Home On the Wards Interrupted much?

Interrupted much?

January 2014

Published in the January 2014 issue of Today’s Hospitalist

INTERRUPTIONS ARE THE ENEMY OF EFFICIENCY. But if you’re like me, your workday consists of constant interruptions. As hospitalists, we pride ourselves on being multi-taskers, but unfocused care is less effective ” and may be why so many of us burn out.

As a locum hospitalist, I see interruptions as a universal issue. Here are the problems I see eating up our time, and some suggested fixes.

Assaults on our time
Phones and other electronic devices are probably the leading time assailant we face. We have the “luxury” of not responding immediately. But I worked at one hospital where hospitalists had to respond within 15 minutes or be reported to the VPMA.

Then there are staff and family members. Unless you hide in a closet, it is almost impossible to avoid contact with individuals wanting to speak with you in person.

While there are polite ways to disengage from nonurgent conversations, if you respond too often with, “I am busy now but would like to discuss this with you later,” you’ll be seen as unapproachable. It is even tougher to disengage from other physicians, NPs and PAs who feel their time is just as important as yours.

How can you protect your time while still sharing information? With electronic devices, one solution is to alter the calling and paging rules. Just as psychiatrists practice the “50-minute hour,” hospitalists can do the same. The paging operator or anyone with your mobile number needs to know that routine calls and pages will be put through to you only during a designated 10-minute period every hour. That still allows two hours of callbacks in a 12-hour shift, but now you can budget your time. Alternatively, text pages can be placed any time but should be marked “not urgent.”

And when a colleague is trying to reach you through the switchboard, the operator should ask, “Is this an emergency? If not, may I ask the hospitalist to call you back between 9:50 and 10?” At 9:50, he or she notifies you with a list of callbacks. Hospitalists on duty at the same time should each have different, staggered callback times every hour.

With staff members, it is perfectly reasonable to answer a routine question in the hall. But sitting at a workstation computer should be considered a “no-fly zone,” except in an emergency.

While it’s impossible to make your workstation a “no-fly zone” for other doctors, the hospital can suggest new guidelines. Lengthy small talk should occur only in the doctors’ lounge, cafeteria or parking lot. What many consultants fail to realize is that the hospital is our office. Just as they don’t allow routine interruptions in their office, they need to respect our time and space. The VPMA would be a good person to champion this policy and bring these suggestions up at the next general staff meeting.

And tell family members you need to schedule a family meeting if issues are complex. If you are dealing with only one family member, you could handle this by phone. One colleague uses his 45-minute commute to and from the hospital to call families from the car.

Making meetings manageable
Think of all the meetings we attend. General staff meetings are held quarterly, and staff members must attend 50% of them. Departmental meetings occur more often, and you need to attend at least half to maintain privileges.

And most staff physicians are encouraged or required to serve on at least one committee. Although the total time spent in meetings may be under 30 hours a year, they break up our daily routine or force us to start our workday later or end later.

Instead of holding general staff meetings, administration could post or e-mail new policies to all medical staff, with physicians e-signing those notices as a receipt. Alternatively, physical attendance should not be mandatory, and telephone conferencing would be an acceptable alternative.

As for department meetings, I suggest holding them after dinner with simultaneous online or phone conferencing. This would interfere less with everyone’s workday except for the nocturnists, who hopefully could break away for part of the meeting.

I used to chair one committee’s meetings at 6:30 a.m. in the cafeteria. Many complained about the early hour, but discovered that the meetings didn’t disrupt their workday.

Streamlining clinician meetings
We should also streamline our meetings around patient care. Take patient handoffs. In groups with more than two day-shift hospitalists, morning report can take an hour.

Instead, 15 minutes before the meeting, the lead hospitalist should meet with the nocturnist for the number of new admissions, then decide which new patients to give each physician.

Once morning report begins, each physician can leave as soon as he or she is finished, with only one doctor sitting through the entire report. (Physicians can work on computers in the conference room, signing or editing medical records, so they don’t waste time listening to other reports.) Hospitalists could rotate through that last-to-leave slot, saving us each about 20 minutes a day.

Then there are patient-oriented multidisciplinary meetings, often called “huddles.” Although these can be very effective in sharing information, there should be guidelines: The attending physician, who’s under the most time pressure to keep meetings on track, should be team leader; no more than seven patients will be discussed at one meeting; and discussion is limited to five minutes or less for each patient.

Meetings are held in quiet places to ensure privacy ” and held 30 minutes before lunch. A late morning meeting allows hospitalists to see new admissions from the night before and take care of discharges, and people are less chatty right before lunch.

As for family meetings, guidelines are also in order. Set a reasonable time limit and schedule another time if the meeting goes too long. And set a goal of either disseminating information or receiving guidance on further care options if the patient is incapacitated.

Other time savers
Doctors who start rounding at 6 a.m. find virtually no distractions. Moreover, the nocturnist is technically still on call, so you shouldn’t be paged. I can see twice as many patients in this golden hour, which boosts my chances of finishing by 5 p.m.

Say three hospitalists work days; two could finish two hours early, while the third stays until 7 p.m. to cover emergencies or admissions. Hospitalists would rotate the days that each stays until 7 p.m., improving job satisfaction and defusing burnout.

There are many other ways to minimize interruptions and save time. But one key strategy is to remain vertical. Sitting down anywhere, either in the lounge or the physicians’ workroom, telegraphs a “let’s chat” message. I use a rounding cart or bedside table adjusted to standing height for a quiet spot free from distractions.

Being vertical allows others to see that you are working and should not be disturbed. And I often do my chart work at the bedside. This increases my contact time with patients “and keeps me out of the hall.

Stephen L. Green, MD, is a locum hospitalist who maintains a telemedicine infectious disease consulting practice. He previously practiced for more than 30 years as a primary care internist and infectious diseases specialist.