When less is more: Addition by subtraction

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This blog was motivated by the book Subtraction by Leidy Klotz, a professor of architecture at the University of Virginia. His book shares that we can enhance what we do by subtracting rather than adding tasks and activities. I am like most physicians, as we are creatures of habit. We keep collecting and adding more to our practice. Still, we need to discard or subtract outdated methods no longer applicable to providing patient care. It took a long time to convert paper charts into electronic medical records. We add new and improved ideas but don't prune the outdated ones. Unfortunately, we are wired to add before taking away. The book provides examples of how subtraction can benefit the practice of medicine.

Two examples of subtraction described in the book are Strider Bikes and H-bricks.

Strider Bikes were created by removing or subtracting the pedals of bikes that are used to train toddlers to ride two-wheel bikes. With a Strider Bike, the child learns balance and can go directly to a pedal bike without the necessity of transitioning to training wheels. Strider Bikes have been used by over 3 million toddlers.

Solid cinder blocks used in construction are heavy, require more material, are difficult to transport, and require more musculoskeletal exertion to use. Subtracting the center of the block or creating an H-block did not impair its strength. The H-block (Figure 2) was not as heavy, made better insulation, was easier to transport, was less expensive, and decreased back pain from workers lifting the heavier solid bricks.

10 Subtraction examples in healthcare

1. I have written articles and papers and used Strunk and White's classic book, The Elements of Style, for help with grammar and punctuation. The authors point out that one of the tenets of good writing is keeping only the necessary words and subtracting words that do not help transmit the message. Now, I have used Grammarly.com, which helps remove excessive verbiage.
2. Do we need to see every surgery patient in the office for follow-up? I discovered it was good medicine to instruct patients to change their dressing, safely remove a catheter, and take their medications. This eliminated what was considered the standard post-op visit, thus making more time for new patients and spending more time with existing patients.
3. The pandemic made it possible to care for patients without the necessity of them coming to our brick-and-mortar offices. CMS facilitated this transition to virtual healthcare by agreeing to compensate physicians for in-office visits. As a result, we learned that we could provide good care without having to physically have a patient in the office. Thus, we subtracted the office visits and became more efficient and productive.
4. Outsourcing billing - Consider subtracting non-core functions like billing, which can accomplish tasks more cost-effectively.
5. By providing online scheduling, you can reduce the responsibility of the receptionist or scheduler. Gen Xers and Millennials prefer this method of requesting an appointment.
6. Unused or outdated equipment: Old or obsolete medical equipment that is no longer used or has been replaced by newer models can be removed from the office to allow more space for patient care.
7. Cross-training employees to perform multiple roles improves flexibility and coverage during staffing shortages and eliminates the need to hire temporary help.
8. You can eliminate the need for data entry and typing by having a scribe in the exam room. You can take this to the next level and even subtract the need for a scribe using some of the newer voice-to-text software programs.
9. Prior authorization is an addition to our abundance of paperwork that can be subtracted by using AI to write the insurance company for permission AI to complete prior authorizations.
10. If you want to get lean and mean, consider becoming a concierge doctor. This will eliminate paperwork, the need to interact with insurance companies, improve your cash flow, and want to spend more time with patients, then consider becoming a concierge doctor.

Bottom Line: Every practice has "excess fat" that can be subtracted. Subtracting results in a more efficient practice, increased production, and improved morale. It may decrease the epidemic burnout rate of physicians.

If you have any suggestions for subtracting in your practice, please let me hear from you at doctorwhiz@gmail.com.

Neil Baum is a physician in New Orleans and the author of The Business of Building and Managing a Healthcare Practice, Springer 2023

* Klotz, L. (2021). Subtract: The untapped science of less. Flatiron Books.