attentive with the patient you are caring for. But then there is another one waiting right after them, and I want to be able to be present with them also. This is NOT an effort to rush clinical reasoning and the differential diagnosis by falling into search satisficing or premature closure. These are great goals in theory, and yet, the reality sometimes is that memory, focus, and task completion is vastly more difficult in real life.

A Typical Clinical Day

When I finish my patient’s exam and counseling, I ask what questions the patient or family has, answer them, and thank them for coming today. I then walk toward the door, when just as I open the door, the parent says, “Oh, I almost forgot, could you refill these other two medicines?” “Sure, I can take care of that,” I respond. “Thanks for coming in. Have a great day!” I then walk back to the staffing room, fully intending to log in to the medical record and take care of this request.

As I sit down at my computer, my nurse asks, “Could you check these orders for the immunizations on my nurse visit?” And then my medical assistant comes up, “The next patient says they have to go to work in 30 minutes, can you head in to the room soon and just keep that in mind?” Let’s pause for a second… These, and others, are all very common, reasonable requests as part of typical clinical workflows, part of a usual day in medicine. And yet, like a computer with many application windows open at the same time, my mental capacity is split between “what immunizations does this patient need?” and “Don’t forget to reorder this patient’s medications that you just saw.”

Closing The Loop

Sometimes, the “be present where you are” mantra means I may need to login to the EMR again in the patient’s room, so I don’t forget to do that extra thing. Other times, it means doing more of that patient’s note in the room and continue chatting, letting them know I already completed the orders for the nurse or medical assistant to process but I am doing a little more of my note so I don’t have as much documentation left at the end of the day, and ultimately that is good for their doctor. It may only take an additional 30–60 seconds, but doing that in real time, again, when I can, this combines the time pressure with a desire to be as done as I can before moving on to the next room. Not only that, but if I do this, I am able to go from one patient room to the next, having already communicated with my staff. This occurs both during our pre-clinic huddle about my schedule and through the orders and post visit communication. Fewer trips back to the workroom, fewer additional logins, wait for the chart to open, write another order, logout, walk back to the next room, it can really help stay closer to on track, when 15 minutes per patient just doesn’t seem like enough many times.

Batching

When I think about being distracted and how to get things done efficiently, I come back to a concept that I have heard multiple times lately. Batching. Doing things in batches helps keep me in the same frame of mind for a particular task or type of task. It may also involve a certain tool or device, and there is often time involved in setting the scene.

Batching and Forms

For instance, doing various forms is something that requires me to be on a computer with the medical record open. I need to be able to review a patient’s last note and physical exam to complete some of them. I need to have a pen and space cleared off on my desk to write on the form. And then I make a separate pile for forms that I have completed for scanning. Another for forms that need staff to fax somewhere. And another for medical Records requests that come to my box but are fulfilled by our system’s Health Information Management team.

So you can see you when I get a bunch of paperwork, checking my box frequently throughout the day could leave quite the attention residue as I see this patient requesting a school physical, another requesting FMLA paperwork and so on. Patients are instructed that forms that are dropped off are typically given multiple business days for completion. As such, checking paperwork once or twice a day is probably sufficient, and I have tried to do that recently. Sure there may be one that comes up where a staff member comes in and asks if I can take care of a form sooner if there is some downtime during the clinic day, and I prioritize those accordingly, but many are routine things for which once a day would be sufficient.

Batching and Notes

Sometimes, after a busy day, I may not have been able to do as many of my notes in the room along the way. Batching my work on notes after clinic time allows me to just stay logged in, finish up the last few things, and not have to have the psychological weight hanging over my head of 15, 20, 25 notes waiting for me, often including encounters from previous days as well.

But sometimes, if I am tired, hungry, know I have too many to finish all at once, or have some other commitment after clinic, I may defer some to the next day or know I will have to complete some on a day off. Some of it is weighing what are my priorities on this day, in this season, and whether I need to leave now or in 30 minutes. This calculation also gets skewed a bit when 30 minutes of notes at work could easily take 45–60 minutes on my work laptop from home. Many medical record systems require significantly more scrolling on smaller screens such as laptops.

Shifting Priorities

And these priorities may change over time. Your priorities, goals, and workflow. Previously I had lots of notes leftover and while I could sometimes stay and get them done, many times there were too many to be able to complete all at once and with that large mountain of notes waiting for me, it often felt better to go home and to eat before starting on them in the evening.

Now I have been more efficient more recently and completing more notes during the day. However, with increased clinical volumes recently, my last patient has left a little bit later than before. I now have to reevaluate how much time after clinic I can stay, since in this season, I have a toddler at home, and I want to get home to dinner with her and my wife. Not that I have it all together by any means, since some of these things kind of sneak up on you and then you need to talk about it, whether with family, friends, or yourself as you consider what you can commit to outside of work.

Illusion of Control

A few years ago, I was talking to a physician friend who mentioned that we often live with the “illusion of safety” and the “illusion of control”. This was two years prior to the emergence of COVID, and I have seen that play out in my personal life as well as in medicine since I heard his thoughts. Today’s discussion here around productivity, priorities, and time management is best viewed as goals to work towards, not absolutes, since we all know that things don’t always go according to plan. You add on an additional procedure, you see a patient for your colleague who had a family emergency and left early, the network is slow as you try to call the video interpreter, a patient walks in to clinic in distress, or you have unexpected computer troubles.

Whatever the case may be, we THINK we have control over so many things. And yet, while we can still do our best for our patients, our colleagues, and ourselves, there are many things we can’t control. However, stick with me, there are still things you can do. You can choose to keep the perspective of how this fits into your big priorities. For me, with the focus on service and caring about other people, this means that I can still care for my patients well with compassion, communicate, build up my staff regardless of whether my computer is available, whether there is an extra form they give me or a patient got roomed out of order for some reason. Excellence does not mean perfection. In many of these situations, things are less than ideal. There may be feedback needed and preferences expressed, opportunities to learn and grow as a team. But, as in quality improvement, growth looks like pressing on towards your core priorities and caring for yourself and others.

Reflect and Take Action

So now, as we wrap up, I want you to reflect on your priorities and goals. Visualize what the end result is. Maybe it is being done with notes and paperwork 15 minutes after the last patient leaves. It could be anything. And then, from there, what is one thing you are committing to changing this week? Small change, like quality improvement, and then measure both your process and outcome. Celebrate the discipline and gains you make in the process measures, even as the outcome will not be fully in your control.

Ok, ready? Now go pursue that change, that next step that will help you in your wellness journey!