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American Academy of Family Physicians
Thursday Mar 03, 2011

The making of a GREAT medical assistant

I am a female family physician in my 20th year of practice.  During my first 6 years of practice, I had one RN who worked with me – the same one every day.  Subsequently our practice has hired medical assistants (MAs) to work with the physicians and RNs to do chronic care management, wound care, RN procedures and patient education and to help the physicians manage their panel of patients with chronic conditions or frail health status.

I used to firmly believe that I needed the same MA all the time (except for sick or vacation days) to create a great system and strong patient relationships.  I've noticed in the past year, however, that things have been utterly smooth and pain free even with MAs rotating through. Recently I've been struck that almost every single patient (20-24 per day) comments on how much they liked the MA, how great she was, how helpful, confident and professional she was, and what great humor she showed.  Though I generally work with the same MA, this occurs on days when other MAs float through as well.

When I have presented our team-based practice model at national meetings, I've heard many physicians say "well, we all know that getting a good MA is about one in a thousand"  or "how do you find good people like this?  We can't get them where I practice."

I know from experience that, over a decade ago, before we had any standard training and professional development programs for MAs, some physicians in my own practice accused me of always taking the good people so that my team's morale was high and the team efficient, and theirs not.

So why are our MAs so great?  They almost all have come straight out of their 6 month training programs, done an externship with us and then stayed on.  So it's not years and years of experience.

We have developed a training program for MAs that delves step by step into "standard work." (I will elaborate.)  While they are externs, they follow one of the competent, established MAs awhile then start to do some of the basic routines.  Once hired, it's the same, except that they are doing the work with coaching from the MA trainer.  They all have the standard work manuals, which are like checklists. Whenever new standard work comes out, it is taught to all MAs and physicians so that both know how a new bit of work will flow.

The MAs and physicians are side by side in "flow stations," which we created out of what were physician offices.  This allows enhanced communication, hand offs, feedback (both ways), and reinforcement of standard work.  The MA/physician dynamic duo has never been so strong!

But that's just part of the answer. I will just briefly let you in on a secret we've found.  The standard work lists, which include such things as this sequence: 

  • Take labels for patient visit and apply to the fee slip.
  • Walk to the lobby and call the patient by formal name.
  • Wait for the patient and walk with them (not far ahead) to the exam room.
  • Help them be seated, hang up coat, relax.  Greet formally and explain that before the visit with physician you will be updating their prescription lists and health care maintenance.
  • Wash hands.  [And there is detailed training on hand washing as well.]
  • Open the EMR, explaining to the patient that you are accessing their online chart.
  • Click on Medication Profile, and update their prescription and OTC meds.
  • Click on Health Maintenance Module and see what's due.  Discuss with patient to verify it's correct.  Check off the items due on the patient visit work sheet; fill out any lab orders that are due.
  • Then open the Ad Hoc for vital signs.
  • Take patient's BP, Pulse, height and weight (if appropriate), and temperature or SaO2 (if appropriate)
  • Wash hands.

In training this way, each MA develops an automatic sequence for rooming, which gives them great confidence, and the ability to interact warmly with the patients.  They know what they are doing, they KNOW their job and don't get criticized by physicians for not doing it their own way.

Knowing their job, knowing all the steps, knowing why it's important and valuable and knowing it improves not only the patient's care and satisfaction but the flow and time of the physician in the visit gives our MAs a degree of confidence and freedom to establish a human touch that is simply amazing.

I thought of an analogy.  Anyone who's ever bought a new car or rented or borrowed a different car faces a similar set of issues. How does the ignition work? How do you turn on the wipers and the lights? How does the climate control work?  How do you open the trunk or the hood? Where is the gas tank opening to fill it? How does the seat move, how do the windows open, how do you lock them?  How does the seat belt work? I've felt like an idiot in some cars when I can't figure out how to turn on the lights or wipers driving in traffic, even though I'm a completely competent driver.  Taking time to go through every step and actually perform the tasks until it becomes automatic is key. That's standard work.

This reminds me also of learning to play the guitar.  The necessary motor skills are learned in tiny increments before one can play a chord or finger pick.  It's attention to detail that allows all of us to be competent at a job or avocation.

By the way, we have done the same thing with RN work, diabetes care management and physician flow through the day. In fact, we create standard work for anything new we implement.  And everyone has to go through hand washing training and audit, step by step.

All this just came to me as I was reflecting on my patients commenting on how delightful my MA was, no matter which MA I'm working with.  She is; they all are, and they've been allowed to blossom because they know that what they do is correct, standard and valuable.

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