Transcript: Time Management Tips: An Interview With The World's Most Productive Nurse Practitioner

​Liz Rohr:
I think that so many nurse practitioners come to Real World NP and they're struggling with time management, and I feel like at least in my personal perspective of time management, we'll get into this with the questions, but it's just, it seems very individualized.

Well, hey there, it's Liz Rohr from Real World NP, and you are watching the Real World NP YouTube channel. We make weekly episodes to help save you time, frustration, and help you take the best care of your patients. So, I had the absolute honor of bringing Jessica Reeves, a family nurse practitioner onto the channel for an interview. So, Jessica's a family nurse practitioner, but she's a member of the Real World NP team and she is also an author. The name of her book is The Secrets from the World's Most Productive Nurse Practitioner which I'll link to down below. She's really just fantastic at time management and she shared a lot of tips when it comes to patient visits, charting, and other pieces that nurse practitioners really struggle with. So, I really hope you enjoy this interview. 

Real quick though, if you haven't grabbed the Ultimate Resource Guide for the New NP, head over to realworldnp.com/guide. You'll get these episodes sent straight to your inbox every week with notes from me, patients stories, and bonuses. I really just don't share anywhere else. Without further ado though, this is my interview with Jessica, the time management guru. Okay, welcome. Thank you so much for being here. Can you go ahead and introduce yourself?

Jessica Reeves:
Yes, thanks for having me first of all. So, my name is Jessica, Jessica Reeves. I'm a nurse practitioner, and before I was a nurse practitioner, I was completely obsessed with time management. For my eighth birthday, I got a watch, a digital watch, and I think that's when things really kind of changed for me and I really became very aware of time. And so, ever since then, I've always been very concerned with time and how long things take and how they could be faster and better and that sort of thing. So, here I am. My husband now calls me the time guru of our household. So, nurse practitioner/time guru I guess is sort of my claim to fame.

Liz Rohr:
Yes. Oh my gosh, I love that so much. I did not know that. So, yeah, as I mentioned in the intro that you are one of our team members at Real World NP and we're so happy to have you. Another piece of information I want to share is that you also have a book. Tell us about your book.

Jessica Reeves:
Yeah. So, the book is funny. I didn't sit down one day and say, "I'm going to write a book," but I did realize when I was leaving my position in corporate medicine and they were talking about who they were going to get to replace me, so from another team or something, and somebody said, "Well, we're not going to be able to get somebody who's going to be able to just handle the visit and handle the time the way that Jessica is." And I was like, "Oh, other people notice that? Oh wow, okay." It became like a thing, and I recognize kind of looking back, I have something to offer, and again, if I looked way back, it went all the way to being eight years old with a digital watch, and ironically, I have no watch on today, strangely enough. So, I felt like, "Okay, I can write an article and get this published somewhere and I've got some tips. I'm sure I've got something that I can share." I sat down and started writing and wrote a little more, wrote a little more. Before I realized, I had enough to fill a book.

Liz Rohr:
Wow.

Jessica Reeves:
So, that's kind of how it came together. I never really thought that would be my future, on the radar, but it was a really gratifying experience and it's been so gratifying. Also, it's brought me into contact with lots of folks I don't think would've otherwise been in contact with. I think that Real World MP counts as part of that as well. So, that's kind of how we cross paths there. It's interesting to help fellow NPs. It's one thing to help a patient and you've gone through all this stuff, and you're like, "Okay, when you've got your blood pressure, you need your lisinopril," and that's it. But this is, I've really been, I don't have high blood pressure yet, someday, but the time management, I've been there. These are things that I know have worked for me. So, it's really gratifying to be able to share that with other NPs, and to be, it sounds corny, but to be part of the solution instead of part the problem.

Liz Rohr:
Wow.

Jessica Reeves:
I didn't realize that I was as much of a time guru until that happened. Yeah, and I really am almost a little too much, depending who you ask, but it's ultimately it a good problem to have. Yeah, yeah.

Liz Rohr:
That's awesome. And can you refresh us again on the title of your book?

Jessica Reeves:
Sure. The book is called Secrets from the World's Most Productive Nurse Practitioner.

Liz Rohr:
I love it.

Jessica Reeves:
I know, right? Isn't that fun? And that's when I knew actually that I was going to, because I thought that was just going to be the title of an article and I was like, "No, this is a great hook to kind of put everything around." But we've got a lot of stuff in there that's about nuts and bolts of how to get through the day, but then there's also some bigger picture stuff about how to know whether their job, the culture's going to be the right fit because there's more than one way to approach time management and there's not really one right answer, but there's kind of one right answer for you or for me or for the individual. So, it makes people think a little bit about what they need because it's not one size fits all.

Liz Rohr:
I love that.

Jessica Reeves:
I'm excited to have... Yeah. It's exciting to have that kind of stuff too.

Liz Rohr:
Totally. And I really appreciate you saying that in the context of time management. So, we have a couple of questions that we're going to share that we're going to talk through, but I guess just to start, I just appreciate you sharing that not only are you really good at time management for life, but also you recognize that it's an individualized custom approach because as you and I have sort of shared before, I have probably what's called time blindness, so I'm probably that polar opposite.

Jessica Reeves:
I like that.

Liz Rohr:
I think it's actually a real term. Well, there's some person that coined that term. I think it goes along with ADHD. But yeah, in terms of the... I appreciate that you can recognize that there is not one right way to do it and not one right way of advising because I think that so many nurse practitioners come to Real World NP and they're struggling with time management, and I feel like at least in my personal perspective of time management, we'll get into this with the questions, but it's just, it seems very individualized. I think that there's definitely some things there, some core principles, and definitely things we can learn, and also, yeah, it's a really custom. Well, why don't-

Jessica Reeves:
Yeah, and I think that-

Liz Rohr:
Go ahead.

Jessica Reeves:
Oh, I was just going to build on that and just say that even for me, it's not one approach. It depends on the situation. Right? So, then if you're like for me, in situation A versus situation B, I need to come at this little differently, then well then of course, right, yeah, somebody with time blindness, right, they can also get things. We can help you see the light, but we need to go about it a little differently. So, there's a lot of different ways to get it right. It's really just about intent.

Liz Rohr:
That's awesome. Well, let's get into some of the questions here. Okay. So, I guess for some context, so you and I have talked about this, but the people that we serve with Real World NP tend to be nurse practitioner students, newer graduates, or in the first couple of years of practice, but then also people who have been practicing in another specialty that are coming back, either coming back or coming into family medicine for the first time.

And so, it sounds like there's some overarching challenges that I've heard about and I'm sure you heard about too based on the stuff we talked about before this of the visits themselves, challenges with time management in the visits themselves, challenges with the time management of charting and paperwork, in my mind, those kind of go together, as well as the challenges of the schedule of the office play, the situation of where you work. So, those are the main challenges. So, I just maybe want to start with one. So, is there one that you'd like to start with? Do you want to talk about charting? Do you want to talk about patient visits in the room? Where do you want to start?

Jessica Reeves:
Yeah, I'll say-

Liz Rohr:
What are your thoughts about those?

Jessica Reeves:
Yeah, the visits, because I tend to be very methodical. So, steps 1, 2, 3, 4. So, the first thing that you do is you're seeing the patient and pre-charting. So, even before that, right, before you actually walk through the door and get face to face with the patient, a lot of people want to pre-chart and it feels like the thing to do, right, because you're being productive and you're like, "Okay, I'm going to go in, I'm going to be so prepared, and I'm going to be ready for this, this, this, and I know that it's a physical, so I have to order all these labs or all these imaging," or whatever, and then the person doesn't show. How much time did you just invest in that, right?

Liz Rohr:
Yes.

Jessica Reeves:
You've just thrown it out the window. Or in a worst-case scenario, the patient doesn't show, but then you've got the note open. Now you have to figure out how do I undo everything I did. Now you're wasting even more time. Oh my god. So, forget that. Pre-charting rarely, rarely benefits you. It feels like it should, and for the amount of time, it really should benefit you, but it doesn't, and I think that that time could be so much better used for a lot of other things. You have to be ready to see the patient. You have to know what you're walking into. Right?

Liz Rohr:
Yeah.

Jessica Reeves:
Okay, this is an annual exam. I haven't seen this person in a year. They're pretty healthy, but these are the things that they have going on. You want to glance at the chart, but you don't need to read the whole thing. Literally five minutes tops and go in with a loose plan because the other thing is they come in for the annual physical and then they're like, "Oh my god, but I think I broke my toe yesterday." Well, okay, so we reschedule the exam.

Liz Rohr:
For a new complaint, yeah.

Jessica Reeves:
Yeah, yeah. The exam we'll come back for, but let's see if the toe's actually broken, and oh, I need X, Y, Z. So, things change. That's primary care. You're always kind of surfing. You have a plan, but you always have like 10 plan. So, pre-charting I would say is a huge, huge, huge no-no as far as I'm concerned because I haven't seen for myself or for other folks that I've worked with, I haven't seen that benefit them. And when it does, it's such a long shot. It's like one times out of 50 that it actually is worth doing. That's not a very good return. Right?

Liz Rohr:
Yeah.

Jessica Reeves:
And in the amount of time that you spent doing that, you could knock out some tasks in your inbox, you could call for that pre-op, you could do X, Y, Z. There are a lot of other things that you could do that would be a better and more concrete use of your time in the future. So, it's a gamble and I don't think it's a risk worth taking.

Liz Rohr:
Yeah.

Jessica Reeves:
Yeah. That's the first thing I would say. It's tempting, but you got to avoid that temptation. Or, mark my words, try it and it's not going to work. So, there's that too. Right? There's that. Prove me wrong. Absolutely prove me wrong. I'm like science. Right? You can leave me wrong.

Liz Rohr:
Totally.

Jessica Reeves:
I love would that, and then tell me how, how you did that. Was it... Yeah.

Liz Rohr:
Totally. And just to set some context for if a nurse practitioner student is listening, one of the common pieces of advice is to look up your patients either the day before, the morning of, and then read through their whole chart. Open a chart, come up with a plan, write all the things you predict is going to happen, order all the things you think you need to order, and some people really stand by it. I think it's important to offer that is not a requirement because it is really disheartening when you put in all of that work and it hasn't come to anything. I found value in it for a little while when I was a new grad because I felt like it really forced me to engage my brain in a very specific way, but then when I realized the utility of it wasn't really measuring out, I was like, "Okay, let's try something else." So, that did not work for me long term, but it was helpful for a short stint.

Jessica Reeves:
Yeah. So, it sounds like for you it was helpful to help to organize your thoughts and your approach to the visit.

Liz Rohr:
Yeah, totally.

Jessica Reeves:
Yeah, just like you can do that on a piece of paper.

Liz Rohr:
Yeah.

Jessica Reeves:
If I had somebody that really wanted to stick with that, okay, how can we modify that, so that then in worst-case scenario, you just ripped that paper up and put it in the shred pile.

Liz Rohr:
Exactly. Yeah, that's the difference. Yeah, I was going to say, that's very different than when you pre-chart, going through the whole pre-charting process versus looking all the patients up the night before is a different process. Yeah, so that's still maybe serving, especially when you're newer to look the people up and then take some notes. So, they'll be like, "Oh, I haven't seen Charcot foot in a really long time. I don't really remember what I should be assessing for that."

Jessica Reeves:
Exactly, right, because that's definitely happened. I think I had that with gout, with my first gout patient. Okay, that's the foot, right? Okay, I better look this up. I don't want to walk in because you don't want to look stupid. So, you walk in and you expect them to have their shoes off and their foot should be red and they can't really touch it. Like, "Okay. All right. So, here's my few things." So, you do definitely want to be prepared, but especially the night before, I think that that can also add to the anxiety.

As a new grad, you've got anxiety. Everything's new, and this is the first time you're without a net or close to being without a net. For me, I'll speak my N of 1 here, if I looked up my patients the night before, I wouldn't sleep because, "Oh no, when that 10 o'clock comes in, oh, I'm going to screw it up, or I'm going to forget something, or I'm going to need to ask somebody else for something, or that visit's going to run on," and you just psych yourself out. And again, I don't see the return on investment. So, for me, not worth it. It's not going to make me a better NP. It's going to make me closer to burnout faster. It's going to make me stressed. It's going to make me not sleep well. All those things are all distractions. So, for me, no.

Liz Rohr:
Yeah, totally. Totally. What other thoughts do you have about charting, aside from pre-charting, considering not pre-charting?

Jessica Reeves:
Yeah. Yeah. So, for charting, I have three templates that I use, and there's one that's for the problem visit, and you can just add problems on, but it's your basic thing where you're like, "What happened? What are we going to do about it? What are the imaging or labs or whatever that I needed to get in the visit?" So, you've got your acute visit, problem visit, your annual exam which is going to... I see adults. I don't really see kids. Occasionally I'll see kids. So, my annual exam is basically the same for pretty much everybody because I'm not doing developmental stuff and that visits.

Liz Rohr:
Totally.

Jessica Reeves:
So, it's like it's a static document. And then my third one is, yeah, so if I'm seeing somebody for pre-op physical, you got to ask questions so that they're safe for anesthesia, but you don't really need to... It doesn't matter if they're up to date on their mammogram. So, you can kind of let ,those things go and then when it comes time to chart it, you already know what you're putting in and where you expect to see it. Like, "Okay, here's where I'm assessing their soft palette. Okay, here's where I put this. Here's where I'm putting their capacity to... If I had to ask you to move furniture, could you do that?" Yes. Okay, and you can just cruise right through. So, that's a big, big piece. Having templates, but also not having too many templates. For me, that's the right number. If I saw kids, I'd probably have another three or four templates just because it's the ages.

Liz Rohr:
Ages, yeah.

Jessica Reeves:
Conceptually, it would still be that same thing where it's like keep it lean and mean. Right? You can always customize in the note for the particular problem or the particular patient, but you don't need to reinvent the wheel every time. That's a big one. Another big one is, and again, this is my personal preference and I'm sure that I am a total black sheep with this, I do not open the computer in the visit. No, no, no, no. Sometimes, like one visit out of 50, it's completely unavoidable and you have to look something up. But the patient starts asking something, "Oh, while you're in there, hey, I never got the results from when I saw the endocrinology." Whoa, hold on. Right?

Liz Rohr:
Yeah.

Jessica Reeves:
So, that's the thing. So, when I'm in the visit, it's me and the patient and I've got my clipboard and I take hard copy notes, but I write very little. I had cheat sheets that I used for the first couple of years and I would highlight stuff so that I would make sure that I didn't forget stuff. So, if it was like a gout patient, right, okay, I want to ask these questions, I want to ask those questions, but it doesn't matter to me if they're having any abdominal stuff, but I want to make sure that I'm asking this, this, and this. So, you've got your little guide and then you've also got, you just check it off, yes or no. And then you can pretext a little bit.

To me that helped me to be more present with the patient and it also focused what I had. If you have a long laundry list of notes, you are maybe a little more likely to feel like you have to include all that, it's embarrassing to be because you want to be like, "Oh, I'll just throw that away and pretend it didn't happen." But if you're more focused with the visit, then that helps you to be more focused with your charting.

Another piece that goes with this, and this is tough, and in some cases I was very much not popular for this, but you kind of have to, I guess, choose your battles, and in a primary care setting, it was limiting the number of concerns. So, in a 20-minute visit we can cover three things, and they may be the things that you booked your visit for plus two more, or you may have changed, something may have changed since you booked the visit and now you've got this, "I think I got bit by a tick and we need to have done that". Okay. So, we might have to take one of the other things and have you come back for that, but I can't really thoroughly investigate an issue if I don't have enough time. It's not fair to me. It's not fair to the patient. It's not fair across the board. So, limiting the number of things that you really... There are always, not examples, exceptions.

Liz Rohr:
Exceptions, yeah.

Jessica Reeves:
Thank you. Another one. There's always exceptions. So, there are always times that it's hard for this patient to get in and they always miss their appointments and they're here right now, I got to strike while iron's hot. But in a lot of cases, that's not new. And if you're going over 10 things in a visit, you're going to have to chart 10 things. You're going to have to go to labs for 10 things. It's going to turn into this... So, try to do one or two or three things, that's ethically appropriate to me, and it's also going to make your charting that much easier because it's more focused, but it's tough.

Liz Rohr:
It is tough. And I think, I guess I want to normalize a couple of things, especially for our newer people who are listening, our newer person that's listening that I had a real struggle with that when I was new of like, "Oh my gosh, do I have to write down every single thing that this person says? I don't want to be liable. What if something happens with this toe pain?" That's a clinical judgment muscle that we all have to develop.

Yeah, and I also would just want to normalize too that it is really challenging to set those limits and visits because... And my personal approach again as a time blind person, I have to do a lot of forgiveness of my own time management. I'm not as orderly in my visits as much as I wish I could be. But some days, and especially with boundary setting, some days I have the emotional capacity for it, and then other days I'm like, "You know what? It's easier and more supportive for me in this moment to choose to address 12 things." Okay, I don't usually address 12, but maybe five, maybe seven if they're tiny things, but in that moment I'm like, "Okay, you know what? Today's the day." 

But yeah, I think one thing that I've been starting to do is practicing setting those expectations at the beginning of the visit, and it sounds like you are doing that, or setting more just general expectations at the beginning of a visit, but especially with the problems of... I think what happens sometimes is that patients just like... We're like, "How can I help you today?" and then it's all the things, and then you have to backtrack and be like, "Okay, I'm so sorry. We can actually only address three," versus we start off the visit, "For your safety and quality of your care, I can only address three things. It's not about me. It's not about inconvenience. It's about literally it is not safe for me to not thoroughly investigate your chief complaints." I mean, I don't say chief complaints to them, but you know what I mean, the concerns that they have.

But it is, I just wanted to add that as a normalizing thing that that gets easier with time. It's a leadership thing. I think that's another part of the role transition that makes time management so hard at the beginning is that you are in a leadership role when you're saying that with your patient. You are guiding them, you are the authority, and you can still be an approachable authority, but you still have to be an authority when you are a medical provider.

Jessica Reeves:
Yeah. The buck is going to stop with you. Right?

Liz Rohr:
Yeah. Mm-hmm.

Jessica Reeves:
Yeah. And if you have been say the past five or 10 years bedside and you're just sort of there, you're there for 12 hours, then you just kind of whatever happens happens. That's not something that maybe you're accustomed to, just saying, "Okay, we have 20 minutes together... a lot in 20 minutes. What are your top three things?" or whatever the case may be. Yes, you're right, it does get better with time, with practice. Another little sneak attack thing is that you can practice that in other parts of your life with your friends, your family. You can practice that sort of stuff like, "All right, I'm going to give those 20 minutes and I'm only talk about whatever," two things, three things, whatever it is, and set that expectation and maintain that way. That way it's a lower stakes kind of thing, but you're getting the mileage of having done it.

Liz Rohr:
Oh, I love that so much because it's boundary setting and boundary setting is not easy for anybody, especially when they're new to it, but it's a muscle that you have to practice of boundary setting especially, yeah, and then when you add in the imposter syndrome, if you're new. It's hard to stand in that grounded place of I am going to set a boundary, a kind and loving boundary that is for our best interest mutually, but yeah.

Jessica Reeves:
Yeah. Yeah, because it's not just a power play. There are reasons and... yeah.

Liz Rohr:
Yeah, yeah. And it's because you're doing your job well. You're not doing it to do a bad job. You're not doing it to whatever, for whatever reason. It literally is to do a good job for them.

Jessica Reeves:
It's funny because our local newspaper is doing some reporting about the healthcare shortage and there's such a shortage of providers and staff members, and so, wait times are crazy, and I was like, "Spoiler alert, they have worsened for sure, definitely, but they were pretty crazy even the last five or 10 years too."

And that was one thing that I felt like it was such a big thing. It was important to me personally to be on time, but for ethical reasons too. Sometimes there are reason where it's just like you're going to run late. You accept those, but most of the time you can run generally on time, and it's important to me to meet those expectations. My time's valuable, but so is the time with my patients and the staff that I'm working with who are not only working for me, they're working with other folks. So, it's kind of about trying to keep all those plates spinning and to not be disappointing people or not to be, "Well, if then I be late with you, then I start late with the next person." Yeah, it's the whole downhill slide from there. So, for me personally, it was and it continues to be a big, it's an ethical thing, like...

Liz Rohr:
Yeah, absolutely. Well, you kind of mentioned a little bit about in the visits with how many problems you address. Are there any other kind of pieces of guidance you have about the actual time in the visit with a patient?

Jessica Reeves:
Yeah. So, a couple of big things. Setting the agenda is a big one and it's because then you've got your transparency, and not this, and it's a little easier than instead of all of a sudden the last two minutes, "Oh sorry, our time's up." That's a big one. But you also have to know what that feels like, the amount of time that you have for your visit. So, I'll use that 20 minutes as an example. And again, especially in primary care, not every visit's going to be the same. Some visits you just are going to do in the chair. They're never even going to need to get on the table. But when you get to that halfway point, the patient should be getting up on the exam table in most cases, and then you can kind of finish the visit with them maybe on the table if they're safe, unless there's some reason they can't be left alone up there. But you can kind of end the visit there and step off, but you have to kind of know.

And I have noticed also in so many exam rooms, there are not clocks, and I've also noticed a lot of nurses, it's like the day they graduate NP school, they're like, "I don't need to wear this watch anymore." Put the watch back on. So, whether you have a regular old-school watch or you have a smartwatch, if you have a smartwatch, you could even set a little reminder, your five-minute warning, and get to know whatever the length of your visit is.

I worked in a setting where I had 10-minute visits so I know what 10 minutes feels like. But then when I got to 20 minutes, I was like, "Okay, this is great. I've got all this time left over," but then it expands to fill the time. So, you have to get to know what 20 minutes feels like and know then also working backwards if that's what 20 minutes feels like, this is 15, we should be winding down. This is for another visit. This is 10 minutes, we should be at halfway point. I should be done with the history. Now, I should be asking them. They should be done talking, and I should be kind of running it now.

So, those are big things. So, having a clock, having to watch, and a clock that you can point to with the patient. We're almost out of time. It's kind of a neutral way to do that. Other things like standing up, most of my visits, they start on a chair or a stool, and then if the patient gets up on the exam table, then that's okay, that should be the halfway point. Some people just keep going and they talk, and I'm a talker too, so I feel like if I say someone else is a talker, that's really... They're really like, "Darn. Oh gosh. They really like to talk." So, cues, and standing up, putting your hand on the doorknob, opening the door, and then worst-case scenario, "I'm sorry but we're out of time." Those are big things.

Another piece that I feel really strongly about is knowing what you're getting yourself into. So, if it's not the first time that you're seeing the patient and if there's a way in the chart that you can have a note for yourself that the patient can never see, but you can have some sort of a note in the chart, even if it's at the end of their previous visit note with you, you have some sort of code. So, I used to put C-H for patients who were chatty, just so I know this person's a talker. I go in with that in mind, and if they were very chatty, I would put capital C-H, to me, very, very chatty, and then you just kind of know, right?

So, that's part of looking at the chart before the visit, like, "Oh okay, we got a talker. Okay, good." Things like that to just sort of then you know, "Okay, when I'm going into this visit, I'm going to need to help this person stay focused. I'm going to need to keep an eye on the clock because they've got all the time in the world and a lot of stuff to talk about." That's a big strategy too in the visit to be prepared.

Liz Rohr:
Yeah. Oh I love that. So, on that note, I just wanted to add, I feel like I've quoted this before, but there's this study about when providers sit down. I don't know if you're familiar with that study, but they did a study, I think it was a qualitative study of patient perception of how long a visit was, and what they perceived was three times as long when the provider sat down versus when they stood up. And so, I just appreciate that you added that you start with your visit sitting because I know providers, some people come in and they're charting on a computer on wheels and that's really great and helpful, but I always kind of use that hack of sitting down, full attention, and then the perception is much longer.

And then I think it also reminded me of this other thing about interruptions, and I don't know if you had any suggestions for that, especially with chatty patients. I do love my chatty patients, but I am trying to be mindful of time. So, one thing that I wanted to add, and if you had any to add, I appreciate it, is that instead of when somebody's talking and saying but, you can say and. And so, when they're talking, "Oh, and," then you change the direction because a but, it's so subtle and this is talking about the English language, not in other languages because I can't speak to that. But yeah, so when you're saying, "And this," it's not negating what they're saying. It's like I've heard what you've said and we're going to talk about blah blah blah next.

Jessica Reeves:
Right. As opposed to saying, "But we only have 20 minutes," right? 

Liz Rohr:
Yeah. Yeah, yeah, yeah. Yeah, and we only have 20 minutes. So, it's just a better connector, I've heard you space and it's so subtle and I don't actually know if there's research on it, but I appreciate it as a patient.

Jessica Reeves:
Yeah. No, definitely. Definitely. Yeah, I think I've been on the receiving end of it too which does make me feel sort of like, "Oh okay. All right." Yeah.

Liz Rohr:
Totally. But do you have suggestions about interrupting? I think that people have a hard time with that and they don't quite know what to say or how to say it.

Jessica Reeves:
So, to interrupt the patient if they're really on a roll and you need to take a break?

Liz Rohr:
Yeah.

Jessica Reeves:
Well, so one thing that I found is counterintuitive and for me it's hard to do because I'm a chatterbox so I can't really fault patients too much because I'm just as bad, but one thing is silence. So, if you keep stoking the fire, the fire's going to keep burning. If you just smother a fire, it's not going to continue to burn. So, we don't want to smother a patient, but to not say anything. I worked with a colleague who had this trick and I was like, "I'll try it." I don't know if it's going to work." And I was like, "Oh my god, it totally worked." And of course she was a physician and she had worked for 30 years so she had all kinds of insights that someday I'll have, but I didn't have them at this point, for sure. And she said, "I let the patient say everything and then I count in my head to 10 and I say nothing," and patients loved her too. I was like, "That's an eternity." So, I was like, "Well, I'll do five. I'll try," and it does work.
So, I don't feel super comfortable doing that all the time. Nice to have that in the toolkit as an option. So, sometimes to be like, "Okay, and 1, 2, 3, 4 and a 5 and okay," and just to count to that, that can be used in a lot of different situations too when you need to slow the momentum down a little bit. Sometimes with patients, and this is a different conversation, but if they're a little bit confrontational, not engaging, and just letting it sort fall where it may, it can work in that case too. I have some other tips for confrontational patients. That's not today, but it can work for that sort of thing too.

So, it really is, it's the kind of multifaceted tool that you can plug into a lot of different situations because people will notice that you're not talking, and then it'll shake them up, and that can be helpful too. I've also had situations where again, knowing that I've had, okay, here comes so-and-so, and they're going to be here all day. You enjoy some of these patients, you enjoy them. If you have time, you would take the time, have the time, and so, if you have a good relationship with the folks that you work with to get that kind of rescue knock. "If I'm still in here at two o'clock or 4:30 or 10:00 PM, knock on the door, would you please?"

Liz Rohr:
Oh, I've definitely done that.

Jessica Reeves:
And it could be anybody. Right? The patient doesn't know who it is. You step out into the hall, and they think it's something very important, and then you just wait in the hall, count to 10, step back in and like, "I'm really sorry but we're going to have to wrap up here."

Liz Rohr:
Yeah, totally.

Jessica Reeves:
So, these are things too that you can do and it helps if you know what you're walking into with the patient who might be a little more likely to do that. There are always new things to learn and there's always new tools to put the toolkit because there's always curveballs. So, there's that piece too. It's like, yeah, give yourself a break. I did not manage every single encounter in the last five years completely perfectly as far as time management is concerned. Sometimes you can't and you have to just sort of accept that. But if you run late, maybe you borrow five minutes from the next visit or something. There's those things too.

Liz Rohr:
Totally, totally. And I guess, we said this off camera, but I think there are a lot of choices when it comes to time management and I have time blindness. I try a lot of things. I'm not great with it in general in my whole life, for my entire life, and so, I just give myself a lot of grace and my commitments are to very high-quality patient care, strong relationships with my patients, and just doing a good job.

Doing a good job includes time management, but I also get to make decisions of the give and take because I think sometimes that new nurse practitioners especially will write in and say things like... I think there's this kind of attachment to every single day I see my patients on time, I get on time, I get all my charts done on time every single week, and I think that people view that, especially when they're newer, of you've arrived, you've achieved, that's what everybody does, that's what you're supposed to do, and then also it doesn't have to look like that, and it's not about perfection. It's about you choosing what is going to work for you and what you can accept and what you can't accept. And so, for me, I'm also okay accepting that if I leave clinic an hour late, I've made that choice because I've a variety of other choices in my life. If I was not okay with that then I would amend my behavior, but it's not at this point.

Jessica Reeves:
Yes. And that's the thing too is knowing yourself and knowing what makes sense for you and what your boundaries are because I think that's a big thing too. In my book I have a little infographic, well, it's not even. It's a chart, not an infographic, and it shows my rate of closing charts the same day versus the rest of the practice, and there were 30 or 40 people in the practice.

Liz Rohr:
Wow.

Jessica Reeves:
Yeah, it was a busy place. But I was definitely above everybody else. I think it was like 10, 15, maybe even 20 points above everybody else because that was really important to me, and so, I was a little way uptight about it, but I was unusual I guess is the point that I'm trying to make and not in a humble brag kind of way, but just that was my thing. That was my OCD of sort, and the point is the average was still really good. The average was still 80s to 85% closing them within 24 hours. So, that's normal if you really want to go super great with the other things. Now, I definitely had times when I had my charts closed, my patient satisfaction scores were not so good. You choose your battles because you can't have both.

Liz Rohr:
Yeah, yeah.

Jessica Reeves:
So, that's a big thing. I think you had a really good point by saying that really, that's kind of like, "Okay, then I'll know, now I'm a real NP." Now, because I knew I was very good at charting and I knew that I was very good at the efficiency and that sort of thing, but there were definitely things that I was... Like the gout, the first time I saw somebody with gout, or the first time I had maybe, I don't know, an atypical presentation of something and it's like, "Oh," or this person who's got polypharmacy and you need to give them antibiotics and things are interacting and their kidneys aren't working right, and so you're like, "Oh god, what do I do?" So, those things. There are definitely other things where you're like, "Okay, yeah, the time management, I'd be great. This other stuff, I'm working on that too."

Liz Rohr:
Totally.

Jessica Reeves:
That's a big, big piece. And this, I'm going to give this a little pause here because we might want, we, you might want to edit this and have this in a different order, but this next piece is a huge part of charting and I can't believe I forgot this. So, from the charting perspective, my number one time saver is dictation. There's nothing else that you can do that's going to get you anywhere close to those same results. My first six months in family medicine, yeah, it was about six months, I was doing it, I was typing. I'm a pretty fast typist. I used to be a secretary back in the day, so I'm pretty good, and I was all right, but really my numbers changed when I started dictating and I thought, "This going to be this weird thing." It's not. Everything's weird the first time do it, but by the 10th time it's not weird anymore. And when you realize, "Oh, this weird thing gets me out of here," yeah.

So, that is a major, major game-changer, and looking for ways to learn that if you don't already know how or to get comfortable with that if you're not there yet, definitely worth because that is what is going to be just a game-changer.

Liz Rohr:
Yeah. And is that something that your clinic already had, or is that something that you sought out, or you paid for, or how did that work?

Jessica Reeves:
So, we had Dragon which plugged into Epic. So, we had all of the top-of-the-line sort of stuff, and yeah, I was the new kid because I was one of the new NPs and I was a younger grad. So, I had a really old handheld microphone. So, we had good stuff but my equipment wasn't great, but it didn't matter because it still, it records my voice and it's learning what my things are.

I had another colleague that was at the same point, we graduated at the same time and she started like a month after me, and she was really good with cardiac stuff. There were clinical topics that she was way better than me at, but charting, I was way better than her at charting. So, she started dictating and she got this huge improvement. She's like, "Oh man, I'm finishing hours earlier," and then something happened, they gave her a new computer and the microphone didn't work anymore, and so, she just abandoned it, and I was like, "IT can help you with that." She abandoned it and she's there till 10 o'clock at night still charting all the time. I'm like, "Seriously?" All you have to do is get this thing and plug it in and be like, "Patient presented with..." Yeah, done.

Liz Rohr:
I have a very not great hack. So, I think the ideal situation is that you discuss this and I have an episode about how primary care offices work and how to navigate scheduling issues and communicate with leadership. So, this is more of on that side of getting support from the whole group instead of you can ask yourself, but you might need support because it's a functional, potentially expensive change for the clinic. So, I do recommend you take that route first, but if you do have to hack it, Google Docs has a dictation feature. It's not great for medical stuff, but Google Docs is free if you have a Google Gmail account and you can dictate stuff. You have to edit it, so I don't know if it would save that much time. That's why I haven't used it, and because we didn't have Dragon, but I think Dragon is specific for medical words and stuff like that. So, it's ready for those things versus Google, it's like, "What is that?"

Jessica Reeves:
Yeah, right. And even so, Dragon isn't perfect. Even if you get just your box of text and then you copy and paste it and then you have to edit a little bit. Even with Dragon, you still want to review your note each time because you never know if there are curveball. It has it's own autocorrect where you're like, "I didn't say that," and it was that Dragon swears I did. So, you still want to be reviewing it anyway. So, yeah, I mean it's still, even if you had to copy and paste it from Google Doc, it's still going to be faster than typing it out.

Liz Rohr:
Yeah, yeah, totally.

Jessica Reeves:
And I found that a lot of nurses are just not great typists. They're not fast, no shade or whatever, but they're just not fast. So, it's going to be faster for you, right?

Liz Rohr:
Yeah. Totally. Totally. Well, I do want to get to the question about scheduling challenges as well as addressing it with leadership. I think that even, and I gave this example off the recording, but somebody just wrote in, I think it was either today or yesterday and was like, "I'm really..." Here's the context. I am in this practice, I have a schedule, and I'm willing to see patients as needed, double or triple booked for emergency situations or urgent matters, and that's how most clinics go. It's like, "Here's your schedule. You know what? I'm so sorry, providers, who can take this kid with a sore throat with a fever?" And it's like, "Okay great, I'll be double booked at four o'clock. That's fine."
But then this nurse practitioner was like, "It happens every day," and we're kind of laughing about, well, emergencies don't really happen every day unless you're in the ER. So, I want to talk about scheduling and how it affects time management, and then also what your thoughts were about that, but then also tying in that piece of this is not a unique problem for this one person that wrote in. This is literally national for the last three years, probably international too because we serve people in Canada regularly and I think they have the same challenges. So, I don't know. What are your thoughts about that?

Jessica Reeves:
Yeah, this is interesting.

Liz Rohr:
How to navigate it.

Jessica Reeves:
I agree that that is a weird trend. I have to see an emergency every day, that's kind of weird. So, that person is right, and they're doing the right thing in that they are recognizing this is what's happening to me and this doesn't feel right. And you have to know a couple of different things. So, when it comes to the schedule, even I would kind of take it a layer back from the schedule, and you want to get a sense, and I used just a time tracker, just like a simple, even just pen and paper, and for different kind of visits, just track how long it takes you to do them. So, if you've got a kid with a sore throat and a fever, it's a quick visit. It should be, unless they've got some other stuff, but the typical visit, that's 10 minutes. They're in and out. They just want their antibiotics and they're good. Right?

Liz Rohr:
Totally.

 Liz Rohr:
Well, not for new grads. New grads, I feel like every visit takes an hour. But yes, once they feel better, it will be 10 minutes.

Jessica Reeves:
Yes. Yeah. So, it's a fairly simple visit. It's not this a bunch of different things going on. Theoretically, so if you're thinking about it, what does that visit entail? Well, you obviously have to assess the kid and you're going to get the history from the kid, you're going to get it from the parent or the guardian. But the assistant in most clinics, it could be a little different, but you're going to probably do a rapid strep or rapid something, but you're probably not going to be the one doing that. So, you're going to have your time to step out. So, how much time are you really going to be spending with the patient and charting at the end and then sending probably some sort of orders, either imaging or whatever, not imaging, but labs or meds. So, you have to know what your different things.

Now, of course, that's going to be faster than somebody who is 50 with a bunch of different things going on and 10 different prescriptions and doing their annual physical, or their three-month diabetes follow-up. It's going to take a little more time if you do them right. If you don't cut too many corners, they should take a little bit more time, but you have to know how long that takes you and what are your quick visits. There are some that are kind of universally a little quicker, a UTI visit versus a diabetes follow-up. They might be both booked as a 15-minute visit, but one is really going to be faster than the other, and get a sense of what that means for you.

Then you need to watch your schedule like a hawk, right? If you have add-ons put on, if add-ons are put on your schedule and people don't ask you first, they just put them on or they double book, again, that depends on the culture of the practice, you need to be keeping an eye on that and raising your hand and saying, "Can somebody else take this?" In the case of the person who wrote in and said, "I keep getting these things," yeah, is that true, or does it feel like you are? Because sometimes it really can feel like it's always you, but if you look at other people's schedules, it's happening to everybody. That's a bigger problem that we need to look at, or yeah, no, these are all falling on me in the last three weeks. It's always been me. Can we talk about this? So, that's an offline conversation.

But then also, the way the rhythm of this schedule, the pace of your schedule, a lot of places will have their first visit of the morning session and the afternoon session will be for acutes and those can be booked until maybe 24 hours before or even the day of, right? And then if it doesn't get booked, then you get a little bonus amount of time. But that's that. You shouldn't have two physicals back to back. You shouldn't have two new patient visits back to back. Some visits you should have a little bit more time if it's going to be a new patient visit. Unless it's somebody who's like 21 and they just have nothing going on. They just need to be actually... there versus somebody who's got a history or a post-hospital discharge follow-up visit. You want to be able to have more time.

If there are things that you know about certain patients, you need to use interpreter services. Those visits... because you're kind of saying everything twice. Those visits, you don't want two of those back to back, or you don't want to have some crazy trifecta of stress where you would have an interpreter services visit, followed by a new patient visit, followed by a hospital discharge for somebody who was in the hospital for a month with COVID and an MI. That is in nightmare. I'm going to have bad dreams tonight.

So, if you saw that under your schedule, raise your hand. This isn't going to work, and they might not be able to really change. It might be too late. So, what can we do about this? Can somebody take some of these? These patients can't be rescheduled, but can we move somebody over to somebody else? How can we go about this? What can we do strategically? Just so many other things with the healthcare and being a provider, they don't tell you this in school. You find this out when you are boots on the ground and stuff could go wrong and you say, "Okay, what can I do? I don't ever want to feel that way again. How can we make it so that..."

And so, having those agreed upon booking algorithms, being really on good terms if you can with the people who make your schedule. So, whether that's the secretaries or a phone nurse so that they'll come to you with stuff, letting them know what is maybe not working and involving them maybe in a solution because they see it too from the... perspective. So, I feel like a rising tide lifts all boats, and if we can make this better for everybody, then we all benefit or many of us benefit. But that's a big, big, big piece. There's also safety things that I saw a lot of when I worked for a larger health system. It would be 10:00 in the morning, I would look at my schedule, and I have somebody book for 3:00 PM that afternoon with chest pain.

Liz Rohr:
Yeah, I was just going to say it must have been chest pain.

Jessica Reeves:
Chest pain or unilateral leg swelling. Are you kidding? Right, okay... so that would be bad, and I would say, "Are you kidding me? Okay, who booked this visit? Let me talk to them. What's going on?" And yeah, sometimes unilateral leg swelling is cellulitis, but sometimes it's a DVT and sometimes chest pain is chest wall pain and sometimes it's a heart attack. Is this appropriate? Also, is this appropriate to be handled in this setting? Should this be in an emergent setting or at least even urgent.
So, things like that are also because... A DVT visit, I think of a DVT visit as fairly black and white. Okay, well, I got to get some imaging and probably grab some labs. You'll come back, we'll talk, we'll come up with a plan. But it's two visits because you're going to see them, then you're going to send them out for their stat imaging, their stat labs, then they're going to come back. You're going to wait for those results to come back. They're going to be there. They're hanging out for the afternoon or the morning. So, there's that piece too, and that can be stressful. Even though the issue is fairly black and white, it can be really stressful, especially as a new grad and the other things you have going on in your day. So, that's a lot of answer.

Liz Rohr:
No, that's good. No, that's good. And I think one thing I realized is that I think I took for granted that I had a template that had the same types of visits, that had rules about booking where physicals were a pink color and then sick visits were yellow, and blah blah blah blah blah, and your template is done out for a month or three months or however long your template goes. So, not everybody has that, and so, if someone's listening and is like, "Oh, you get that?" You to ask for stuff like that and you get to have an opinion about yours because for me, I would have procedures on Thursday afternoons and it was so delightful because it's like I love procedures, but then it was just this nice mental, physical, energetic break in between. It was just so nice, and so, that's what my request was and that's what the demand of the clinic was.

And I think the other thing I want to highlight about what you said is I think that there's a component of individual and a component of systems and the whole ecosystem of a clinic because I think that the common thing that I hear from new grads, especially if they're coming from a nursing background and they're thrown into this, not thrown into, we walk ourselves into these roles, but we are asked to step into a leadership position without really a ton of training for it, and then we're just, like you were saying, it's just boots on the ground and then now you have to be the end of the line and you're a leader who's sort of formally/informally supervises people.

I think a lot of people are intimidated by that, and then they also don't want to make waves is what people say a lot in terms of like, "Oh I don't want to because trouble. I'm so lucky to have this job." Even if they don't say that out loud, I know that I had that. That's why I'm saying that because it was in my head and I've heard it from some people. But when we speak up about things in a healthy environment of your workplace, you speak up, people listen. If they don't listen, and I talked about this a little bit in another time management video I talked about, but if they're not responding, then it's not escalated, escalated sounds like a confrontational word, but it's really like, "Okay, well, now we need a couple more voices and then we need to all get on the same page, and what are our policies too."

So, we had a policy about the nurses only got to approve those double book visits because they would clinically assess a person and see if they actually needed that urgent visit that day. A kid with a sore throat, for example, at 4:30 PM on a Friday or any day really. But yeah, we have rules in place, and so, I just want to offer that too of that's how that works, and definitely go back and watch how primary care offices work episode to learn a little bit more about the kind of chains of command parts. But yeah, it's really tricky, and it's heartbreaking to hear about how dysfunctional a lot of primary care offices are and that's like the norm. But do you have any other thoughts about that, about leadership? Actually, this conversation was reminding me, I have two good friends who are now medical directors, and so, I'm thinking about asking them if they want to come on and share from their side what it's like. I think that that would be really helpful. But, yeah, any other thoughts to share about that?

Jessica Reeves:
Yeah, I mean, I definitely, when you were saying the whole I don't want to make waves thing, I think that's very understandable and relatable, and I kind of wagged my finger metaphorically at the person who said that, "Don't think that." I get it. I can definitely get that. But, and I am in general an optimist, even though what I am about to say might not sound very optimistic, nobody's going to look out for you, but you busted your ass to get where you're are. You spent time, you spent money, you spent just years of your life. The opportunity cost of becoming a nurse practitioner, you're invested, you're in this, right?

Liz Rohr:
Yeah.

Jessica Reeves:
You now have to protect you, and the secretary isn't going to do it. The nurses aren't going to do it, the medical director's isn't going to do it. It's you. And so, you have to assert yourself. That's harder than being an NP, and also because they teach you how to be an NP, and then you... board and you're assessed, okay, yes, you are fit to practice, but nobody is like, "Okay, so are you good at speaking up for yourself? Do you know when you need to?" Nobody cares. It's actually kind of better for them if you don't.

So, now I'm going to get out my... I get on too big of a soapbox. But the reality is you have to recognize the need for that and backfill, coming to Real World NP is a great way to do it, to backfill those skills so that you can get to that point so that you're comfortable speaking for yourself or working with others so that as a group, you can say, "Hey, this is something that I think we need to look at as a practice, as a group, as a blah, blah, blah," and get that kind of consensus because nobody's going to do it for you.

When I've been in supervisory positions in the past, it's a lot easier to make a decision, especially a decision that potentially could impact the bottom line or that could impact a lot of folks. It's not just about like, "Oh yeah, you can have next week off." No, it's a bigger-picture decision. Easier to make those decisions if you have data. Otherwise, you're always, even leaders are human too, and so, they may be like, "Geez, I don't know. Did I do the right thing?" But if you've got some kind of data that you can match with, people feel a little bit better about that, and you still get right, but you feel better about it.

So, that's where tracking your time, seeing how you're doing, what's not going well, why isn't it going well, and then having that to bring with you when you do speak up for yourself, I think can go a long way. It doesn't always guarantee it, unfortunately, but it can go a long way, and if nothing else, it can help you to understand what you need and what you need in a certain work environment so that if it is time for you to switch to another work environment, you can have those questions that you know need to ask, like, "How do you guys handle X, Y, Z? Because I know I haven't liked the way it's been in the past."

Liz Rohr:
Totally.

Jessica Reeves:
But you have to look out for yourself and treat yourself, advocate for yourself as much as you would advocate for your patients, if not more than yourself because if you don't and you end up burnt out, what's going to become of your patients then.

Liz Rohr:
A hundred percent.

Jessica Reeves:
You have to put your... down first.

Liz Rohr:
Totally. Totally. And I always say that too because I think that was a transition for me of if it's not for me, it's for my longevity in this career and for my patients, and now I'm at the point of no, it's for me too. But that was a nice bridge for me because I was so in that place. But thank you so much for being here. I'm going to leave a link to your book in the description. Any parting words you'd like to share?

Jessica Reeves:
Don't be afraid to ask for what you need. If you need more time, if you need more support, if you need more blah, blah, blah, think about it. Think about what works for you. Reflect on it and find the way, whether it's through colleagues, through friends, through family, through working with Real World NP. Get those skills, backfill those skills so that you can ask for what you need, and time management is a huge piece of it. You can work on your skills, but if you're in the wrong setting, great time management skills aren't going to save you because I have them and I was in the wrong setting, so I had to leave. So,... that was a better fit. So, time management can go a long way. But really my bigger takeaway is that you need to not be afraid to ask for what you need. Know what it is, ask for it.

Liz Rohr:
I love that. Thank you. That's awesome.

Jessica Reeves:
Thank you for having me.

Liz Rohr:
Totally.