The Executive Suite: Patient flow's impact on the practice

Rebekah Bernard, MD

For 15 years, I unquestioningly followed my organization’s standard process for patient flow. After all, I had been “flow mapped” and “cycle time measured” by a team of managers with Toyota-lean precision, so I assumed this must be the most efficient way to run a practice.

You know the routine I’m talking about. The patient arrives at the check-in window to register and sits down to wait. A medical assistant (MA) shows up holding a chart, calls the patient’s name, and walks them into the clinical area. First stop: the dreaded scale for a weight. Next, into the exam room for vital signs: blood pressure, pulse and temperature. Now, the MA barrages the patient with questions, typing furiously into an electronic system for the next five to 10 minutes or more, depending on the historian. Many of these questions will turn out to be completely irrelevant, already in the chart, or repeated by the physician. Finally, the MA leaves the patient alone in the exam room to wait — and sometimes wait, and wait — until the doctor finally rushes in.

Ah! This is the big moment, and in my opinion, where the magic happens. Doctor and patient sit together and have what seems to the casual observer to be a simple conversation. As the patient talks about their concerns, the doctor probes deeper, asking the relevant questions that have been honed by years of practice in history-taking. During this interview process, the physician will use open-ended questions, work to establish patient trust and apply advanced techniques like motivational interviewing to help guide the patient toward optimal health. The physician not only asks about physical complaints but also addresses wellness issues such as ensuring that appropriate screening tests have been ordered. After a medical plan has been determined, the physician leaves the exam room to rush to the next patient, leaving the MA to complete orders and accompany the patient to the checkout area.

If this orchestrated ballet works perfectly, the patient is out of the office in about an hour, perhaps 15 minutes of which was spent with the physician. Administrators and workflow experts assure doctors that this type of streamlining leads to the most efficient visit and “patient experience.” After all, it takes a team to care for patients these days! Or does it?

Flipping the script

Imagine a different scenario. The patient arrives at the office, checks in, and takes a seat. Their own doctor arrives at the door of the waiting room, recognizes their long-term patient by sight, smiles and beckons them into the office. Wait, what?

Stay with me.

The doctor then walks the patient down the hall into the exam room, making small talk and building rapport. Both enter the exam room, take a seat, and continue to chat for a few moments. The patient has gotten over their surprise at seeing the doctor so quickly and is now relaxed and comfortable, entering into the history portion of the visit without the usual irritation or even anger at waiting or repeating answers to the same questions over and over. Empathy and trust now sufficiently established, the doctor opens the patient’s chart, and moves right into obtaining the patient’s history.

Now I’m about to get even more radical on you.

Imagine that, once the history has been taken, the doctor obtains their own vital signs.

It’s shocking, I know, and counterintuitive to everything the Toyota people have told us about delegation of duties. But doesn’t it make so much more sense?

First, the patient has been sitting for about 10 minutes, ensuring a more accurate blood pressure reading than one taken immediately after the patient walks into the office. It also helps patients avoid anxiety and stigma over being weighed. While obtaining weight as a health indicator is critical, we know that the scale can be emotionally distressing to some patients. Explaining to a scale-averse patient the rationale for obtaining their weight or allowing them to stand on the scale backwards to avoid seeing the number (a technique some patients with eating disorders employ) may improve their willingness. In many cases, patients who entered the office dreading being weighed will jump on the scale when they realize that their doctor is supportive.

Second, obtaining vitals after the history is consistent with the way physicians are trained to think. In a “SOAP” (subjective, objective, assessment, plan) note format, the physical exam supplements the history in medical decision-making, unless, of course, the patient appears immediately unstable when they walk in the door. It allows the doctor to decide whether additional vital signs like temperature or pulse oximetry are indicated, perhaps not if the patient is presenting to follow up on depression, for example. Most importantly, taking your own vitals ensures that the physician does not miss abnormal readings that are easy to gloss over when looking at a piece of paper or a computer screen. We know that vital signs truly are “vital,” and yet I cannot be the only doctor to admit that I have found myself distracted by a patient’s multiple concerns and noticed an abnormal vital sign reading only as I was doing my notes later in the day, necessitating an urgent recall of the patient.

Hands-on care

Probably the most important aspect of taking your own vitals is that it allows the physician to have a truly hands-on experience with the patient. In a traditional busy office setting, patients may feel rushed and that “the doctor never even touched me.”Sometimes there is a good reason for that; maybe the doctor didn’t have the chance to examine them because so much time was spent in discussion, or because an exam wasn’t medically necessary for that particular complaint. Perhaps the doctor did do an abbreviated exam while talking to the patient, but the patient was too distracted to even realize it. Taking your own vital signs allows the patient to truly feel a physical connection with their physician, even if it was only the minute or two that you took to apply a blood pressure cuff.

Another way to achieve a truly hands-on experience is to consider performing your own phlebotomy. Although many physicians haven’t drawn blood since medical school or residency days, consider that phlebotomy is far less invasive than many other procedures we do for our patients, and skills can be quickly refreshed after a few hours watching and practicing with an experienced phlebotomist (most labs are happy to offer this service). Drawing blood is also a satisfying way to wrap up your patient visit, drawing the visit to a natural conclusion.

Physicians may also find that they enjoy other clinical tasks usually relegated to assistants, like administering immunizations or performing EKGs, or may choose to bring in an assistant to complete those tasks. After the clinical work is complete, the final step is to perform clerical duties like scheduling tests, procedures, and referrals; tracking down medical records and setting up a follow-up visit, which can be assigned to a nonclinical assistant.

Results of this approach

I know that the idea of doing more hands-on clinical duties as a physician completely contradicts the past 20 years of practice management advice, which has urged us to practice assembly line medicine to “see more patients.”But patients are not machines and medical offices are not manufacturing plants. In fact,patients report the most satisfaction with their office visit when the time they spend with the physician “meets or exceeds their expectations” and get better outcomes when they feel a true connection with their doctor based on trust and mutual understanding. By cutting out intermediaries, patients get exactly what they want and need: time with their doctor.

Physicians also benefit from this strategy. Happier patients are more adherent to medical regimens, show improved disease self-management skills and are less likely to sue for malpractice. Having fewer staff members may reduce the risk of data entry errors and increase team accountability. Believe it or not, taking your own history and vital signs may save you time, as one of the biggest bottlenecks in a practice is time it takes to “room” patients.

But can this strategy actually save a practice money?

It depends. If the physician’s labor must subsidize a C-suite of managers — the kind that pay hefty consulting fees to those office flow “experts” — probably not. But for a small practice where support staff salaries and benefits make up the largest portion of overhead, a reduction in staff members may balance a decrease in total number of office visits per day. Adding a scribe to take notes during each visit can allow a physician to see more patients.

While implementing all these measures may not be possible in your office, consider what small changes you could make to allow you to spend more time with your patients.