From punitive measures to radical compassion for late charting

A few years into my faculty career, my division chief met with me to discuss late charts. “Britt, charts,” she said. “You just have to make it happen.” I don’t remember much about the specifics of what was said in that meeting, but I know exactly how I felt: a flood of shame overlying simmering anger. This someone that I respected, someone who had carved a way for the department to reimagine what training and practice might look like for parents of young kids. How could she not remember?

My eyes welled in frustration as I asked: “How?!”

There wasn’t really an answer to that question. There were reminder emails and in-basket messages, and—at a certain point—there were fines. There were offers to be mentored by a colleague who was “chart successful” that felt awkward and ill-fitted; there were after-hours sessions about EMR hacks.

With all of that, there was a lot that was missing: no conversation about how I was doing as a parent of two young kids (so tired), or how I managed my academics and clinical time (not well: overworked and un-boundaried). There were wildly vacillating assessments of whether I was on track for promotion (“You’ve got nothing to worry about!” to raised eyebrows and the ever-helpful instructions to publish more) and no acknowledgment of how that might be what floated to the top of the priority list. I was getting great feedback from families and patient evaluations, and my in-basket was clean (except for that pesky “open charts” header). I replied to electronic messages, signed refills, and sent back clear explanations that the nurses thanked me for. And I could not finish my charts on time.

I am a pediatrician. I view the world through a lens of development and relationships. As I tried to push my way through solving my chart problems without strategy or guidance, I entered a phase that I now recognize as a regression to my adolescent self: attempting to separate myself from a “parent” system that offered me no solutions, I pushed back and pretended not to care about the consequences that the system threw at me. Like a rebellious teenager, I was angry. I was angry at a system that set a requirement with no time to meet it and sent reminder message after reminder message as if I had simply forgotten while I was constantly (obsessively) running the list of clinic days with open charts in the back of my mind. I was angry that the solutions were not solutions: EMR hack sessions that often generated another unachievable list of things to do to be able to execute the hacks, more in-basket message reminders, and fines, which quickly drove me to rebellion and alienation rather than improvement. I was frustrated that the most basic concepts truths that we know in parenting and harm reduction counseling –  that shame is a terrible motivator for behavior change – were unacknowledged in a world that was, ostensibly, built to help adults flourish in their careers.

That teenage perspective delivered an important message: my chart problems were part of a greater system that wasn’t seeing or valuing me as a person. I also knew that I was not alone. A colleague with similar struggles compared the chart conversation to a scarlet letter: “I think that some people look at me and see only late charts.” She felt that every other accomplishment – incredible community engagement and strong and lasting relationships with families with kids with complex medical conditions – was overshadowed by the constant conversation about chart completion.

To spoil the end of this story, I did not, thankfully, crash and burn in a fiery explosion of chart fines and termination. My kids are older, my boundaries are clearer, I have a scribe, and my chart situation is much, much better. It’s not perfect, but it’s not an angry and rebellious disaster. I am more organized and have a different perspective on my time, priorities, and what counts as an urgent request from others. And I am kinder to myself.

The journey between then and now included a lot of twists and turns, including trial and error and some deep work in acknowledging the emotional experiences that impacted my relationship with charting. I started to see that what made me a strong and compassionate doctor also made charting challenging, as I had to re-enter intensely emotional spaces a second time. With a 15-year-old with a history of trauma who is navigating depression or chronic pain, who has had to grow up and move through the world independently with almost no financial resources on a backdrop of the structural barriers of racism and poverty, I do my best to bring care, compassion, and patience to that space. Going back into that chart can feel like facing the unsurmountable challenges all over again: documenting how we will work to get them mental health support in an overburdened and under-resourced system that they, as teenagers, are often navigating with limited support, knowing that the impact of structural racism is a tsunami that will continue to crash over their lives. When I document, I feel that encounter all over again. Once I could name that emotional challenge, I could better strategize about how and when I re-entered that space when I had more capacity.

A year or two into my journey out of the charting pit of despair, a colleague of mine texted me and other clinic leaders: “Anyone have a recommendation for a chart-successful mentor to work with someone who is struggling?” At that moment, I shot back to the moment of shame and anger that I had experienced in my conversation with my division chief so many years before. At that moment, I started to imagine a different conversation around charting, one that used the principles that we know are effective and ethical approaches to behavior change in other areas, such as motivational interviewing, harm reduction, and building psychological safety. These elements acknowledge that individuals are motivated by different factors, that small precedes larger change, and that psychological safety, “a state of reduced interpersonal risk” in which one can mistakes and grow, helps people perform, learn, and innovate more effectively.

From these questions, and a deep respect for MI and harm reduction, I sat down and wrote for 2 hours, creating a path to addressing chart completion that I sent as a reply to that text message. I tried to imagine: What if we dispensed with shame and met this challenge, pervasive throughout health care, with compassion? What if we used the evidence-based principles of motivational interviewing to help people identify their own barriers to chart completion and set small, meaningful, achievable goals? What if, as in physician coaching, we tried to use an individual’s strengths, foster self-compassion, and align chart completion with their values? What if we acknowledged the intersection between charting hours and burnout and how that influences people’s ability to change their charting habits?

I wanted people struggling with charting to have an alternative to the scarlet letter experience, to be able to acknowledge that inner teenage anger, to feel seen and acknowledged, and to use that empowerment to identify their own barriers, challenges, and ways forward. Since then, this piece has been shared throughout my institution by colleagues and leaders, and people from different corners have reached out to learn more about this approach. I received notes sent by individuals who let me know that this was the first time that they felt seen and heard in conversations about chart completion. As this work spread, I saw what it looked like to start, in a small way, to change the conversation away from the idea that physicians are somehow, fundamentally, different than their patients when it comes to changing behavior. We are unique intersections of our experiences, personalities, emotions, and values, and we are doing our best to honor ourselves, our families, and our patients every day. What if something as mundane as chart completion conversations acknowledged the complex emotional challenges of our jobs?

What if we said that this is fundamental in our work, but it is not the entirety of your identity as a doctor? How can we find a way forward?

Britt Allen is a pediatrician.

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