11 June 2010

Friday Flashback - Advice for Interns Part Three

I am one of the more efficient docs in our group. Not the most efficient, but I do pretty well. Because of my leadership position within the group, I spend a lot of time thinking about operational processes and efficiency, and because of my reputation for being a “fast doc” I field a lot of queries from partners on how to do better. So I thought I would share some of my thoughts with you. The ability to move the meat effectively is really a win-win-win – you do better (both reputation and financially), the ED flows better, and the patients are happier and get more timely care.

Be motivated
It sounds stupid, but if you are not coming to your shift with energy and a strong motivation to clear out the rack, you are not going to. It’s not always easy to get yourself in this frame of mind every day, but the way I think of it is that we are paid more than 95% of all Americans to do this job, and it’s not supposed to be easy. You need to take a moment before you walk in the door to put on your game face and get yourself just a bit psyched up. Leave your home life at home. Most importantly, pay attention to your productivity – know what most docs at your facility do, know what you usually do. Set yourself a goal, and a stretch goal. Track your progress – within the shift, and over the longer time frame as well. If only via the Hawethorne Effect, this alone should increase your operational efficiency.

Be organized
“Never begin a shift with an empty stomach or a procedure with a full bladder.” So sayeth a wise elder partner. Try to bring a consistent approach to things. This is idiosyncratic, but find what works for you and do it every shift. Show up a few minutes early and spend some time assessing the state of the department before leaping into the fray. Make sure you have your favorite pen, or PDA, or whatever gadgets/accessories you find useful. I carry an index card with the name and sticker of every patient I have seen. This allows me to keep track of the patients’ progress, to-do items, location, etc. I do mental rounds with my list every twenty minutes or so. Whatever works for you. Pay attention to your work environment. Make sure your charting station meets your personal needs.

Focus with unwavering intensity upon achieving the disposition.
I joke, but it's not really a joke, that I am an unusual type of doctor, because I am not looking for a diagnosis; I'm looking for a disposition. Direct your workup towards the life threats and emergencies. The moment you know the patient cannot go home, start the process of bed assignment and transfer of care to the inpatient team, as these are usually the rate limiting steps. Avoid “the long goodbye.” Many times I have seen someone waste hours chasing their tail with multiple consults and tests when it was perfectly clear the patient needed to be admitted for a work-up. It’s a radical new concept in American medicine that the work-up does not end at the elevator. Note: this may take a little salesmanship. The admitting docs like things neatly packaged. See this post for advice on how to make the pitch to your consultants.

Initiate Treatment Early
A medicated patient is a happy patient. The sooner you get pain meds, anxiety meds, diuretics, etc, into the patient, the sooner they will feel ready to go home – and the higher your patient satisfaction scores will be! Every patient who comes in has some sort of agenda. You should be able to figure that out in the initial point of contact, and address it explicitly. Especially so if they are drug-seeking and you intend to decline to provide narcotics. Say so up front, get the fight out of the way, and you won’t find yourself hamstrung when it comes time for discharge. Stage your orders and let the nurses know what the plan is (i.e. Toradol and vistaril, if no relief of pain in 30 minutes, then dilaudid 2 mg IV q30 min till relief). That way the therapy can proceed on autopilot while you are doing something else, and you will have fewer interruptions.

Be selective in your testing strategy
When able, utilize point of care testing – istats and the like. Don’t order a full lab panel if the only data you care about will be in the istat. Don’t order ANY test unless a) it will be resulted while the patient is in the ED, and b) is required for the correct disposition. Defer urgent tests to the outpatient setting – that chronic pelvic pain patient doesn’t really need the ultrasound at 2AM. Enlist the PCPs, when available, as your allies in setting an outpatient work-up in motion. Be evidence-based in your ordering rationale. The toddler with a cough and fever doesn’t need that CXR if their oxygenation is 99% and the lungs are clear.

Your productivity is measured in patients per hour. This is impacted by your average length of stay and also by the number of patients you carry at a time. I think of it as water flowing through a pipe – the rate of flow and the diameter of the pipe determine the total volume capacity. Pay attention to the size of your pipeline and learn to carry one or two extra patients at a time. It can dramatically improve your personal throughput. When possible, try to intercalate all your complex patients with a couple of simple ones. It makes the shift more interesting and allows you to fill some idle time while waiting for the mega-work-ups to finish. And if allowed, cherry-pick like crazy the last hour of your shift. It can clear out the bottom of the chart rack and really put your productivity over the top wile helping you get out more or less on time.

Of course you should apply the usual caveats and disclaimers – not all of these prescriptions are applicable to all cases, all facilities, all practitioners. Look at your practice and see where the opportunities for improvement are. Use your judgment and pick the items from this list that make the most sense for you and your practice. Also, I should give credit where it is due: much of this as been cribbed from talks given at various seminars on ED operations. I don’t recall the lecturers’ names, and this is my own synthesis, but I cannot take credit in toto for the contents. More later.

Originally Published 20 June 2007


  1. Think I will print this out and laminate it for the next ED visit with my Wife, a SLE patient. "Focus with unwavering intensity upon achieving the disposition" should be tattooed on the forehead of some of our local ED docs. Who sometimes decide they want to play "Dr. House" with the SLE patient.

  2. As a third year EM resident, graduating in 6 days, I appreciate these pearls of wisdom as I embark on my first job this summer.

    I am nervous about the volume (>110K visits/yr) at my new job, which is twice what I'm used to seeing in residency. It's hard to gauge my efficiency in residency with the nature of academic residencies, but I look forward to applying these principles in my practice.

  3. This post is awesome. I'll be starting my intern year at MGH in a week, and these tips are very helpful!

    As a quick question, may I you what you write down on your patient index cards?

    I've often strayed on the side of writing too much information down (leading to rather long pre-rounds), and was wondering if there is a pared-down list of essential information that you always write down.


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