Enlightened Practice Podcast
In the first episode of The Enlightened Practice podcast, our hosts, Dr. Ken Braslow and Kari Kagan, talk about scheduling and the joys of putting together a jigsaw puzzle. They go over their routine from the start of their day to the end and discuss topics like cancellations, being a “lumper” vs a “splitter”, daily scheduling, and the challenges they face in their practices.
If you are looking to improve your scheduling process and make it as streamlined as possible, then this episode is for you.
Transcript of the podcast
Ken: Hi Kari, welcome back to the podcast.
Kari: Hi Ken.
Ken: Today, we’re going to be talking about scheduling and the joys and the pain that go along with running one’s own practice, and scheduling the clientele. We can talk about the very basics, but also maybe talk about some scenarios, and talk about administrative point of view, but then also there’s a lot of psychology underneath scheduling that shouldn’t be missed out on. So, maybe we should start off talking about what it’s like in your practice now and then we could think about what it would be like for a new grad that’s just starting out in practice and has a blank slate and wants to set up their schedule template.
Ken: So, I’m curious now tell us what your general schedule is and then we can start to pick it apart.
Kari: Yeah, I know. And it’s so important because my schedule has evolved so much from when I first started out in private practice to where I’m at now. But for where I’m at now, my schedule is daytime hours only. So, I start early at 8:00 AM and I’m done around three or four just depending on the day. At this point in my career, I’m pretty rigid about my schedule, as in, I don’t make many exceptions because I chose those hours for reasons that are important in my personal life. Like for example, I have children and I need to be there for my children after those hours. So there’s not much flexibility. And that’s a big guiding, you know, it has guided me in terms of making my schedule that way or a big part of what’s guided me. And that’s really different than when I first started out. But these days my schedule is early morning to late afternoon, three days a week. That has also changed because of the pandemic. I used to be four days a week, but in the pandemic I’ve had to adjust and it’s three. I’m happy to talk more about why I made those changes and what it was like earlier on, but I’m also curious to hear where, what your schedule is like.
Ken: Sure, and do you work weekends at all?
Kari: I don’t work weekends, no.
Ken: Okay. And holidays?
Kari: No which has also been a change. I now don’t work all the federal holidays. The holidays that someone would have off in a, I guess, normal, not private, precious job. However, I used to work holidays in the beginning or some holidays anyways. Now I’m a bit more protective of taking some time off when other people are taking time off as well.
(03:21)Ken: Yeah, it makes sense. So, I work about half time in private practice, because I’ve got Luminello to occupy me much of the time. So, it’s three to four days a week and it’s mostly during the middle of the day. However, because I work with kids and families, I do reserve a little time, two days a week in the afternoons to see kids after school. But in general, most child psychiatrists probably work a lot of afternoons and maybe into the evenings. Certainly when I started out my hours were weighted very differently. I started much later in the day. No kid wants to come in at 8:00 AM. Nor does any parent want to bring their child in at 8:00 AM. So, I would start early afternoon and then go into the evening. And that was ideal for my patients, but as my life evolved, and those hours we’re also wanting to go elsewhere, I had to come up with a balance. When I started out, I would occasionally see people on the weekend, because I lived very close to my office and it worked for them and it was nice. I could sneak in a patient or two. So it seemed like a win-win. But yeah, once you have kids all of that seems to go away pretty quickly. And I used to work most holidays because I thought, I want to choose my holidays. I don’t want anybody else to tell me when to take a day off. And now I just don’t even bother because so many of my patients or their families are off those days and don’t want to come in and it’s just too challenging to fight it. And the amount of rescheduling was more an administrative burden than it was worth.
Kari: Yeah. I’ve had a very similar experience on those kinds of days. And I’m curious in terms of how you set up your schedule on any given day. Do you see clients back to back, or how do you integrate breaks throughout your day?
Ken: I typically do see patients in bundles, but I do allow a small break in between each patient. I’ve gone back and forth on this throughout the years. When I was starting out, I wanted to be as efficient as possible and get as many patients in consecutively. And what I found was that it worked okay until I moved to an office where the bathroom was like on the other side of the building that I was working in. I would end up starting sessions late because of the transit time it took me to get to the bathroom and come back, and it was just too much pressure. I didn’t want to have to sprint you know, between patients. So, I decided to put a five minute interval in between, and that allowed me to do two things.
One, allow me to run over a few minutes if I needed to, without this feeling inside of anxiety, because I knew my next patient was in the waiting room getting anxious because we were starting late. So, I typically like to start on time and end on time, but lots of powerful things come up in session, and that’s not always appropriate to end right on the dot and I didn’t want the pressure. I wanted to be fully available for my patient without thinking about that we’re running over. So, mostly I just didn’t want the stress from it. But only doing five minutes allowed me to still maintain a mostly efficient schedule as opposed to like scheduling on the hour, which sounds nice. But my med checks are typically half an hour and my therapy patients are typically 45 minutes.
Ken: So, on-the-hour just doesn’t really fit. So, I ended up having some like funky scheduled times. Like, I see people on in five minute intervals, so 10:55 or 11:40. But I’ve never had anybody say, wow, that’s a really odd time to start a session. So doing it, that’s worked out well.
Kari: Yeah, makes a lot of sense.
Ken: Yeah. I used to have days where I saw patients all day and I would try and bundle phone call time with email time, with lunch. Typically like 20 to 30 minutes after a certain consecutive number of patients. And I experimented throughout with how far could I go before I needed a longer break? And generally I found that I could see five patients in a row without a break, but I was really feeling it at the end. And my stomach would growl in session. It was just working too hard. So, typically I would go four in a row and then take a break and then however many more, three or four more.
Kari: Right. My stamina has evolved over time, as well as lessened. But yeah, I guess for what we do, we have different kinds of schedules. Because I don’t have med, so I don’t have those like 30 minutes or shorter appointments. So, I do schedule on the hour and usually I see six in a day. I’ve toyed around with two and then a 30 minute break, and two and then a 30 minute break, and then other times doing three, an hour break , and three. And honestly, either one works for me it just depends on the day or what has been going on in my life. So, more like a specific thing that I’ve had to take into consideration with breaks was being a mom, two different times, two different babies.
I’ve had to think about needing to take time for, for, mommy things like pumping and that’s influenced when I schedule breaks and how I do that. But, I definitely need one to two breaks, either two shorter ones, or one longer one, and this speaks to more of, like, the clinical implications of the schedule that I think was more earlier on in my career. I was more inclined to push myself and then just as I’ve changed, as my life has become a little bit busier, just becoming a parent over the course of being in private practice so far. I’ve realized how important these breaks are for me to be able to do this job, right. It’s a pretty emotionally demanding job, not one that’s easy to like power through. I’m sure this is true for a lot of different jobs, but it feels particularly true in this case that breaks are really important just for being able to like, do, to do a good job, what we do.
So, I think it is important for anyone starting out to really think about or to test out like where their limit is and considering planning breaks where that limit is, and not necessarily trying to push too much because it does take away from the clinical work at that point. So, it’s worth putting thought in and it’s worth paying attention to, and being super open to the need to change which I’ve had to do as well when I realized something isn’t working in my schedule because it’s too many clients in a row or an hour is too late or too early, you know? Needing to give myself permission, but oftentimes needing to get permission from colleagues that it was okay to make a change. Even once I had already committed with a client to a certain time that’s been really important because sometimes we’re just learning as we go and we might need to make a change that’s in everyone’s best interest.
Ken: Oh, I changed my template every six months when I started. I remember thinking even, what’s the best quality care here? When I started out, I was seeing up to 10 therapy patients a day and I really enjoyed it. You know, it was like in training, you were doing all this admin stuff or rotations that weren’t really things that I was so interested in. But when I got into my practice, I thought, oh, I can finally just do what I love doing. And I just went a full bore into it. And then I realized around maybe my ninth patient of the day, like if it were a 10 patient day, I was just like, Ugh, the sun had risen and set. And I was still in the office and I was getting cranky with dinner times and I was just fading, and I just didn’t think it was fair.
Like for my last patient, I would always rally, you know? I’d hear like the Rocky theme song in the back of my head. And I was like, okay, one more and I’m out of here. But I thought for my second to last patient, I always felt like they’re not really getting a hundred percent of me and they deserve that. And so that’s when I shifted gears to cutting back a little bit. So, I didn’t burn out and to be more fair to them and scheduling more generous breaks in between. So that it was a win-win for everyone. I think when you’re first starting out, we’ll talk about new grads in a little bit, but I’ll just say in general, first starting out, you just want to get that schedule filled, at least I did. And then I think you hit a point where you’re like, okay, that’s not actually the highest value and there’s also some risk in doing that. We can come back to that later though, so, okay. That’s interesting. So, if a new patient says, I can only meet after work or on the weekends. What do you say to them?
Kari: Yeah, at this point I don’t make exceptions. So, I say, I don’t have that availability and I’m happy to connect you with someone who might. And I will work to try to find them someone who might have that availability and give them those references. But at this point, as I mentioned earlier I’m pretty rigid and strict with my hours. And in comparison to earlier on, I would stretch a little bit. And what happened when I did that was sometimes I found myself kind of feeling resentful. And it wasn’t the client’s fault of course. But when I found myself in the office, for example, for an 8:00 PM client, when I really only wanted it to end at 7:00 PM, I would be annoyed that I was there.
So, I learned early on that it’s, again, not anyone’s best interest to push in and it’s better to refer out. And that’s more important to me now, but yeah, earlier on, I might’ve felt more, if the goal was to see as many clients as I can just for training purposes and getting the experience and building up momentum in private practice, it makes a little bit more sense to maybe have like more flexibility, But as my priorities have shifted, I realized I can do it all. Even though I will say, I remember being scared at first to set boundaries around my schedule. I felt worried that I wasn’t going to be able to fill my schedule or didn’t feel in a position to turn people away. But as advice that was given to me, it was, basically if I hold the boundaries and then people do adjust. If someone really can’t like another person will be able to, or clients can actually be more flexible than maybe they originally thought. And that’s been absolutely true for me. But I remember it felt like a risk or a little bit of a leap of faith at first when I gave up some of my flexibility and held onto more of my ideal schedule. How do you handle it?
Ken: Well, I have on my voicemail on my website and on my prescreen form that I do not work weekends and I’m not available for early morning or early evening appointments. And that probably keeps people from even contacting me further. However, still sometimes people do, even in spite of all of that and I try to make it really clear. And even in scheduling the evaluation session, you can see if people really need it, sometimes it’s just not meant to be. And I agree with you far better to just say, I’m sorry. I’m just not the right person for you then to push it, because if you push it for the evaluation session, you’re setting an expectation for them that you have the option to push it. And then what if you don’t in the future and that could trigger psychological dynamics between the two of you where it looks like you’re in the position of power and it’s just all this meta-psychology that’s interfering with the actual clinical questions they’re coming to work on with you.
So, I just don’t do it now. Perhaps later on in life once the kids are out of the house and on their way, I would consider it. One of the schedule ideas that I’ve toyed with for down the road is a few patients in the morning, like three or four in the early hours and then go live. And then come back in the early evening for a few hours. And that way you don’t feel overwhelmed at any one time. And, but you’re offering prime time slots, but yeah, not there.
Kari: Yeah. That would be interesting.
Ken: So, I noticed we’re coming up on time for today’s discussion. So, we didn’t get to talk about approaching, setting up a schedule for a new grad. So maybe let’s talk about that next time. And then also, we didn’t talk about online booking and how that plays a role, so we can add that to the list. But thank you for chatting with me about the intricacies of scheduling today.
Kari: Yeah, always.
Ken: Talk to you soon Kari, take care.
(20:19)Kari: Okay, bye.