Moving Us Closer To Osler
A Miller Coulson Academy of Clinical Excellence Initiative

Tick Tock


Clinic visits are like the new Major League Baseball’s time limit for each pitch. Health professionals do their best to deliver excellent patient care while being aware of the clock.  

As a baseball fan, I was curious when earlier this year, Major League Baseball changed its rules to include a pitch timer. Instead of the longstanding back-and-forth “dance” between pitcher and batter that could add many minutes to the game, there’s now a rule for how many seconds there can be between pitches. This was created in order to speed up the pace of the game and has already been used in the minor leagues.  


What do the players think? Interestingly, this is what ESPN reported: “There’s been mixed reactions to the pitch clock, with veteran relievers worried about rushing through high-leverage situations. But many young players who have spent time in the minors during the past couple of seasons are already used to it.” 


So how does this fit in with clinical excellence? Those of us in outpatient medicine have had a certain time allotted to patients for decades, even though the time scheduled doesn’t always fit the patient’s clinical complexities or the discussions that we need to have. Physicians who are proceduralists and surgeons are increasingly having their time tracked and monitored to improve “utilization.” Some doctors express concerns about how to manage higher complexity with the same amount of time, just like the more veteran baseball players. Others accept this is the paradigm in which we must provide care–someone tells us how much time we have (the administrator or clinical leader) and we must make it work. 


So how do you provide clinically excellent care with time constraints? 


1. Prioritize essential topics.

Did you make an error and need to disclose it? Need to make sure the patient is adhering to her new medications started in the hospital for a heart attack? Identify the priorities for the day.  


2. Be aware of the clock, however, don’t let it influence the key parts of care

In outpatient medicine, we often have topics that would be “nice to do” but not “essential to do” at a given visit. Flex with timing and be ok with not covering it all. At the same time, don’t rush through the important items to stay on time. 


3. Make use of your team.

Think about what things you may cover in an office visit that you might delegate to other team members. 


4. Manage time expectations.

Ensure your office staff notifies patients if you’re running behind. This is especially important if you have video visits within your in-person schedule, as patients online can’t observe how busy the office might be. If patients have time limitations (for instance, needing to get to daycare pick-up or to a work shift), be proactive and ask staff to schedule them at times that fit better with their schedules. Sometimes, you also must politely tell patients that you don’t have time to cover everything on their list in order to serve others. 


5. Realize and accept that sometimes you will completely blow the schedule.

Sometimes something serious will happen and you just have to accept that it will totally throw you off. For me as an internist, this happens most often when either someone is very ill and needs emergency care and we’re managing them until the ambulance arrives, or the patient has a very emotional event happen, like a family death or their own serious illness and you absolutely must have a longer conversation.  


6. Give yourself grace.

Tight scheduling is hard for everyone. There are many systems reasons why this takes place, and perhaps you might have the energy to advocate for change in the health system, locally or nationally, that would change how scheduling works. But many of us are using all our energy to do our jobs. Know that when you get behind, you’re not failing. Instead, you’re not always being given sufficient time to do all parts of your job well. Just do your best. 








This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.