Newman's Notions | August 2014 | FREE
Most ACP Hospitalist content is available exclusively to ACP Members. This article is free to the public.

High efficiency

A fictional tale about the need to balance speed with thoughtfulness.

It's 4:57 a. m. The first alarm of the morning blares from the clock radio, which is set to an annoying tween top 20 station. I smoothly hit snooze and am back to REM. Exactly 4 minutes later, 5:01 a.m., the annoying station is back on, and downstairs the coffee pot automatically starts to brew. Before I can regain blissful REM, my phone alarm starts to quack, quack, quack from across the room, where it had been charging overnight. I leap out of bed and into the shower for a 60-second, ice-cold, wake-up rinse. My clothes are laid out: underpants, overpants, socks, shirt, jacket, and tie already coordinated. No hair to blow dry. My toothbrush is pre-loaded, the deodorant cap is loosened, the electric razor is charged.

I head down the stairs, brushing my teeth with one hand and running the electric razor across my stubble with the other. There's a basket at the bottom of the stairs waiting for the brush and razor. I had sliced my grapefruit the night before and left it in the refrigerator in a bowl with a grapefruit spoon. My keys, phone, pager, wallet, nametag, pen, ophthalmoscope, stethoscope, parking pass, and breath mints are laid out neatly on the counter. Each has an assigned spot on my person. I ritually tap each to assure proper placement as I walk out the door at 5:12 a.m., exactly on schedule. Twelve steps to the garage, then I hit the opener as I get in my convertible, lowering the roof as the garage door opens. I back up while plugging my phone into the sound system. It is a 13-minute drive, enough time to listen to a medical podcast at 1.5-times speed.

Photo courtesy of Jamie Newman
Photo courtesy of Jamie Newman.

I meet my team and listen to morning handoffs as I roll my pager, check my emails, look at the admit board, and straighten my tie. There is a new fourth-year medical student on service. I tell her that I want crisp, quick, concise presentations. The team starts to sit in the conference room, but I get them on their feet. They present as we walk, using portable laptops for orders. I hopscotch cases between interns so the next patient's labs and images are already pulled up. I dictate notes on the move. Fourteen patients are seen and documented, with everything ordered, in 140 minutes or less. This will leave time for teaching, writing, and coffee before my 11 a.m. meeting.

I tell the students and residents that there are other attendings who might know more, but nobody will teach them how to get through rounds faster. The nurses know I am coming and have their checklists in hand. I want the key information: catheters, skin integrity, pain, mentation, pending tests, and placement, all at their fingertips. No Brownian motion, bouncing around like overheated molecules. I want curvilinear rounds, point A to B to C. No backtracking or tangents.

The medical student begins to tell me about our next admission. She pulls out her notes. I stop her: No notes allowed. She begins to tell me about a patient with a completely negative past medical history on no medications, who presents with a facial photodistributed rash and painful, weak shoulders and hips. I stop her. I have heard enough. It's Thursday morning, and unless we start ordering the tests I think she'll need, we will never get it all done before the long holiday weekend. I call my friendly neighborhood dermatologist, and tell her I have a patient with probable dermatomyositis. She lays out what I need, rapid-fire, no time for chit-chat.

I tell the first intern to order a paraneoplastic profile, CPK, LFTS, CBC, electrolytes, Mg, Ca, CRP, ESR, CA125, aldolase, fasting glucose and lipids, ANA, urinalysis, and anti-Mi2 and Jo-1 antibodies. I tell the second intern to set up a full-body CT, EKG, chest X-ray, colonoscopy, barium swallow, pelvic ultrasound, DEXA scan, PFTs, and mammogram. I ask the student to set up a skin biopsy with direct immunofluorescence, and consult surgery to do a muscle biopsy. The team dives in, and spends the next 20 minutes frantically clicking away on their keyboards, as I review my notes and sign off from yesterday.

The student finishes her task and begins to question my strategy. We have not even seen the patient yet or heard the whole history, but we are ordering all these tests, she points out. I explain that it's efficient to get it all going quickly, or it won't get done at all. She acquiesces to my more experienced approach. We enter the room and as I shake the patient's hand I look for Gottron's sign over her knuckles, and it isn't there. Her face is certainly not heliotropic, more diffusely bright red. There is no shawl sign or calcinosis.

I reluctantly stand still and take a deep cleansing breath. The student turns to me. She explains that what she was trying to say before we got sidetracked ordering tests was that the patient had been fishing and came home with a tick bite. She admitted to taking her husband's doxycycline, which he had on hand for rosacea. She was afraid she might get Lyme disease from the tick bite. She then went on a weeklong desert backpacking trip, and that is when her skin turned red, and her shoulders were weak and hurting from carrying a 60-pound pack for a week.

We walked out of the room. I smiled at the team, my mind racing about how to make this a teaching moment and not an attending debacle. I told them that I hoped my lesson in efficiency had taught them the importance of not leaping to conclusions, and the importance of taking a good history and performing a solid physical exam. As they spent the next 10 minutes un-ordering tests and canceling labs, the patient got antihistamines and steroid cream, got a lecture about taking other people's medicines, and was discharged. My length of stay and costs were as low as always. A testament to efficiency.

The events in this column are fictional.