To the YSM Community:
Near the end of my residency, my beautiful, talented, and irreverently witty mother-in-law developed an expressive aphasia and was diagnosed with an inoperable grade IV glioblastoma multiforme. She was referred to a world-renowned neurooncologist at our academic hospital. When my father-in-law called for an appointment, the office did not call back for a few days (an eternity at the time), but he persisted and was able to schedule an appointment. They arrived promptly on the day of the appointment, but the physician did not. The nurses were very kind and explained to my in-laws, not to worry, Dr. XX, often wandered over late from his laboratory. He was very good, however, and could provide access to cutting-edge therapies. The neurooncologist arrived an hour and a half later.
Over the next 15 months, the family went on an odyssey in pursuit of hope. Eventually we found another neurooncologist who was compassionate and attentive and earned the respect and gratitude of the entire family. However, the encounter with the first neurooncologist left my father-in-law feeling disillusioned with medicine for several years and left me feeling embarrassed by my profession.
In this context, I note with gratitude the extraordinary commitment of our faculty, trainees, and students to patient care. Almost weekly, we receive notes about the impact you have had on someone’s life. And whenever a patient reaches out because he or she is having trouble getting an appointment, our clinicians respond generously, sometimes heroically, to see them.
Nevertheless, we have systems issues that make access to our world class clinicians unreasonably difficult. These systemic barriers create inequities, as the patients most likely to be able to navigate our complex and dysfunctional system are the most familiar with medicine. In our early town halls, many of you expressed moral angst over the difficulty both patients and referring physicians face in scheduling appointments. To address this need, we have embarked on a three-year journey to fix access with the Access 365 project, which requires a collaboration among leaders, faculty, non-faculty clinicians, staff, and outside experts. Waves 1 and 2 of this project launched with orthopaedics, radiology, primary care, neurosciences, heart and vascular, and urology, and we are now in Wave 3 of 8, with active work ongoing in digestive health, rheumatology, endocrinology, dermatology, and ophthalmology.
Untying the Gordian knot of patient access requires engagement, openness to change, and a committed focus on the needs of our patients. We currently have three asks of our clinical departments and faculty:
- First, we ask that our specialists and subspecialists agree on the appropriate appointment duration necessary to see their type of patients, considering national benchmarks. Over the years, we have developed hundreds of personalized templates within individual specialties, making it extraordinarily difficult to schedule patients.
- Second, we ask that specialists work with access leaders to revise templates to accommodate new patient visits in accordance with best practice for their specialty. We have learned that a few of our specialists could do better at returning patients to the referring physician as their condition comes under control.
- Third, we ask that clinicians adhere to standard hours. This is necessary as bespoke start and stop times can wreak havoc on staffing and operating a clinic. We have heard that this is a hardship for some. In the long-term we will examine the feasibility of developing staggered start times at our larger clinic sites.
Because change can initiate urban legend, it is probably worth saying what Access 365 is not. The access work does not require clinicians to change their number of clinics or meet some quota. The number of clinic sessions they hold is still determined by their section or department according to their track and clinical effort. Sections and departments assign faculty to clinic periods and can work to balance needs for morning or afternoon clinics, in the same way they distribute inpatient call schedules.
The efforts to improve access and clinic flows is enhancing the ability of clinicians to focus on patients while in clinic. The introduction of ambient AI (Abridge) enables physicians to spend more time face-to-face with patients, and less time on the computer. Increased levels of support staff and better coordination of staff schedules enable physicians to spend less time scheduling tests or making sure that they are performed and more time teaching and learning. Investments in clinical triage are routing patients to the most appropriate level of care and markedly improving warm handoffs, positively impacting patient outcomes. Further plans this year include initiatives to support in-basket management and prescription renewals, reducing administrative burden on our clinicians.
We are already seeing the benefits of this work in patient access. In Orthopaedics, we reduced the number of visit types from 38 to 21 and improved capacity by 24% without adding clinics. Redesign of imaging templates increased MRI capacity by 11,000 – 13,000 additional scans per year, providing important support to clinical program development in areas such as Alzheimer’s disease treatment. Positive patient satisfaction comments with our internal medicine primary care group rose from 68.2% before to 88.7% after the access work, with overall improvement driven by the categories Care Provider and Access to Care.
We are on a journey that began with conversations about access in listening sessions and town halls. We are now engaged in difficult work, but we must remain focused on the goals of enabling patients to access our world-class care and enabling clinicians to dedicate their clinic time to doing what they love—caring for those patients. I am grateful to the leaders in Wave 1 who have shown how this can be done with grace and whose teams are starting to reap the benefits. I appreciate those leaders who will continue to improve on the process over the next year and the teams who are in the trenches making this work happen. You embody the best of our profession
Sincerely,
Nancy J. Brown, MD
Jean and David W. Wallace Dean of Medicine
C.N.H. Long Professor of Internal Medicine