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Some clinicians say we have lost the art of physical examination with medical technology having increased presence in our practices. In my cardiology practice during a patient examination, I must remain mindful so as not to miss something unexpected or new, despite often knowing the echocardiogram results before entering the room. Sir William Osler might very well think this is like putting the cart before the horse, and perhaps the stethoscope will soon enough become obsolete. But, before we discard our physical examination skills, what if we broaden their application and apply these exam skills to our everyday practice environment too?
Diagnostic Clues in Our Work Environment
The idea of performing a daily examination of my work environment came to mind after a recent discussion with a coaching client who sought to improve her work efficiency. One irksome issue was how many yellow sticky notes her nurse placed on her desk each day, rather than sending those memos along to the EMR inbox. We discussed how the yellow sticky note was likely a sign of a deeper issue related to workflow. So we took a diagnostic dive into the "sign of the yellow sticky note."
What came to light for this physician was that each time she stopped at her desk between patients and saw more sticky notes on her desk, her level of tension rose. She already had a full patient schedule, full inbox, and these seemingly random notes triggered powerful negative emotions. We discussed the ideal situation, which was to reduce or eliminate these stacks of memos. She knew the yellow stickies were reflecting her nurse's desire to communicate important information to her more immediately. The notes were a physical sign in her environment that something was misaligned in their communication stream.
The 'Monkey on the Back' Analogy
The sticky note issue is reminiscent of the first described in 1974 by William Oncken and Donald Wass in the Harvard Business Review. This strategy refers to unsolved problems as 'monkeys on the back' and how managers unwittingly reducing their effectiveness by taking ownership of monkeys that rightfully need to stay with the employee. It is important to note that sometimes the monkey moves laterally within a team, such as in this case where the nurse's monkey, the yellow note, was transferred to the clinician's back for ultimate resolution. Oncken and Wass refer to these monkeys as time management drains, of which many others exist in our daily practices. Imagine what it would be like to remove a few of the monkeys we carry around each day? How much lighter might we feel in the moment?
Moving Toward a Treatment Plan
Once the yellow sticky note was recognized as a sign of a deeper systemic issue, the client began exploring next steps. As providers who live in a time-constrained work environment, the easiest communication might be to tell the nurse to stop putting sticky notes on your desk! This is like putting a bandaid on a festering abscess, when it would clearly be best to take time to drain the abscess. Self-management skills come into play here. If we are looking to support the nurse, make a change of habit, and improve our workflow, we must pause to have a more thoughtful conversation as a team.
Take a moment to recall a diagnostic dilemma you have faced or a difficult diagnosis that you had to research to solve. Chances are you brought a degree of curiosity to that situation as you dove into discovering the answer. We can use this same approach to discovering what the nurse might really be indicating when the yellow sticky note gets placed on the desk. Asking powerful, open-ended questions, rather than announcing what behavior you want changed, can lead to greater understanding for both parties. The clinician learned from the nurse that the note was a way to prioritize information that needed the provider's more immediate attention. If the urgent message was sent to the inbox to be attended to later in the day, the nurse would be under a greater time constraint to resolve the patient issue. In other words, the nurse was trying to pass the monkey quickly, so it might get back to her to deal with sooner.
Together, the two developed a more feasible solution that would help each of them feel less frustrated, yet allow more pressing work to be completed in a timely fashion. The ultimate solution was for the nurse and clinician to do a short huddle, twice a day, to exchange more urgent information. The nurse also worked to improve her triage technique, sending less-acute issues to the provider's inbox. The final treatment plan dramatically decreased the number of sticky notes placed on the provider's desk, lowered everyone's tension, and improved work efficiency and communication. An additional benefit was discovered in that there was more face-to-face time for the two to engage in some brief camaraderie.
The sign of the yellow sticky note was a clue to an underlying workflow issue. What was frustrating tolerance of an ineffective communication habit became an opportunity for the team to develop a more time-saving approach to patient care. The take-home message is to curiously examine signs in your work environment to discern ways to improve your day. Although developing mini treatment plans for the identified issues means committing time upfront, it does pay off in the long run. In the end, the "sign of the yellow sticky note" was a beneficial clue that led to the successful treatment of a practice dilemma.
, is a pediatric cardiologist and can be reached at .
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