Dr. Sarah Smith spent 15 years buried in Sunday charting before she cracked the code on finishing documentation inside the workday. Now, as The Charting Coach, she helps thousands of physicians reclaim their evenings — without seeing fewer patients.
In this episode:
How to break the after-hours charting cycle for good
Inbox strategies that stop the patient-message ping-pong
The sneaky daily habits creating your documentation backlog
The honest truth about AI scribes (and how to use them without making more work)
Dr. Smith is a family physician, host of the Sustainable Clinical Medicine Podcast, and founder of the Charting Champions Program at chartingcoach.ca.
Explore physician jobs → pacificcompanies.com
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Full Transcript:
Stacey Doyle (00:00:01)
Welcome back to the Doc Lounge Podcast, where we explore the ideas, innovations, and conversations shaping the future of medicine. If you’ve ever found yourself finishing patient visits only to spend hours catching up on charts long after dinner, you’re definitely not alone. For many physicians, after hours documentation has become such a normal part of practice that it almost feels unavoidable. ⁓ Today’s guest is here to challenge that belief. Joining us is Dr. Sarah Smith, better known as the Charting Coach.
After spending 15 years buried in evening charting herself, she discovered a sustainable way to consistently finish her documentation during the workday. Now she helps physicians and clinicians do the same without sacrificing patient care or working impossible hours. She’s also the host of Sustainable Clinical Medic Medicine Podcast, where she helps thousands of physicians rethink charting inbox management burnout and what it really means to build a sustainable medical career.
Doctor Smith, welcome to the Doc Lounge. We’re excited to have you today.
Dr Sarah Smith (00:01:05)
Well, thank you so much. I’m excited to be here too.
Stacey Doyle (00:01:08)
Well, you’re you’re really talking about a subject that’s very, I would say, hot and one we love to discuss here of just work-life balance and and bringing that back to providers and clinicians. So tell us, I know you spent fifteen years doing after hours charting, you know, before finding a better way. So what really made you realize something had to change?
Dr Sarah Smith (00:01:31)
Well, initially I wasn’t sure what the problem was and and if it would just get better. So when I was doing my training, I asked mentors, like, how do we deal with this paperwork problem? ⁓ And their answer was, you come in Sunday. ⁓ And I’m like, ⁓ okay. ⁓ I guess this is a problem for everybody, not just for me. ⁓ What I now realize looking back on that time, some 20 plus years later, is they were talking about things that came in when they were on break or
occasional extra pieces like insurance documentation, they weren’t doing their chart notes ⁓ and referral letters from the encounters on Sundays. They were getting that done in real time and I had missed that understanding of what it looked like to get work done in real time. So I’m looking at this mountain of work ⁓ every Sunday ⁓ and they’re thinking of it as an occasional excess paperwork problem.
So we had this misunderstanding, and I ⁓ feel like at that point, ⁓ I’d done five years in family practice. We then moved and traveled around Australia for a couple of years and then moved across to Canada, set myself up again in family practice, and boom. Within months, I had this same problem of I was there after the last patient left for hours and hours. I just going home without the work being done. I was then working in those evenings and weekends.
And it was when my big kid was in grade 10, ⁓ and I was listening to him have a conversation with dad ⁓ about going to uni in two years, that I my heart just sank. And I realized, wow, I’ve been their mom and a doctor since you know, ⁓ he’s now grade 10, and I still haven’t figured this out what’s wrong with me. Cause I thought it was a me. ⁓
Well, I thought it was definitely a me problem because it followed me from Australia to Canada. ⁓ and then I’m like, well, will I ever figure this out? And I had no idea how to figure out this problem. It was completely impossible. ⁓ I had not g been given any other way of doing medicine, and this was my life, and I I was done with it. I was resenting it fully by that stage. ⁓
Stacey Doyle (00:03:48)
Well, I feel like it’s something that’s become so normalized in medicine, you know, people almost think, Okay, I can’t avoid this. So do you think now is it really unavoidable?
Dr Sarah Smith (00:04:00)
So I do believe that many of our systems are not looking after doctors ⁓ or clinicians. So one, our EMRs, EHRs, are not designed for us. They’re designed for being able to track how many, you know, what we’re doing in a day ⁓ and to be able to hold a lot of information about patients. ⁓ But it takes so many steps to be able to do something within that EMR. And even finding information back out of that EMR is not well looked after for us. ⁓ So that’s
Part of the problem is it’s not set up for us. Secondly, especially since COVID, but I know many physicians in the US were already ⁓ managing massive my chart inboxes. So they’ve got that direct patient to doctor conversation happening. ⁓ A lot of the ⁓ physicians didn’t have that happen until the COVID times in Canada, for instance. So this was going from ⁓ something that never existed, which was patient direct-to-doctor questions, started to become a bigger feature of.
And if we don’t start to notice the ask on us, we are always, always asked to do more. They never ever, I’ve never, not once in my career, ever heard of a doctor who somebody comes up to them and says, Hey, can you see a third less patients tomorrow? Can we, you know, do your inboxes for you for the next week? Like never. But we’ll get asked, can you cover Sally’s inbox for the next week, next month?
Can you pick up so-and-so’s ships that are sick today? We’ll get asked to do more. ⁓ And so it becomes important that we notice what we’re being asked to do and we have strategy on how we do it. So that inbox can be light or heavy, depending on how we’ve been taught or learned to approach it. And the same number of items can look very different for humans if we’re not.
Stacey Doyle (00:05:29)
Yeah. ⁓
Stacey Doyle (00:05:53)
Well that’s
Dr Sarah Smith (00:05:57)
Port strategy.
Stacey Doyle (00:06:00)
I think that is so true. And I love hearing you say that. It’s being able to set those boundaries and have that right communication. ⁓ so tell us what are some tips and strategies that you’ve found that you’ve deployed? I know we’re gonna get in here more about what you’re what you’re doing to help with the charting, but tell us what what have you just found works ⁓ being a practicing ph ⁓ physician or clinician and and then kind of pushing back?
Dr Sarah Smith (00:06:28)
Yeah. ⁓ So we know that direct patient to doctor is not or clinician is ⁓ not ideal because often the questions coming to the physician are not physician questions, like can I get an earlier appointment? That’s not a a a question you need to be answering. It’s not for you. ⁓ So starting to think about who else is in my team, who else can be doing this, who else is looking at this ahead of me. A lot of physicians will have a nurse, an MA, or somebody looking at those messages before they’re passed on to you.
And so sometimes you will I hear a lot, but my nurses are s are busy too. I’m like, yeah, but when you have them read it ⁓ and then action it to you, and you have to read it and action it back to them, then they’re doing work twice anyway. And they’ve already had to read it to assign it to you. And therefore, if we give them our step, a permission step for some of those things to be automatically deferred to the other person.
Back to please rebook this. We now remove some of them out of your inbox. So starting to be curious who’s available, who can help me with this? Now, some of you will say there’s no one, it’s just me. In which case, we just need shortcuts for you. ⁓ But just be wise before you say that. ⁓ Really be curious, is that true? Is there anyone else in my team? Can we start having conversations about what it looks like?
To be just deferring everything on and not having some think. ⁓ Because the nurses have a lot of skills and they can do some of that high-level thinking for us. We can permission give for even ⁓ some of the items will reduce the things on your
Secondly, it can so we had a an example. One of my physicians recently came to me and she counted her items. She’d done 1200 items in a week. Yeah, that’s in addition to patient care, yeah. Right? ⁓ And this was overwhelming and unsustainable. Now it took us a number of weeks and we looked at everything she was doing about her inbox. And you’ll have some places, some administrative organizations who really want to push the patient portal. They want patients using this.
Stacey Doyle (00:08:22)
Crazy. Yeah.
Dr Sarah Smith (00:08:41)
But it’s up to you how you approach that. You can’t stop them having this angle at patients, but you can certainly stop the tennis that happens, the back and forward of these messages with your approach. So she would ⁓ ask for clarification from the patient, and the patient would write back. Now that’s creating another item in her inbox. Rather than that, defer to, well, I can’t.
Look at your rash in a patient portal message. I need to see it to do good quality patient care. And so saying, this is a great question for our next appointment and getting that patient in. Now that requires systems to be able to create room for that patient coming in. But it’s important that she’s not spending three paragraphs trying to figure out what sort of rash it is. That’s not good clinical care.
Stacey Doyle (00:09:37)
Well, that that is great advice. And I think it’s something that, like you’re saying, sometimes is a learned behavior because you want to take on everything and you think, okay, I don’t want to push anything off. But with by doing so, you’re you’re really, you know, ⁓ it almost burdening yourself with with too much work. And so I love that advice. And I wanted to also ask you, because I know you talk a lot about, you know, what are some habits that kind of quietly create this documentation.
Backlog throughout the day.
Dr Sarah Smith (00:10:10)
Okay, so habits during the day, ⁓ look, they’re they’re everywhere because habits, like you said, are learned behaviors that we have practiced over possibly decades. And so to intervene, the first step is noticing. What am I doing? So ⁓ the noticing isn’t the fun part because we often want to judge ourselves so badly. ⁓ An example, I notice that at 10 30 I’m running half an hour behind. Now you’ll have this sinking pit in your stomach when you realize that.
But rather than to pay attention to the sinking pit in your stomach, I want you to say, I wonder why. And start to notice what’s happening, that’s creating that result. Because there is the place that we can intervene. So I wonder why. Well, I rushed in at five past eight. My first patient starts at eight. Why? Well, I had this dread and anxiety in the morning. I didn’t want to get out of bed.
And then my lunch took three minutes extra to you know organize because I hadn’t blah blah blah. ⁓ There’ll be reasons, right? So we dash in the door at five minutes past the hour. The door gets unlocked at eight. ⁓ So the patient couldn’t even be in a room for eight o’clock, even if you wanted them to. And that five-minute delay of getting started now compounds. But you ⁓ looking at yourself saying, I’m a terrible doctor because I’m running X number of minutes behind.
And you you didn’t even create some of those minutes. You were sitting around waiting for somebody to put someone in a room or someone to get weighed in or someone to get measured. ⁓ So it’s important to start the noticing. It can look like the words we use in in an encounter can add to those minutes too. How are you today? Cost you five minutes, five minutes, rather than a professional and friendly, what are we doing today? Can shave minutes off your encounter time.
We’re only given X number of minutes with a patient, whether we’ve chosen that ⁓ or we’ve been given that appointment length, because physicians and clinicians work in environments where they’re either choosing that or they’re being given that. We can help you run on time by the noticing what minutes am I given? If I understand that the encounter includes ⁓ all of the aspects of the encounter, any referrals that need doing, all the orders and the notes, now how will I approach that?
Dr Sarah Smith (00:12:34)
Time. Because if we just a a a how what are we doing today? And we get the list from the patient and we try and figure it all out. And then an hour later we’re like, no, I only had fifteen minutes.
Stacey Doyle (00:12:37)
Rough. Yeah.
Stacey Doyle (00:12:48)
And I know there’s that time squeeze. And I know that that’s something that you kind of feel like, okay, the clock is ticking. Here we go. ⁓ and so I know that there’s a lot that sometimes can be done in advance. Like I’ve just, you know, I’ve sometimes patients can answer questionnaires in advance. And like you’re saying, how do you kind of lead that first intro can guide and save save a lot of time? So I think that’s a really practical ⁓ tip for everybody. And
Is there something in terms of I know you were talking about inbox, like what what do you recommend or what have you seen work for other physicians? Do they is it best to tackle it first thing at ongoing throughout the day at at the end of the day? What strategies have you seen work there?
Dr Sarah Smith (00:13:33)
Yeah, it’s important because ⁓ we’re rarely given protected inbox time. Rarely. Like we do see models of that s happening some places. Like you’ll be given an hour of admin time or you’ll be given whatever. But most don’t. And so now we know there’s a time requirement for this in basket. And I’d love to have that. So whatever you spend, like if it takes me three hours to do my inbox, I’d love it to take an hour and a half. And that can be possible to say, how long does it take me?
And then how can I make that half? That’s a great question to ask your brain. But now, when are we going to do this work? So, what is available? What is that protected time? Because the last thing we want to do is do it between patients. We come out of that room, we open the inbox, we hit the first item, we look at it and say, Well, I don’t have time to figure that out right now. And we close it again, and now we’re doing that inbox twice or more for each item. So we want to set aside some time. ⁓
It’ll look different for you ⁓ by day, by week, but we need to really say where are my moments of time where I have time for that? So it could look like you’ve got 20 minutes in the middle of the day. It could look like I’ve got 10 minutes before I see the first patient. ⁓ And then ⁓ the last question you want to ask yourself is where should I start? ⁓ Because we’ve just used up that initiation energy. So we need a plan. So I’ll give you an example.
I would get script refill requests. And I said yes to doing them. I wanted to do them outside of a patient encounter for me. It worked at the time. But if I did not get that to the chemist or the pharmacist ⁓ by lunchtime, I got a second reminder. Now I have two things in my inbox for the same problem. Now I’ve just doubled my inbox. No thank you. ⁓ So I would hit those script refills first thing. I then realized I would open it up. ⁓
I’d see what pharmacy, what thing that they wanted for that patient. Then I’d have to go to a different screen. And then I’d have to remember, ⁓ hang on a minute, what chemist was that again? And I’d go back to and I was toggling between pages. Well, that wastes time. What do I need? I need two screens.
Dr Sarah Smith (00:15:47)
So it’s starting to be aware of what is taking me time, because all the minutes and seconds count. What do I need? I’m starting to ask that question: what do I need to make this faster, easier, and done? I might need to have helped myself. So if I have put into the free text box why they’re on this medication, it helps me decide how often I need to monitor it. So if I’ve written receiver statin.
primary prevention diabetic has a different ⁓ level of monitoring than post STEMI. So that already saves me time too when I go to do that script refill. I’m not then saying, ⁓ are they up to date with their lipid profile?
Stacey Doyle (00:16:35)
Love that advice. Now tell us, I know we talk about A AI scribes and you know documentation tools. They are becoming more common. Are you seeing this help solve some of this you know, problems with with just time management?
Dr Sarah Smith (00:16:44)
Mm-hmm.
Dr Sarah Smith (00:16:51)
⁓ That’s a great question. For some of the physicians I look after, this is the missing piece of the jigsaw, and they are thriving with that extra little hand. For others, they’re using it as a tool to hurt themselves with. And that’s this is what I mean. They use it in the encounter, and then they say, Well, the note is done somewhere in the ether. So they leave it to later. Now they’ve created a brand new work list of items to do later. Wonderful.
In addition, ⁓ most of the AIs are still hallucinating. So you have to read through it for accuracy. Then you’re reading it in somebody else’s language because it’s rarely looks like something that you would create yourself with the language that you would use in the format that you would do it. So now you have to read it fully to look for error to understand what happened. And when you see that note next time, when you’re going into the patient encounter, it’s not your writing.
So now you have to read it ⁓ to be able to figure out what was going on last time. So it’s actually time, time, time. So if we’re going to use AI, we still need, I see the patient, I close the chart. How am I going to end the AI, ⁓ read it for accuracy, edit if needed, ⁓ and close the chart before I move to the next patient. Otherwise, all I’m doing is creating myself yet another inbox. No thanks. ⁓ The workload. ⁓
Stacey Doyle (00:18:15)
Another workflow. Right. Another workflow of things to get to.
Dr Sarah Smith (00:18:20)
Write another list to figure out. Plus, some AIs will kick it out after 30 days, it’s lost forever. ⁓ So some physicians aren’t getting to it within that 30 days. So now they’ve got zero about that encounter when they go to do that chart note for some of the physicians who are really behind in their backlog. So a couple of possibilities. One is I leave myself a mental hook at the top to my my little concise summary if I’m going to use AI.
So something quick that I can have a look at next time I’m in the patient chart so I don’t have to read through everything. ⁓ Some of them have better processors on the back end so they can start to look and sound like you. And some of them you can put templates in as well, so it can be closer to the format that you’re used to reading things in. So when you’re looking for an AI, you’re looking for a really high-level processor, something that’s highly editable, so it’s a little bit more familiar to you when you’re looking at that note later.
And don’t leave it till later. Don’t give yourself a brand new inbox of things to do. That’s not fair.
Stacey Doyle (00:19:22)
Are there any that you particularly like, Dr. Smith?
Dr Sarah Smith (00:19:26)
No, none that I can tell you are amazing. None. None of them. ⁓
Stacey Doyle (00:19:30)
So we’re getting there. That’s the whole whole trends with AIs. We’re getting there. ⁓ Well, I appreciate that. Well, tell us now. I know obviously this is something you’ve studied a lot. So with you know, the after hours charting and all of the documentation, how correlated is that with physician burnout? If you see somebody that’s able to break that cycle, do we see them rebound in terms of
you know, their work life balance and just being overall more happy while they’re practicing.
Dr Sarah Smith (00:20:06)
Yeah, so we’ve studied the physicians who came through charting champions, and we saw a statistical significance in improved quality of life, reduced burnout, ⁓ reduced time working after hours, improved job satisfaction. ⁓ And then also they weren’t seeing less patients. So this was able to get that work done without dropping numbers of patients in a day, which I think was really important for them to see because they were worried that I was going to tell them to just halve the patients they see in a day. ⁓
And I can tell you some of the physicians who’ve come into my world have halved the patients, and it hasn’t helped because they just expand the appointment to include all of the time and their habits of leaving it to later continue. ⁓ Plus, we’ve generated more items in that appointment, so we’ve now got more items to do later in the inbox. So ⁓ it’s really important that we understand the time working outside the room is really contributing to our job dissatisfaction, is giving us a whole second job that’s
Typically unpaid. So we’re doing all that paperwork, administrative burden, and it’s typically not generating dollars for you. You’ve earned the dollars in the room. Now you’re diluting your income. You’re using up your required time for rest and recovery of your brain so that your executive function can be restored and optimized by tomorrow morning to help your decision making. So we end up with a vicious cycle of tiot that it’s harder to do the work. So we want to define.
further work so then we’re having to do the work later then we can’t rest and recover. And we can understand this is not a now a me problem. It’s an us problem. If my colleague is here three hours after shift, they’re having less time to recover, they’re more likely to want to leave. And so that’s not helping physician retention. And that’s really important that we understand this is not just about me and my suffering. It’s about us and our retention. Because if you leave, I have to do double
⁓ And I don’t want that. ⁓ And so it’s about looking after each other and noticing, hey, I noticed that you’re still here when I leave at night. What’s going on? Can we help you? Is there anything that we can do to get you out of here on time? Like as we start to do that for each other, it’s wonderful. We see this in emergency departments, hospitalists, and clinic staff. If they’re starting to watch each other and say, you’re administrative and charting is important.
Dr Sarah Smith (00:22:28)
If you’re not getting to it, how can we help you and starting to be curious about what do they need to be successful?
Stacey Doyle (00:22:36)
I think that is a perfect ⁓ segue into if you have any advice for healthcare leaders, what would you recommend for reducing physician burnout?
Dr Sarah Smith (00:22:48)
Yeah, I think listening, watching what’s happening with your physicians and listening to what they’re saying. ⁓ Remove any patient to doctor direct contact. ⁓ We don’t get that with our dentist or our lawyer. Why would we do it to our doctors and clinicians? Like, and who is in the middle and what are they actually given permission to do on your behalf? So I think the more we offload as we realize the patients want this. They want to be able to ask questions between appointments. ⁓
How do we improve access for physicians? I see so many companies want to have our doctors fully booked six months in advance because they’re worried it won’t fill up. And the doctors are now having to approach that inbox in a way that I don’t have an appointment for six months, so I’ve got to do this inside the inbox in a different way because I know I can’t get them back in. And that’s ridiculous. You can be half booked in the morning and be fully booked by afternoon.
And those encounters are then so different because they’re timely and necessary rather than the patient deciding I need to be seen in so many weeks when that isn’t necessarily the right person for that ⁓ appointment that day. So starting to watch what’s happening for the physician, see what the issues are in regards to emptying the in-basket, and access is a big deal, looking at the teams that are supporting them and getting them to their highest level of ability to help you.
So having the nurses have permission to do some of that inbox work ahead of the physicians, the permission giving to get that. Yep, that looks like a great question for a visit. Let’s get you booked in, rather than sending it on to the physician to have to then send it back saying appointment, please. So they would be some of the places I would start. And then listening, what do you need? I need two screens. My current workplace had me a second screen by that afternoon.
Stacey Doyle (00:24:43)
We like that. ⁓ That’s great listening, yeah.
Dr Sarah Smith (00:24:45)
We love that. ⁓ What do you need? You might not know what you need. So you might need someone to come and sit and watch what you do and be like, I see that. Blah, blah, blah. Right. ⁓
Stacey Doyle (00:24:55)
Right, right. How can we make your work more efficient? Well, that’s great advice to the healthcare leaders that are listening. And I wanna give you the opportunity, ⁓ if you could leave, you know, every physician listening with one message about reclaiming their time and building a more sustainable career, what would it be?
Dr Sarah Smith (00:25:13)
I say it’s possible. So it’s possible to be having a different experience right now with the systems that are happening at you and to you, with the patient numbers that you have, with the inbox that you have, with the staff that you have. There are places where we can help you start to approach it differently. So if you’re experiencing dread, anxiety, overwhelm, have no idea where to start, that’s okay. The just the knowing it is possible to be having a different experience.
What could I do today to look after me too? How could I start to do this in a different way? Asking your brain good questions ⁓ and then going and finding the answers. So going and saying, How can I make this different? What is available for me to do this in a different way? Because I tell you, we will do things ⁓ on repeat day after day for decades. This was my lived experience. Nothing changes until you do. And then ⁓
Everything can change, infinite possibilities if you want it. And I think that’s just so important to hear that it doesn’t have to be like this. You have choice always. ⁓ Even the way you start and end encounters or the way you handle your inbox items is all up for negotiation when you want different.
Stacey Doyle (00:26:31)
Great advice. Thank you so much, Doctor Sus. Now tell our listeners how they can work with you and improve their work life balance and overall satisfaction.
Dr Sarah Smith (00:26:41)
Yeah, I would love to be able to deep dive with your listeners. So we have Charting Champions Program, which is a ⁓ opportunity where you can come in and ask your direct questions that you don’t understand my stuff, la la la, right? ⁓ that’s what we do inside the Charting Champions program. We meet weekly so that our members can come and ask questions or just listen in to other doctors figuring out their clinical day. You can find all that information at chartingcoach.ca. ⁓
And like you said at the beginning, my podcast free to air is sustainable clinical medicine.
Stacey Doyle (00:27:16)
Great resources and valuable tools for all of the providers that keep us all so healthy and we wanna give back and make sure that they’re getting some time to enjoy their lives ⁓ and and be, you know, their best version of themselves. So thank you so much, Doctor Smith. Really appreciate your time on the Doc Lounge podcast today.
Dr Sarah Smith (00:27:37)
Bye all.
Stacey Doyle (00:27:39)
One sec, let me just stop this. ⁓
