Tips on efficiency

[energy_girl]

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hey guys, I just started PGYI year, and am realizing that I am really sloooow and have trouble managing more than, say, 4 patients at once. A lot of it has to do with learning a new system of how to do things (orders, consults, admits)--and obviously that will get better with time. I'm wondering, though, how to develop a system that allows for for better multi-tasking. Any advice on what you guys do to be more efficient, and general tips on being a more efficient resident? Thanks!

 

[SoCuteMD]

I have no advice, just the contribution that I, too, am SLOOOOOOOOOOOOOOOOOW.

 

[TysonCook]

don't worry about it, you're an intern...learn the ropes first, then some MDM, then start to worry about efficiency....nobody (should) expect more than you are comfortable with for the time being.

Long story short, your efficiency should be where you are comfortable and safe, save the "time cut" for next year.

 

[Speed Racer]

My 2 cents:

-Wait to chart until you have a lull
-Order EKG's, FS's and recheck of vitals early on or while you are seeing some one else
-Eye ball some one with an obvious ortho complaint and then send them off for films.
-Do everything the same way. Your H+P, Presentations, Charting and change the least possible while still making everything specific to the case.

 

[Jeff698]

You're what, on your second day of being an intern? I think it's a bit early to start beating yourself up about being slow. Don't worry, though, there will be plenty of time for that. 🙂

Everybody develops their own system and what works for them. Unlike SpeedRacer, I'd advise to keep up with your charting. In my experience, waiting for a lull to do them means I'll be spending a couple of hours after my shift ends doing 35 charts.

The one thing that I try (not always successfully) to do is never let a disposition wait. Make the dispo as soon as you've determined what it is.

Think dispo starting the moment you walk in the room. Get an idea of what questions you need answered to make the dispo and start answering them as soon as possible. With time, you'll make an internal list of what those things are for different complaints and focus only on those things. The other stuff becomes background and you won't let it distract you.

Obviously, as you learn the medicine, your efficiency improves. That's what residency is all about.

Good luck and take care,
Jeff

 

[USCDiver]

Unlike SpeedRacer, I'd advise to keep up with your charting. In my experience, waiting for a lull to do them means I'll be spending a couple of hours after my shift ends doing 35 charts.

The one thing that I try (not always successfully) to do is never let a disposition wait. Make the dispo as soon as you've determined what it is.

I'm with Jeff here. There is no such thing as a lull. Absolutely do your charts as soon as you can, preferably as soon as you come out of the room. This was my biggest hurdle getting through intern year. I was routinely staying an hour or two after my shift to chart. If I got 3-4 charts behind, I just said '**** it' and blew off all charting until the end of my shift.

And to combine two of Jeff's points. If you get behind in your charting, you should always finish a chart before dispo. And the absolute rule in your mind regarding charting is NEVER EVER check a patient out at the end of your shift with an incomplete chart.

 

[GeneralVeers]

I'm with Jeff here. There is no such thing as a lull. Absolutely do your charts as soon as you can, preferably as soon as you come out of the room. This was my biggest hurdle getting through intern year. I was routinely staying an hour or two after my shift to chart. If I got 3-4 charts behind, I just said '**** it' and blew off all charting until the end of my shift.

And to combine two of Jeff's points. If you get behind in your charting, you should always finish a chart before dispo. And the absolute rule in your mind regarding charting is NEVER EVER check a patient out at the end of your shift with an incomplete chart.

I see some of the guys in my group do all their dictations at the end of their shift. Sometimes they have a stack of 30 charts and dictate each one. How do they remember what exam they did on the patient, or the dispo/follow-up on each one?

I do all my dictations as the patient is being admitted or discharged. I routinely roll out the door within 30 minutes of the end of my shift.

 

[Pinner Doc]

At my program, the interns are expected not to be efficient meat-movers, but to really work on learning how to work up common complaints. That way, by the time they are second years, they have a good foundation on which to become more quick and efficient. You need a good base to grow from.

Regarding your question, though... I think you'll find it comes with time.

 

[BKN]

I see some of the guys in my group do all their dictations at the end of their shift. Sometimes they have a stack of 30 charts and dictate each one. How do they remember what exam they did on the patient, or the dispo/follow-up on each one?

In the service, many years ago, we had to see 7 pts/hr on the day shift to keep up. It was not fun but mostly possible, since the vast majority had minor complaints. However if you had 1 or 2 sick patients, you had to go to crisis mode. In that case I would just leave a lot of blank space on the chart, write the diagnosis and meds and go on. That left a stack of 50-100 charts at the end of shift. It was weird, but I always remembered the details of every patient except one child with a URI. I faked that one, but I did feel guilty.

 

[lowbudget]

To add, know your medicine.

If you understand the important/unimportant questions in the history, are skillful on your physical exam, and have a full grasp on the accuracy of your H&P and the added value/accuracy of tests, you can make faster (and more confident) decisions, allowing you to see more patients.

No matter how great of a paperpusher you are, if you don't know your medicine, you will be inefficient.

 

[gramcracker]

Yeah. Think through differentials, algorithms, management plans, medications and dosages. Your intern year is getting those down so you're ready to pick up the pace later!

 

[roja]

Your job as an intern is not to be fast. Its to be thorough, to not lie, and to learn.


Do not wait to chart. You will be killed at the end of your shift. Plus, charting forces you to organize, put your thoughts together and remember things you need to do. In general, I tell residents: see two, chart two.

Other things that can help, run your patients every hour or so. This means sit down and go over each patient and what needs to be done. Reprioritize each time (ED is fluid, priorities will change).

Stay on top of your charting.

Write stuff down. cards, paper, whatever. until you get really good, you will need some kind of reminder. Or you will forget to do something really important.

 

[Apollyon]

How do they remember what exam they did on the patient, or the dispo/follow-up on each one?

Not to be snarky, but, maybe, they're smarter than you are? I mean, medicine is full of two groups of people: the brilliant and the amazingly hard workers (and, when you put 1 and 2 together, you get the people I saw at Duke). To some people, it comes without effort, for as-yet undiscovered reasons. If I review a chart of a patient I've seen in the past, chances are VERY good I can tell you in which room I saw the patient, and something else germane about the patient, the room, or the visitors.

One of my glaring weaknesses (among many) is that I cannot recall the name of the PMD in many cases, even after having viewed it specifically just beforehand.

 

[southerndoc]

We dictate charts at my part-time hospital. Often I would dictate as I go along, but occasionally it would get busy and I would need to save all the dictations until the end. I never had a problem remembering details, even after a night shift. It's amazing what you can remember when you just picture the patient's face. Sometimes I would make notes (primarily to remember to dictate something instead of an actual finding, i.e., dictating that I discussed with patients options of LP v. MRA/CTA, etc.).

One of the things that I love that I didn't find out about until maybe 6 months ago was the ability to leave jobs open. I would see a patient, come back and dictate the H&P, and then leave the job (dictation) open. As soon as I made a disposition or after my shift, I would dictate the labs, MDM, and disposition.

 

[kungfufishing]

I'd say do the chart right now, although I think this also depends somewhat on what type of system you have. If you have paper charts, do it before you leave the room. If you have a fast computer system, which we did where I trained, you can leave a few more for later when need be - during really busy periods I would do no charts, and then come back a bit later using a "write a current chart -- write an old chart -- go see a couple new patients" sequence.

Start learning to group your tasks. This is a habit that won't force you to focus on doing things quickly but will make you faster nonetheless. If you are going to be up and moving around, find three things you can do with that time. Recheck that patient, write an order, block that finger. When you sit down, see if those labs are back, do your xrays, admit that old lady. Print a discharge, see somebody new, write their orders, sew the finger.

The above "see two, chart two" is a great strategy, as is "see two, dispo two" if possible.

 

[Apollyon]

Write stuff down. cards, paper, whatever. until you get really good, you will need some kind of reminder. Or you will forget to do something really important.

And learn to do everything exactly in the same way, in the same order, every time. That way, you don't miss anything. When you mess up is when your system is messed up (either by internal or external causes).

 

[DrJosephKim]

Use a systematic approach and keep notes on a simple card. As you gain experience, you'll improve. Make sure you're pushing yourself and constantly asking for feedback. Sometimes people may be too nice or busy to provide you with constructive criticism. However, if you ask for it with hopes that you can learn and improve, then it may be very helpful.

 

[docB]

Early in residency speed isn't that important. Quality matters much more. THE MOST IMPORTANT thing is to get to know sick vs. not sick. If you think the patient might be sick get help.

Remember that ED patients generally flow with triage->initial eval->testing/therapy->re-eval->dispo. The very critical and the very minor fall out on this but it holds for the majority. Early in residency the presentation to the attending needs to happen right after the initial eval to determine what testing and therapy they need. Remember that all testing is not benign. In my opinion interns should not routinely order contrast CTs without attending guidance.

When it comes time for dispo you have to go do the re-eval. I'm going to ask how they're feeling now so you need to know. If the chest painer is not pain free they can't go to the chest pain unit and we need to get them pain free. If the gastroenteritis is better they can go home. If they're still puking we've got to try something else.

One thing that used to give me lots of problems was the patient with multiple complaints. Early in residency the best way to deal with them is to treat each complaint like a seperate patient and work each of them up.

 

[energy_girl]

Thanks for the advice, everyone. I know that quality and thoroughness is key--but I also don't want to be very slow and not carry my own weight. Your tips, i.e. how to organize and think about the dispo and not get behind on charting, are very helpful. And I'm already a lot faster and feel a little more confident after a couple of weeks, so hopefully it gets better over the years!

 

[anonymousEM]

Make a call for a consult etc as you sit down to start charting or some other tasks at the desk. Don't stand around idly waiting for returned calls.