Denise 0:07
Myth, Magic, medicine, and everything in between - two doctors talking. Hi welcome again to Myth Magic Medicine with me Denise Billen-Mejia and today's guest is Ryan Stegink. And Ryan is also a pediatrician as was our last guest. And but a little bit different take on how he's handled, making sure he has a life as well as, as a medical practice. Hi, Ryan, thank you so much for joining me.
Ryan 0:36
Thank you so much for having me. It's an honor to be here.
Denise 0:39
So tell us, where did you Where did you go to school? Did you have? How long have you been in practice?
Ryan 0:45
Yeah, so I did my general pediatrics training in the Midwest here in the US in Indiana. And I've been out of residency for it'll be seven years this year.
Denise 0:56
And did you find it was a real change between residency and this is a bit of a loaded question with you because you are a resident and all of a sudden, they were paying you a bit more serious money, you are an attending, but you stayed at the same institution, did you find that an interesting transition?
Ryan 1:13
I did. It was really helpful to be at the same clinic during residency and at least one of the two clinics they had me stationed at as a new attending, but there was some significant changes that it's hard to anticipate until you actually go through them. Because in residency, there's a structure there's a month at a time you go to do something new, there's an end in sight. There's also a protected educational time, you get to see your colleagues, many times they provide you some sort of food, it's just a different pace, as opposed to every 15 minutes -another patient, another patient. And that's assuming that 15 minutes is actually adequate for many of these things like walk through the door.
Denise 1:57
Some appointments, that would actually be generous. A lot of people complain, this is seven minute increments something just crazy.
Ryan 2:04
Yeah. And it's like the what patients come to me with that. It does sometimes. That's sometimes I think, what leads myself and others to burnout and moral injury, because it's just a weight that just seems to be pressing in.
Denise 2:24
Yeah, that's, it's nice if the patient's verbal, which isn't always the case with pediatrics. If they know why they're there. Sometimes it's just "my mum brought me so I'm here", but they're too old for the mum to be in the room. It can take a while with adolescents, there is your practice very general pediatrics, or do you lean towards adolescence? ,
Ryan 2:46
Yeah, so I take care of children from newborn all the way to 21. And so I do have one half day a week where I see just adolescents. But otherwise, it's a pretty broad range. And I enjoy the variety. And being able to see the young kids with their developmental issues, the teenagers that may or may not be there with a parent and how I counsel someone about a particular thing, whether it's mental health or something else, it all depends on that particular patient I have in front of me. So it makes it a good variety.
Denise 3:19
But it also means it's difficult to jam it into 15 minutes. And also that it's let's get straight to the meat of the conversation, documenting that conversation. How long does it actually take you to complete a chart? Let's let's give the reasonable not terribly complicated medically, but socially complications of adolescence that you want to document. So you've got some information when you sit down the next one.
Ryan 3:48
Yeah. And I think the biggest thing is just acknowledging that medical practice in general has changed. Over the last even my career, I had one rotation in medical school where I had paper charting. And yeah, that was the case for decades before mine. So it's a matter of figuring out okay, how do I either utilize templates, things that may or may not have some checkboxes in them, which can be useful in some situations, but can provide a hindrance and others, but especially for the adolescents and some of the social histories and any age patient. It's about getting things down as best you can, but doing it in a way that's succinct, because I grew up working hard and trying to do the best that I could. And in medical school, I'd take this history from this patient and I was so excited to present it to one of the third or fourth year medical students and it would take me a couple of hours to be able to say, Alright, here's my history and physical for review. And yet, it needs to be a lot more succinct and not necessarily even complete set. Which if I was telling myself this 10 years ago and medical school, I would have probably had some issue with that.
Denise 5:08
Bullet points are wonderful. So what led you to realize that you you wanted to help other people do this, you you've figured out a system that worked for you? How long did it take you to really have a system down where you could actually get home in the evenings and see your own children?
Ryan 5:27
Yeah, it honestly took me a couple of years, I went through burnout, mere eight months out of residency, because I was bringing charts home, I was doing charting in the evenings and on weekends, staying late, and doing a chart at the clinic, or at the hospital, it typically takes me a lot less time, because there's bigger screens. I'm already in the patient's chart many times because many of the rooms weren't even set up in a way that I could document and still maintain eye contact with the patient. And so it's some of those rooms weren't designed for computers. And even some of the rooms that were built after computers were a thing in medicine. They weren't necessarily arranged with the ergonomics, and rapport of the patient and physician,
Denise 6:18
I must say, as a one of the wearing my patient hat. The first time I went into doctor who was who was older than me, and clearly had been brought screaming and shouting about electronic health records. And he had his back to me the entire time. It really I mean, I understood, but it still it was was jarring. He was using a regular computer. So he had his back to me, I'm now finding most people are looking over the laptop, typing away for doctors are getting younger and sort of like police officers. But but so how long how much of your charting do you do without the patient there? Are you able to to type and look at the patient that
Ryan 7:05
I am able to type and look at the patient for the most part, if there's something that's really sensitive, I can tell that there's a lot of emotion that they're bringing to that particular concern that they brought up with me, I'll often pause and give them my full attention. But many times, because I remember growing up in first second grade doing typing class, that's something that I've been able to integrate more seamlessly. And yet, those times when I tried to turn and still maintain eye contact with the patients, I wasn't just back to them, I found that I was actually having some older compression symptoms with some numbness down my, my pinkies. And I was like that was within the first two, three years. And I was like this has to change. So I got a split keyboard that was more ergonomically accurate and just have been more mindful of that in my practice.
Denise 7:56
So you now don't ever take charts home or only occasionally?
Ryan 8:01
It's only occasionally now. Typically, I'm able to finish most of the chart while I'm in the room with the patient. And I realized some of the things that actually are seems small, but actually add up over time as if I go from the patient room, back to the work room, talk to my staff and go on to the next one. There's logging off the first computer in the room going into the work room, potentially getting interrupted for something that if I don't have any patients, that's totally fine. But maybe I'm trying to finish up this chart. So I can go on to the next one more quickly. I've actually found that charting in the room with the patient even after I've told them, and especially with working with children, they often think it's funny when I'm like, Do you want more homework? And they say no. And it's like, Well, neither do I, as a physician want extra homework. And so I will tell them, hey, my orders are already done. And the nurse or medical assistant that's working with me is getting your vaccines, stuff for the blood draw already printing your paperwork. And I'm just taking an extra minute to finish my charting. While I'm here in the room with you. Now there's times when that's not possible patients really sick the there's three children or they brought extra visitors and it's a bit chaotic, but it means that I can potentially go from one room, right to the next room. I can put in my orders a communication to my staff. And so that way, it's all wrapped up. And potentially all I have to wait for is the immunizations to be documented and I can sign the encounter. It's probably 85 to 90% and then I can catch up more quickly without having to open each one. Another thing is that really by dealing with all of that all at once, it's not adding too much extra time. Throughout the day I thought oh if I I get all my notes done, I'll be able to get home so much sooner, it's honestly pretty similar. Because ultimately the flow of the clinic while there's certain optimizations that can be made, it still takes time to get vaccines, it still takes time to room patients and do vitals. But if I'm able to take that extra minute, get it done, then I don't have to a rethink about it later in the day. And wonder was that the right year, or the left ear that had that ear?
Denise 10:30
Even worse, was this the right patient? When
Ryan 10:33
it was like I saw four patients with a rash today, which one was it, but the bigger thing for me, honestly, is the cognitive load. Because if I have to try and remember that deal with a computer deal with my own, like, I've been pouring out my emotional energy connecting with patients, caring for them. And sometimes they tell me really traumatic things. And it's hard. And if I can take care of that, be present with them, but documented sufficiently so that if, say, they end up in the emergency room tomorrow, this weekend, that a colleague could see them and provide have good continuity of care. Also, I've really tried, if I have them coming back in a month with, say, my nurse to get some more vaccines, I try and deal with it right there and say, what are they coming back for? We have standing order protocols, and I don't need to think about it again.
Denise 11:31
So obviously, you you now, teach this through a course. But let's let's not make Let's not turn this into an ad, although the information to contact Brian about his course will be in the show notes. What would you suggest people first do when they realize that they could be more efficient? What would you suggest they take a look at first.
Ryan 11:50
So honestly, I think it's the stories and the thoughts that each of us tell ourselves because sometimes there's a lot of shame around, hey, I have this many charts left, I'm this far behind this is how long it typically takes me to close my encounters. And just saying, I am still a good doctor, I'm still a good medical professional, because it's so easy to just beat yourself up that just say like, here I am. I tell my patients when I'm counseling them on unhealthy habits, can you change the past? And then they look at me? And they're like, Well, no. And then I say it's like, well, yeah, and neither can I. So let's, let's start where we are, take that next step forward. It's one of the things I love about getting to do some optimization sessions, as part of my employed role is to be able to say, Hey, let me see what you're doing. And I'll be able to say like, oh, you're wondering where this is? Or how to do this? Let's help you with that specific question you have, but then I'll maybe put something else out there to say if, in case you want to know or in case you might find this helpful in the future, like this is a little beyond where you currently are. So it's kind of assessing, hey, where am I now? And what's that next step? You don't have to think, Okay, I'm gonna get all my notes done. It may just be figuring out, Hey, can we reconfigure the rooms so that I can actually look over my laptop look more at my patient, and document something in the room, even if you start with just getting the history of present illness down in bullet point fragment format, that's sufficient.
Denise 13:33
You've not used a scribe.
Ryan 13:35
So they had piloted scribes in my system, in the ambulatory space, they've been using them in the emergency department for some time now, which is pretty amazing. But I realized that there are enough things about documenting and doing orders, and sometimes I'm going back and forth, when they tell me their meds, I'm able to have both my note and my orders up at the same time, that I haven't had the opportunity to work with a scribe. But I think in my current workflow, I'm able to keep things moving. It might require having my own laptop to do orders at the same time. So
Denise 14:18
They of course can write down what you're saying, but they don't have the authority to actually have dispensed. So. Yes, yes. Adding another layer.
Ryan 14:29
Some people ask me about the like the microphone, there's a variety of proprietary technologies for dictation. And while phone dictation was more of a thing, years ago, there they have microphones. And I've worked with someone who still uses that in a way that supports his ability to still be in medicine taking great care of patients. But the issue for me is sometimes if you're using that primarily say in a workroom, you have to typically have minimal background noise, you may have to extensively train it both in your voice. And in some of the additional special vocabulary, you may have particular colleagues, referrals. And so it hasn't been something that I've used consistently that I have had the opportunity
Denise 15:18
I like the idea of people being able to do it at the time, because it will take us back from feeling like you're doing documentation to make the bean counters happy. And instead, it's a document so that other health care providers, all of them, the doctors, the nurses, and you know, the school nurse, you can have something that's usable, and it's going to benefit the patient, which is why we all want to be there. Right? Good. So how long does it take? Do you think to change that mindset? Not just the technical stuff, but the mindset for? Or do you think they've already changed their mindset when they get you?
Ryan 15:58
I'd say it's, it's still a challenge. It takes some time, because it took me a while, I realize I'm my own first client. This took me months to figure out to say like, Okay, once I have, like what I generally want to do, being able to say, okay, my thoughts kind of create my feelings, I would think, Oh, my charting is so stressful. And yet, if I don't know that they added four extra newborns to my schedule. The next day, I'm in clinic, I'm not stressed about, Oh, am I going to be able to get to lunch? Am I going to be able to make it to dinner with my family? It's, I don't know. So I didn't have a thought that this is stressful, or I have too many patients for the timeframe that I've been given. I think even just understanding the difference between the facts, the amount of patients that I may have the amount of notes that I may have, because if I had maybe 20 notes that I was behind from the all the ones from yesterday, plus all but the five that I was able to complete in clinic today, back when I was my first year out of residency, but someone may have been drowning under 50 charts, they may have said no, that's not that much. And so drawing those distinctions, I think really opens up people to being able to say, Oh, maybe I could see this differently. And then having those intentional thoughts to get more towards where you're wanting to go.
Denise 17:28
How long do you think it takes to, to most of us works around muscle memory? How long does it take until it's, that's just that's just the way you're operating? Once you've got once you've reconfigured the templates to fit your particular practice was obviously a template, for a dermatologist doesn't work that well for a cardiologist? How, how customizable are these templates that you're suggesting people use?
Ryan 17:55
So I think it can be really customizable. It's, I don't talk about any one specific EMR. And a lot of it is figuring out what is the minimum amount of things that you typically do for a particular patient, whether it's someone coming in with a complaint of diabetes, or someone coming in that's a four year old coming in for their annual checkup, and saying, What do I need to definitely cover and having some sort of placeholder for that, whether it's some sort of block that you can click some boxes, a drop down list, and there's various things within each EMR that allow for that to flow more smoothly. And what you said earlier about it being a document to help communicate clinically, is definitely true, and why many of us really want to be doing well with our documentation. Now, there are regulatory interests, legal interests, billing interests, quality measures. And yet, when I have the opportunity to speak into this, and that's why I really, that's honestly, from my burnout, to getting some training within the EMR to then optimizing it for myself and now wanting to coach others. It's really a matter of saying how can we make the EMR flow for the physicians so that they can say, hey, I'm already counseling my patients on you should go to the dentist, you should. It's like these healthy habits around eating and exercise. And yet, they need a discrete data point in order to actually capture that, but it needs to actually be easy to do, especially if there's multiple ways that it could be done.
Denise 19:45
So, is there anything else you you have garnered since you became an attending Do you think people should not because charting isn't everything in your life, right?
Ryan 19:56
So go ahead. So it's It's really important for physicians, anyone in medicine, really anyone in life to really take a moment and step back and say, Hey, why am I here? Why am I doing this? Like to know your deep? Why, like the priorities. And so for me, it's like, saying, it's like, my family, my faith, my friends, it's like, these are all really important things to me. And that ultimately drives me. I mean, I got certified as a US Citizenship and Immigration Services, civil surgeon. And so I just like I can now sign the medical paperwork for my patients seeking adjustment of status to permanent resident. And so being passionate about global health, this is something that it's even been interesting for me to realize that it's like, I can find purpose. And again, this is why my thoughts about the situation matter, I had three hours of paperwork, and I was happy to do it. Because it was for these three kids that were then going to be able to get their green card as a result of me doing paperwork for them. Now, could there be ways that I ultimately am able to figure out that I could write their name on the top of each of 14 pages, perhaps, because that one was not part of the fillable. PDF, but it's still an opportunity to see, okay, connecting to your "why" can then take you back to say, Oh, I didn't go into medicine, just to say, I got all my charts done. I got my number of visits, per my expectations, my quality bonus. It's like, I went into medicine, because I wanted to help people. And I know I'm not alone in that. So finding what drives you what maybe did and whether there's a disconnect, and priorities changed. But that still was really helpful for me to figure out that, that was potentially holding me back. If I didn't address it.
Denise 21:53
I wonder if you as an American born here, realize how much stress you took away from those children and their parents. When you did that paperwork? Having had my status adjusted way back in the 80s.
Ryan 22:09
Yeah. And it's, it's really rewarding to see just how much they they were appreciative. And yeah, it was just really rewarding.
Denise 22:21
So where do you see your career? Do you think you're gonna stay and that part of clinical medicine at the clinic? Or do you see yourself in private practice? You enjoy the the hospital clinics setting?
Ryan 22:33
Yeah. So I have really been passionate about global health for a long time. And due to some medical complications, in my family, we haven't been able to go and then COVID happened. And so we're not really sure what the future holds any more than any of us otherwise do. But I have really been blessed to be at a clinic that has allowed me to grow professionally, I have great colleagues. And I get to speak Spanish every single day. And now during this civil surgeon work, it's at somewhere I could see myself being for quite a long time,
Denise 23:11
You can meet people from all over the world
Ryan 23:13
Absolutely, I've kept a list of the countries since residency that either my patients or their parents have been from, I think it's up to 50 different countries. So it's like the world is here.
Denise 23:30
In Indiana. I don't think of Indiana as needing particularly Spanish speaking. Obviously, the Latino population is huge. If you look for my last name, I'm married to a Dominican. But I trained in New York, that was where I used my Spanish all the time. As I moved west through Pennsylvania, I got the opportunity to use it less and less. But yeah, that's great. How come you speak Spanish? Did you learn it intentionally for this? Or did you grow up speaking Spanish?
Ryan 24:00
So I took classes probably from sixth grade on and had taken a few trips with my family and some others to Mexico doing some service work. But I actually passed out of it in college, which was actually not helpful for my development, but doing medical school in Chicago. There were enough native speakers in my class that did a medical Spanish course. And they either had a conversational track or a beginner's track. And because I hadn't been speaking for a while, I thought, oh, I need to be in the beginner track. And yet I went there, and I was definitely past the beginner stage. So I was like, I may not be fluent. And I'm still not fluent, but I'm conversationally fluent, such a medical interview.
Denise 24:51
So thank you so much for coming today. Is there anything else you think you would like to help people?
Ryan 24:56
Yeah, yeah. So I think it first knowing your why the priorities but then you have to fill your toolbox, both the physical and mental tools that you need, whether it's templates, your preference list, kind of the stories, the self compassion, the imposter syndrome that shows up comparing yourself to other colleagues who may get their notes done faster or not. It's like you are on your own trajectory. And you don't have to compare yourself to all the other doctors in your clinic around you. And then just find your flow, how you take best care of patients how you feel like you are doing a good job, even if it takes longer than 15 minutes, and you say, my patients end up waiting a little bit, but they know that I am there with them. So those three things really help take charting to that next step in a way that really supports being a physician. So as far as the charting in the course, I open a six week group coaching program for other physicians called Charting Mastery, I open it up every couple months. I also have a free PDF guide with 10 of my top tips that make available in the shownotes.
Denise 26:13
Get that from there. Otherwise, also give you their email address. But most of these come with that,
Ryan 26:20
but anyone's Welcome to get it and then unsubscribe if that's not something you want to see on an ongoing basis. You can find out more about me by going to MedEdWell.com I'm also on Instagram, LinkedIn, Facebook, and the med Ed well podcast.
Denise 26:44
I look forward to hearing about when where you decide to take your interest in global medicine, and global health. But thank you so much for joining me today. It's very kind of you. And I look forward to reading more about you and seeing you in L&G of course.
Ryan 27:00
Thank you so much.
Denise 27:01
Thank you.
you, you for joining us at Myth, Magic, Medicine. If you have found this episode useful, you can apply for free CME credits for the link provided in the transcript. If you're not a medical professional, please remember, while we're physicians, we're not your physicians, so please consult with your own healthcare professional if you think something you have heard might apply to you or a loved one. Until next time, bye bye
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