The Seven Pillars of High Performing Primary Care Practices – Part Two

In a previous post titled, “Is Making Primary Care More Professionally Satisfying as Simple as Lowering Panel Size” I observed that lowering panel size and implementation of an electronic medical record did not change how doctors worked. Those doctors who stayed late continued to stay late. Those who left earlier tended to continue to leave earlier. Within a health care organization often touted by many to be an example of how health care should be delivered in the country, this phenomenon existed. Why?

Our doctors work in a very large multispecialty group practice. We use a common electronic medical record. Doctors in both primary care and specialty care can discuss cases, review information, and determine together with the patient the best course of action. Our primary care doctors have lower panel sizes than a decade earlier. This panel size is adjusted and normalized for patient age, medical problems, and other factors so each primary care doctor has similar clinical responsibilities. Our doctors have clinical autonomy. There is no prior authorization needed for specialty care referral or prescription medication which can also occur in a fee for service setting. With that autonomy, there also is responsibility that our doctors provide the best care.

After observing colleagues in their practices and then collaborating and coaching them, I created a framework on how physician leaders might help improve the lives of primary care doctors. There are seven pillars of high performing primary care practices. Within the seven pillars are three areas of focus. They are: (1) individual doctor, (2) primary care module, and (3) outside the primary care module.

Individual Doctor

For each doctor, there are 4 skills or pillars that a doctor can work on. They are in no particular order: mastery of the electronic medical record, patient-doctor communications, clinical expertise / judgment and time management. Doctors who work on all four skills will have effectively done everything possible within their individual control to make their lives better. In the previous post we covered mastery of the electronic medical record and patient-doctor communications.

3) Clinical Expertise / Judgment

Two doctors see the same patient for knee pain. Yet after the visit, one doctor may have ordered many more tests than the other. Patient gets better with either treatment. Which one was the better doctor?

Diagnostic accuracy is a cognitive skill that can improve if a mindset of continuous improvement is adopted. A doctor who diagnoses a patient accurately and correctly the first time by being every thoughtful and focused on ordering the right tests or initiating referrals, if needed, is a behavior often seen among many high performing primary care doctors. The sharper a doctor’s clinical acumen the fewer tests that are needed. The fewer tests that are needed means there are fewer lab and imaging results needed to handle in the EMR. Fewer tests and imaging results to act on also means fewer abnormal incidental findings which invariably can occur.

Getting just necessary tests and care is the focus of the Choosing Wisely campaign, which was led by the American Board of Internal Medicine in 2011 and subsequently helped by Consumer Reports. In Choosing Wisely, the ABIM and other professional medical societies have:

• identified “five tests or procedures commonly used in their field, whose necessity should be questioned and discussed. The resulting lists of “Five Things Physicians and Patients Should Question” will spark discussion about the need—or lack thereof—for many frequently ordered tests or treatments.”
• recognized “that patients need better information about what care they truly need to have these conversations with their physicians, Consumer Reports is developing patient-friendly materials and is working with consumer groups to disseminate them widely.”
• understand that “Choosing Wisely recommendations should not be used to establish coverage decisions or exclusions. Rather, they are meant to spur conversation about what is appropriate and necessary treatment. As each patient situation is unique, physicians and patients should use the recommendations as guidelines to determine an appropriate treatment plan together.”

Finding which tests and treatments are evidence based and which ones are not is simply a reflection of the evolution of medicine. Finding the right balance of not ordering too few tests (if any are needed) or too many tests than is needed requires clinical acumen and a mindset to hone that judgment even better. Diagnosticians should always be thinking about clinical cases and wonder if a diagnoses could reached sooner and if so, what could the doctor to, if anything, to get their sooner. As UCSF professor and associate chairman of the department of Medicine Dr. Bob Wachter notes, diagnostic accuracy is something that has not yet had the visibility of other patient safety initiatives, but should.

With increasing deductibles, patients will expect to have problems solved more quickly and will ask doctors if tests are needed because of their increased out-of-pocket expenses. They will ask doctors to be making important judgment calls. Is a MRI needed today? Can it safely wait to see if the problem resolves? What other alternatives might be options and less expensive?

4) Time Management

Doctors always get the work done even at personal sacrifice. This self-motivated ability is part of the reason they were successful in getting through both a pre-med and medical school curriculum. However, given the vast amount of information available in an EMR, the various ways patients requests can come in (email, phone call, in office visit) might there be a way for doctors to manage their work more effectively? How might they shape how they approach work to maximize their ability to make decisions? This challenge is not unique to doctors. Everyone is under more stress.

Particularly for a cognitive specialty like primary care, we coach doctors to be mindful of decision fatigue. As a NY Times article, Do You Suffer From Decision Fatigue, noted:

• No matter how rational and high-minded you try to be, you can’t make decision after decision without paying a biological price. It’s different from ordinary physical fatigue — you’re not consciously aware of being tired — but you’re low on mental energy. The more choices you make throughout the day, the harder each one becomes for your brain, and eventually it looks for shortcuts, usually in either of two very different ways. One shortcut is to become reckless: to act impulsively instead of expending the energy to first think through the consequences. (Sure, tweet that photo! What could go wrong?) The other shortcut is the ultimate energy saver: do nothing. Instead of agonizing over decisions, avoid any choice. Ducking a decision often creates bigger problems in the long run, but for the moment, it eases the mental strain. You start to resist any change, any potentially risky move — like releasing a prisoner who might commit a crime. So the fatigued judge on a parole board takes the easy way out, and the prisoner keeps doing time.

In addition, attention and focus are other skills we review. Being in the moment and how to structure the workflow accordingly. A June 2006 article Too Many Interruption noted:

• the average amount of time that people spent on any single event before being interrupted or before switching was about three minutes. Actually, three minutes and five seconds, on average.
• not all interruptions are the same. Some interruptions are from external sources. A person comes in, or your e-mail signal comes on, or the phone rings, or people chat through the cubicle wall to you. Those are external interruptions. But there are also internal interruptions; for whatever reason, people interrupt themselves of their own volition and switch to something else.
• people interrupted themselves almost as much as they were interrupted by external sources.
• when you’re interrupted, you don’t immediately go back to the task you were doing before you were interrupted. There are about two intervening tasks before you go back to your original task, so it takes more effort to reorient back to the original task. Also, interruptions change the physical environment. For example, someone has asked you for information and you have opened new windows on your desktop, or people have given you papers that are now arranged on your desk. So often the physical layout of your environment has changed, and it’s harder to reconstruct where you were. So there’s a cognitive cost to an interruption.

We recommend doctors steal a page from aviation and adopt a sterile cockpit mindset. For 30 minutes per day, close the doctor, let all phone calls go to voice mail, and focus on charting, reviewing labs, and getting the work only a doctor can do, done. Using the understanding of decision fatigue and knowing themselves and schedule, doctors should choose what time of day and where (office or home) that is best accomplished.

We recommend when tackling the inbox to use the 4Ds – Done (touch everyone just once. Don’t just look and do it later. Commit to getting it done. It takes more time to resume a task partially completed). Delete (no action needed). Delegate (do it early to get others to help you. do it maximally – get staff to off load you to the scope of their practice) and Defer (the last option, which is inevitable, but always should be the last resort. Avoid at all costs to prevent procrastination). To be more specific, we talk about a 2 minute drill. The first 3Ds should always be the option if a decision can be made within 2 minutes. If not, then consider defer.

The Seven Pillars of High Performing Primary Care Practices – Part One