In last week’s post, I made the case that physicians should chart as they go.
Looking at Medscape’s annual physician survey data, I also previously wrote about how charting is the leading cause of physician burnout.
This week I thought I’d examine the top 17 reasons physicians fail to complete their charting in a timely manner.
The bad news is there’s a lot of them. The good news is that they’re all fixable!
Read on!
Totes Legit
The first point I want to make is that there are many correctable reasons physicians don’t keep up with charting. No matter the excuse for why they cannot fix these things (even if they are borne out of challenging situations), very few of reasons given are truly not correctable.
That being said, before diving into the fixable reasons (the main thrust of this post), let’s first take a brief look at the non-fixable, totally legitimate reasons.
1. Patient with physical emergency – E.g., an acute chest pain or rapid response/code blue will naturally pull you out of your groove and take time. But it’s what we’re here to do!
2. Patient otherwise in crisis – E.g., having a panic attack or perhaps actively suicidal (which can be a physical emergency). They require a lot of time for reassurance or determining safe dispo.
3. Direct admission – E.g., often related to #1, but sometimes just to expedite needed care or prevent a patient from presenting in extremis.
4. Clinic emergency – E.g., fire alarm goes off or, as sad as it is to have to say this, active shooter events, which my organization tragically experienced recently. Obviously, your safety is paramount.
5. Personal emergency – E.g., call from daycare or about a loved one. These force you to stop where you are and physical leave clinic, many times for the remainder of the day. The rest of your patients are worked in by your partners where feasible, otherwise rescheduled or canceled. Daycare calls are probably more frequent now as classrooms close for positive COVID-19 cases.
Few and Far Between
I’m sure there are a few that I am missing, but you get the point.
Thankfully, these scenarios are quite rare in reality, though some like acute chest pains often seem to flock together, especially if you’re superstitious.
Like a flock of gallimimuses coming at ya!
(If you were wondering, there is fierce—okay, maybe not fierce—debate about how to pluralize dinosaur names. It’s a whole thing!)
So when I say that they’re “non-fixable,” I mean that they aren’t caused by a workflow or similar issue. They are emergencies in one form or another.
That’s not to say that having good workflows or strategies won’t help you manage them.
Often, the thing that needs to be managed the most in these scenarios is our mindset. We often think very negative thoughts about them and continue to perseverate even after the interruptions have concluded. This actually affects our ability to get the rest of our work done.
It’s important to note that charting as you go, a strategy I practice and wholeheartedly recommend, still helps you in several ways even on your days that have gone awry, namely:
- Keeps you caught up until the point of the interruption.
- Decreases your mental drag helping you stay focused and in the moment.
- Helps you ensure safe and timely transfer of care communication (think sending someone into the ED or direct admissions—you already have your note mostly done so you can finish it off while talking with the ED/bed board).
And Now the Top 17 Rea—
I Don't Want to Read a List of 17...
Oh. That’s reasonable.
Tell you what: I’ll break them up into loose categories that will be easier to digest. I say loose because there’s a lot of overlap amongst them.
Let’s get to it!
"Time Laughs as I Stand Still"
That’s a lyric I wrote in my angsty high school years.
You laugh?! Don’t tell me you didn’t try your hand at writing songs as a teen?! Oh, you probably wrote poetry…one of those….
All that to say the first six reasons relate to time:
1. Leave charting for the end of the day. They don’t chart as they go. The time given to a task is the time it will take. Meaning when they say they’ll do charting “at home” then charting is allowed to take up all of “at home” time.
2. Don’t account for the time it takes to complete charting. They don’t factor in time for charting in their day. They know they spend 20 minutes per patient on average so they set their schedule template to 20-minute slots instead of 25. This is time mismanagement 101.
3. Don’t care about the time it takes to complete charting. This is often because they just want to see as many patients as possible for a variety of reasons, some virtuous and some less so, including a form of buffering to stay away from home.
4. Don’t prioritize tasks. They don’t have a set agenda for what needs to be tackled first and then next and so and so forth. This leads to a lot of time wasted trying to decide what to work on or constantly scanning between different tasks to decide which one to complete.
5. Forced into unreasonable schedules. Perhaps their employer or partners require them to work a schedule in which they cannot function—e.g., 10-minute appointment slots for primary care (which is the same as double booking 20-minute slots; both of which I’ve seen).
6. Don’t value their time. By this I mean, they will always say “yes” to everyone and every request made of them instead of focusing on what needs to be done. Think of physicians who don’t set agendas with patients and get the “oh, by the ways.” This is a form of people pleasing, done to satisfy an urge (a negative emotion) described more in examples below.
Excuse Me While I Buffer
The next category includes four things physicians do to buffer. Buffering is any activity in which we partake to avoid feeling a negative emotion.
7. Don’t know how to handle something. For example, there’s an endocrine lab you order rarely and it has returned abnormal. Dammit! You know you need to do some reading to figure out the next steps. But you click on that result five times, get overwhelmed each time, and then “run away” to do other tasks to buffer the negativity of the uncertainty involved with that lab result.
8. Don’t delegate. They don’t delegate because the discomfort of asking someone to do a task outweighs the potential benefit of having something taken off of their plate. As mentioned above, this is often seen in those with people pleasing tendencies.
9. Can’t escape perfectionism. They think their notes will be judged harshly by the Muses, and thus need to be literary works of art. Or perhaps a staff member completed a task incorrectly or not “up to snuff” and they deem that they must forever take up this task unto themselves—this can be another reason for #8: the discomfort of something not being perfect outweighs the benefit of someone else doing less than perfect work.
10. Don’t want to be charting at work. This is the easiest form of buffering to identify. They choose their phone over a note that needs to be completed because they’d rather get a quick dopamine fix from reading texts, perusing social media, or watching Netflix.
Something About a Square Peg and a Round Hole?
The next two reasons are the most classic ones cited by physicians, with the exception of #5. (Notice how they’re all external factors?)
11. Don’t have the right tools. They lack adequate note templates, dot-phrases, order sets, etc., to speed up their charting. Perhaps it’s a lack of dictation software or a scribe (especially for the slow typers). It can also include things like not having a printer in every room to print off after visit paperwork.
12. Don’t have the right workflows. Their systems for handling the inputs and outputs involved with charting are inefficient or rely too heavily on them instead of support staff. Many blame their support staff for shortcomings, but more often than not this is a training issue. Doing the right work at the right time and batching are key.
Pardon the Interruption
13. Are distracted. The same types of activities listed in #10 are also distractions. Most people have all manner of notifications set up on their phones that buzz and flash constantly vying for their attention. And this creates an urge to check.
14. Are fatigued. They are mentally drained from the constant barrage of decisions that need to be made, made worse by interruptions (e.g., knocks on the door, EHR alerts, etc.; these all require more decisions be made). Thinking burns calories; brains use more energy than any other organ. Especially if they leave charting for the end of the day, their brains are literally depleted from overuse.
Your Thoughts Betray You
The last three reasons relate to mindset (duh, this is a coaching website).
15. Are burned out. They are emotionally exhausted, perhaps detached or cynical, and struggle with thoughts of inefficacy. They give their all to their patients, maybe some to their families too. There’s little left of them to give anything else like their hobbies, much less charting.
16. Resigned themselves due to backlog. They have built up such a backlog that seems insurmountable that they think, “why bother?” See #17 below.
17. Don’t think they can get it done. They rely on past instances of not getting it done as evidence that they cannot, and self-perpetuate the cycle. Henry Ford’s famous quote encapsulates this perfectly: “Whether you think you can or you can’t, you’re right.”
Well, That Was a Doozy
Not to overwhelm you with a laundry list of potential negatives around charting, but this is the reality for many, if not most, physicians.
I don’t want you to come away thinking that this is all somehow doctors’ fault. That’s not the case and my intention is not to come off as victim blaming.
Some may be offended by the notion, but we physicians are human too. And our human brains do what they’re best at: look for the easiest option or path of least resistance that expends the least amount of energy.
And that traps us in these maladaptive patterns, same as everyone else. Just amplified based on the nature of our work.
But there is hope. These are all fixable. Yep, all of them. But they must be identified and addressed in an organized fashion.
If you struggle with charting, do any of these reasons resonate with you? Which one do you think is your “worst offender?” I’d love to hear your thoughts on this issue. Let me know in the comments section below.
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