Learning my Limits
Posted January 18th, 2008 by Justine
Seeing many patients at once reminds me of waitressing. I enjoyed waiting tables because it was busy, fun and social, for the most part. Sure I had my difficult or demanding customers, but for the most part it was a good way to earn some cash while in school. I am also quite glad to have many of the skills I learned as a waitress now that I am a community acupuncturist. There is that dynamic of always having to multi-task and keep things going smoothly while in the clinic. There is also the possibility of things getting screwed up when you aren't prepared to handle them. Back when I waited tables, for instance, there was this consistent pattern of being understaffed and the whole place filling up on Sunday evenings between 6 and 7 pm, and that was the most difficult situation for me to handle. Suddenly overwhelmed by everyone sitting there, ready to order or needing to have their food brought to them from the kitchen, or needing their bill, or needing something packed to go, could get a bit out of hand. Even on my best days with my best system I could get overwhelmed and forget to place orders, give them the wrong drinks or make some other error, or keep them waiting too long. I would always apologize and try to make up for my shortcomings; we are humans and we make mistakes, and I realized that in the grand scheme of things this wasn't really a big deal to have made an error for the sake of the customer- they surely wouldn't starve if they had to wait another 10 minutes; on the other hand, the restaurant had a good reputation and I didn't want to ruin it, and most importantly I did care about my work and in doing the best I could. I cared about keeping the patrons happy and coming back.
I had a great learning experience similar to this while practicing at Manchester Acupuncture Studio yesterday. I have been working there on Tuesdays and Thursdays since the beginning of October, and practicing there has been my first experience in a community acupuncture clinic. I love working there for so many reasons: it's busy, it's fun, it's challenging, I think on my feet, I have given successful treatments and gotten good feedback which has boosted my confidence, I have established good rapport with many patients, and I have learned a TON.
I was graciously given a schedule that eased my way into the community practice. Andy's experience allows his schedule to be 10 minutes for follow-up patients (so 6 patients/hour) and 30 minutes for an initial intake. This would clearly not work for me initially, so in my first few shifts I was given 20 minutes per follow-up and 30 minutes for a new patient. It didn't take long for this to feel comfortable so I then went to 15 minutes per follow-up. I also have seen a lot of new patients who then needed follow-ups, and as the clinic got busier my schedule of 4 follow-ups per hour recently changed to 5 at times; fortunately I have still felt grounded and able to perform well. The days would ebb and flow and generally I would feel okay, but there have been times when it is challenging. Everyone has to find their own system of how to work in a clinic. I like to take my notes with me on a clipboard, have a quick chat with the patient in terms of their progress, then take a moment to think through what I'd like to do and draw up the treatment plan on paper before putting in the needles. I also like to be able to check in with a patient during the treatment to see if they are responding- for instance, I ask them to shift around and feel if the pain has dissipated or changed locations, and if I need to make any further adjustments. I also have to make sure they're comfortable, keep the room neat, and look around to see if other patients are ready to leave and if so, take their needles out.
The challenge comes when patients come and go not according to schedule, or seem ready for me to check in on them when I am not. Yesterday I learned my limits in clinic. It was my busiest schedule ever, with 11 patients booked into the first two hours, followed by a mix of some new patients and follow-ups that then thinned out toward the end of the shift.
The first patient was supposed to show up at 10 am and wasn't in until 10:40; the second was supposed to show up at 10:10 and came at 10:15, and the patient scheduled for 10:20 came at 10:10. From the start I was essentially "behind" schedule. It wasn't difficult to just get started with the first one and then the second one in that order, but then this pattern of patients coming in out of order continued; the 11:10 patient showed up at 10:50, the 10:50 was late, etc. My files were all out of line and I wasn't sure who to go to first; do I go to the man who came early and seems a bit impatient for me to get to him, or do I go to the patient who came in late and is still waiting for me to get to her because I am with a patient who is on time, etc.? As I continued seeing the new ones come in, ones who had been there awhile started to open their eyes and be ready to leave. I began to let the pressure get to me and I began to slip. At one point I threw used needles in the trash can in haste and had to then go into the trash and pull them out; then I threw used needles into a cotton ball jar and again, had to clean up my mess. I had to be reminded by a patient to remove her needles at LU-2 (out of sight, out of mind). I also was consciously aware of the issue that I was lacking the time to think through, and practice, the point prescriptions in the most optimal way. Clearly I needed to slow down, become grounded and not be frazzled by all these people waiting and by my desire to keep everyone happy. I also had to stay on course of clinic appointment times as best I could, approach patients in that order and tell those who were early and having to wait that I had to stay on schedule. Furthermore, I had to talk to Andy and to the volunteers and let them know that I am clearly not ready to be handling 6 patients in an hour yet. I sometimes wonder if I ever will be; I know that many CAN'ers practice in this way. I think that this will be something I will have to determine as time goes on. I am not willing to compromise my quality of work for money or for others "convenience." I know that if I need to max out at 5 patients in an hour and work an extra hour to earn a living to feel most effective and grounded, then I can make that choice. I realize that by saying this now I may be sounding a bit naive because I have only been practicing for a few months so I do not truly know what will ultimately be my limits in the future. But for now I do and it is important to honor them and learn from them, just as I learn from and honor all the patients that I get to treat.
Re: Learning my Limits
I agree 100% with Rob's statement:
"Most of my clients can see how busy I am and know that their time slot is narrow. That's what makes it so affordable. They are responsible for remembering their appt and showing up on time. That's small compared the responsibilities of a CA acupuncturist. If they are turned away once, they will be more likely to arrive on time in the future. I don't like enabling bad habits."
I found Rob's post, along with mountainlaurel's, to be very encouraging and realistic.
Justine, I applaud you in that you are not willing to compromise your quality of work for money or for others "convenience."
Re: Learning my Limits
This is a really interesting discussion.
I've been a server on and off since college, and I feel like the skills I learned in that job really have helped me here at WCA, especially in terms of time management and efficient caretaking.
When I first started a few months ago, I was appalled at how no one ever seemed to turn up on time. Tons of people were either early or late. How the heck was I supposed to work in those conditions? Are you kidding me? I would NEVER do that to someone. Ha, yeah right. It (thankfully) didn't take too terribly long for me to realize that the angst I was feeling had less to do with actual time issues and more to do with my wanting to control the situation. Acknowledging that helped me see that it always seems to work out-as someone said above, when one patient is late, another will turn up early, and it works out. Suddenly the stress was gone and it became more like riding the wave. AND, as was suggested to me by Lisa and Skip, as long as I communicate with everyone and make sure that patients know that I know they are there, everyone seems patient and totally untroubled if they have to wait an extra 2 minutes.
Another thing that helps is that most of the time I am working with another acupunk, so they'll let me know if someone has snuck in and is waiting!
Re: Learning my Limits
More great comments- thanks Rob!
It is really good to have all this feedback!
Re: Learning my Limits
I know what you mean. I see clients every 15 minutes and it can still get hectic. I was always concerned about running late and sometimes by the end of the day I'd be 15-20 minutes behind. As I get more practice that time is getting shorter as I adapt and learn from the pace.
When a client shows up late it can throw off your flow. With only 10 or 15 minutes per client it doesn't leave a whole lot of slack. I find that most of the time it works out. One person is late and another is early. It always amazes me when the shuffle happens without any drama. Sometimes though, it can be a trainwreck and I can feel my Liver seize up under the stress.
When my schedule is full and someone arrives 20 minutes late for their 15 minute slot, I tell them that I don't have time and they missed their appt. Most of the time I can squeeze them in, but I don't want to be stressed out because the client messed up.
Most of my clients can see how busy I am and know that their time slot is narrow. That's what makes it so affordable. They are responsible for remembering their appt and showing up on time. That's small compared the responsibilities of a CA acupuncturist. If they are turned away once, they will be more likely to arrive on time in the future. I don't like enabling bad habits.
When first learning it's good to have more space in the schedule and as your abilities quicken and you develop a familiarity and rapport with clients then start pretending you have less time and try to be done in 10 or 15. After a while you find your rhythm and that extra time in the schedule becomes a boring pocket of nothingness that you wish was filled with another appt. That's when it's time to take the training wheels off.
Re: Learning my Limits
You are doing great! Just remember, you are treating more people in one hour than I would treat in one day of my former boutique practice.
Re: Learning my Limits
It takes a hundred and twenty years for an acorn to become a grand old oak tree, and it is beautiful at every stage of growth!
Re: Learning my Limits
THANKS Skip! That is extremely helpful feedback and advice - and I can completely relate to your bicycle training analogy, too.
Re: Learning my Limits
A couple thoughts are crawling through my brain:
1) I remember one Friday night when my schedule was filled (six patients/hour or every 10 minutes). I got to the point in the shift when everyone was needled, everyone was charted, everyone was asleep and I was waiting around for the next person. They were late.. and so was the next when their time came. So I had a nice conversation with Ilse our receptionist ("nice" meaning we didn't throw anything at each other lol) and... the next person was late too. WTF???
Ilse meanwhile called the earliest people who were late but they didn't answer. Soon after her phone calls, the late people walked in... along with the next five scheduled people! I literally saw eight patients at once walking from our parking lot to the front door.
Needless to say I was busy. But between Ilse only being able to take one person's money at a time and some people just taking longer to get settled there was never more than three people waiting in a chair for me. I worked fast and no one waited more than 10 minutes- and that included pulling needles of people who were done.
From my experience, scheduling every 10 minutes means that the acupunk must expect people to arrive sometime around when they are supposed to. I don't think there's been a day at WCA when all the patients arrive on time every 10 minutes like clockwork. I've long since given up expecting it.
2) The thing is, its hard to re-orient yourself from the speed of a school clinic or a one or two people an hour practice to six/hour. What's hard about it is thinking that you need more time to get the information. Eventually, however you learn that's not the case, that 10 minutes is plenty of time and that if you need to go faster that 5 minutes is also more than enough time to do a great treatment. It just takes reorienting yourself.
But how to do that? At WCA we've hired seven acupunks now and each one has had a different training experience ranging from very little guidance to lots of guidance. In general lots of guidance for new acupunks is important. But not too much. For a few of them we also gave them more than 10 minutes per patient at first but we found that with 20 minutes, they were still doing unnecessary things and they were not closer to the 10 minutes/patient goal. In other words being used to 20 minutes/patient is still a big difference from 10 minutes/patient. There's still some behaviors that need to be shed in order to get lean and mean, so to speak.
What we have found is that once our acupunks got down to 10 minutes/patient that even though they definitely struggled for a few weeks they all got a clue on how to make it work out for themselves. We still talk to them about it (and so do our receptionists who make sure they stay on schedule) but they all eventually got the idea, and our newest hires (since last October) are getting quite creative with their treatments. We have monthly acupuncturist meetings and in those I notice that the others really soak up what Lisa and I have to say as we give them tips on how to stay on schedule while really helping their patients. That you and Tom are both new to this I can imagine wondering if you can indeed, do it.
10 minutes/patient is really like learning to ride a bike after using training wheels. As a parent I didn't find that training wheels helped my boys become bike riders any faster. Same with taking a longer time with patients. Justine, I know you very very little- most of it from the videos of setting up your clinic. I also know Andy just somewhat, though I can imagine him practicing pretty clearly. From the videos I know you have what it takes to be able to handle 6 patients in an hour. Just remember for now that all you need to be is good enough. Not great- just good enough. Plug in specific protocols ( your choice) for certain very common complaints (low back pain, headaches, knee pain, depression) at first until you get fast at them and they become second nature. Slowly and with purpose being specific on why you are changing the protocols, branch out from those. Stay simple but don't over think your point selection. (Sometimes I put in two or three points when I know it would take me longer to think out which of the three is best.)