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Psychological Fitness Foundations, SDT Part 3 - Autonomy of Time

We are in a series exploring the three foundational needs for physicians to optimize their psychological fitness – autonomy, connectedness, and competence (SDT). This week, we will reflect on time, the first of four domains within autonomy for physicians - Time, Tasks, Team, and Techniques. I'll also highlight a fifth "T" – Thoughts/Mindset within each facet as we unpack them each week.


Time. There is great variety in the amount of autonomy given to physicians. Many residents and employed physicians working in certain large healthcare organizations lack agency as it relates to time. Physicians who own their practices may work just as many hours, if not more, but it's by choice to make the business fiscally viable. However, no matter the setup, there are ways to increase agency for individuals or groups.


An example of supporting autonomy of time with constraints for an individual: The large healthcare organization I worked for set expectations regarding the number of patient slots that must be open throughout each week. I controlled days, times, and length of visits for three predetermined patient visit types (new patients, established patient regular visit, and acute care visit). They also allowed me to designate some individuals as requiring two consecutive regular visit slots as long as it was the exception and not the rule. My MA and I worked out what mutually beneficial hours would look like within the guidelines. We found it quite freeing to approach it this way. 


An example of supporting autonomy of time with constraints for a group:  Within that same large healthcare setting, each office had a local medical director, and we were empowered to meet monthly to make group decisions - what time we opened, what time we closed, after hour call policies, weekend clinic coverage, etc. All six of us had agency in collaborating and balancing the needs of the larger system at the local level. It was indeed a team effort - and actually helped us congeal as a team. Giving physicians autonomy does not have to lead to toxic individualism. It actually can do quite the opposite.


How can you, in your setting – whether you're a leader or not – be creative in honoring reasonable boundaries that the organization sees as crucial to sustaining the mission while increasing the physician's control of time and schedule? The growing complexity of medicine and communication requires admin time. How can the system allow for that flexibly? What could that look like in your location? I'd love to offer that not every physicians' patient panel is equal. And if empanellment adjustments aren't made, additional consideration would benefit those with more complex patients (medically and socioeconomically). 


Time thought-work: Herein lies the opportunity to take back agency even before circumstances change. 

First, identify where you DO have the ability to make "informed, uncoerced decisions" concerning your time. When your brain offers "Nowhere!" then put on your detective hat and really try to find answers. Areas to consider:

 -What time you arrive

-What you do with your lunch break 

-How much time you spend in the room 

-How much time you spend chatting with staff and colleagues

-How much time you spend on the note

-How much time you check email, messages, and social media

We are already prone to seeing where we don't have control. So, point your brain in the opposite direction. Our brains like to find answers. It's nice to discover that we do have some volition regarding our time.


Second, for those areas above where you automatically thought, "Nope, I don't control that," give yourself some space to consider otherwise. Often the default is: "I don't have a choice on how much time I spend addressing my email if I want to get it done before I go home." But acknowledge that it is a choice - I choose to get to my email. I choose address it at work. I choose to glance over it and only respond to important things I care about.  It's a choice. You make the choice because you prefer it over another. You could choose not to. Yes, there may be consequences. But you are not coerced to check it. Where can you start to see choice when there doesn't appear to be any at first? 

-I choose to show up 15 minutes early to tackle my inbox.

-I choose to show up 10 minutes after the first patient is scheduled so I know they'll be roomed and I can drop my kid at school.

-I choose to stay in the patient room this long because they were more complex or needed the time.

-I choose to only address the main priority for the patient because I want to run on time for my other patients.

-I choose to do notes during lunch to lessen the burden at the end of the day.

-I choose to work a patient in because I know them best and I want to help.

-I choose to have shorter visits to see as many patients in need as possible but aim for having time outside of medicine while making a dent in access issues.

These may not be yours. It is worth exploring. Yes, there will always be trade-offs to your choices, but many are yours to choose, even when it doesn't feel that way at first glance. Don't worry; accepting how things are currently and finding a way to feel better about it, and having a say does not mean you are endorsing the way things are now. Nor does it mean you can't advocate for change. It simply means you're looking for ways to find agency despite your circumstances. Stick with me.


Third, can you free up time currently used for venting and ruminating/perseverating about the system? Trust me, thoughts are under your control, even if you are uncertain that this is true. We know we are most efficient when tapping into our brains' creative and prefrontal cortex areas. Those same areas are suppressed when we are in the stress response - reliving the injustices experienced in our work. What tools can you utilize to help close the stress cycle, disarm the amygdala, and have those neurons firing on all cylinders? This will help you be more present, effective, and efficient. Read more here: Closing the stress cycle  


Last, but certainly not least, what areas do you feel most need change within the system to improve physician autonomy? Pick your top three, compare with colleagues to confirm the top one or two. Next, decide what is your burden to bear in leading or supporting the change effort. Consider your current bandwidth, post-pone until you have the energy, or encourage a champion. Small, practical, achievable changes can be negotiated when brought to leadership calmly and collaboratively armed with data. Even if you help move the needle 1% at a time, it will be a relief in the right direction. Then, you move it another few% later, and so on.


Next week we will continue to unpack the remaining domains of autonomy - Tasks, Team, and Techniques. Oh, and you know me, Thoughts

Have a joy-filled week,


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