Inbox Actions

Accepting emotional responsibility for the tasks of your job is critical.

When you argue with reality, you always lose – but only 100% of the time. 

– Byron Katie

Here are some hard truths:

1. You are responsible for most of what ends up in your inbox

• • investigations – reviewing bloodwork you ordered; you may wish to review guidelines about Choosing Wisely to determine if you may be over-ordering screening bloodwork
  • consultations – these are generally received in response to your referrals; you may wish to review your referral patterns to determine if there is some additional training you may benefit from in order to refer fewer patients
  • messages from patients – have you taken the time to discuss with your staff how they should manage message requests from patients? have you reviewed your accessibility so that patients can have access to care with you within a reasonable amount of time? have you reviewed how you handle routine follow up when you have asked patients to do some investigations?  Consider advising more anxious patients to book a followup 1-2 weeks after investigations to review in detail.

2. You are responsible for what action to take with each item in your inbox

• • Nothing (reviewed) – this is the most common action.  This is appropriate for routine monitoring of chronic conditions, routine screening bloodwork/imaging, consultant reports with no changes to management, discharge summaries with no significant changes in management.  Generally speaking most of your results will fall into this category, most of the time.
  • Arrange further investigations depending on symptoms – for example, if a urinalysis returns abnormal and the patient has symptoms, urine culture may be appropriate.
  • Call the patient in to review – ask your staff to book the patient in for a virtual or in person appointment
  • Call the patient right now – usually appropriate only for advising the patient to proceed to the emergency department or if you have to arrange an urgent consultation or further imaging/bloodwork
  • Review at the next routine visit – I caution the use of this approach as it creates opportunity for delay in care if the patient does not attend their next visit; this is of course dependent on the frequency with which you review your followup tasks; I definitely advise at least creation of a followup task
  • Refuse the work – usually by writing a letter back to a consultant or having your admin do so.

3. You are responsible for how your schedule is arranged

• • You can decide what your access looks like.  Many physicians accept that it takes 2-3 weeks to get in to see them for routine issues.  Then, they feel guilty when a patient has an acute issue, so they squeeze them in.  This results in overwork, probably a shorter visit, running late and a feeling of martyrdom and helplessness.
  • You can decide how many visits per day will be allocated to same-day access, patient recall, routine refill visits, comprehensive health exams.
  • You can decide what your policies are for fax refills, patients who attend appointments late, appointment length, returning phone calls, squeezing people in for prescription refills, how long you fill prescriptions of various kinds for etc.  Each of these decisions will have an impact on your daily work flow.
  • You can decide how your staff should communicate with you regarding urgent patient matters – triage to the clinic nurse, urgent EMR message, knock on your door, double book in a couple of pre-determined spots.  Clear communication regarding your preferences will reassure staff and patients regarding care.

Hero-Victim-Villain Triangle

This thinking pattern is very common.  We naturally think of ourselves as heroes or victims and the others as the villains or victims.

Family physicians feel like heroes to their victim patients and like victims of their villain patients.  Universally, they feel like victims of the villain consultants and the government.  Feeling like a victim leads rapidly to burnout due to the intense feelings of disempowerment and being taken advantage of.   Interestingly, feeling like a hero also rapidly leads to burnout, because heroes are not real people, who need to spend time with their families, go out with friends, engage in joyful physical activity, get enough sleep and nourish their bodies healthfully.  Heroes spend hours on a weekend figuring out how to handle something for a patient.  They chart every night.  They check their results on weekends.  They count mild discomfort on the part of the patient as more important than hours of effort on theirs.  They try to handle all medical issues within the medical home even when another service might be more appropriate.  Occasional heroism is wonderful and inspiring but routine heroism tips easily over into martyrdom and leads to burnout and leaving work that is both meaningful and fulfilling to the physician as well as useful and necessary to the patient, society and the consultants.

We MUST learn how to look after ourselves and step outside of this vicious triangle and see ourselves as humans who are expert in our own area of medicine but who cannot be heroes to all our patients.  When we are heroes to our patients, we are robbing them of the opportunity to be their own heroes.  When we paint our colleagues as villains, we stop thinking of ourselves as on the same team and this results in worse patient care.  When we think of ourselves as victims of our inboxes, we naturally avoid dealing with them and we don’t show up in our personal lives the way we want to because the inbox hangs over us.

TL;DR

Do not make yourself a victim or a hero and do not make patients and ‘the man’ the villain.  Accept that you are in control of the vast majority amount of your work situation.