Adding value via quality, craftsmanship, and the art of medicine

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Adding value via quality, craftsmanship, and the art of medicine.

Wait?!? A physician who does medical record optimization still not feeling like he can get everything done how he wants? Who still feels the pull of responsibilities from various roles and wants to do right by his core priorities? Who wants to feel like he is really moving things forward on his big professional goals and yet have enough time in the day to be present at home too?

Burnout to Wellness

Previously I have talked about my story, my first clinical position out of residency and my path to and through burnout. Though I say through burnout, the pursuit of “wellness” is an ongoing journey, as though burnout is just nipping at my heels, lying in wait. I mentioned a few things that helped me return to a better place with my wellness. Those things included leaning in to my core priorities, having enough margin in my life to be present at home, but also finding meaning in my work and having some different opportunities to serve others and to add value. Some of those are in my clinical role and also with the medical record optimization.

Deep Work and Value

But before I get into the specifics of my story, I want to share some insights from a book I read and how they apply to concentration and adding value. Cal Newport is a computer science professor who wrote a book entitled Deep Work. In it, he describes changes in what is valued in the workplace of the future, including mastery of hard things and high level production, both quality and speed. This production is often dependent on deep work, involving concentrated effort over a period of time, requiring intense focus. He describes the mastery of a cognitively demanding task as requiring deliberate practice with attention focused on a specific skill or idea and then receiving feedback on your approach to hone in on what you need to learn and be productive. Essentially this is learning and then adding value. Sounds a lot like medical training.

Busy or Productive?

And yet, Newport observes “busyness as proxy for productivity.” Certainly sounds like medicine with some of the process measures or checkboxes that live in our templates or quality measures. Those clicks or keystrokes may satisfy an external entity, but the action itself may also have limited clinical relevance, no value added as you note “counseling provided” for any number of metrics as a completing action, potentially even just providing a handout. How did checking that box, or bringing in that dropdown list and selecting an option help you in providing that counseling?

Deep Work in Medicine

Deep work in medicine could certainly include scholarship, grant writing, publications, quality improvement project design. But…I believe that the quality, mastery, and craftsmanship that Newport speaks of could be applied to medicine in different ways. I think it could be more broadly conceptualized in the value you add to your patient’s life when you use motivational interviewing for the third visit that you are now seeing them and they finally decided to try to quit smoking. The art of interviewing compassionately and with cultural sensitivity, effective use of the interpreter that may be in person and may only be available via phone or video. Building the rapport that allows your patient to finally open up about their mental health struggles and choose to see a therapist. The procedure that you can not only do proficiently, but you explain it in a way that the patient really understands what is happening to their own body and really trusts you.

What’s Really Important?

These skills are part of the value that is added by physicians and others in medicine. Cutting through the noise of the clinical workday to find what matters. It may not take a long time, but it takes intentionality. I, like many of you, went in to medicine to be able to HELP people, to serve. And yet my focus is so easily distracted by what I AM TOLD is truly important. Check this box, review that, sign this form, attend this meeting. Some of these things are verbally emphasized, some are indirectly encouraged, and yet, some of these things are the shallow, not deep work. Many of these tasks may be needed at some level. However, if I promptly keep up with all my emails, paperwork, and everything that everyone wants from me, I have less time to read about that new treatment my patient might benefit from. Less time to call that community organization and hear about their upcoming event that would help my patients with some of the social determinants of health. Less time to arrange and hold another case conference with a patient’s school or extended family.

Say Yes To What?

I have to stop and ask myself sometimes, are these additional things passions of mine that I can say “Absolutely, I want to be a part of this”? Some things are requirements that I don’t get to change, my licensure, forms I have to submit. But others are things that someone may ask me about because I either have those skills, have participated in the past, or perhaps “I just thought you might be interested.” One of my core priorities and values is service, and even in college, I saw needs and wanted to help. I signed up one semester to be a lab teaching assistant for not one, but two, physics lab sessions. The amount of time prepping, facilitating and then grading the submissions on top of my own course work and extracurriculars, the next semester, I decided one session was plenty for me. While I saw it in college, the desire to say “yes” and please others has not gone away. Again, I like helping people, I like being a man of my word and following through, but sometimes that means learning what to politely decline up front.

Prioritization and Meetings

Fast forward to being an attending, I jumped in to 1.0 FTE attending life only to find out after a few short months that I am burned out. Previously, I talked about how I managed to decrease my time and then partially replaced it with a electronic medical record optimization role in my system. Ok, great, but then I had this extra role, worked as a part of three different clinical teams across two different clinics, and with the meeting that I chaired and all the other meetings of each team, I had requests for up to 8 meetings a month. Still working three and a half days of clinic, having my half day of EMR work, half day of admin time, and then being off one afternoon, how was I supposed to attend 8 meetings a month? Even with the COVID-19 pandemic moving all of them virtual, most of them permanently, this was too much.

I had previously tried to jump on the call for 5 or 6 of them, but now I regularly go to 3. Consolidating my time at one clinic has helped some, but even then, I have realized there are still lots of meetings. I can’t do it all. I am a human with limits. Value may be created as consensus is built with your colleagues around a new initiative, or any number of other benefits, but many of the outcomes of a meeting end up being information transfer. Yes, it can allow for discussion that may not happen otherwise, but for some of the meetings, I just have to be ok with saying, “I am unavailable at that time, I have… fill in the blank”. It could be my medical record optimization time, my scheduled time off, or that I am in clinic. And the key to why this has worked is that I try to be engaged otherwise. Some of these meetings are more peripheral to my role, and others are central to me being a part of whichever team, but in briefly reading the minutes, if there are things that I need to follow up about, I try to do that. Whether it is sending an email, trying to find them at lunch in the clinic, or even just calling them, I see that as part of closing the loop in communication, and it keeps me from getting overwhelmed with meetings. By keeping some of that margin, I am able to get my patients seen and cared for, complete my notes, and try to manage that boundary in my wellness journey.

The Right Goals

By knowing your priorities and high level goals, you can then figure out what tasks support these goals and how you need to take steps in moving them forward. Meetings that help you move forward on those priorities, some of which may be more of a system or company goal, those kind of meetings may be worth prioritizing more. Also, if you have some influence or leadership over the meetings, you may be able to change the structure or streamline them to allow for more value creation by the participants.

Adding Value with Deep Work

Sure there are the day-to-day adding value and craftsmanship in the art of medicine that we discussed earlier, finding what are your priorities and finding the activities that are supporting that throughout the day. But I want to take a moment to have you think, what could some deep work allow you to accomplish?

Maybe it helping synthesize an anatomy class study guide in a way that benefits you and your fellow med students. It could be writing up that case you saw on that residency rotation last month and submitting it for publication or a conference. Maybe it is designing a quality improvement project or taking some time to crunch the numbers and see what conclusions you can draw from it.

For me, an example where deep work ultimately yielded a valuable outcome was in my medical record optimization role. I had just finished my training on building things in my system’s EMR, and I was ready. I had a list of things I wanted to do, and I was ready to tinker. It was a time when my wife was working and pre-kid that I could have multiple hours to devote to a project like this. Since that time, I have set better boundaries with some of those creative projects, thanks in large part to my wife’s loving feedback and the fact that I only have three hours per week for a couple of regular meetings and the opportunities to offer input and build things. But at the beginning, I was able to spend the time to really dig in and experiment, learning about the different properties.

Eventually, I found a way to reference the date that a particular group of diagnoses had been used at the encounter level within a lookback period of the last year. This group of diagnoses was for the last wellness visit which is particularly important for billing in primary care. Stringing those different things together, I was able to get it to work after a couple afternoons of deep work. I didn’t know why certain properties behaved the way they did, and I had to talk to a couple technical analysts to review it and help move it through to the live medical record. But now, I, and all my colleagues and staff get to make use of it on a daily basis in chart review and note templates. Deep work applied. This is the type of thing that can happen. Does it need to be a week or day or full afternoon to work? No, not necessarily, but having concentrated focused time, even if it is 20 to 30 minutes at a time, multiple times per week could push forward a project, an initiative, or even just prove to yourself that you can do hard things.

Final Challenge

I challenge you to consider how this deep work and craftsmanship might fit into your current season as a physician or medical student.

• What are your high level priorities professionally in this season? It will look different in med school, in training, after training.
• How are you adding value to yourself and your learning, your project, your vision and how does that ultimately help you provide value to others and help them?
• Where do you need to apply some of these principles around deep work to help move your vision forward? Are there some things you can graciously move off your plate?

Choose one action and commit to doing it this week. Take the next step in your wellness professionally today! Your future self will thank you.