What happened to medicine? Regulatory requirements and increasing administrative burdens are often blamed for generating meaningless extraneous work aptly deemed “stupid stuff.”¹ While our professional organizations work to advocate for those of us in the trenches, how can we work within the current system to recapture joy in work? One approach is to improve clinic efficiency. Principles include: (1) elimination (identify and get rid of “stupid stuff”), (2) delegation (each team member should function at the top of their license), (3) automation of repeatable work, and (4) don’t reinvent the wheel. The question, of course, is how?

Where to Start: Growth Mindset and Cognitive Hacks

Surgeons are particularly skilled at task completion. For many of us, this morphs into a status symbol where “busy” becomes a proxy for “hard-working,” and busyness is socially lauded.² Being busy, task-oriented, and deferent to tradition makes us particularly vulnerable to the status quo bias, or a preference for doing things the way they have always been done.

First, let us recognize that nothing changes if nothing changes. We need to challenge our behavioral inertia. Better yet, mimic colleagues who have already discovered a better way. For the efficiency superstars among us, publish your successes!³ Secondly, we must admit that cognitive energy is a finite resource. Inundation with low-level tasks and questions leads to decision fatigue, a well-documented phenomenon.⁴ Lastly, the myth of multitasking has long been scientifically busted. When we believe we are multitasking, our brains are in fact rapidly task switching. Unfortunately there is a cost for every switch in attention, which makes multitasking cognitively inefficient.⁵ Monotasking, or task-batching (performing cognitively similar tasks together), is the ideal. Examples include clustering visit types (eg “vasectomy Fridays”) and avoiding interruptions such as email and phone notifications.

Harness the Electronic Medical Record

The electronic medical record (EMR) is a key driver of increased physician administrative burden and professional dissatisfaction.⁶ Optimizing one’s EMR is a mundane but important task for improving clinical efficiency. Quick wins include:

• Utilizing favorites or preference lists, which are shortcuts for common orders.
• Creating order sets. Outpatient order sets are less commonly utilized than inpatient order sets, but are high yield. These bundle common diagnosis codes, orders, patient handouts, follow-up requests, and billing codes in a single easy-to-access screen which mimics the clinical workflow. With just a few clicks, all charting is done save for the note.

To learn more EMR tips (which are often EMR specific), seek and take advantage of educational modules, online shared resources, and personalized EMR training. Alternatively, identify an EMR “champion” within your practice who can do this legwork for you. Collaborate with your existing institutional support—clinical informaticists, your chief medical informatics officer, and any EMR-related committees so you can tackle problems together.

Is this all really worth it? The answer is an unambiguous yes. EMR training can vastly boost end user efficiency. One EMR optimization pilot program born of a wellness initiative at the University of California Davis led to a median reduction of 25 hours per month in time spent charting after hours.⁷

Efficient Documentation

Clinical documentation represents the most time-consuming administrative task performed by physicians.⁸ Moreover, note quality has deteriorated over time leading to increased time spent reviewing the chart. Developing well-designed, highly usable note templates is foundational to efficient documentation and minimizing chart review. Fortunately, the 2021 evaluation and management guidelines from the Centers for Medicare and Medicaid Services freed physicians to document meaningfully and concisely. Quick wins include:

• Formatting new, return, and procedure templates. Important and nonstandard information should be emphasized, eg, bolded. To ensure accuracy, avoid creating templates that default to normal findings and using copy/paste functionality. Plans should be easily located.
• Voice recognition software. This allows physicians to dictate portions of the note and is often faster than typing free text. Such software may also offer the ability to create note templates which are portable between clinics and different EMR systems, as well programmable microphones that accept voice commands.

Practice Management: Standardization, Delegation, Resource Management, and Team-building

Practice standardization is key to effective delegation, decreasing decision fatigue, and increasing quality of care. Some tenets of practice management that lead to efficiency are as follows:

• Shared documentation templates: Standardizing note templates within a practice facilitates documentation review not just for you, but for your entire team.
• Create robust protocols: Standardized, protocol-driven decision trees agreed upon by the group practice improve efficiency by automating low-level decision-making and eliminating questions surrounding oft-repeated tasks. Examples include refills, clinical care pathways, and common results follow-up. Reaching consensus within a practice can be a challenge at first. Urological conditions with clear guideline-based care recommendations are a good place to start.
• Inbox management: Ideally, physicians are not first-line responders to the unfiltered inbox. The American Medical Association Steps Forward Curriculum has produced several tool kits focused on inbox management, including suggested delegation trees. Additional tips include scheduling protocols that ensure lab/imaging results are available for review at the time of the visit and setting boundaries around patient portal messages including limited message length.
• Resource optimization: A perfectly efficient practice has no idle time and no wasted resources. This requires an in-depth and practice-specific assessment of resources (rooms, equipment, personnel, time). The rate-limiting resource should be the focus. For instance, batching office procedures is an excellent efficiency strategy; however, in an office with limited procedure rooms, alternating procedures with consultations to allow time for room turnover is the better strategy. Hiring a practice management consultant can be a wise investment.
• Team-building and organizational culture: Perhaps most importantly, a productive organizational culture begets efficiency by bringing out the best in your team and decreasing turnover. Team huddles, clear roles, and an open-door communication policy can inspire autonomy, offloading reliance on physicians. Workflows for staff should also focus on efficiency and meaningful work. Medical assistants, for instance, may be afforded dedicated time for indirect care to avoid interruption and multitasking.

Leveraging Technology, Current and Future

Urologists have long been on the forefront of surgical technological advancements, and increasingly technology is finding its way into our outpatient workflows. Examples of technological advancements in the clinic include:

• Creation of high-quality patient information including personal websites and custom videos for patients to access prior to their visit.
• On the administrative side, various software programs exist to automate clerical tasks including the clinic check-in process, appointment reminders, and patients surveys which get automatically uploaded to their medical record.
• For those who delegate documentation to scribes, off-site/virtual scribes became increasingly popular during the pandemic, and artificial intelligence scribes that generate documentation and orders via ambient listening technology are just around the corner.

The golden olden days of medicine are gone; however, with creative problem-solving, resource-sharing, and thinking big, our best days may still lie ahead. Stay tuned!