Margin and wellness. How to beat the time crunch in medicine.

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Margin and wellness. How to beat the time crunch in medicine.

What time is it? Did that alarm clock just go off again? Can I go home yet? I feel like I barely can take any time off. I’m overwhelmed with the administrative tasks and charting that comes home after work. I get so distracted and then wonder where all the time went. Leisure reading, what’s that? A little time for myself?!? MARGIN…what’s that?

If you have thought any of these things, stick around for the rest of this post.

How Much Time Do I Have?

This is first of two posts examining margin. You know, the extra space that exists on the certain papers, or the shoulder of the road so you potentially don’t fall off if you needed to pull over. Well our discussion of margin will examine two distinct, yet interrelated aspects of margin in each of our lives. TIME and MONEY. Today we will talk primarily about time and next episode about money. You will hear stories from my journey and have opportunities for reflection, where you may have margin or where you may need more of it.

Where Did The Time Go?

So, back as a child, I thought time moved so slow. The school year seemed like it would never end. And yet, elementary school, middle school, high school, college, med school. They all passed by, and here I am, wondering where all the time went.

A friend of mine told me you will never be less busy or have less responsibilities than you do right now. Looking back, I can see this to be true. Even in medical school, I had to study, and study hard, but I still was able to make time to spend with friends and family. I played saxophone in a band every couple months. I was able to take a study break and go ride my bicycle on the Chicago lakefront. As an aside, if you haven’t done that, or at least walked along the lakefront path, I would highly recommend it if you get a chance to visit. Not to say med school was easy, it wasn’t, but looking back, I was single, no kids, and had freedoms that I don’t have now. In med school, I was able to do a six week family medicine rotation abroad. Now with a family, being an attending, I have been blessed with new opportunities and new responsibilities.

Healthy Habits with Time and Wellness

So time is valuable, you can’t get it back, and you can’t make more of it. Sometimes we think we can use productivity hacks or use systems to achieve what we want…correction, what we think we want. We think we can always squeeze more out of the day. And yet, sometimes that removes any extra space, any margin. When margin decreases for each of us, many times it is easy to let the healthy habits get crowded out. That could mean less sleep, less activity and exercise. It could mean more consumption of unhealthy foods, more thoughts that are unhelpful and discouraging as things continue to pile up. Less time with friends or family. The list could go on, but you get the picture. These are some of things that when thoughtfully addressed can be helpful in one’s pursuit of wellness. Things that are important but not urgent. Let me tell you, in general, many of these things are challenges for me even now. Sleep, exercise, mindful eating. This is particularly true after a long day or a long week as a physician in medicine.

The Margin is Gone

This lack of margin and healthy habits were issues for me as I found myself in the worst of my burnout. I still know that the primary causes were the system inefficiencies, time pressures of seeing patients so close together, and charting. Charting at home, charting in the evening, charting the next day, charting on the weekend. You know it’s true. It is exhausting.

My first year out of residency, I was a productive, hard worker. I had a long stretch of shifts that February, with a combo of newborn nursery rounds and coverage at the hospital and separate clinic days. Altogether, this was about 11 or 12 days. I finished, and I learned a lot from being an attending on the wards for the first time. But I was exhausted, not able to fully recharge after those days even with the subsequent weekend off. It was not long before I found myself on the couch with my wife and her telling me “something has to change”.

Where Did All The Time Go?

So, let’s back up for a minute. Margin as a construct can be threatened and attacked from so many angles. There was the learning curve of being a new attending and junior faculty. Looking up more medication doses. Reviewing my differential a little more. Finding characteristic images of particular rashes. Does this patient look more like this photo or that one? Figuring out flow with 8 to 11 patients per half-day rather than the 5 to 7 at most that I would see in residency. And that was only 1 half-day a week, not 9 of them. So many things eating into my time at work when I am trying to get things accomplished.

Getting Flow Going

Medical knowledge, clinical flow, charting. From a professional perspective, those are all things that every physician and physician in training has to figure out. These are some of the things that I cover when working with medical students and residents. I regularly have residents with me one half day a week as they come through on a couple of rotations. It can range from new intern to a resident who is mere months from graduation. I send them in to see the patients first, and for some patients, I know they may be in the room for awhile. Medical or social complexity, chatty personality, it could be anything really. But I sometimes know that in advance, and I am really thankful for increased continuity when compared to my resident clinic. Continuity is often difficult in today’s environment with the emphasis on patient access, but I digress. So I send in the resident, and for those that are close to graduation, I give them a long time before I or my nurse knocks and checks in on them. They are almost done with residency and need to figure out their own flow and how to get from one patient to the next.

In my first year out of residency, I was still figuring out my flow as a new attending. The big challenge was, and often still is, how much of the note can I finish in the room or shortly thereafter? I can see a bunch of patients with fewer of my charts done and manage to stay closer to on schedule. But more notes would pile up, eating into my margin.

Restorative Habits

I love people, and I enjoy the opportunities to interact with my patients and families at work and to spend time with family and friends outside of work. But at the same time, I am an introvert at heart. I get energy from being able to read a book, to work on the more or less “intro to coding” platform that is iOS Shortcuts, to play the piano, to spend time in nature. Having space or margin for these things is really important for me and my wellness.

Creating Margin FOR Priorities

Creating margin often looks different in different seasons. There are certain fixed responsibilities (work, family, or otherwise), some that you may be able to change and others that appropriately take precedence. Other things creep onto the schedule that may or may not be as high of a priority for you. They also may not be as life-giving. And yet they are easy and often require less energy or engagement. Checking the news, sports, social media, video games, any other thing you can come up with. It is an issue for me too, just ask the screen time report for my phone and tablet. I consistently need to look at what my true priorities are. Then evaluate the things I have to do. And finally look at what space I need and restorative activities to schedule. This will often include planning a number of things in advance. I am pretty good at collecting tasks and documents, things to do in my task management system. It is the overwhelm and desire for comfort that often impairs my followthrough.

Taking Action, Making Changes

So what could that look like to make some of these changes? It could mean scheduling some time to have a phone date with a friend or family member you haven’t talked to in awhile? It could mean asking for things that could help you at work, whether adjusted system templates for documenting or potentially an adjusted schedule some days so you could actually make it to your kid’s after school event. The worst they say is no.

Planning some of those things is really important. Rest, exercise and other life-giving things. For me as an attending, it may mean actually scheduling some of these things. Yes, like exercise, Ryan. I still need to get better at that one. That way, these things still happen even if I do have to bring notes home. If you are a student or resident, maybe your hours are longer on a particular rotation. It is really challenging to come home tired and wanting to relax but still needing to help out at home while also wanting to read about your patients. Not to mention finding time to study and do practice questions for the tests that never seem to stop.

Self Care in Medicine

When you can, you may need to schedule some of these self-care things farther in advance. And by the way, that is just not possible sometimes, life just happens. I remember how hard it was to get my routine dental cleaning when the days off on ward months were NEVER weekdays. Or hobbling around the neonatal intensive care unit, just trying to finish early so I could go to the employee health clinic to get my infected ingrown toenail assessed. It hurt like crazy, I was seriously limping. Gross, yes, but this podcast is for physicians and others in medicine, so I think you can handle it. And these types of things are reality sometimes. Not being able to have the flexibility to deal with these things is a big stressor and negatively impacts wellness.

Self Advocacy in Pursuing Margin

For me, more margin at work initially meant cutting to 8 and then 7 sessions rather than 9, with the addition of my medical record optimization role. However, more recently, I had the opportunity to continue advocating for myself. I have desired to be at a single clinic since I started out of residency, at the time of this recording, over 5 years ago. I was told the system needs meant my time needed to be split among two clinics. At one point, it was three. But I had recently attended the White Coat Investor financial literacy and physician wellness conference earlier in 2021. While attending virtually, I heard Dr Linda Street’s talk on nailing your next negotiation, and I was equipped with newfound skills and confidence in myself.

This was put into practice mere weeks later when I had the opportunity to approach a leader in my group about consolidating my time at one clinic. I obtained my visit data and made my case in terms that showed how my request could align with system goals. I even advocated for others, suggesting ways we could have a “3 clinic trade” of physicians that would increase continuity and make the physicians more satisfied in their jobs. No, we can’t accommodate that at this time based on the system needs. But a month later, I was able to talk with leadership again as a new physician was scheduled to start in a few months. Realizing mid-conversation that an immediate transfer for me was not going to happen, I pivoted. Well, could we close my schedule at the one clinic when the new physician starts? And open my schedule at the other clinic as of that date?

After some leadership discussions, I was told that could work, and it happened. All that to say, self advocacy and negotiation can work, but keeping those lines of communication open is really important. Also, figuring out the where the leverage is. I knew my numbers at the desired clinic were higher, which aligned with systems goals of seeing more patients, more access. And yet, while my fragmented clinical time did add some stress at work and was a dissatisfier for me personally, I had good colleagues and staff at each place, and I wasn’t ready to quit over it.

How Did It Turn Out?

And yet, now a month into being all at one clinic, I find it helpful for me. I can see patients back more often in a couple days if that is clinically indicated because I am on site 4 days rather than 2 at each of two clinics. I can leave my stethoscope and supplies in my locker. And I get to see and talk with colleagues and staff more, especially since few of my colleagues work a full 1.0 FTE schedule. More opportunities for continuity, less complexity in my schedule, my paperwork.

Paid Time Off…Take It!

Then, let’s look at time margin at work from a macro level. A word for all the employed docs out there, like me. Take your PTO. Take it all. Don’t leave it sitting there. It is called PAID TIME OFF after all. Commit to yourself to be proactive. Taking your time off may just include putting a couple weeks or random days on the schedule a few months from now. Whether your system prefers 60 or 90 days notice or something else, having some on the books early makes it easier to switch later. Typically, there is then more availability into which staff can reschedule patients. You can often give some time back if needed. My schedule will usually fill if opened a few days or week in advance. I keep track of my own on a Google Sheet spreadsheet, and this tracking allows me to keep accurate track apart from my human resources portal which may not have everything entered yet that I have requested.

Adjusting Expectations

Now I know what you are going to say! But then I may not hit my productivity target! If you don’t hit the threshold for visits, or in other cases many still use work RVUs, what happens? Do you go below a particular base salary? It comes down to understanding how your contract and compensation plan are structured. For so long, physicians, including myself, were like, “I’m going to be a great doctor, practice medicine, and get compensated”, rather than digging into the details of these compensation plans and advocating accordingly.

“Bonus is Bonus”

If there is a base salary, sometimes you could have a higher base if you had a sustained increase in your productivity. Say by adding extra procedures, or not taking all your time off, you got the bonus consistently and were up for the base increase. Then maybe you understand that you deciding to take your time off will mean you get bumped down a tier next year or whenever your employer reevaluates it. For me, as an employed physician, I said “bonus is bonus”, and it was extra margin for me as I didn’t meet my goals with time off for the birth of my daughter. Financial margin that was super helpful, and something I’ll talk more about on the next episode.

If you are in private practice or have a solely production-based contract, figure out where you need to be for production relative to your priorities, and make sure that you get the time off that you need.

Action Time!

So to wrap up today, take a moment and reflect. What do you do with time away from work? How do you want to plan your time on a weekly basis? Take the big things first, and then fit in others around them. Plan things in advance. Restorative activities, reading, self-improvement, Exercise, sleep, relationships. Mindfulness, meditation, or religious practices. These are part of the why behind margin.

Then for more of the macro view, your next step toward wellness. If you are out of training, look at your time off balance. The time you need to schedule off and just adjust your own expectations of your productivity. Then make a plan for the rest of the year. It can be a rough plan, but commit to putting some additional dates on the calenfar this week, even if you have to move some of them later. Regardless of whether you are still in med school, in residency, fellowship, or afterwards. Go ahead and look at your calendar. When is that next break or time off is and decide what you want to do. It could be connecting with family, taking a hike, reading that book you’ve has on your shelf, or going somewhere to get out of town. Whatever it is, write it down, and tell someone about your commitment.

To sum it up. Find the time, decide what to do with it, and seek to create margin in your schedule. By then intentionally using your margin, you can do things that are both priorities and support your wellness. Take that next step today.