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Physician executive Grace E. Terrell discusses her article, “Physicians must innovate and focus on medicine’s core, not chores.” She introduces the concept of “core vs. chore,” urging health care workers to distinguish essential patient care duties from the administrative tasks that often dominate their time, exemplified by an incident where staff prioritized EHR procedures over immediate patient needs. Grace highlights how poorly designed technology like EHRs, regulatory demands, and inefficient workflows contribute significantly to physician burnout, administrative burden, and information chaos, noting that physicians spend nearly twice as much time on EHR and desk work as they do on direct patient care. The conversation explores solutions such as redesigning care delivery models to delegate non-essential tasks, utilizing technology-enabled support teams, and enabling clinicians to practice at the top of their license, ultimately aiming to recenter health care on its core mission, reduce costs, and improve both patient and clinician experiences.
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Transcript
Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome Grace E. Terrell. She’s a physician executive, and today’s KevinMD article is “Physicians must innovate and focus on medicine’s core, not chores.” Grace, welcome to the show.
Grace E. Terrell: Thank you. Glad to be here.
Kevin Pho: All right, so just tell us a little bit about your story and then jump into the KevinMD article that you shared with us.
Grace E. Terrell: Absolutely. So, I’m a general internist. I’ve been in practice in medicine in one form or the other since I got out of training in 1993. Along the way I’ve done things such as run a large independent, multi-specialty medical group in North Carolina called Cornerstone Healthcare. I’ve had the honor of beyond that doing some things like running a whole genome sequencing company in rare disease.
And working in an integrated primary care and mental health model in the long-term care space. Currently, in addition to continuing to see patients on a regular basis, I’m the chief medical officer of a company called IKS Health. And everything that we’re focused on focusing on right now is about understanding and working to solve this core versus chore dilemma.
Kevin Pho: All right, so tell us more about the core versus chore dilemma as you put it.
Grace E. Terrell: OK. So, I think what’s happened to physicians over the course of my career has been that there has been a real problem: what ought to be the actual practice of medicine, our core mission of taking care of patients in the way that we’ve been trained and ought to be doing, has been displaced by more and more chores that are getting in the way.
Most of them are technology focused or they’re payment system dysfunction focused. It has to do with the hours and hours that we spend documenting in the electronic medical record. It can have to do with things such as the unfortunate work we have to do around things such as prior authorization.
All of these things have happened for a reason that have to do with the focus on making sure that the right types of payment gets done. But what’s happened along the way is that as a result of that, less and less of the actual core work that physicians ought to be doing is being done and more and more chores are in the way.
Kevin Pho: So you mentioned you’re a general internist, as am I. So just to give an example, for those listeners who may not be familiar with the day-to-day obstacles that we internists or physicians face, just give us an example of some of these chores that we’re talking about that gets into the way of the core work that you do.
Grace E. Terrell: Well, a lot of it is administrative. It’s the fact that we are mostly doing data entry right now. So if you think about the types of work that you’ve probably done over the course of your career, I’ve certainly done over mine. The best part of what we do is listening to patients, making appropriate diagnoses after we hear their story and examine them, after we get the appropriate type of test, and making sure that they get the right types of treatment, if it’s something that needs treatment.
And although that tends to be what gives us joy, is that actual work with patients, it’s become less and less of what we do. So much of the chores that we do right now have to do with clicking all day long on electronic medical records. Things like if there’s an appropriate medicine for a patient, having to go through all sorts of processes to get that medicine approved for insurance.
A lot of it has to do with the burden of how we have to do clinical documentation now, get it just right so that we get paid or get paid in the right way. Some of it has to do with more and more inbox type of work that we have to do. Patients like being able to communicate directly now in between visits with their clinicians that are serving their needs.
But much of my inbox that still happens is things that I used to not have to do at all. They were handled by my staff and now they come directly to me. And much of it doesn’t have to be done at all.
Kevin Pho: Now, if you were to estimate a certain percentage, what percentage of your day would you say is spent on these chores, these inbox related things, these prior authorizations versus directly communicating with patients themselves?
Grace E. Terrell: Well, you know, it is interesting when you talk about the concept of a day. OK. Because used to, that would be the time that you were actually with patients either in the hospital, in my case, also the nursing home, or the clinic or making home visits. And it might run, you know, because physicians tend to work long hours, anything from seven in the morning to five o’clock in the evening.
Nowadays I’m an ambulatory physician so I see patients just in the office. And so my day during the day when I’m doing the clinical documentation, probably 40 to 50 percent of it is actually not in direct patient care, but doing all the clinical documentation, the answering the inbox, the prior auth and things like that.
But there’s also the evening hours. There’s a term that is being used called pajama time, which I think is an insult. It basically says that because physicians are typically conscientious people, what we tend to do is we try to do as much as we can during the day. Then we go home, we are with our families, and then we’re having to do more documentation.
I actually think that’s stolen time. It’s stolen time by good people that are trying to do the right thing for patients. So if you add that to it, many clinicians are spending sometimes two to six hours a week in the evenings also doing work. And all that work is chore work. It’s not the core work.
Kevin Pho: And we’ve been talking about this core versus chore debate on this podcast and on KevinMD for what seems to be years now and if this doesn’t get better, that’s going to lead to things like burnout and moral injury and more and more physicians leaving clinical practice, right?
Grace E. Terrell: That’s right. And fewer and fewer physicians are actually attracted to the types of work that you and I have done our whole careers as general internists, which is that type of work where there tends to be more of this because it’s become just, it’s been sort of a clinical documentation game that’s happened over the last few years.
So it has to be solved. I think it’s one of the major reasons that we have a primary care shortage in the country right now. I have a daughter who is a pediatric intern at University of North Carolina Chapel Hill (UNC) Hospitals, and my belief is that my mission in life at this point is to make sure that we get this fixed for her.
She’ll be a third generation female physician. My mother-in-law was an internist. And much of what she ought to be doing over the course of her career is taking care of children. There’s a huge shortage of pediatricians right now. We need people like my daughter that are going into this. If we don’t fix this, no one’s going to go into it. Pediatric residencies weren’t getting filled this past year.
Kevin Pho: So I know that this isn’t an unknown problem. We have a lot of different potential solutions that are out there. We have technological approaches like AI solutions, ambient AI scribes, for instance. So from your perspective, what’s the best way to get out of this? What are some of the potential solutions that we can do to reduce the chore work physicians have to do?
Grace E. Terrell: I think there’s several. One of them is related to understanding what physicians ought to be doing and eliminating all those other things that are getting in the way by several things. One is, you know, the concepts of having other people doing them for them. If it doesn’t have to be done by a clinician, it shouldn’t be. If it doesn’t have to be done in person, it shouldn’t be. It can be done by other people, it can be done by technology. Part of it I believe, is the redesign of technology itself.
So, the company I work for, IKS, we have done a lot of thought about many of the aspects of clinical of the clinical work and think about things like virtual medical assistants that can do some of this work. Part of it is our human beings. Part of it is the AI that we have developed around a lot of these chores.
But part of it is redesigning the technology and the workflows themselves. So I think that there’s been basically five stages of health information technology. The first stage was really the revenue cycle management, the billing and scheduling, all that. This sort of 50-year-old technology.
And the second stage has been the electronic health records, the third’s probably, you know, population health and longitudinal care. The fourth is the internet of things or what we call remote patient monitoring. And the fifth is AI and predictive analytics. And unfortunately in health care, each of these has a friction point. They’ve been built one on top of another without really human-centered design as part of it. And so what we have to do as we are in the middle of re-imagining what ought to be done is to understand the system that we’re in and use people and technology to eliminate those friction points while we’re really focused on human-centered design. And in this case, the human being needs to be the clinician, their staffs, as well as what works for patients.
Kevin Pho: So tell us, in your ideal world, what would those improved workflows look like? You mentioned everyone practicing to the top of their license. You mentioned virtual medical assistants. So in your ideal world, just give us a scenario of what that would look like.
Grace E. Terrell: Absolutely. So I would imagine that either if it was in person or in some sort of, you know, telemedicine type of interaction with a patient that was seeking my help as an internist or perhaps my daughter as a pediatrician, that when I had that interaction, what was done ahead of time was understanding what had happened since the last time the patient had had that interaction, that the longitudinal care, the gaps in care would’ve been identified. The type of work around that would’ve been done by others through reach out and through care management.
As I entered a room, perhaps if it’s an ambulatory visit, what has happened since that’s relevant? The patient and my clinical practice is told to me either in some sort of virtual way or whatever way I need to consume it. I would go in and have the interaction with the patient. And I would not be clicking or looking at a computer the whole time. I would be having an interaction. That interaction would help generate a note.
And then the clinical documentation that went along with my assessment and plan and all the things that I need to do for that patient, including being able to just call out visits for call out orders or which could be evidence-based and perhaps helped with the use of AI to make sure that the right things were done, were done in a way that all the time I’m looking at my patient, examining my patient, my eyes and ears are focused on the patient.
And then after the interaction, if we’re using today’s time, smooth access for the patient for getting those services are done. The patient isn’t bankrupted as a result of it. And then the results come back in a timely way. The patient’s questions are asked and the interaction is one that actually meets their needs.
So every single one of those steps. You know, what we’ve done at IKS is we’ve actually looked at 16 different places in sort of the patient journey. Some of them are on the administrative side, some of them are on the care delivery side, where we can actually work now with either people or or technology to take the friction out of that. But as we move forward, we need to have that being a singular platform. And it needs to be something that, you know, works for patients everywhere, any place, anytime. It needs to work for the clinicians as well.
Kevin Pho: So what’s preventing us from reaching that ideal goal? Is it a matter of the technology not being there? Is it a cost issue? Is it a person power issue in terms of staffing?
Grace E. Terrell: So tell us some of the, there’s several friction points. Several, yeah. Several points are that much of the staffing is related, and it’s been designed for somebody in the office to do many of these tasks that are just asked, you know, just put one on top of the other. So, and there’s just not enough people that are available with the right skill sets in many offices to do this a cost effective way.
Some of it is the fact that everything goes back to the point of care and ought not to be part of what the clinical interaction is to begin with. We don’t do a good job in our payment system of paying for the longitudinal care that’s needed for good outcomes. And so some of it in my opinion, needs to be about payment reform, which has been shown to make a great deal of difference. And something I’ve had some, you know, background in, I haven’t gone into.
I actually think that you have to have payment model and care model redesign at the same time to get a lot of it done. And the third component of that is technology redesign. So, a lot of what I do and think about in this day and time in my current role is the technology and care model design. But at the same time, I’ve had some background in payment model redesign in the past and it’s really almost a Rubik’s cube. You’ve gotta have all of it working together in all the different dimensions to get us where we need to go.
Kevin Pho: So it sounds like a lot of these approaches are more macro based approaches. How about for the individual clinician? While we’re waiting for some of these improvements to come along, is there anything that individual physician can do to better delineate core versus chore and better make that ratio more favorable?
Grace E. Terrell: So I think that depending on the environment that the clinician is in, understand what tools are out there, understanding how to give up things that your staff can do or that, you know, your staff outside of your practice can do for you. So, a really simple example that I’ve seen for years is every single mammogram report still comes back to me for me to sign off on that’s normal. Now there’s no real need for that.
What’s needed actually is if there’s an abnormal mammogram report, I likely need to know about it for one of my patients. Or if my patient didn’t get a mammogram then it may be important for me to know that when I see them in the practice. But all that is right now, at least in our system, designed to come back to me, that really isn’t the best work for a primary care physician in my case. It ought to be taken care of by, you know, by other aspects of how we actually manage those things for patients.
Kevin Pho: Now, I always like to ask this of my fellow internal medicine physicians. You’ve been practicing for decades now. You’re still seeing patients despite all the obstacles that we’ve been talking about. You’re still practicing. Internist. Yes. Why do you stay in the field? What makes you keep on going despite everything that we talked about today?
Grace E. Terrell: You know, my practice at this point is very small because of my other responsibilities and things I do in my career, but a lot of these patients I’ve literally been seeing 30 years and I feel that I make a difference in their lives. I’ve experienced, you know, the personal satisfaction of taking care of patients and making a difference and, you know, it’s something that I think is really important.
And so, as I’m thinking about the way to redesign things for the future, if I’m not out there practicing myself, I don’t think that I would be nearly as effective. So I think actually being in the trenches where you really understand what the real chores are is the only way that we’re going to actually get this solved. One of the issues we’ve had with our technology oftentimes is that there’s not been the right type of design process because the people that are actually using the technology are not involved.
Kevin Pho: We’re talking to Grace Terrell. She’s a physician executive, and today’s KevinMD article is, “Physicians must innovate and focus on medicine’s core, not chores.” Grace, let’s end with some take home messages that you want to leave with the KevinMD audience.
Grace E. Terrell: The first message would be really think about the work you do and determine how much of it is actually chore versus the core mission that you have, and start thinking about how you can redesign in your own environment for that.
The second message is to not assume that the current state is where things have to be. And join me to help think about how we might innovate on the spot to actually start, where we need to go to actually improve health care.
The third thing is my personal mission statement, which I hope is something that will resonate with any of you all and that you might have your own personal mission statement and mine at this point in my career is: I’ll use my talents, my experiences, and my scars, and work with other people to radically improve health care. And that’s what I’m about. And I hope that it’s something that will help, help for all the clinicians that are out there.
Kevin Pho: Grace. Thank you so much for sharing your perspective and insight and thanks again for coming on the show.
Grace E. Terrell: Absolutely.