I am certain that we can measure the efficiency of a healthcare system using Fitbit.

While reading my Twitter feed yesterday, I noticed healthcare leaders Tweeting about their Fitbit scores and the number of steps they’ve taken while at the HIMSS Conference (see footnote). Conferences and airports are prime for high Fitbit scores as you wander from room to room, lecture to lecture, gate to gate.

I’ve blogged about how I use Fitbit to make sure that I walk 10K steps each day. I want to live a long time, so I do things (like moving) to stay healthy.

On days when I am seeing patients in the Emergency Department I easily log 10K steps, while on other chair ridden admin days I need to dash to the treadmill with my Fitbit and pound the rubber conveyor belt. I get in the car. Drive 1.5 miles. Run 3 miles on the treadmill. Then I get back in the car and drive 1.5 miles home. It makes perfect sense.

The Perfect Fitbit Medicine Workday

Walking 10K steps during a workday is a sign of process failure.

The perfect workday: You know, that’s the one where families cheer as you walk in and praise your healing abilities. You effortlessly document, diagnose, and treat (perhaps not in that order) the ailments of the entire population of your large town before noon. That ideal workday would consist of walking into the room the healthcare system has built around you (or your EMR) to unleash your magic. Simple and efficient. Fitbit daily total: two steps.

When my Fitbit is reading 10K after a workday, however, I am walking six miles. That is six miles of process steps. The more process steps I have taken, the more physical steps I have taken.

You step inefficiently when

• you have to go down the hall to get supplies.
• you have the patient walk from here to there.
• you are seeing patients in bed 1 and bed 100, and then bed 1 again.

I bet that not only are you inefficient, but your whole team is inefficient.

Fitbit Medicine Healthcare Efficiency Ratio

Let’s get the LEAN process ninjas to hand out Fitbits for healthcare workers to wear during their workday.

The goal: Collectively accumulate the fewest number of steps to provide perfect patient care.

Let’s examine the number of steps by a physician, a tech, a nurse, the patient and an admin and then let’s figure out the cost of each of those steps. We could create a Fitbit Medicine Healthcare Efficiency Ratio of step/cost. Our ability to accountably care for our community is going to be better if our highest cost individuals have the lowest Fitbit scores. A tech walking is not as bad as a physician or a nurse walking. We certainly don’t want our patients logging high steps.

Perhaps CMS could post Fitbit efficiency scores on their website. Over time we will see healthcare workers walk toward efficient systems. A Fitbit win for one system, a Fitbit loss for the other.

One of the doctors I worked with said that he didn’t mind the steps. “That is how I gets my exercise.” That is not the goal.

Footnote: Healthcare Information and Management Systems

Each of us carries a long list of tasks that we need to get done. Things at work and things at home, hobbies and chores, alone and with others, on the phone and online. A mishmash that fills our brains and keeps us thinking about remembering, remembering not to forget.

Photo courtesy of iStockphoto.com/petesaloutos

David Allen, the guru of Getting Things Done, says that the average executive has a list of 250 next actions on her to-do list. I tend to forget things if I don’t have a system. I’m very comfortable with vision, less comfortable with detail, and I have found that technology can palliate my task-oriented stumbling. There are three things that I rely on to keep order, to provide a structure for success with tasks.

Three Apps I Use to Get Things Done:

1. OmniFocus

OmniFocus is a very robust to-do application that I use on my iPhone, MacBook Air, and iPad, to keep track of bits of information that I need to discuss or act on. I have OmniFocus configured to remember tasks based on the location, on the activity and on the specific individuals with whom I work.

For example, I might have the following tasks:

• Talk about the scribe contract at our executive meeting.
• Talk to Dan about a case that needs to be reviewed.
• Remember to pick up the milk.

The first task, “Talk about the scribe contract at our executive meeting,” is an example of a meeting agenda item that I need to remember. At some time before the executive meeting, I will open OmniFocus and populate the meeting agenda with the various tasks I have captured. I can attach files, links to webpages and links to emails in the task. In this way, all of the supporting material that I need is available.

The second task, “Talk to Dan about a case,” is an example of a person-specific task. I keep a list in OmniFocus of the people I work with. As an idea that I need to discuss or a task that I need to assign pops into my mind, I enter it under the appropriate person. The next time I am with Dan, I look at OmniFocus and run the list.

The third task, “Remember to pick up the milk,” is an example of a location-specific task. I can assign tasks to specific locations. OmniFocus will use the location-aware service of the iPhone or iPad to prompt me to buy milk when I am at Whole Foods. It also knows that I don’t have executive meetings at Whole Foods, and it therefore will present geographically aware to-dos.

I have a hotkey combination on my laptop that I can type to rapidly enter tasks in OmniFocus using a pop-up window as I’m working in any program. It’s a very fast way to keep track of the tangential and cluttered thoughts that I tend to produce and harness them to create purposeful action.

2. Pomodoro

It is easy to start to work on something and then get distracted by something else. I start working on a contract, and then I want to look something up. Then I check my email and start to answer it, but the phone rings. Then someone walks by the office and asks a question. Twenty-five unfocused minutes later, I’ve accomplished little.

I have found that I need short disciplined periods of focused and uninterrupted work to give me the clear space to finish single tasks. Pomodoro is a work timer for the Mac or Windows that I set for 25 minutes (one Pomodoro) to focus on completing one specific task. After 25 minutes, I take a five-minute break to do whatever I want, and then I start the timer again for another 25 minutes. I repeat this process throughout the day.

During a timed Pomodoro session, I set the following rules:

• I close the door.
• I don’t answer the phone, check email, or open the browser.
• If a distracting idea pops into my head, I can write it down as a brief note or enter it as a task in OmniFocus.
• If I get interrupted for more than two minutes, I start the Pomodoro over again.

For example, I’d like to improve my writing, and I use Pomodoro to accomplish a goal of writing for one hour each day. This translates into two Pomodoros; two 25-minute sessions with two five-minute breaks. I know that on average a post like this will take four Pomodoros (two hours) of writing, and I plan for it.

I can estimate that a policy review will take one Pomodoro, answering emails will take two Pomodoros, and so on. I set up my day to get things done. After I have completed a bunch of Pomodoros, I take a longer break.

Pomodoro hooks into my calendar and logs the hours I spend on work projects. It is an effective anti-procrastination tool. It helps me get things done.

3. Note Card

I keep a note card in the front pocket of my shirt. A note card is not technically an “app”; it’s not electronic, it’s made of paper, and I use a pen. However, it is a very efficient, simple, app-like PDA (Parietal Disgorgement Aid).

At the beginning of the day, I write down two or three tasks that I definitely need to accomplish on that day. It may be something simple like, “Mail letters,” or it could be something more involved like, “Talk with Mike about Med Exec.” I enjoy checking things off as I do them. Very gratifying.

I also use the note card to write down bits of info that I gather. Sometimes typing into an iPhone or into a computer during a meeting can make it appear that I am not listening, or that I am texting to friends. Writing on a note card can be a much more socially acceptable way to capture information. Typing to-dos into the iPhone is also too slow for my bumbling thumbs; a note card and pen is rapidly elegant for the job.

Things You Can Do

1. Read David Allen’s book, Getting Things Done. It is your first read when you are wanting to get serious about creating a method for productivity.

2. Read more about the Pomodoro Technique. It’s a time management technique created by Francesco Cirillo. You can go to his website to download a pdf about the technique for free. There are also links to various Pomodoro timers that you can install.

3. Read Marc Andreessen’s guide to personal productivity. Marc invented the first widely-used web browser, Mosaic; he sits on the board board of directors of Facebook, eBay and HP; and he runs a very successful venture capital firm. He writes about not keeping a schedule and creating an “Anti ToDo List”.

Summary

OmniFocus, Pomodoro, and a note card make up my current system of getting things done. These three items help me work efficiently. I am always on the lookout for a new program, application, or gadget to try that I can use to be more effective. What do you use?

“I blame the government. I blame insurance companies. I blame the hospital. I blame the patient.”

Photo courtesy of iStockphoto.com/Gannet77

You know that physician. He is the victim of a thousand enemies. Each enemy is dumber but more powerful than he. If only he were in charge, things would be different.

Yet he won’t be in charge. He blames others for his problems, which prevents him from getting what he wants. He will never get it done. He may want something; however, there is a big difference between wanting something, and him working his butt off to get it.

Stay away from that physician. Reasoning with him will get you nowhere. Don’t give him your time.

It’s hard enough trying to change someone who doesn’t think there is a problem; it’s a losing game when you try to change someone who thinks everyone else is the problem.

Who should you focus on?

1. Focus on those seeking solutions.

You’re surrounded by colleagues who point out problems. They drone on about the problems, and the problem with the problems; this is not helpful. It’s a problem.

You already have a long to-do list of important things that you want to fix. A rehash of the known problems is a dead-end, circular effort.

Pick out the specific colleagues who not only understand the problems, but also offer ideas for solutions. Work with them.

2. Focus on those looking toward the future.

You have permission not to care about what happened back when there were different people, a different market, and a different setting. Yes, there is a history. No, things didn’t work out when you did this and they did that. However, things are different now. You are laying down a new path, not digging deeper into the old path.

One of the worst things you can do when trying to improve something is to focus on what got you there. It’s more effective to look to where you want to go.

History tells you that things need to change. Now change it with the future result, and not the past result, in mind.

3. Focus on those who appreciate the value of incremental improvement.

Change rarely occurs in giant leaps. Most improvements in throughput times, most increases in revenue, most of the solutions we drive create improvements in small steps.

This past May, one of my radiologist colleagues climbed Mount Everest. I asked him, “Why didn’t you just climb it in one step?” He assured me that it took him multiple purposeful, difficult steps. He’s the kind of guy I want to work with to improve radiology turn-around times.

Small improvements create significant improvements in overall morale and patient care. It creates a snowball effect; the kind of snowball effect where the rolling snowball gets bigger and better; not the snowball effect where big kids throw them at you because you wear glasses and are good in science.

4. Focus on those who can get things done.

It’s one thing to have great ideas for solutions; it’s entirely different taking those ideas and getting things done. You need to work with those who can accomplish goals.

You can have meetings and you can create action plans, but if nobody is doing the work, you are wasting your time. The value of an idea, a concept for improvement, is negligible compared to the value of that idea executed. Spend your time with those specific people who get things done.

Summary

Your time is limited. Stop wasting it with the wrong people. Start spending it with effective people.

Things You Can Do Now:

1. Stop attending a meeting where nothing gets done. Just cross it off of your schedule. In its place use the hour (or three) to get something done.

2. Stop answering emails from colleagues who think that everyone else is the problem. No matter what your response, you are the problem.

3. List the names of three people who get things done. Thank them. Schedule more time with them. Find out what you can do to help them. Be like them.

“First, let’s make sure that you have a heart and lungs.”

Photo courtesy of iStockphoto.com/ideabug

That’s a joke I use in the emergency department when I ask patients to sit forward so I can listen to their chest with my stethoscope.

If the patient laughs, I know one of the following is true:

• They have a sense of humor.
• They have dementia.
• They thought I said something else.
• I make them uncomfortable.

In any case, the response yields useful information.

I’m still looking for the patient who is missing these vital organs and is able to talk to me. I’m thinking I could get an academic paper out of that.

Am I Alive?

I’m a healthy guy. 175 pounds. 6 feet 1 inch. I’ve got a smokin’ hot wife. I’ve got two confident young daughters. I love my work. Life is good.

I want to live a really long time. I want to be healthy. However, health doesn’t just happen: It’s a habit I need to nurture purposefully.

I’ve found three applications that help me track how I am doing on my path toward health. They provide me a real-time awareness that helps me stick to the goals I have made. They help me minimize the variability of behavior that can prevent me from achieving goals.

3 Apps to Stay Alive

1. Fitbit

Fitbit is a little clip that I attach to my clothes and use with their iPhone/online application. It monitors the number of steps I take and how long I sleep. I take at least 10,000 steps and sleep at least seven hours each day. If I don’t, I lose health.

The easiest way for me to get to 10,000 steps is to run 30 minutes each day. The easiest way for me to get sleep is to lie in bed and close my eyes.

Tony Schwartz wrote a good post about the effects of aerobic activity and sleep on our ability to improve sustainable performance. Most of us just get through our days. I want to own the day. I want to feel alive.

Fitbit also estimates the number of calories that I burn as I go about my stepping and sleeping life. It can tell when I am exercising vigorously, like when I am running my daily 50K, and it can tell how well I sleep during a long meeting. I could keep track of the number of calories I eat in the application’s food diary, but I’m pretty simple when it comes to estimating my calorie intake. The more I eat, the more I need to step, or the more I weigh.

Fitbit is easy to use. I clip it to my shirt or my pants and it does its thing. Its battery is iPhone like; it’s not removable and it comes with a charger. It only takes about 15 minutes for a full charge. It uploads my data via wifi when I am close to the charger attached to my computer.

The application, available on your iPhone and online, is elegant and quite usable. It allows you analyze your data with William Tufte-like depth. There is a community of knowledge at the site and it has built-in social networking so you can share data with friends.

Fitbit costs $100. I think it is worth it.

2. Don’t Break the Chain

I’ve used Don’t Break the Chain for a couple years. It is a very simple online site and iPhone application that keeps track of whether “you did” or “you didn’t.” I have found it very helpful in reinforcing and reminding me to accomplish new goals.

I currently have three goals that it keeps track of:

• Write 1 hour each day.
• Take 10,000 steps each day.
• Meditate 20 minutes each day.

As I do each daily activity I go to the Don’t Break the Chain calendar to check it off. It tells me how many days in a row I’ve “been getting things done.” The goal is to have long strings of days of accomplished goals. It creates a pretty subtle and yet potent psychological pressure to keep me healthy.

It’s free.

I’d been wearing my tuxedo T-shirt for six days straight.

3. Equanimity

Equanimity is a meditation timer for the iPhone. Meditation is no longer just for hippies and worshippers (though it’s fine if you are): It’s for those who want a healthy mind. The data are pretty clear that meditation is good for you. You should see my cerebral cortex. You know how you have a six-pack abdomen? Well, you should take a look at my frontal lobe. It’s toned. Meditation is the abdominal crunch of the mind.

Meditation works, whether you are agnostically counting breaths or concentrating on structured religious ritual. It improves your ability to handle stress, your self-esteem, and your ability to concentrate. It also improves metacognition: your ability to think about thinking.

You can set Equanimity to variable times. It keeps a log of each sitting, and its interface is unobtrusively refined. It has a calendar that tracks the hours and frequency of meditation that encourages daily practice. This encourages me to sit.

Equanimity is $4.99.

Summary

Creating healthy goals and sticking to them is getting easier. Key causes of failure in achieving goals are variability of practice and a lack of feedback about goal-oriented activities. The latest technologies are highly portable and easy to use. They improve our awareness of the effects of our daily activity on our health. They have the potential to help us feel alive. First, heal thyself, doctor; then suggest the same applications to heal your patients.

Things You Can Do Now:

1. Read about wearable computers and the cool things that people are doing with them at Quantified Self. The site discusses self-tracking and the knowledge that can be gained through personal data, such as data about sleep, exercise, work, and mood.

2. Create one healthy goal and use one of the above apps to help you attain your goal.

3. Share with the readers of this blog the applications you are using either for yourself or for your patients.

I speak English. I also speak broken emergency department Spanish.

Photo courtesy of iStockphoto.com/franckreporter

I can request of a Spanish-speaking patient, “Siéntese, por favor.”
This respectfully means, “Please sit.”

Or I can implore, “No empuje! Por favor!”
This loosely translates to, “Don’t push! Please have your baby upstairs in the obstetrics unit!”

It is not unusual to have a patient who speaks Hmong or Armenian or Portuguese visit our emergency department.

I request, “Siéntese, por favor.” But they look blankly at me.
So I say it louder. “Siéntese, por favor!” This doesn’t work.
It’s as if they speak a completely different language.

The Language of Business

I see similar language barriers occur when physicians talk to administrators.

The physician speaks Medicine louder, and the administrator who speaks Business doesn’t get it. The physician says, “No empuje!” and the administrator pushes harder.

One of the most effective things you can do to better communicate with administrators is learn their language. I went to business school to learn the language and science of business.

Five Things That Business School Taught Me

Here are five things that I learned in business school that helped me master the language of the healthcare business:

1. Managerial Accounting.

You want to buy a robot, or hire more nurses, or build a new clinic? It helps if you can say something other than “We really, really need it.” You need to understand the budgeting process. Your department, your group, your practice is being measured.

Do you agree with the budget? Do you understand the costs? How are you going to promote your position if you don’t speak the language?

2. Negotiation.

Physicians are notoriously poor negotiators. They have a tendency to approach each negotiation as the final battle in a war of used car salesmen.

You have a position. You have a price. They’d better give in.

Unfortunately, while you speak a used-car salesman’s language of positional bargaining, you leave a trail of animosity and a lot of interesting opportunities can be taken off the table. There is an art and a fairly good science to negotiation. You want to know it. Through negotiation and discovering mutually aligning interests, you gain the potential to create significant profit.

3. Operations Management.

Why is there always a line in your waiting room? What is keeping the hospital from starting surgeries on time? What is taking lab so long? The answer lies in process analysis and a clear understanding of queuing theory. There is a better way.

You can use the same science that Apple and Amazon use to get things done. You learn how to destroy the bottlenecks of waiting that prevent you from being efficient. If you don’t understand the science, it is very likely that your limited working vocabulary will convey cluelessness as you present your isolated view of how to fix the system. The administrator will nod politely, but chances are they think you’re a bottleneck.

4. Economics.

I hear you talking in our physician lounge. Taxes and investing and leveraging. You have strong opinions. Economics is the class you take to make informed choices about the small, daily matters of life and the global, long-term issues effecting healthcare and the world.

Your economic decisions directly affect your bottom line. You need to speak the language of sunk costs, and opportunity costs, and setting prices. You learn about rent controls, labor unions, and subsidies. This is the class that makes the market come alive. Without a good understanding of economics, you are in good company, with a number of politicians and, perhaps, you talk like one too.

5. Organizational Behavior.

I learned how to communicate more effectively, build effective teams and manage conflict. The language of organizational behavior gives the basic nomenclature of how to drive change and build commitment to ideas. There are Jedi-Mind tricks of behavior and influence and this is the domain of these secret teachings.

Do you incentivize with extra salary or is there a more effective approach? A great question for the study of organizational behavior. You may think an offer of more money will do the talking, but your broken vernacular misses a key phrase.

A Strong Physician Voice

It is clear that a strong physician voice is needed during this time of disruptive healthcare market change. This strong physician voice needs a foundation of deep business knowledge to promote a physician and patient centered healthcare model.

It is also clear that there are several strong non-physician voices available to fill the gap if physicians are hesitant to step up. I encourage you to speak for yourself, using the language of healthcare business, and not rely on the words of an interpreter.

Things you can do now:

A physician MBA is not your only option. It is quite easy to pick a specific business topic that you are interested in and learn about it. The American College of Physician Executives offers an excellent selection of conferences and online courses on healthcare business topics that you can immediately apply to your practice. Additionally, they offer a Certification for Physician Executives if you decide to continue with your studies.

There are several other options if you would like to pursue an MBA or other master’s degree. I received my Executive MBA in Healthcare Management from the University of Texas at Dallas. My class had 40 students, all physicians, who came from all over the United States. I flew to Dallas every two months for a four-day course on healthcare management related topics. It was a great experience to be able to discuss healthcare cases with the professors and classmates who were PhDs, MDs and C-Level Executives. This was supplemented by very good quality online learning.

There are several MBA or master’s degree options for physicians, both online and classroom-based; there are a variety of flexible curriculums to meet your specific scheduling needs. Just google “physician MBA.”

Subscribe to this blog.

Postscript:

Please note that I use a language interpreter when I see my patients. However, I wouldn’t trust a Business interpreter to handle my healthcare businesses.

Some of the biggest mistakes I have made as a physician leader occurred when I heard one side of a story and took action.

An incident report arrives. A nurse stops me in the hall. A physician calls me or an administrator emails me. My suspicions about the individual in question have been confirmed.

And I pounce.

J’Accuse!

Finally I have something documented and now I can take action.

I meet with the individual in question. I point out the facts, I point out the history, and I point the finger.

But I am wrong.

My Story

It becomes obvious that I have missed some critical aspects of the situation. The story that I pieced together about the incident fits together so nicely. However, it is fiction.

The incident report, the nurse, the physician, and the administrator left out a broad perspective. And now from my stifled and embellished viewpoint, my integrity and my ability to manage the individual (and everyone else) is in question. In 5 minutes, I’ve lost my credibility.

5 Steps To Get To A Better Conclusion

You don’t need to lose credibility. There is a better way to investigate incidents with integrity. Follow these 5 steps in order to get to a better conclusion:

1. Listen.

Ask questions and listen.

• “What happened?” Listen to the allegations of the incident.
• “What else was happening?” Probe for deeper information and truths.
• “What do you think was their perspective?” Ask for possible alternative viewpoints.

Take notes.

2. Thank Neutrally.

You don’t need to agree. You don’t need to validate. Just accept the information as information and thank the individual for bringing it to your attention.

You:

• appreciate “The information that they have provided.”
• will “Take what they have told you into consideration.”
• say “Thank you.”

3. Think Neutrally.

You are a detective. You’re an objective third party just finding the facts. It is important for you to remain neutral. Reserve judgment. Don’t create fiction.

Use:

• Neutral words.
• Neutral expression.
• Neutral energy.

Be Sherlock Holmes. (Or Deputy Chief Brenda Leigh Johnson from The Closer.)

4. Repeat.

Seek out others who may have been involved in the incident. Listen to them. Repeat these first four steps until you can look at the incident from a broad perspective.

5. Conclude.

After you have investigated the incident fully, decide if any action is needed. Only then can you take informed action.

Investigating incidents with integrity will make you a more effective physician manager. You will be fair. You will be considerate. You will be credible.

Things You Can Do Now:

Read about how I missed a large tumor while seeing a patient; it’s the same kind of error. It’s a result of anchoring bias and it occurs both clinically and administratively.

Read about the three major cognitive errors that physicians make at KevinMD by Drs. Groopman and Hartzband.

Practice validating complaints without agreeing with them. You can say that you understand what someone experiences without agreeing with specific perceptions of that experience. This will allow you to investigate without being anchored to any specific response.

There are moments when I am a great physician for my patients. We laugh. We connect. We work together through health issues. We get to the answers.

During these moments I adroitly pivot projected worries, fears, and helplessness towards empowerment, positivity and purpose. I inspire.

There are days when I do not connect with my patients. I evoke subtle anger, and worries, and fear. I am disconnected. Sometimes I am aware of this. Often I am not.

And life goes on.

Being Better

I have a sense that I can be a better physician. I want to be the best.

I live with the idea that I can learn the skills to take the most difficult patient with the most challenging disease and help them. I can improve their sense of themselves and their perspectives of the world. And I can do this in a few minutes.

I don’t think this is a pipe dream. I know exceptional individuals who foster their abilities to connect and inspire. They are the healers, the helpers and the leaders whom I look up to.

I want to be like them.

It Takes Practice

My wife is a surgeon. We met as medical school classmates.

She does advanced laparoscopy. She uses small cameras and long precision instruments to operate through small holes in the patient’s abdomen. She performs surgery while watching a video monitor. And she records her procedure.

At the end of the week, she sets aside time to think about how she performs surgery. To think about how to be better. She watches the videos.

She sees wasted moves. She sees pauses. She sees crossing of instruments. And she works to eliminate them one by one.

Each week, the prior week’s mistakes go away, and new opportunities to improve surface. And each week she is a better surgeon.

How To Improve?

My satisfaction scores arrive. Good, but not great.

I’ve been to lectures about using “key words at key times”. I smile and shake the hands of everyone. I tell patients that “we are going to take excellent care of you”. Yet my scores show that this may not always be the case.

There is something about what I am doing. Something about what I am not doing.

I think of my wife watching her surgical videos. Where are my wasted moves? Where am I crossing my instruments?

I don’t know.

Expanding

I’m talking to one of my clients. She is a physician leader at a large academic medical center. I am her executive coach.

She believes that few individuals can sustain their best performance on their own. She has come to coaching because she wants to be better.

Each week we talk about her challenges. She enters the session wondering about her approach to a contract, or thinking about how to manage a particularly difficult colleague, or trying to figure out what to do in her career. As we finish each call, she has processed her possibilities. She has developed her future actions.

Coaching provides her an outside set of eyes. Someone who can help her see through her blind spots. Someone who can help her edit her actions, her thoughts and her responses to create a more powerful narrative to what she does, to who she is.

She could talk to friends, or co-workers, or her family, but they have connected and emotional agendas. They respond as friends, or co-workers, or family. The coach has none of these agendas. Her agenda is the coach’s agenda. Her thoughts, her relationships, her career are all safe in this setting to explore and to improve.

And she does.

Coaching the Coach

“You need to interrupt him.” My coach tells me as we listen to a recording of a coaching session I had with one of my clients. The irony is that as an emergency physician, my interrupting skills are definitely one of my more honed skills.

I’d been having difficulty getting this physician client to transition out of talk of a recurrent problem. So the next session it comes up again, I quickly interrupt.

“Yes, yes.” and I repeated back his problem talk. “And what do you want to do now?”

There was a long pause. And then this physician formulated the future. The problem now in the past.

And I had learned, through coaching, how to be a better coach.

Lifelong Learning

Atul Gawande, a surgeon and journalist, wrote an excellent article about coaching in medicine. He points out that professional athletes, opera singers, and Fortune 500 CEOs at the top of their game have coaches. They believe that you never get good enough. There is no graduation. You are always a student. You can always use guidance to help you reach new goals.

The practice of medicine is a lifelong learning process. A lifelong of learning about the way we think and do. We are not born from residency with the innate knowledge to accomplish all of our possibilities. We are born into a field of opportunities with tools for professional and personal growth.

We are being measured. We are challenged to measure ourselves and our self. To strive to improve our abilities to connect and positively impact patients. To practice to be better leaders in healthcare and in society. To be better at the technical details of our art.

The opportunities for the coaching model in medicine are vast. They are available at the bedside, on the phone, over the network, in groups, through simulation, from recordings, etc. They will be powerful.

It’s time we fully embrace the coaching model in medicine. It will make us better physicians.

Things You Can Do Now:

Read Atul Gawande’s article about coaching a surgeon or watch his presentation at The New Yorker Festival. He talks of his experience of being mentored and coached. He explores the use of coaching in other fields.

Attend the Institute of Coaching’s Coaching in Leadership and Healthcare conference at Harvard on October 21 and 22. I am a founding member and find their evidence-based approach to coaching science to be refreshing.

I have a graduate certificate in executive coaching. I am very interested in hearing your ideas about coaching in medicine or talk to you about how to train to be a coach. You can read about my physician coaching practice at Big Needle.

Photo of Coach Wooden and Kareem found at Project Be Bold

You own a physician group.

The line in your waiting room goes out the door. Appointments are delayed. Reimbursement is decreasing. Regulations are increasing.

You’re having a hard time making enough money to maintain business operations.

People are mad.

What do you do?

Your Business Is A Factory

Think of your healthcare business as a factory. You operate an assembly line.

Your business takes in patients with healthcare needs. It outputs patients who have received comfort, care and answers.

There are three operational levers that you can adjust in your healthcare factory to create profit. However, beware. Pulling these levers can create profit, but they can also create loss. You want to be mindful about what you are doing.

The 3 Levers of Healthcare Profit:

1. Operational expenses are your costs. They are the paychecks you pay employees. The supplies you purchase. The building where you do business.

2. Inventory is the number of patients in your system at any time. The patients with appointments, in your waiting room, and in your exam rooms.

3. Throughput is the number of patients for whom your office can complete care during a period time. The number of patients who present with healthcare needs and leave having received comfort, care and answers.

You want to:

1. Decrease operational expenses. The less your costs relative to your revenue, the higher your profit.

2. Decrease inventory. The more patients waiting for an appointment to see you, sitting at registration, or staring at the walls of your exam room, the higher your inventory. The higher your inventory, the more employees, the bigger the office, and more supplies you need. The higher your expenses.

3. Increase throughput. You get paid for throughput. The more patients who leave having received comfort, care and answers, the more your business makes.

You want to spend less, use less resources, and see more patients. Sounds easy.

The Amateur Move

The first instinct of any business in a challenging environment is to cut operational expenses. This makes sense. Reduce the costs of business to preserve cash.

You decrease the use and purchase of supplies. You reduce or freeze the hiring of staff. You’re frugal.

But what happens to inventory and throughput? What happens if you cut expenses and it increases the patient’s length of stay and decreases the number of patients that you can see?

You make less. Things are worse. An amateur move. But so common.

Reduce staff and increase waits. Increase the menial workload of your highest paid physicians and nurses and reduce throughput.

Be careful. Each lever you pull can effect the others. It is good to reduce expenses, but not if it increases inventory and decreases throughput. Not if it decreases revenue and profit.

The Primary Goal of Business

The primary goal of your healthcare business is to make money.

Yes. Your mission may be to palliate and cure. You may want to promote a healthier lifestyle. However, the primary goal of any business is to make money.

Money is the fuel for business. Without money your business ceases to operate. Your mission is not fulfilled.

You are paid to see patients. You are paid for throughput.

Figure out the barriers to throughput. Pull that lever. How can you most efficiently address the unmet needs of your patient? How can you most rapidly get them through your healthcare factory?

Putting It Together

To improve the profit of your business you have three levers to pull. You should never just pull a lever. Each one (operational expense, inventory, and throughput) can effect the other. Think and plan accordingly from a global view of these effects.

Throughput pays your bills. Your mission is reflected in throughput. Decrease operational expenses and inventory only in the light of their effects on throughput.

Things you can do now:

Write out the steps of each process in your office. Figure out what resources are needed at each step. Time them. Figure out the key steps that create the longest waits and improve them.

Read The Goal: A Process of Ongoing Improvement by Eliyahu Goldratt. It’s a very accessible and fast read about this topic. Or you can read my kindle highlights.

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Photo by Mait Jüriado at Flickr

Are you running the meeting?

Do you have the ear of the meeting’s Chair?

Or do you want to just blend in?

Where you sit in a meeting directly influences your effectiveness.

1. The Power Position

The power position is at the head of the table. Everyone in the meeting can see you. From this seat you can best facilitate the flow of the meeting.

Sitting in the power position doesn’t mean you have the biggest ego. As Chair, you need to keep the agenda moving, keep people on task and get to decision.

The meeting gets sloppy when there is no clear Chair. Whether you use this spot to wield personal power, or to encourage the social good is up to you. However, if you choose to sit in a weaker position at the table your ability to be an effective Chair has decreased.

2. The Other End

The seat immediately opposite the Chair is the second power position. This seat tends to be reserved for the guest. It is visible to all and a good location for people who need to pop into the meeting to present specific items on the agenda.

This end seat can be a powerful spot to voice disagreement with the Chair. You sit here and you sit opposite the leader.

The smart leader may want to minimize divisiveness and have no seat at the opposite end of the table. Put up a screen for slides or a whiteboard to prevent individuals from sitting there. Or create a different table configuration for the meeting.

3. The Flanking Position

The individuals who sit next to the Chair have the ear of the Chair. When you sit in this position you can influence the flow of the meeting by assisting the Chair. You can draw attention towards or away from topics. You can prompt a speeding up or slowing down of the agenda.

Classically the seat to the right of the Chair is the spot for the second in command. The left seat is the spot for the up-and-comer.

4. The Middle Few

The individuals who sit in the middle are out of sight to many at the table. They are being talked over and around. Only the heads of the table can see everyone.

You may want to sit in the middle next to individuals with opposing view points to soften or mitigate their opposition. Sit closer to the Chair and your opposition has to talk over or through you.

The middle of the table is also good place to sit if you don’t want to be heard. Sit here if you are unfamiliar with the group and you’d like to quietly size up the situation. This is the seat if you want to be forgotten or overlooked.

Circular Tables

These are the best tables for collaboration. However, the bigger the circle, the less effective the collaboration becomes.

It’s best to sit closest to the facilitator to wield influence. Sit farther away and off to the side to have less influence.

No end chairs.

Sometimes there are no seats at the end of the table. The power position in this setting is the middle of the table. It has the best view of the most individuals. The weakest position is at the end of the table on the same side as the Chair.

Most meetings are a bit like musical chairs. Individuals come in and sit in the closest chair. They may sit closest to the food or the door. They may sit next to friends or away from others.

Think about how the choice of where to sit effects the flow of the meeting. Having this knowledge will make you more effective.

Imagine how effective you would be if you tried to lead a meeting from one of the orange chairs.

We are superheroes. Each of us with our own super power.

The power to diagnose. The power to heal. The power to palliate.

We roam the corridors of healthcare. We stomp out disease.

But we face an organized and powerful foe, the Legion of Doom. Its members have united and they threaten our existence.

High cost, limited resources, and unproven quality. Each is a member of the Legion of Doom. They will defeat us if we stand alone.

High Cost.

We operate our healthcare business with a transactional model. Each practitioner, each visit and each treatment is a trip to the cash register. We make money as we do more. The more we do, the more we cost.

Limited Resources.

Employers and individuals see their profits erode as healthcare expenditures rise. They find it hard to compete in a healthcare economy without a budget.

They face difficult questions. Do they relocate to affordable care? Do they layoff 200 employees to maintain the status quo? Who can they partner with to compete?

Quality.

You are being challenged. Prove that your care improves the life of your patient. At what cost?

High quality at a higher cost is no longer an option. Quality now has a budget and it must be engineered. You are pressed to identify standards of care that create reproducible effectiveness. For each patient. For your population of patients.

Money has a choice.

We watch the government. We talk of the Affordable Care Act and accountable care organizations. We debate constitutionality, bureaucracy, and politics. However, we may fail to see the bigger picture of the market.

Employers and individuals seek a system of high quality care at an affordable cost. They may need to leave you and your community to find it. Their lives depend on it.

The Legion of Doom will find them. The Legion of Doom will find you.

The Justice League of Medicine

Take a look around your practice. Your executive team. Your board of directors.

Are you a group of individuals sitting around a table representing individual interests? Or are you a cohesive group working together to respond to the needs of the market?

The Legion of Doom does not care about your individual physician, your individual group, or your individual hospital. In isolation you are weak. You will be picked off.

Your value to the market will come from your ability to understand and serve the needs of the whole. This needs to lead individual short-term interests. Yet, it will serve your long-term interests.

You are superheroes. It’s time to align your powers and work together. You must create the Justice League of Medicine. You must fight The Legion of Doom together. Or you will be defeated.

Photo: Cover to Justice League of America #1. Art by Mike Sekowsky.
http://en.wikipedia.org/wiki/File:JLofA-1.jpg