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Embracing change

Strategies to help dermatologists adapt – and be happy about it

Dermatology World abstract illustration of faces

Embracing change

Strategies to help dermatologists adapt – and be happy about it

Dermatology World abstract illustration of faces

By Ruth Carol, contributing writer

It seems as if a day doesn’t go by without changes to regulatory requirements, delivery systems, or payment mechanisms, all of which impact how dermatologists practice or would like to practice. These changes can be perceived as interfering and overburdening, but they can also be seen as opportunities worth embracing.

Engagement strategies such as cognitive restructuring, problem solving, social support, and expression of emotion can help dermatologists cope with change, learn from it, and move forward in a positive way. These strategies develop resilience, enabling people to respond to stress in a healthy way so that they achieve their goals at minimal psychological and physical costs, noted Suzanne M. Olbricht, MD, AAD president. Resilient individuals bounce back with increased strength because they use their energy in a way that produces more energy instead of draining or depleting it, she added. 

Reframing change

Dr. Olbricht views cognitive restructuring, which involves reframing changes in a positive light, as the most important of the aforementioned engagement strategies. Cognitive restructuring requires accepting that change happens. Change is a pervasive part of life; there is no way to avoid it. “Once we accept that change happens,” she said, “we learn to expect it as the natural course of events. The change is the same; it’s just how we think about it.” Turning that neutral position of “change happens” into a positive one requires considering that change is often good and then looking for the parts of change that are enjoyable. Ask yourself, how can these changes benefit my patients? My practice? Me?

Some physicians, however, struggle with the notion that change is inevitable and it’s best to embrace it, according to Steven K. Shama, MD, MPH, who was in private practice for more than 30 years in Brookline, Massachusetts, before retiring in 2010. That’s because most physicians, being conscientious people, like to have as much predictability in their life as possible, especially as it relates to diagnosing and treating patients. This notion ties into the loss of control that physicians across the specialties are feeling. “We think we know the best way to treat our patients,” Dr. Shama said. “And we don’t like people telling us what the best care is, especially when they put financial benefits ahead of patient benefits.” But physicians cannot insulate themselves from what happens in the rest of the world (i.e., the government, pharmaceutical industry, and insurance companies) and they can’t totally control it, either, he explained.

Although physicians can’t prevent unwelcome change from creeping into their world, they can alter how they perceive it. Dr. Shama views change as a message that is always positive. “This change being asked of you is a message to make you even better than you currently are in this world,” he said. Change is an opportunity to learn, be creative, adapt, and improve.

Finding the positive

Finding the positive can help dermatologists embrace change.

As an example, many physicians complain about the electronic health record (EHR), but as William M. Gould, MD, who is in private practice in Menlo Park, California, points out, his records are now more readable and complete than when he was just taking notes. It’s true that he is not happy about the extra time it takes to input his notes. “But I’m not going to let that get in my way of enjoying my work and seeing patients,” Dr. Gould said. To ensure that the EHR doesn’t interfere with him connecting with patients during office visits, he has chosen not to bring the laptop in the room with him. Instead, he takes notes on a piece of paper and puts them into the EHR after the appointment.

Another option to solve the problem that EHRs present is to use scribes to input the data, Dr. Shama said. It’s not the EHR that is the problem; it’s inputting the data. The EHR makes clear, concise patient information instantaneously available to other clinicians. Data in an EHR also help researchers of a particular disease to determine how it is being treated, the number of visits that are necessary, etc. These are benefits for both patients and physicians alike.

The federal government’s requirement to report quality measures using the Merit-based Incentive Payment System (MIPS) pays dermatologists more money if they, for example, follow-up with patients with melanoma and biopsy results, or track basal cell carcinomas. “These are things dermatologists should be doing anyway,” he said. “Yet because it’s imposed on us, we think it’s wrong.” MIPS offers a better system to recall these patients to ensure they don’t fall through the cracks. “All of these things take effort, but who said taking care of people would be effortless?” Dr. Shama asked.

The need to report quality measures is not going away, Dr. Olbricht added. But dermatologists can gain some control over the process by reading the quality literature and contributing to the discussion either in print or through committee work. Consider joining the AAD’s Patient Safety Task Force or working with your state society to develop measures that are important for your office, she suggested.

The same holds true for quality improvement (QI) projects. For many physicians, engaging in QI projects doesn’t seem to translate into better care, Dr. Olbricht said, adding, “It feels more like a box that has to be checked.” But that’s because many physicians have never done a QI project, so they don’t feel competent doing it. “By working with our colleagues, we can develop QI projects that are relevant and effective for our practice settings, which in turn promotes relevant and positive change,” she said.

One of the biggest frustrations for physicians is that their “prescription pad is only a suggestion pad,” Dr. Olbricht noted. Consider joining professional associations to engage in advocacy activities to work with pharmaceutical or insurance companies. “Trying to work through barriers can help you feel better because you’re putting energy into solving the problem,” she said. “Maybe something positive happens for a larger group of patients based on your efforts. If not, at least you’ll be able to help your patients navigate the system better.”

Preparing for and implementing change

Changes in medicine happen quickly and are often dictated by external sources.

But sometimes you may want to make small tweaks internally to improve patient flow or even need to make a staffing adjustment because someone called in sick. How can you get everyone on board without these changes (large or small) becoming disruptive? According to Felisa Lewis, MD, MBA, former chief of dermatology at Fort Belvoir Community Hospital in Virginia, the key is to implement a culture that is patient-focused and emphasizes communication, teamwork, and flexibility.

Establishing this culture should focus on small daily efforts with large impact. A simple way of getting the staff on the same page is instituting a short daily huddle of the staff before the day starts. Gathering everyone together allows people to greet and get to know each other, allows short-notice changes to be communicated and adjustments made, provides situational awareness of the clinic flow, and reinforces the group as a clinic team (even if people are not working together per se). This 5-minute huddle should set the tone for the day.

The ideal person to run the huddle is the person who oversees the daily flow of the clinic. To maximize the benefit of the huddle, everyone from the reception desk staff to the physicians and other providers must be present. For efficiency, it helps to have a routine agenda of reviewing clinic schedules and assignments. If there are special patient considerations (e.g., specific instruments or medication), this is a good time to communicate those needs. Cross-leveling or staff coverage adjustments can be made and communicated to everyone. Finally, general announcements pertinent to everyone (e.g., reminders to put in timecards, clinic supply shortages/updates) can be made. If necessary, smaller team huddles (a physician and assigned medical assistants [MAs]) take place after the group huddle. 

The clinic manager and/or physician should be alert for digressions or issues that come up during the huddle that may warrant further discussion or only concern a few people. The huddle is not the appropriate place to hash these issues out. Instead, they should be noted so that a dedicated time like a clinic meeting can be scheduled to discuss them. 

Over time, these short daily interactions can be a conduit to implementing changes that require more effort from your staff. However, larger process changes such as the addition of a mid-level provider or a new business process don’t just happen by announcing it in a huddle — they must be led. “As physicians, we may not necessarily think of ourselves as leaders, especially if we are not the owner of the practice or in charge of the clinic,” noted Dr. Lewis. “However, by virtue of our expertise and experience, other staff will naturally look to us for guidance or model our behavior.” Drawing upon her MBA education and military leadership experience, Dr. Lewis advocates physician-led change through a more thoughtful process that can be broken down into three phases: preparation, implementation, and consolidation. Reinforcing those tenets of communication, teamwork, and flexibility will be invaluable during the change process. 

embracing-change-icon2.pngThe preparation stage is the most crucial. The whole process must be thought through from the rationale for implementing it to the consequences. When introducing the change, the leader must provide the vision and direction. Especially with externally forced changes, the focus is on the solution, i.e., the end state that must happen. What is left unstated is the purpose for the change. “As a leader, it is up to the physician to fill in the gaps to communicate the ‘why’ to the staff in a meaningful and personal way,” Dr. Lewis stressed. “Resistance to change often stems from not understanding the necessity for change.” Thus, providing a vision requires defining the problem as it relates to your clinic. The clinic’s mission statement can help put the change in context by explaining how it will support the mission, she said. More importantly, a sense of urgency (“why now?”) must be conveyed to make the case for why the status quo isn’t sufficient. For example, if the clinic doesn’t incorporate quality measures, you will have to pay a penalty to the government. As a result, you can’t afford to hire additional staff or may have to let someone go.

embracing-change-icon3.pngThe leader needs an administrative team to assist in planning, disseminating, and supervising the change. Here, the 20/60/20 rule is a good one to keep in mind. Dr. Lewis explained that this is a general guideline for the percentage of supporters (20%), fence-sitters (60%), and naysayers (20%) in an organization when change is introduced. In a clinic, supporters are often those with greater authority or responsibility such as the office manager and the head nurse. It may be equally obvious who the naysayers are. For the rest, it is important to understand the office politics, specifically who the key influencers are and where they stand. The daily huddles can help inform your understanding of who these influencers are, because they may not be in key positions. For example, it could be an MA who has been working at the clinic for a long time and trains new hires. Getting that influencer on the team, perhaps as the representative for the frontline support staff, can be helpful. That person can also serve as the leader’s eyes and ears, and be able to provide valuable insight. As the change effort goes on, the fence-sitters will be swayed to one side or the other (supporters or naysayers) by the group that has greater influence. 

embracing-change-icon4.pngDuring the implementation phase, communication is critical. The communication to the staff should include the rationale and the briefing of the entire process, even if it doesn’t affect them individually. From an internal teamwork perspective, the change may affect individuals disproportionally but there may be opportunities for ancillary staff to assist if they know the process or are cross-trained. Particularly when the process involves patients, the external message to the patient must be consistent and conveyed in a patient-focused manner. One such change may to keep credit cards on file. On one hand, the staff should understand that the practice is losing money when patients get cosmetic procedures but leave without paying. But for patients who inquire about cosmetic procedures, it is more important that the MA inform them that the credit card will be charged when they check out as a convenience to them (as opposed to a surprise bill in the mail). In other instances, patients may not complain about a policy change to the physician, but they may do so to an MA. “You don’t want the MA telling the patient that the policy doesn’t make sense,” Dr. Lewis said. A scripted message for the staff to memorize may be helpful when changes involving patients are first made.

embracing-change-icon5.pngWhen planning and implementing change, it is important to empower staff, examine process flow, and reinforce teamwork such that the responsibility doesn’t fall on just one person, Dr. Lewis said. For example, if the physician is being asked to see more patients in a day, support staff may require additional training to assume tasks such as entering prescriptions for the physician to review and sign. To help the physician stay on schedule, when the MA rooms a patient who rattles off multiple problems, the MA should be empowered to educate the patient on the time limits of the visit and facilitate scheduling a follow-up visit to address concerns not covered. More support staff may be necessary to assist the physician with documentation in the EMR, patient education, etc. Once the physician has completed the examination, made a diagnosis, and determined a treatment plan, he/she can move onto the next patient, while the assistant completes the visit. The support staff benefits by taking a more active role in caring for the patient, which conveys to the staff and the patient that it is the team, not just the physician, who is taking responsibility for each patient. “It’s important that staff, individually and as a team, feel ownership in patient care, but they need to be appropriately trained and empowered to provide that support,” she said. 

embracing-change-icon6.pngEstablishing realistic goals that can be achieved early in the process, or “quick wins,” is important to keep the team motivated and inspired to keep up the effort.Acknowledge and show appreciation for the hard work that has been put in. For example, if the goal is to decrease the incidence of superficial wound infections, then after one month without wound infections, Dr. Lewis suggests a small gesture such as bringing in breakfast for the staff. Recognizing and/or rewarding early adopters, both individually and as teams, can help spread the change by providing role models.

embracing-change-icon7.pngThe final step — consolidating change — is the most difficult. because it requires 60 to 70 percent of staff acceptance (of that initial 20/60/20 mix) to have a cultural shift, Dr. Lewis explained. You will know when this has occurred when new hires are indoctrinated to the new way to doing business from the start. Consolidation may also mean some long-standing employees leave because they are unable to adjust. But Dr. Lewis points out that personnel transitions should be expected, but not dreaded. 


SEEKING SOCIAL SUPPORT

Another strategy is to actively seek others who have gone through the same change, Dr. Olbricht said. “Not just to get information about how they managed the problem, but to gather social and emotional support,” she said. “Or even to whine a little bit before we move on.”

One way to find that social support is by attending professional society meetings. “I make a commitment to attend a couple of professional meetings every year, and I always come back inspired and feeling good about my specialty,” she noted. Studies have shown that physicians who pursue continuing professional development, particularly by attending continuing medical education meetings, have higher job satisfaction than those who don’t, Dr. Olbricht pointed out.

Support systems — whether they are colleagues, good friends, or family members — are essential. “Trying to handle everything on your own is very difficult,” Dr. Gould said. “It’s healthy to get things off your chest.” He has two partners with whom he discusses how to cope with the many changes facing physicians these days. They do a lot of problem solving, such as figuring out how to train staff to help with some of the tasks that take the dermatologists away from their clinical work.

embracing-change-quote.pngSupport from friends and family members can help alleviate some of the stress that physicians experience due to change, as well. But as a general rule, conscientious people such as physicians do not do well with expressing emotions as it can be perceived as a sign of weakness, much like how physicians show up to work even when they are sick, Dr. Shama said. Conscientious people often have a Superman or Superwoman complex. The world needs them and they will not disappoint, even if it means self-destructing to help others, he said.

That culture has to shift to become more supportive of physician colleagues, Dr. Shama maintains. “When we hear colleagues are suffering, whether they’re addicted to drugs or alcohol, which can be negative responses to change, we need to help them rather than have the tendency to shun them.” Something as simple as bringing back the doctors’ dining room, where doctors gathered and talked with each other, would help bolster their professional support system. Dr. Shama remembers the doctors’ dining room where the chief of medicine was just known as Bob. Additionally, when colleagues do something wonderful, they should be praised. Colleagues should be acknowledged for the good that they have done not just when they are sick or near death, but rather while they are alive. “It’s not part of our persona to praise colleagues publicly, but it should be,” he said. “Change is actually teaching us that there’s more that we can do to honor our patients, ourselves, and our systems. That’s the good part of change.”

PRACTICING MINDFULNESS

When it comes to honoring the patient-physician relationship, adopting a mindfulness approach to practicing medicine helps facilitate meaningful relationships with patients, Dr. Olbricht said. She cited a Canadian study that correlates appreciating the value of patient relationships with greater job satisfaction among physicians. “As dermatologists, we have this opportunity every day with each patient that we see,” she said.

Mindfulness is a purposeful activity that involves being acutely aware of what is happening presently and not about the last patient you saw or the phone calls you need to make later in the day, Dr. Olbricht explained. It involves being aware of your thoughts and experiences without judging them, the latter of which engages you in an emotional way. The medical literature supports the value of mindfulness practices, citing such benefits as reduced stress and improved physical and mental health, she said.

Mindfulness practices include medication, yoga, and tai chi, but when Dr. Olbricht is having a busy day with many distractions, she does something much simpler. Just before Dr. Olbricht enters the room to see a patient, she pauses, puts her hand on the doorknob, and leaves it there for a moment. “I feel that the doorknob is round and cold, and I actively engage in opening the door. I take a deep breath. Then I open the door. That resets my mind so I am present when I walk in,” she said.

“Whatever your routine is for seeing patients, it’s important to create an office environment that’s not chaotic,” Dr. Olbricht said. “So when you see the patient, you can be present for that period of time. Meaningful relationships come when you’re present with another person.” She is also grateful for being part of such a wonderful profession. Dr. Olbricht starts every day with the following thought: Today, I will see patients who need me and I’ll be able to help them with their quality of life.

His interaction with patients is what Dr. Gould enjoys the most about being a dermatologist. “Every time you walk into a room to see a patient, it’s a little bit of an adventure. In the process of practicing medicine, the patient tells you all kinds of interesting things. That’s a real privilege.”

Dr. Gould focuses on the positive aspects of his work: continued learning and helping others. “Even when treating common, mundane skin conditions, it is satisfying because it satisfies my curiosity about the natural world and fulfills my desire to help others, which is why many of us became physicians,” he said. Using a mechanical or routinized approach to patient care can foster boredom, depression, and burnout. “You really have to look forward to doing your work every day,” Dr. Gould noted. “That’s what keeps me going at the age of 84.”