This week on the podcast…
This week on the Uncharted Podcast, Dr. Andy Roark and practice manager Stephanie Goss are answering a question you asked in the mailbag! That's right, this is going to be one of those episodes where everyone is asking “Are they talking about my practice? Are they talking about my doctors? *Gasp* Are they talking about… me??? Stephanie felt a bit seen too when they recorded this episode so fear not, you are all in good company. We received an email from a veterinarian who said “I’m drowning in records and it is the major source of my anxiety in life right now. I look at my colleagues to see how they do it, but I realized they literally just don’t do them. That’s not an option for me and I need help!”
Let's get into this…
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Do you struggle with team building? Does the mere mention of it make you break out in a cold sweat or make your team roll their eyeballs so far back in their head, you worry they might stick? Or do you LOVE playing games with your team and are looking for some new ways to have fun with them? No matter how you slice it, team building is Camp Counselor Stephanie's jam and we are going to have a blast digging in to team-building exercises that are fun, accessible for everyone regardless of physical abilities and won’t inspire eye rolls from the team. Get ready to learn quick, easy-to-execute games and activities you can lead with minimal prep time. Every exercise takes less than a 60-minute staff meeting to run – most of them topping out at 5 or 10 minutes!
March 5, 2023
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This 1-day virtual event on March 22, 2023.
Episode Transcript
Stephanie Goss:
Hey everybody, I am Stephanie Goss, and this is another episode of the Uncharted Podcast. This week on the podcast, Andy and I are diving into a question from the mailbag, from a doctor who finds themselves absolutely drowning in records. And they are struggling with their own mental health and well-being as a result of it. And it's complicated further by the fact that their partner is also a veterinarian who finds themselves in the same boat. And now, they've found themselves spending time that they want to be spending together outside of work, working on work. It just doesn't feel like a sustainable situation, and they are wondering, “How do I get out of this mess?” Let's get into it.
Speaker 2:
And now, The Uncharted Podcast.
Dr. Andy Roark:
We are back. It's me, Dr. Andy Roark, and Stephanie Goss.
Did you hear that? Do you hear that? Behold the technological might of the Uncharted Veterinary Podcast. Didn't know we had power like that at our fingertips, did you, Goss?
Stephanie Goss:
I didn't know you had power like that at your fingertips.
Dr. Andy Roark:
I think if you said something and then sound effect, I think it would happen.
Stephanie Goss:
I've always suspected that Dustin Bays has that power at his fingertips.
Dr. Andy Roark:
Well, Dustin, who puts our podcast together because he holds the power. Yes. Cool. How are you doing here?
Stephanie Goss:
I am good. I am good. It is been a crazy busy morning. Yeah, it's like when you go away. So we just got back from VMX and this was the first time that we've traveled since the beginning of December. And so I actually felt really good about leaving this time. I felt like I had my little checklist, did I get all the things done? Did I give everybody they needed so that everything, the wheels can keep turning while you're gone. And even when you do all the things and then you come back and it's like you got to dig out of the email and the messages. And I got back yesterday and I was like, “Holy Batman, there's like 900 Slack messages to read.” And it's good, but it's just that busy, busy feeling of jumping back in. And I always feel guilty because I've gotten to this place where I usually block a day or two after coming back from something to catch up and dig out where my calendar isn't really open, I'm not doing things.
Dr. Andy Roark:
Yeah. I did not feel good leaving, because my daughter turned 15 last week, and the Friday that we were leaving for VMX, she had Friday off, that was the Friday before Martin Luther King Day and she went for her driver's permit test and she did not pass it. And so as I'm trying to go to the airport, my daughter is coming home and she's devastated, because of course she's told her friends, getting my permit and she will not come out of her room. And I'm like, “See you in five days.” And it sucked so much.
So I thought on the teaching of Stephanie Goss and I was like, I want her to feel supported even though I got to go. And so I thought, what is her language of appreciation? What is her love language? And Jacqueline's love language is gifts. And so I sprinted to the grocery store and bought her a bouquet of flowers and sprinted back and I was like, “These are for you. I love you. Everything is going to be fine. I also failed my permit test the first time it happens to everybody. Here you go.” And I came with the flowers and I left, and she survived. And so I got home and she had gone to get her permit and so I get home the day that she actually went, she rescheduled, went in the morning next week when I got back from VMX and got her permit.
And so her mother, who's a rule follower, was like, “We're going to wait until this weekend and then we're going to go to a parking lot and we're going to let her drive the car that we think she's probably going to drive around and she's going to get acclimated to the brakes and things like that.” And her mother left last night and Jacqueline looked at me and she was like, “Hey, can you show me the buttons in your car?”
And I was like, “The buttons? Us? Let's go for a ride.” And so I took Jacqueline out and it's like nine o'clock at night is pitch black and we live in the country, but I'm like, “What could possibly happen?” And so I've got her on this road in our neighborhood and I'm letting her drive and she almost put us in the ditch about three times. But once I was in it, I couldn't be like, You know what? This is a bad idea. Just put it in park and get out because this is a mistake.” But I'm a smile on my face. Super dad. And I'm like, yep, no, it's okay. That tree came,
Stephanie Goss:
I changed my mind.
Dr. Andy Roark:
… out of nowhere. So anyway, we made our way down and back.
Stephanie Goss:
Okay. Yeah. In fairness. Wait, wait, wait. In fairness, I've driven on your road and I would not want to drive on your road as a brand new driver at night when it's pitch black. That's like you made the fatal mistake where you should have taken her to an empty parking lot.
Dr. Andy Roark:
That's what my wife said, and I am willing to consider the idea that my decision might have been bold. I will also say for the rest of her life, she'll remember the day she got her permit and she and her dad drove down the cul-de-sac by themselves.
Stephanie Goss:
Almost driving in the ditch.
Dr. Andy Roark:
I don't know that she knew how close we were. It's kind of like…
Stephanie Goss:
Fair. It's probably better for her that way.
Dr. Andy Roark:
Oh yeah. I didn't want to be like, “Oh, by the way, if that could have been really bad.” I was like, “Nope. We had it the whole way.” Basically the first three years of me being a practicing veterinarian have trained me to be like, everything's fine,
Stephanie Goss:
Everything's fine.
Dr. Andy Roark:
No, it's all good. I know exactly what I'm doing and everything is fine. And so I have those muscles and I used the heck out of them last night.
Stephanie Goss:
Oh, poor Jacqueline.
Dr. Andy Roark:
No, she was so happy. She was so happy. And it was absolutely worth the risk of property, life, limb and neighborhoods, and the neighbor's mailboxes. They were all worth the risk that was taken.
Stephanie Goss:
The parking lot at the school is usually a good choice. Not when school's in session but after hours because it's usually pretty wide open because of all the bus space and there's usually nobody around.
Dr. Andy Roark:
Well, we're going to do that, but it just…
Stephanie Goss:
Let's start on your road, which is narrow. It has lots of trees, ditches off to both sides. It sounds like a great idea. And to put this in perspective for you guys, I've been to Andy's house and I'm afraid to drive backwards down your driveway.
Dr. Andy Roark:
Yeah, well I drove her out of the driveway and then just kind of let her go. But yeah, it's one of-
Stephanie Goss:
Like, Goss, you're not helping the story here.
Dr. Andy Roark:
No, you're not helping me at all. But it is one of those things too where after it's over, you look back and go, wow, that was a bold choice. There's a number of things in my life where I'm looking back, I'm like, I see how that could have gone badly, but it didn't. And so we're just going on. Everybody's going to be cool.
Stephanie Goss:
Oh, man. Oh, man. Well, I am excited about today's mailbag questions. This one is, it's funny because it is business related but also a little bit medicine related and I just thought it was a good one and one that we have gotten kind of repeatedly in different ways. So we got some mailbag questions about record writing because they basically all said, “Oh my God, I need tips because I am drowning in records, I'm drowning in records. How do you keep up with record writing, particularly as the veterinarian?” And we have seen several of these. And this, I thought I pulled out some pieces out of this one because it was so great. They were just, “Records are a major source of anxiety in my life right now I'm looking at my colleagues to see what they're doing because they're all leaving at the end of the night. They finish their cases and they walk out the door and I'm there for hours. And so I was looking to them to see what could I learn from them. And what I realized is that they just aren't writing the records.
And so this vet was like, that's not an option for me and I need help because I find myself working all day and then I'm staying late. I spend days off doing them and I'm still behind. And their partner is also a veterinarian and they are also in the same boat. And they both feel like they're spending so much of their free time that they should be spending together. They are spending it together, but they're spending it together, writing up their charts, which is miserable. And as they were saying, it's straining us both. And I don't think that it's sustainable. So they were like, “It seems like a easy answer should be work stays at work and home time is home. But we can't seem to manage that while being overwhelmed with patients at the clinic.” And so they were like, “I know this is a common problem, I've talked to some of my peers and other people are having it too. But is this just something that I need to accept? How can I balance and try and keep up with the record writing?”
Dr. Andy Roark:
Yeah. I love this topic. I love this. I could speak very passionately about it and I'm going to, and I'm going to.
Stephanie Goss:
Is this is going to be a soapbox episode for Andy.
Dr. Andy Roark:
Okay, let's begin. Because writing up charts is part of being a doctor. It is a big part of being a doctor. People don't recognize how big a part of being a doctor it is. And God, a lot of people really suck at it. I mean I don't come on here and say, boy, people suck a lot, but this kills me.
Stephanie Goss:
That's a truth.
Dr. Andy Roark:
People suck at this and the vet schools train people in a crap way to do this thing. And it starts at the vet schools and people are like, “This is how you do it.” And I'm like, “That's a terrible way to do it.” And I'm going to talk about why it's a terrible way to do it, but I'm not telling saying the vet schools should do it differently and I'll impact that in a second. But here it comes here. So we just came to-
Stephanie Goss:
They do it terrible. But don't James the way you're doing it.
Dr. Andy Roark:
It's terrible. It's terrible and, okay here's why it's terrible. The point of medical records in a vet school are to teach people. It is basically like you writing an essay about the case that you're on for your attending clinician to read and understand your thought process and see if you understand what we're doing. And so for that reason, a robust medical record of your thoughts and feelings and emotional journey with this case is valuable.
Stephanie Goss:
Ok. Fair.
Dr. Andy Roark:
That is not the point when you're in general practice and you're trying to push cases through your clinic and get care to people on a deadline, right? It is, you're not being graded by anyone. The robustness of your entries is a negative, it's not a plus. But we're trained in vet school to write more. There were times in vet school I was a hundred percent hammered for not writing more, giving more possible differentials, explaining more what could be done and when. And I go, I get that in vet school they were trying to get me to extrapolate on what I knew. In practice, that's a massive problem and I'll walk through that. But that's why I say, I'm not saying the vet schools should do it differently. I think the vet schools should say, “This is how you do it in vet school.” And before you leave vet school, here's how you do it in practice. And that's what I think. So anyway, it's a bit of a racket.
Stephanie Goss:
This is going to be a feisty episode because I feel like I disagree.
Dr. Andy Roark:
Okay, well let me lay out my position-
Stephanie Goss:
Go for it.
Dr. Andy Roark:
… before you start to disagree.
Stephanie Goss:
Go for it.
Dr. Andy Roark:
But here's the thing.
Stephanie Goss:
All right.
Dr. Andy Roark:
Medical records are important and we were just at VMX and I talked to a veterinarian who works for the AAVSB, American Association of Veterinary State Boards. And these are the people who review your medical license when there's a board complaint made against you. And she was wonderful. I'm so glad we got to meet. She was very kind, but basically she was like, “Help us to help you. If it's not written down, if you don't have a medical record, we can't help you. You're toast and we can't help you. But if you have a basic functional medical record that says a couple of things, you are probably going to be okay in most board complaints, assuming you didn't do anything obviously medically negligent.” The chances of someone's mad at you and you didn't really do anything wrong. If you don't have a medical record, the chances are good that you're going to be in trouble. And if you do have a medical record just are good, you're going to be just fine.
But these are a big thing. They're also obviously a big thing for patient care. And I don't have to tell you the importance of writing up your chart with care. But anyway, let's start with head space. Okay, so we got a question, how do we do this? And my husband and I are both tapping out and other doctors just aren't doing it. And what do we do? Okay, so the first thing in head space, and I challenge doctors that are working in practice to do this. I need you to sit down and think of for a second and think about your medical records and then think to yourself what is the point?
I mean seriously, what's the point of a medical record? What is the point in vet school, which I already said. The point in vet school is a lot of times a learning opportunity and they're trying to teach the most legally sound approach to medicine. I get it. Okay, what is the point in emergency medicine? And in emergency medicine, the point of a medical record is different than in GP because you are not going to see this patient again. They are going back to their regular veterinarian, and part of your medical record is communication back to the doctor of what did I see? What did I say, what did I do? So that you can pick this case back up tomorrow and you feel comfortable about what was done and you know what expectations have been set.
And the last is what the point in general practice. So let's just say that you're a general practice vet like myself and you're seeing case patients, what's the point? The point of the medical record is to, in an accessible way, and that's critically important, in an accessible way to document key findings, to document recommendations that were made, to document client decisions and to lay out the plan going forward. That's it. That's it. Those are the things. That's the whole point.
And so put aside the novels that you were taught to write in vet school and just say, if this is the point, document key findings, document recommendations, document client decisions, and lay out the plan. You should think about how you're going to accomplish that and stop just doing things the way you've done them in the past. And so that's the head space for me is stop. Stop if you're doing it and it's not working for you, you need to stop and you need to say what is the point in this? And then get a clear point in your mind. And now let's come up with a new way to do your records. So that's where I go in head space first.
Stephanie Goss:
Okay. I'm kind of on board there. I'm with you. It has to be accessible and I think your points about the key findings, the recommendations, the client decisions and the plans going forward are great. And I think that what you said about the point in emergency medicine is, for a lot of us in general practice, is also somewhat the point in general practice. Because gone are the days where you're the solo vet and you're picking up after yourself. Right?
Now somebody else, whether it's a member of your front desk team who then is faced with talking to the client and trying to interpret what you did or why you did it, or another doctor who's picking up because the pet's back two days later or whatever, were for me, what I think about it from the business perspective and the manager perspective and having been on both sides as the patient care team, the technician, and on the client care team, as a front desk person, I have to know where your head was at. That's where I love your bullet points. What were the key findings? What were the recommendations? What did you talk about with the client and what did they decide and what is the plan moving forward? That's it. Yeah.
Dr. Andy Roark:
So almost there. The other thing I want to make a couple other pushes here to rethink the way you're doing medical records. So the first one is a time benefit, okay? Think about how many medical records you touch in a day. Okay? You're in practice. How many medical records come through your hands? Now think about how many times you log into your system and open that record back up, right? So one is, how many patients did you see? How many records did you look at? And then how many times from different computers did you log into this record, right? It's a huge amount of time. It's a huge amount of time.
Stephanie Goss:
How many do you think you touch on an average shift?
Dr. Andy Roark:
So this is the question of how many appointments should a doctor see? Which is a dangerous question because practices are very different. I would say in a day, I'm probably somewhere in the mid-twenties, you know what I mean? Of how many patients I see versus also people calling in to talk to the doctor, making recommendations on the phone. Things like that. You started thinking about, and I'm not talking about repeat visits to a record, I'm talking about how many different records pass through my hands.
Stephanie Goss:
A single record that gets open. Yeah. No, that's why when you said that, that was where my head was going. And I would say, like you said, everybody's clinical structure is set up and we have clinics that our colleagues work at that they might see seven to 13 patients in a day. And we also have other practices where they are seeing 25 or 30 patients in a day or ER, which I could imagine could be way more than that in a super busy shift. But then you think about to your point, what about the prescription refills and that where the client had a question and all this. It's probably upwards of a hundred or more that the average team member touches in a day.
Dr. Andy Roark:
It could be. It's a lot.
Stephanie Goss:
It's a lot.
Dr. Andy Roark:
Okay. So it's a lot. And when you're dealing with a lot in a day and every day, think about how that adds up. Now think about the difference that one minute per record makes. That's huge.
Stephanie Goss:
I'm with you.
Dr. Andy Roark:
That is huge. It's big in a day. It's real big in a week. It's enormous in a month. It's a lot. It's a lot of time. So the idea of getting intentional and smart about how you're doing your records, this is work-life balance, my friend. This is a significant thing for opening up time, is in this medical records. And people just, they refuse to think critically about how they do their records. And it's dumb when you think about how many you do. There's a communication benefit. I am a big believer of putting tangible pieces of information about what was happening into a client's hands. Give them something they can see. I like to print it off and give it to them because it's tangible. They paid their money, they have something they can hold in their hand.
It empowers the person who came in and deals with you to be able to defend their purchase decisions to people at home. Like think about the percentage of people who like, there ain't a lot of us that are the sole financial decision makers in our family and nobody questions how we spend the family money. That's not most of our realities. And so I like to equip pet owners who were there to go home to their spouse and say, “This is what we did. Yes, we paid that money and this is what we got and this is what we did. And here's a thing that you can hold that we learned.” It's a CYA by providing it to the pet owner in writing. And so if you said, “I strongly recommend heartworm. Told owner that heartworm disease is extremely prevalent in our area. Owner declines heartworm at this time.” And you give it to them, worst case scenario, push comes to shove. I wrote it down, I told you, yeah, I wrote it down and I gave it to you. And you even have a copy of it.
It's just a quick CYA. And the last thing is signposting for the next visits and for follow-ups. It is so nice to say to people, you say, “Great, you've elected to treat this patient empirically. If this patient does not get better in 24 hours, you're going to come back and you can expect to do, or at that time we will do radiographs, blood work X, Y, and Z.” And they come back in and I told them what was going to happen, and it's in print what was going to happen. And they come in and they're like, “Well, I guess this is what's going to happen.” And it's just really easy for getting compliance and getting them on board and it saves me time, but it's a big motivational thing for them coming in and doing the diagnostics that we need to do. And so that's called signposting.
And the last thing is the tech leverage benefit that a lot of people don't think of. If you want to leverage your technicians, if you want to work collaboratively with your paraprofessionals, they need to know what is going on and what your plan is. And the medical records are a far superior way than you individually telling each one of them with your mouth while you're doing other things, what the plan is. And so your technicians are prepared to do callbacks to see tech appointment follow-ups, to do rechecks, to do so much communication for you. But they can't do it if they don't know what the plan is. So just the ability to get good use out of your techs comes from doing a good medical record that's accessible to them. And so getting medical records right and doing them efficiently is really, really important. There's huge benefits to stopping what you're doing and stepping back and going, “Okay, we can do this differently.” And it's worth thinking about how we do it and to make some workflow changes.
Stephanie Goss:
I would agree with all of that and I think most of my argument probably is going to come in the action steps part.
Dr. Andy Roark:
Okay. All right.
Stephanie Goss:
Because I'm still with you. I agree in all of that.
Dr. Andy Roark:
Okay, well then we will take a break here and we'll come back and we'll get into the action steps of what exactly should we do according to Andy in this situation. And then you can tell me where I'm wrong.
Stephanie Goss:
Have you done it yet? Have you headed it over to the Uncharted website? The one that's at unchartedvet.com/events and have you clicked on that link for the April conference? If you haven't, friends, you need to head over and click on that link and then you need to hit the register button because I want to see you with us in sunny Greenville, South Carolina in less than 80 days. We are going to be diving deep into tackling internal communications this Spring. We want to talk about how do we improve our communications amongst our teams in a whole myriad of ways. How do we set boundaries? How do we have conversations about the affordability of pet care and communications outwardly towards our clients as a result? How do we use language and maybe think about changing some of the language we're using to have better communication as a team.
Just previews of some of the awesome stuff that we're going to be talking about. So if you haven't done the thing, if you haven't, put your fingers to your keyboard and typed unchartedvet.com/events, go do it now because I have hugs waiting for you in Greenville and you should not miss out on this. And now back to the podcast.
Dr. Andy Roark:
All right, so let's get into how we actually start to do these medical records. Okay? Now, I'm going to break this down the way that we break down efficiency and core processes in a practice. So the first thing I'm going to do is step back and look at the system as a whole. And so bear with me, this is really honest to God how I think about appointments, okay? Let's step back when we're going to look at the system as a whole. And so medical records are part of the workflow of the doctor. My belief and I can back this about a number of different ways is, one of the mistakes that doctors make and it isn't just how we're trained, but it's true. They think of an appointment as a single unit. I see 13 appointments a day. That's what I see.
I think that that's a really limited way to think about what you do and it's limited in how efficient you can make yourself if you think of an appointment as a unit, right? Appointments should be thought of modularly. There's admission of the pet owner, there is the patient history, there is the physical examination, there is the recommendation, there is the diagnostics, there is the treatment, there is the follow-up diagnostics after the first diagnostics. And you can break this thing all the way down into being a couple of modules. I like to break an appointment up into modules and then I like to look at who does what. So for example, when an appointment comes in for me, my technician gets a TPR and gets the client history and then Andy comes in, does the physical examination, makes the recommendations, steps out, technician does the diagnostics, does any treatments that are needed, and then I return with diagnostic results and recommend additional diagnostics or additional treatments, based on those results.
Or we move to discharge, which is done by the technician. And so really when you look at an appointment, it's not one block. It's technician, me, technician, me, and then that repeats if we need to do advanced diagnostics and then discharge is by technician with my medical records in their hands. Okay? So that's the workflow. If you break your appointment apart like that, you can really start to make this thing go. You can dial into training your technicians specifically on history taking. I can dig into how long am I spending doing a physical examination? How long am I spending doing recommendations? And then when I'm done with recommendations, how long is my team taking to take pets out to get diagnostics done? I can drill into the specific efficiencies of each of those steps and you guys can see, I'm really serious about making this thing flow.
But if you're doing 25 appointments a day, every day, for the rest of your career, shaving three, four minutes off of your appointment time, buddy, that pays real dividends in you getting things done and you getting out on time, on you being able to help more people. And the medical record is part of that. While my technicians are doing the treatment or the diagnostics, I am writing up the medical record. That's where I go. And so I know that I go in, physical exam, out, medical record, in to report, out, update medical record, and then off with a discharge and it goes out. So I really believe you have to understand that's how I think about appointments. I'm not messing around, they don't kind of willy-nilly get done. But that approach is it allows me to really leverage my techs, which is why I'm such a huge fan of techs and to pull people in and for us to run a well-oiled machine. Okay?
Stephanie Goss:
Yes, I'm with you on that.
Dr. Andy Roark:
Cool. So when we talk specifically about the medical record part of this, this is a module in that system. And so I want to drill into this like it's an efficiency exercise.
And so when we have efficiency exercises and you want to go faster, the first thing you do is document your current workflow. And so you need to look at how this is actually happening. What is going on? And what happens is people say, “Well, what do you mean what's going on? I sit down, I think about the thing and I write it down.” And I say, “No, you don't. No, you don't. Touched this medical record three different times at three different computers, logging in each one, navigating your way to find the patient to open that file up. You're waiting for it to load, then you're getting over to the soap and you're doing this three different times. That's wildly inefficient.” You want to minimize the number of touches you have on any project. That's just across the board.
I don't want to go over to the pharmacy four different times to get one appointment out the door. That's not efficient. I want to think about going to the pharmacy one time, grabbing the four things that I need, getting them done, packaged and out the door. And so that's what we talk about when we start to really drill into the efficiency. So think about the number of times that you're that you're touching this. And so I want to minimize the number of touches I have on the record. I want to open it up and I want to largely get it done as fast as I can with as few engagement with it as possible. And the last thing is inside that record, I want to automate as many steps as possible. It's amazing how many of us basically do the same physical exam for every patient and we type that physical exam in every time.
That's bonkers. Automate, automate, automate that thing. And it's amazing, I don't have a problem with doctors saying to the management, “Hey, would you be okay if I set up my own template for physical exam findings and just be like this? It'll be Andy's wellness exam and I can pop it up and I can use it.” Think about the number of appointments or charts we see in a day and then think about how much time over the course of a year you would save by having this thing generate your objective findings, and then also your plan. Even just in a template of how do you write your plans if you're always like, these are the next steps, these are the follow-up things, whatever. The more of that stuff you can just auto-generate so you're quickly filling it out, the better off you're going to be. And this matters because of how many records we touch.
Stephanie Goss:
So I don't disagree with any of that. Where I think for me, I zoom out even further and it's actually something you taught me, when you think about it, and this works for, I really do believe all branches of veterinary medicine, including ER. If you zoom out and you think about in an average day what kind of cases we see. It's going to be easier, if you are a cat-only practice, you might have a handful of things that you see wellness appointments for cats, you might see dentistry appointments for cats, you might see sick cats. And then your sick cat, you might have five or six different things that you see really commonly. And there's going to be zebras, there are always zebras. But on your average day, what are those things that you see? If you think about that from a clinical perspective, you can probably count on two hands everybody, the kinds of cases we see.
We've got vomiting, we've got diarrhea, we've got the ADR.
Dr. Andy Roark:
Skin, yeah.
Stephanie Goss:
You've got itchy skin or itchy ears, you got itch factor of some variety. So if you start at the beginning and think about what kind of cases does your practice see, no matter what type of practice it is, and what I mean by even the ER, like ERs see some crazy, crazy things. And there are things that they see every single day just like GP, right? So what are those things? Hit by car, broken bone, things like that. If we zoom out and we think about what are those things and make a list and then we start by thinking, okay, to your point, I love your point Andy about it doesn't even have to be the same across the board because each doctor's approach to those things might be different.
But, and if I ask you Andy, “Okay, take a vomiting pet, a pet with diarrhea, an itchy pet, and write down, think about the most high-maintenance client that you could see with a pet with that issue, what would your chart look like?” And if you take the time to sit down and think about what would that look like, how would I hold their hand? How would I communicate those things? And you write it out, it takes time to do that process and you're doing it once and then you're done. And what I mean by that is if you think about that case and a high-maintenance client, chances are you can use that template to cover 99% of the bases, because then it's just deleting. Then it's just taking out things that might not be applicable, adding in some things that might be applicable to this case and now you're just editing, instead of writing.
And I every day, hear from people who are like, it used to happen to me in the practice and I would have doctors who would sit there, they're seeing the same things, but they're literally doing what you said, which is typing out the whole thing every single time. And it blows my mind that that's still where we are as a field, because to your point, we have the technology to fix that problem. Even if your PIMS is not the most advanced of PIMS, there is nothing to stop you from opening a Google Doc and writing your templates in a single Google Doc, and making a table of contents for yourself so that you can pull out of that what you need when you need it. But I think when we, I've done this exercise with my practice multiple times with multiple doctors, and what we found was they all were like, “We all write our charts differently.”
Fair. You all went to different medical schools, you all have different backgrounds, you all have different things that you feel more strongly about than others. And the reality is for most practices, there is an average in there somewhere. And so it is once you start this process to look at, what are we writing and how are we writing it? It becomes easier to make the template and then look for those commonalities. And in some practices, it works for there to be one template that works for everybody. And in other practices, it works because there's a system, to your point, for each doctor to have it individualized. And your practice management software can do that. You can do it with a push of a button. I can literally hit three keys in Avimark and drop in my customized, I've written this out as technician notes that are different from my team members' notes.
It's not hard to do, but I agree a hundred percent. I think we have to zoom out from a starting perspective and it's a worthwhile exercise to your point about shaving tons of time off in the long run, to sit down, make a list of the cases, the kind of cases you see, and start working your way down it. And what I found when I did this process, most of my doctors, if I said to you, “Hey Andy, what's the last super itchy pet you saw?” You probably could have a patient that would come to mind.
And then I could say, “Great, I'm going to pull up that chart. I'm going to take, going to cut and paste. Here's what you wrote for that case. Is there anything else? If you are making this your standard, is there anything else you would want to add to this? Anything you want to change?” Now, instead of you having to sit down and say, “Oh, Stephanie wanted me to think about what I would write for an itchy pet.” Now you're taking something that you've already done and now you're just editing the work, which makes the process exponentially easier. I think a lot of us are like, “Oh gosh, I have to.” It's this huge bit. We make it into a mountain when it really can be really easy to start with a molehill, because those patients stick out in our minds.
Dr. Andy Roark:
So the way I handle this, okay, and there's you got to be a little bit careful here, because I can get on board with this, but going all the way back to the beginning where I say, “What is the point?” Right? If the point is client education, we need to be upfront about that, because I didn't put that in my list, but it's not wrong. You know what I mean? To be like if you say, I want to write this in a way that my most demanding client is going to get it. I think you can do that. But I think that, and here's exactly why I rant about the vet schools and maybe I was unfair, but I don't think so.
Stephanie Goss:
I don't think you're unfair.
Dr. Andy Roark:
When I do a medical record, it is for my techs and my other doctors, and I know that they are super busy. And what kills me is I have worked with veterinarians who are great veterinarians, but they write four pages in their medical record and it makes me angry every time I look at what they did. And I know they're like, I'm such a good doctor. I wrote 3000 words on that thing. And I'm like, “You know what? I'm not reading this crap. I'm going to skim it as fast as I can, and then I'm going to go look at what you invoiced so I can see what you actually did because this is ridiculous.” I don't have eight minutes to read that they had an ear infection last time they were here. And again, I know this is heresy and people go, “What? My four-page description of an ear infection is a masterpiece.”
And I go, “It's wildly inconvenient for me. You are slowing me down when I am overbooked and trying to get to an emergency because you did not communicate efficiently.” And so I think you can do that client education part and write up a robust template that you say, “Aha, here's the thing.” I would say you should put that at the bottom of your medical record so that everyone else on staff can immediately skip it. They'll say, “Here is important points for the pet owner.” Or “Have your plan and have your real plan and then below it have your templated in plan that clearly explains everything, but I can ignore that and just look at your assessment and your actual plan and know where we're going and what we're doing.” And so that's my sticking point.
The vet school teach you to take, in my opinion and experience with a limited number of vet schools, they take all the information, they put it in one place, which makes it confusing for the pet owners and overwhelming for busy practitioners and technicians who have just been handed a telephone and said, “Talk to this person.” And they're like, “I'm sorry, I'm going to have to call you back when I get to chapter three because that's where we are.” So anyway, I think I do love your point about you doing your client communications on a template. My point is I have strong feelings that separating the intra-hospital communications and the client-facing communications, if you're going to go into great depth, I think that's important.
Stephanie Goss:
Yes, I am a hundred percent with you. I think we've come to this place in veterinary medicine where, and like you were saying, I don't know if it comes from the vet schools or because we're just living in a litigious world now. We've just come to this place where the patient care side of the chart and the client care side of the chart have melded together for a lot of us. And I am absolutely a huge advocate, and my number one rule in my team, if it isn't written in the chart, it didn't happen, right? Because that's like to the point about the medical board, that's how they look at it. What is written? Because we can only go off of what is written in the chart. And so I, a hundred percent agree with you, and I love setting up a practice management software so that you have that separation because I'm with you.
It used to drive me crazy when I would be the tech and I would have the client on the phone and I'm digging through four or five paragraphs trying to figure out what you actually said. I want the high level and I want to make sure that the important pieces are called out. And that's where I think our technology allows us to do that. And so many of us underutilize our practice management software to leverage that and make it easier for the team. Because I think your point about minimizing those touches and thinking about how do we automate those steps, is really, really important. Because if I can think about how do I, nine times out of 10, how do my doctors treat an itchy skin case? And I think about the bullet points that I would want that record to include, that's what I'm talking about from a template perspective.
Like what does that say, so that if I'm picking it up, you Andy, were in my practice as a relief doctor two weeks ago and we haven't talked to you since, and now Mrs. Smith is on the phone asking questions? I want to be able to go pick up that record as a technician and go, “Yeah, I could get inside Dr. Roark's head because it's all here. I know what he was thinking. I know what those major concerns were. I know what he recommended to you. I know what the plan was and I know what your decision was as the client at that point in time.”
Dr. Andy Roark:
The last part of this that I think is really important, and this is a hill I will fight and die on. The filling out the medical record is part of the appointment, right? It is a module and it is there. Separating the time that you do medical records from when you see patients is a mistake. A doctor should dig their heels in and push against it. And your practice might not like that, and I think you should tell them to stick it. And you don't hear me say that a lot, but you should. This is me coming down on the part of the doctors. You should tell them to stick it. And it's because first of all, it's not good medicine for you to see an appointment and then three hours later use your recall to remember what you talked about and put yourself in there, is not good medicine.
And the other part is, this is a way, it's a subtle way, and I don't think people mean to, they don't think about it. It's not an evil plan. But it is a way of making doctors take work into their lunch breaks and take them home with them. And when we're dealing in major burnout, that's not okay. That needs to change. We never say to someone who worked at a fast food restaurant, “Hey, go ahead and make french fries while you're at home tonight, so they're ready for tomorrow.” It's like, “No, that's part of the job. And I do it at work on the clock.” The same thing is true with your medical records. The thing that needs to happen here is, the doctors need to dig their heels in and say, “My appointment is not over until I finish this medical record.” And I think that you should fight that fight and just say, “That's how it is.” And that's how you get out of here on time.
The fact that if the practice says to you, “But if you write up your medical records, we can't see all the patients that we want to see.” I would say, “Then we don't have capacity to see the patients that you want to see.” Because writing up the medical record is part of the job. So again, I don't think it comes from a bitter place. I don't think that practitioners are trying to take advantage of doctors. I don't think they're like, “Ha ha, let's make them spend their nights writing these things.” They are just trying to see all the patients and to do all the work. And one way to stuff it into a certain number of hours is to just not ask questions about when the charts are getting done because the doctors are going to do it, because they have a moral obligation to it, and they're good people and they also want to protect their license, so they're going to do it.
So that's how that kind of gets set up. And I just feel really strongly it's time to push back against that and say, “No, these things go together.” Now to be fair, and on the flip side, if you have a doctor that takes 22 minutes to write up a chart, and I know those doctors. Yes, I understand why the clinic would say, “This is not okay for you to take 50 minutes to see a 30-minute appointment.” That's not hard to understand, and the staff's going to get frustrated and everything. That means that there has to be some flexibility on the side of the doctor, which goes back to efficiency, which is, I'm going to write these charts up, but I'm going to do them in an efficient way that doesn't involve me writing 5,000 word essays on every one of them. And if the doctors are unwilling to make that concession, then none of this stuff that I'm talking about is going to work.
Stephanie Goss:
And I think, I have been there working with doctors who have the mini novel for the records, and to your point, from the vet school lens, they were beautiful. If I sat there for 25 minutes and read through their whole mini novel, I would have a fantastic idea of what they were thinking, why they were thinking and what's coming next for this patient. I would. They're so thorough and complete and beautiful. And if you are that doctor, it's also not wrong to figure out how to make that for yourself and make it replicable, because you can't expect yourself to have to have to write that out over and over and over again. Because otherwise you're going to be this doctor who's there till 10 o'clock at night, writing up their charts. You have got to figure out a system. So I'm totally with you, I think.
And I think if we're not doing our jobs as managers, if there isn't some sort of process to look at this and evaluate this and make sure that we're supporting all of our doctors. So for me, that conversation would look like, “Look, I get it. Maybe I can't ask you to change right now.” Because especially when you're working with newer grad doctors, that is how they sometimes get to their thoughts. Or when you're standing there, I remember being a new technician and thinking, if I don't talk through in my head all of the possibilities, how will I know that I'm not missing something? So I know what that feeling feels like, and that's where you have to be willing to accept help from your team. And so you have to figure out a system that is going to allow the rest of the team to help you. But this is not a healthy place to be where you're sitting there until 10 o'clock at night.
And so if you're like, “This is the only acceptable way for me to do it.” Totally fair. You have to be willing to work with me to create a system. Because as the manager, I also have the responsibility to the rest of the team, to the business, to our patient care model because there's other patients waiting for you that also need your attention, to say, “I have to help hold you accountable to being able to move this along because it does not work for you to take 50 minutes to do a 30-minute appointment and constantly be making your clients wait 20 to 30 minutes and be running behind.” That's not fair to the patients. It's not fair to the clients, so I need you to help me. And it's about finding that middle ground.
Dr. Andy Roark:
Well, I'm glad you said that, and I'm glad you brought that up because I just want to really emphasize, I don't think I said this very clearly before. When I'm looking at my systems and my workflows, there are other people besides me, the veterinarian making $75 an hour or whatever. There's other people besides me that can do 80% of the medical record for me and my assistants can, my technicians can. And so I didn't say that super clearly, and I think I've been talking as if the doctors is the one king and all this. That's part of the system of the workflow is to go, “Okay, how do we do this and where are other people and how this, can be broken up.” I mean, I know doctors that are a high-producing doctors and they have a scribe chasing behind them. When I go see my doctor, the GP, every one of them now has a scribe in the room and they're doing the records and they're making it happen.
The economics of vet medicine are a little bit different, maybe a little bit. But I do know that I do have, I've worked at those practices. I've worked at a practice that I had the doctor, the technician and the assistant all go into the room, and it's this really beautiful rotation of, the technician is asking questions while the assistant is getting the pet ready, and then the doctor is in, and the doctor is doing the physical exam, and the technician has rotated over to the keyboard and they're serving as the scribe, and then the technician is doing the diagnostics and feeding them back to the doctor. And it's this beautifully coordinated dance. But that record is done every time they're done in that room. And it's impressive. It's super impressive.
Stephanie Goss:
Yeah. No, I'm on that page. That was my preferred method in my own practice because it makes you be able to be leveraged to, as a team member to your skillset. The doctor is putting their hands on the patient and diagnosing and answering the client questions that need to be answered to make a diagnosis or move forward. And then I want to be able to help the doc. I want to be able to take all of the patient care pieces off of their plate. I want to be able to help drive that forward. And also, I'm the tech that love client education, so why should my doctor stand in the room and answer some of those questions that I'm totally capable of answering for that client? Because then I also can not only answer the question, but I can have the financial conversation.
So I'm with you. I'm a big fan of figuring out what that dance looks like. And look, this is where, should is a very dangerous word because it's different in every practice. What works in my practice is not necessarily what's going to work in Andy's practice or your practice. Everybody is going to have something different, and everyone needs to have a system and a process. And the fact that we, as an industry, spend hundreds and hundreds of thousands of hours doing this over the course of a year in practice and years in practice, and so many of us don't take the time to on this as a team and figure out those systems, is really, really sad because it is a part that is, it is broken. And it should not be up to just the doctors to say, “Hey, I'm drowning, and this doesn't work for me on a personal level because I'm spending all of my time off work, working on work.” The whole of the team should look at this and say, “How do we make this better for each other and also for our patients and our clients?”
Dr. Andy Roark:
Yeah. I just have really strong feelings about this is you can tell it's because I have seen my good friends burn out and quit. I mean, I know veterinarians that work at IDEXX because they couldn't go home before nine o'clock, and not that working at IDEXX is bad. It's great, but it hurts my soul because I want my friends to be in practice. I know that's what they want to do, and I feel like I'm bashing IDEXX. I love IDEXX. I don't seeing my people burn out in the trenches in vet medicine. I love clinical practice and I don't like seeing people leave for burnout.
And I've seen good friends break their marriages for this exact reason. And I go, “I'm sorry if your marriage is breaking down because you don't come home before 9:30 at night because you're writing up records. That's not okay.” And that's the emotional driver for me to say, “Nope, the record gets done when the appointment gets done, and I hand the record to the pet owner because that stops me from falling back into that habit of, I'll fill these out later on.” But to me, it's a wellness strategy to say, “Nope, I'm tying these things together. I'm not interested in breaking them apart because I don't want to live that life.” And just, I've seen that too much.
Stephanie Goss:
Yeah, no, I agree with you a hundred percent. It hurts when you have people on your team who truly love clinical practice, and I think that's what I heard you say when you were talking about somebody leaving and going to work in industry. There are people who are suited for industry. They try clinical practice and they are not happy and they go elsewhere. That is not the problem. It's when people who genuinely love clinical practice but leave for an alternative, whether it's industry or leaving the industry altogether, because they can't figure out how to find that work life balance, that's the one that hurts them. That hurts. Right? That's the one where you look at it and you feel like, this isn't good.
Dr. Andy Roark:
I agree.
Stephanie Goss:
And I think it's our job as leaders to help fix that. And so this is an elephant, and if your practice has no system and everybody is doing it a different way, especially if you have multiple doctors and multiple techs, and each different team does it differently, this is not a thing where you're going to be like, “All right, we're going to call a huddle and in the next 15 minutes we're going to solve this problem.” That is not a thing that's going to happen.
Dr. Andy Roark:
You have to do the math. You have to do the math and recognize how many appointments you see in a day and how many people log in and search for a pet and pull them up. And just think about how much time you spend logging in and pulling up a pet on one computer, and then five minutes later you log in and you pull it up on a different computer and oh, you can't access it because it's still open on the first computer, and so you have to go figure out where you open up. It's just ridiculous. But those things, especially across a three-doctor, five-doctor, 10-doctor practice, they're bonkers. Also, I feel like we going to need to do some sort of hiring push for IDEXX because I'm like, I wasn't trying to use them as a bad example, and now I'm really torn with guilt. I'm like, so if you're thinking, if you are burned out-
Stephanie Goss:
I understand what you were saying.
Dr. Andy Roark:
If you are burned out and you're thinking about leaving a clinic, consider IDEXX because I do have friends who have gone there, but they're very happy. And so just think about it.
Stephanie Goss:
I think you're just digging the hole for yourself.
Dr. Andy Roark:
This episode not sponsored by IDEXX.
Stephanie Goss:
Not brought to you by IDEXX.
Oh man, I love it. I love it so much. If you're sitting here and you're listening and you're just like, “Okay, guys, this sounds fantastic, but how do I actually do this?” This is the kind of thing that I love about the Uncharted community because we ask these of kind of questions. We are asking our peers, I have no idea how to do this. I know I need to do it because I have doctors who are sitting here until 10 o'clock at night. I want to fix this problem, and this is the kind of conversation that I love seeing happen in our community because it's where we dig into the weeds of what are we actually doing? What are the different styles of doing it? How do you approach this? What are people's different perspectives to how do you project managements this?
Because it is an elephant and you have to eat it one bite at a time, and there's no better way, I think to do that than to sit down with some of your peers and say, “How might I approach this and how may I also be able to ask for help?” Because it will be a process. It is an undertaking. I have done it with multiple practices. At my last practice, it took us a year once we identified like, “Hey, we need to solve this.” Because we did it in stages. And it started like everybody's going to write up, let's take a wellness appointment. What does that look like? And you just chip away at it, little by little by little.
But you know what? When we got there and when the wheels started churning faster and faster and that train started chugging down the track, it feels really good because there is a world that exists where you can go into an exam room, you can see an appointment, and you can walk out of that exam room and the client can leave the building and your chart is done. And all of the client communication is in the client. Like you said, the client left with a copy of whether it's a report card or copy of the record or whatever. They leave with that in their hands. There is a world where that can exist. I'm here for that world.
Dr. Andy Roark:
Yeah, I agree. Awesome. Well, thanks for talking through with me, Steph.
Stephanie Goss:
Yeah, this is a good one. Have a fantastic week everybody.
Dr. Andy Roark:
Thanks, everybody.
Stephanie Goss:
Well, that's a wrap on another episode of the podcast, and as always, this was so fun to dive into the mail bag and answer this question, and I would really love to see more things like this come through the mail bag. If there is something that you would love to have us talk about on the podcast or a question that you are hoping that we might be able to help with, feel free to reach out and send us a message. You can always find the mail bag at the website. The address is unchartedvet.com/mailbag, or you can email us at podcast@unchartedvet.com. Take care everybody, and have a great week. We'll see you again next time.
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