Inbox management and other lifestyle questions

[MifflinDunder]

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Agree. There’s a huge difference in activation energy between texting your doctor (10 seconds) and having to call deal with a secretary that routes you to a pager etc (3-5 min endeavor).

Every new patient I see in the clinic asks me if I have mychart before they leave. I also often get updates about everything happening to their lives and any symptoms they’re feeling, even if non-onc related (I had a hip repair, just wanted to let you know). The dynamics in heme-onc isn’t the same as other outpatient specialties. Add in the worst notes out of all IM specialties and this could easily be a 60 hours a week job, probably what’s reflected on these surveys.

 

[gutonc]

Every new patient I see in the clinic asks me if I have mychart before they leave. I also often get updates about everything happening to their lives and any symptoms they’re feeling, even if non-onc related (I had a hip repair, just wanted to let you know). The dynamics in heme-onc isn’t the same as other outpatient specialties. Add in the worst notes out of all IM specialties and this could easily be a 60 hours a week job, probably what’s reflected on these surveys.

If you do it wrong, sure.

1. Boundaries
2. Boundaries
3. Boundaries

Remember that the "done" button exists for a reason.

 

[ONC2023]

This conversation is reminding of all the patients I’ve seen in fellowship who come to see you at an academic cancer center once and then want to keep you updated every two weeks about what their community oncologist is doing and if you can chat about it (not as a visit, just by email/phone - yes, I’ve given people my cell and email. Never again.)

I’m exaggerating a little, but not by much.

 

[gutonc]

This conversation is reminding of all the patients I’ve seen in fellowship who come to see you at an academic cancer center once and then want to keep you updated every two weeks about what their community oncologist is doing and if you can chat about it (not as a visit, just by email/phone - yes, I’ve given people my cell and email. Never again.)

I’m exaggerating a little, but not by much.

You're not wrong, but you're also more or less illustrating my point for me. Most of the people in this thread whining about how horrible it is to deal with MyChart messages and InBasket stuff are still trainees. And the people saying "it's really not that bad in the real world" are...wait for it...out in the real world. I do know plenty of people who complain about this stuff as attendings, but they are also the people who are so disorganized and inefficient that they start their clinic day 30 minutes late and get to be an hour or more behind schedule by the end of the day. The InBasket is not the problem here.

 

[MD46]

You're not wrong, but you're also more or less illustrating my point for me. Most of the people in this thread whining about how horrible it is to deal with MyChart messages and InBasket stuff are still trainees. And the people saying "it's really not that bad in the real world" are...wait for it...out in the real world. I do know plenty of people who complain about this stuff as attendings, but they are also the people who are so disorganized and inefficient that they start their clinic day 30 minutes late and get to be an hour or more behind schedule by the end of the day. The InBasket is not the problem here.

I agree with this, in practice for more than 7 years now, in basket coverage is basically with 15 minutes of coffee in the morning before starting and subsequently 15 minutes again with coffee after being done with clinic in the afternoon. Rest the supporting staff handles unless super urgent

 

[gutonc]

I agree with this, in practice for more than 7 years now, in basket coverage is basically with 15 minutes of coffee in the morning before starting and subsequently 15 minutes again with coffee after being done with clinic in the afternoon. Rest the supporting staff handles unless super urgent

My approach is a quick review at the beginning of the day (5 min or less), then I hit up the InBasket after every 3rd or 4th patient in case there's something urgent (usually 2 min or less), again at the noon hour (maybe 10 min at this point) and another 5 min or so before I walk out the door...usually with all my charts closed and <15 min after walking out of the last patient room for the day.

 

[dozitgetchahi]

Every new patient I see in the clinic asks me if I have mychart before they leave. I also often get updates about everything happening to their lives and any symptoms they’re feeling, even if non-onc related (I had a hip repair, just wanted to let you know). The dynamics in heme-onc isn’t the same as other outpatient specialties. Add in the worst notes out of all IM specialties and this could easily be a 60 hours a week job, probably what’s reflected on these surveys.

Oh believe me, rheumatology is a contender here too.

I have several neurotic patients who regularly send 3 or 4 part MyChart messages about their random functional symptoms. I once had a crazy patient send me a lengthy, 10-15 page handwritten treatise regarding his feelings about the ACR lupus criteria (in Shakespearean style English, to boot).

 

[HaemOnculus]

If they send too many messages or call too many times they get an office visit to discuss.

 

[IM_to_ortho_hopeful]

Oh believe me, rheumatology is a contender here too.

I have several neurotic patients who regularly send 3 or 4 part MyChart messages about their random functional symptoms. I once had a crazy patient send me a lengthy, 10-15 page handwritten treatise regarding his feelings about the ACR lupus criteria (in Shakespearean style English, to boot).

Sounds like a chatGPT prompt

 

[RainerMaria]

I also have started asking them to call their PCP if they have UTI symptoms and not on cytotoxic chemo. I know we are thought of as the PCP by the patient, the surgeon, and yes even the PCP, but we’re not. Our energy is best spent focused on helping a new patient with a new diagnosis who wants our help, not trying to decide between macrobid or cipro and counseling about tendinopathy, and forgetting that this is a patient who was cured years ago.

 

[VA Hopeful Dr]

I also have started asking them to call their PCP if they have UTI symptoms and not on cytotoxic chemo. I know we are thought of as the PCP by the patient, the surgeon, and yes even the PCP, but we’re not. Our energy is best spent focused on helping a new patient with a new diagnosis who wants our help, not trying to decide between macrobid or cipro and counseling about tendinopathy, and forgetting that this is a patient who was cured years ago.

As a PCP this is how it should be unless you think it might be related to their oncology treatment. If you've got someone on Keytruda I'd prefer you lay eyes on them if its a symptom that has a decent chance of being from that.

 

[gutonc]

As a PCP this is how it should be unless you think it might be related to their oncology treatment. If you've got someone on Keytruda I'd prefer you lay eyes on them if its a symptom that has a decent chance of being from that.

If there's a chance that whatever they're complaining about is my fault, I'll at least get them in and evaluate. Even then, unless it's something like a UTI/PNA or other generally time-limited thing, I'll manage that. But if it's worsening HTN or DM related to disease or treatment, or something else the PCP is already managing, I always defer. I'm fortunate to work somewhere that I can get most people seen same week for PCP follow up too.

 

[RainerMaria]

I'm not above giving a week of abtx if I'm seeing them that day and they happen to have the symptoms when talking to them, but if it's someone I see only 1-2x/year for scans/follow-up and they write out of the blue for unrelated symptoms I think it's better they talk to PCP or urgent care. Now with telemed (if it stays covered, who the **** knows) people can get a visit within minutes and get an antibiotic. Even if they don't have a PCP often they can get on the phone with Teladoc. There's always more to do with these "telephone medicine" calls, you have to check their meds, do a med rec, review allergies, check DDIs -- and honestly we're not really doing that with quick telephone encounters in epic inbox. That it's unreimbursed work is not really so much the point, just that it's out of scope. Playing telephone medicine and activating my staff to send the UA/UCx and the mental load of following it up and writing for the meds -- it adds up if you do it for each patient.

 

[gutonc]

I'm not above giving a week of abtx if I'm seeing them that day and they happen to have the symptoms when talking to them, but if it's someone I see only 1-2x/year for scans/follow-up and they write out of the blue for unrelated symptoms I think it's better they talk to PCP or urgent care. Now with telemed (if it stays covered, who the **** knows) people can get a visit within minutes and get an antibiotic. Even if they don't have a PCP often they can get on the phone with Teladoc. There's always more to do with these "telephone medicine" calls, you have to check their meds, do a med rec, review allergies, check DDIs -- and honestly we're not really doing that with quick telephone encounters in epic inbox. That it's unreimbursed work is not really so much the point, just that it's out of scope. Playing telephone medicine and activating my staff to send the UA/UCx and the mental load of following it up and writing for the meds -- it adds up if you do it for each patient.

I'll 100% do it for someone in front of me. But you are correct that for someone you see a couple of times a year for surveillance, that's not your job. But nobody answers the phone and calls back like oncology does, so people just come to us first.

 

[bobsmith]

But nobody answers the phone and calls back like oncology does, so people just come to us first.

No good deed goes unpunished

 

[guildsman]

I'll 100% do it for someone in front of me. But you are correct that for someone you see a couple of times a year for surveillance, that's not your job. But nobody answers the phone and calls back like oncology does, so people just come to us first.

I think this is 90% of the issue. Patients realize that the cancer center always calls back, which I understand their perspective when their PCPs take 1 week to respond to a simple message or months to get a visit.

Being in medical education it also it very clear to me this issue will get worse as almost every resident and specialist at this point thinks what we do is "magic" and the words immunotherapy, targeted therapy, etc. lead to instant "talk to oncologist about this" to double check. I think this will become increasingly a major disservice to patients because diabetes is still diabetes. The issue is the level of hematology / oncology education is dismal in medical school and residency.

 

[MifflinDunder]

Another discussion on this from an attending.



Can anyone here NOT using EPIC comment on how their inbox burden is?

 

[HemeOncHopeful19]

I mean the constant stream of labs is annoying.

My triage nurse(s) are amazing though so I don't really get a lot of patient messages directed to me. I'm not even sure patients CAN directly message me in our EMR, but if they can then it must be difficult to do...

 

[gutonc]

Another discussion on this from an attending.



Can anyone here NOT using EPIC comment on how their inbox burden is?

I honestly don't understand how people let their inbaskets get out of control. As of the end of tumor board at 8 this morning (the end of my work week), I had no open charts, no unread labs, no unread patient messages, patient calls or staff messages, no unsigned orders and all referrals reviewed. It took 5 minutes to finish my 2 open charts from yesterday and another 5 minutes to deal with the rest of it.

Anyone who has so much unfinished work in their inbasket that they can't finish it in 10 weeks has a lot of other issues that need to be worked on. Epic isn't the problem. Nor is their practice.

 

[gutonc]

I honestly don't understand how people let their inbaskets get out of control. As of the end of tumor board at 8 this morning (the end of my work week), I had no open charts, no unread labs, no unread patient messages, patient calls or staff messages, no unsigned orders and all referrals reviewed. It took 5 minutes to finish my 2 open charts from yesterday and another 5 minutes to deal with the rest of it.

Anyone who has so much unfinished work in their inbasket that they can't finish it in 10 weeks has a lot of other issues that need to be worked on. Epic isn't the problem. Nor is their practice.

Yes, replying to myself here, but I've thought about this some more and have a few more comments. I stand by everything that I've already said.

First...I wonder if "Papa Heme" has to clear out his inbasket because he's quitting that job and moving somewhere else. In that case, the only thing "Big Papa" really has to do is close open charts. Everything else that he's ignored for lo these many years will get punted to some poor sucker who's been assigned the "departed providers" account.

Second...I think we're conflating a lot of different issues when we talk about "inbox management". As above, there are a lot of different categories of stuff that Epic (and I assume other EMRs) throw at you. But they can be broken down into 4 categories.

1. Open charts: This is the bare minimum amount of work expected of you as a physician. Anyone who complains about this needs to consider a new career.
2. Results review: IMO, this is second only to closing charts. If you're ordering tests, you need to review, interpret and act on them. Again, bare minimum expectation for a physician. There are lots of ways to manage this. None of them is "right" but the clearly wrong way is to ignore the results.
3. Patient communication: Calls, portal messages, communication from clinic staff about patient care, messages from other physicians, etc. 20 years ago, this would be an hour or more of phone calls and a giant pile of paper on your desk to deal with. Clearly, being able to quickly review and manage this stuff electronically instead of having to dig through papers or make/take a bunch of phone calls is a superior approach.
4. Patient management: Cosigning orders entered by your MA/RN, med refills, chemo and other treatment plans (relevant in oncology). Again, in the olden days, this would be a pile of papers on your desk that would need actual signatures. And since there weren't any built in checks on paper, you'd actually need to review them closely before signing them. EMR FTW here.

Finally, if you really can't be bothered to do your actual job, you can always just go in to the sections of your inbasket (results, staff message, patient calls, etc), select all and hit done. It's terrible patient care, but it would get the man off your back, until you failed to do your job for another few weeks and it backed up again.

 

[randomhemoncpd]

Yes, replying to myself here, but I've thought about this some more and have a few more comments. I stand by everything that I've already said.

First...I wonder if "Papa Heme" has to clear out his inbasket because he's quitting that job and moving somewhere else. In that case, the only thing "Big Papa" really has to do is close open charts. Everything else that he's ignored for lo these many years will get punted to some poor sucker who's been assigned the "departed providers" account.

Second...I think we're conflating a lot of different issues when we talk about "inbox management". As above, there are a lot of different categories of stuff that Epic (and I assume other EMRs) throw at you. But they can be broken down into 4 categories.

1. Open charts: This is the bare minimum amount of work expected of you as a physician. Anyone who complains about this needs to consider a new career.
2. Results review: IMO, this is second only to closing charts. If you're ordering tests, you need to review, interpret and act on them. Again, bare minimum expectation for a physician. There are lots of ways to manage this. None of them is "right" but the clearly wrong way is to ignore the results.
3. Patient communication: Calls, portal messages, communication from clinic staff about patient care, messages from other physicians, etc. 20 years ago, this would be an hour or more of phone calls and a giant pile of paper on your desk to deal with. Clearly, being able to quickly review and manage this stuff electronically instead of having to dig through papers or make/take a bunch of phone calls is a superior approach.
4. Patient management: Cosigning orders entered by your MA/RN, med refills, chemo and other treatment plans (relevant in oncology). Again, in the olden days, this would be a pile of papers on your desk that would need actual signatures. And since there weren't any built in checks on paper, you'd actually need to review them closely before signing them. EMR FTW here.

Finally, if you really can't be bothered to do your actual job, you can always just go in to the sections of your inbasket (results, staff message, patient calls, etc), select all and hit done. It's terrible patient care, but it would get the man off your back, until you failed to do your job for another few weeks and it backed up again.

Papa Heme is moving to Sarah Cannon Las Vegas

 

[bobsmith]

Can't clear your inbox if you're too busy tweeting about your inbox

 

[gutonc]

Papa Heme is moving to Sarah Cannon Las Vegas

So all he really needs to do is close his charts and ignore the rest. AKA, the bare minimum expected in the job.