Not organized enough?

[Calahin]

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Hey all,

Sorry this is a long post.

Long time lurker here but seeking for some advice. I'm a 2nd year in a good but tough 4 year allopathic ER program. I've been working as I usually do and by nature I'm a pretty dedicated person. I admit I'm not the fastest among the ED residents but I also try to make sure things are done and completed thoroughly. My program director pulled me in today and told me that a few attendings have told him that I'm not as "organized" as I should be. He said a few attendings have been critical saying that I don't "get things done" when the ER gets busy.

Oddly, my assessment of myself was rather different. I know I need to read more and I honestly thought that was my biggest weakness when it came to issues with coming up with plans for patients. But the attendings have expressly said it has not been a "fund of knowledge" issue but "organization" and that my "plans" aren't always fleshed out.

I think this stems from my lack of confidence of my own plans especially in the cases where the differential is very wide or it isn't so clear cut. My PD says he's going to work with me on this and help me figure out what it really is and perhaps it is entirely perception and how I present. Strangely, I've gotten good feedback from other attendings saying the opposite like "has good plans, gets things done and dependable with sick patients"

I'm already reading more and working on getting more organized. I will present my plans more clearly and communicate with the attendings more so they know what's going on.

My PD told me to "take this as feedback" and "don't freak out". But it's hard not to. Am I close to getting kicked out? I didn't get that sense but its my greatest fear. And what else can I do? 😕

 

[JSdoc]

Well, what are you doing/not doing right now? Do you try to remember everything in your head, or do you make to-do/lists schedules?

I had some organizational issues during my residency, however, something that has drastically helped my organizational ability was getting a smartphone. Really! There are tons of apps out there designed to keep you organized. I have an android phone, so the calendar and task widgets are right there when I turn on the phone.

I also have it sync'd with the calendar on my computer, so whenever I'm on my computer or my phone (which is a lot), I see the tasks and deadlines that I need to fulfill. All this tech has really kept me on the ball in recent years. I can't even remember how life was before it.

 

[keeping-it-real]

I'm not sure if this is what they're referring to, but they might be concerned about your ability to multi-task and manage a busy department. As an EM2, you should be moving beyond just medical-knowledge type assessments and looking to take part in managing a busy department. This means that in addition to considering the differential and work-up, you need to become more effective at managing multiple problems at once and having a clear plan with each patient. The way I'm reading your post, it sounds like this second part is where you're having trouble.

The advice I would give is that you always need to keep the big picture in mind. In the ER world, this means disposition. This means that when you leave a patient's room after an encounter, you need to consider the medical diagnosis/workup but almost more importantly, you need to have a clear plan outlined for ultimate disposition. Without the disposition, you're just doing a work-up and will quickly become overwhelmed with multiple sick patients. This is probably the biggest difference between junior ER residents and more senior residents and attendings, and until you develop the ability to outline a clear end-point, it will be very difficult to manage a busy department.

The other piece of advice I have is that you should continually update yourself on each patient you have. If you are managing 8 patients, when you see your 9th, you should leave the room, put your orders in, and then run through each of the 8 other patients to continually remain updated on where their work-up statuses are. Don't forget where your other patients are at, and everytime you get a new piece of information that completes a dispo, complete that dispo before moving on to a new patient.

I think if you become adept at the above two things, you'll probably address what your attendings are referencing. This way, if you have 8 active patients and they come to you, you can tell them exactly what your plans are and how you anticipate their ER stays to go. "Bed 1 has chest pain with an atypical story but certain risk factors, if the labs are negative, i'm going to recommend admission for the obs unit for possible early stress. Bed 14 is a poor historian with general weakness and dementia but seems to be at baseline now, i have a pannel of labs cooking to r/o occult process and then i'll ambulate and see if she can return to the nursing home. Bed 16..."

Basically, try to know the outcome before you even put the orders in. It seems like you have the medical knowledge down, now it's time to work on efficiency and multi-tasking effectively. Good luck.