(Not) Saving the Best For Last

A clever little study was published last month in the Archives of Internal Medicine, and it – plus the fact that I’ve just started a stint as ward attending – prompted me to think about the importance of managing a set of tasks in the hospital. In my quarter-century of mentoring residents and faculty, I can’t think of an area in which the gulf between what people should do and what they actually do is larger, nor one in which improving performance yields more tangible rewards.

In this blog, I’ll begin by reviewing the Archives study and then consider its lessons for time management, particularly on the wards. In my next post, I’ll describe – just in time for New Year’s resolutions – a little technique I’ve developed that has helped me and others complete tasks that feel overwhelmingly large.

In the Archives paper, a research team led by informatician Michael Cohen of the University of Michigan set out to tackle the “portfolio effect”: how to allocate scarce time when discussing multiple patients. Cohen’s team videotaped 23 end-of-week resident sign-outs of ICU patients; on average, 11 patients were signed out per session, and each session lasted about 27 minutes. The patients were reviewed in bed order, not based on severity of illness or anything less random than where they happened to be lying in the ICU. (In my experience, this location-based sequencing is the most common method of organizing sign-out; going in alphabetical order of patients’ last names is a close second.)

Try to guess which patients were discussed at most length by the residents. The sickest? The oldest? The youngest? Those with the most complex social issues? Patients who were potentially eligible for ICU discharge that day?

The answer is none of the above. Rather, the patients who received the most air time – 50 percent more, as it turned out – were those who happened to be discussed first in the sign-out. It’s easy to understand why: during a time-pressured sign-out, people run out of steam and clocks run out of minutes, immutable phenomena that conspired to create a de facto prioritization scheme that no one would actually choose. “Oh yeah,” we say when we get to the end of the list, bored and breathless, “and then there’s Mr. Z. He’s doing okay” – even if Mr. Z is the most complicated patient in the building.

While the sign-out issue tackled by Cohen and colleagues is interesting and important (particularly in the era of resident duty-hour limits), in teaching hospitals I see morning rounds as the epicenter of the portfolio problem. Consider the task that residents face when they run a ward team: they may need to round on 8 to 15 patients, somehow ensuring that all the right things happen clinically, sick patients are cared for, timely discharges occur, the team’s esprit stays high, and the interns and students learn something useful. They are given about 90 minutes to meet all these goals, time that will inevitably be punctuated with pages from nurses, taps on the shoulder, and unanticipated turns in patient conditions. Compared with this, running a Fortune 500 company’s board meeting has got to be a cakewalk.

I sometimes talk to our residents about how they deal with this challenge. They frequently throw up their hands. “We never seem to have time to teach. I have a few great talks prepared for rounds, but I never get to them,” some lament. Or, “Yeah, I wanted to see all the patients with the interns and students, but Ms. X crumped overnight and she took us 45 minutes. So we didn’t get to see the other folks.”

The solution to this, I tell them, comes from approaching morning rounds systematically – as a fast-paced mobile meeting with an agenda that must be completed in a fixed number of minutes. I ask the residents to create a mental tally of all of their tasks and goals for rounds, and then to map them out on a pie chart, allocating a certain amount of time for each patient or task.

At this point, I need to break out of role and take you behind the scenes in my blogging “process.” As you may know, my wife Katie Hafner, an accomplished writer and journalist, edits all my blogs. Katie is a lovely person who inevitably says supportive things (I am particularly fond of, “Honey, how can you be so brilliant?”) while offering sage but gentle critiques. Anyway, Katie’s response to what you’re about to read was a bit different from her usual atta-boys. “Are you sure you want to say this,” she laughed, “’because you sound like a f-ing robot.”

Perhaps so, but if I can improve the lives of hardworking residents and students, and maybe even the care of a few patients… well, wouldn’t it be wrong of me to keep my method to myself? I think it would. So, armed with the courage borne of moral certitude and a really good glass of Port, here goes.

A typical work rounds plan, including the estimated time per task, for a team caring for 11 patients (including some in the ICU) might look like this:

Clinical Work

• Sick, truly unstable patients (n=2): 13 minutes each

• Sick, stable patients (n=2): 9 minutes each

• Stable patients who might be discharged today (n=3): 10 minutes each

• Not too sick, not unstable, not going anywhere (n=4): 7 minutes each

• Transitions between rooms (walking, stairs): 30 seconds per patient

Total clinical time for 11 patients: 26 (sick, unstable) + 18 (sick, stable) + 30 (discharges) + 28 (stable) +5 (10 transitions) = 107 minutes

Additional Time for Teaching/Icebreaker

• Brief chalk talk on topic from previous day (differential diagnosis of pleural effusion, use of the BNP, that sort of thing): 7 minutes

• Opening segment (including greetings, an icebreaker, prioritization of tasks): 3 minutes

Total time for teaching/icebreaker: 10 minutes

Total time required for morning rounds: 117 minutes

• Now let’s add in an extra 10 percent for contingency time (unexpectedly sick patient, interruptions): 11 minutes

Adding it all up, the total time required for all tasks on morning rounds: 127 minutes

While that exercise was wholesome fun, our problem remains unsolved: the team only has 90 minutes available. So I next ask the resident: What do you want to prioritize? Where can some time be shaved? Well, she may say, I can shave a minute off for each of the sick, stable patients, another minute off for each of the potential discharges, and 2 minutes off for the patients that are rock-stable. In addition, she realizes that she can see two of the stable patients herself (without the team) after rounds, switching up the next day so that the team sees those patients together every couple of days. So the new math is:

Clinical Tasks (revised)

26 (13*2) + 16 (8*2) + 27 (9*3) + 10 (5*2) = 79 minutes

Adding 8 minutes (10 percent) for contingencies results in a total of 86 minutes for clinical tasks.

OK, better but still not good enough, since we have only 90 minutes and we have to find time for our mini-lecture and the icebreaker. So the resident recalibrates once more, deciding to see only one (not two) of the completely stable patients. That brings the total clinical time (including contingency) down to 81 minutes, leaving us 9 minutes for our icebreaker and our chalk talk. Bingo.

Now, how do we actually organize the morning? On the way in to work, I tell the residents, think about your cases and what you want to accomplish. In essence, you’re developing a draft agenda. Here are a few general principles that should inform this process and keep it from jumping the rails.

1) Always start with the icebreaker. Ask your team members how they’re doing. Bring up a news item or an interesting development – in the hospital, in the outside world, anything to create a sense of team – that this isn’t all about work. Then ask your team members, “Were there any developments overnight that should change our priorities?” This is where they tell you that Ms. Jones crumped and is now in the ICU, or that Mr. Smith stabilized. Tweak your timeline. Now get cracking.

2) But before you rush to see the first patient, consider doing the teaching (your “chalk talk”) now. Saving your formal teaching to the end, to be delivered “if we have time,” is like planning to buy something crucial at the end of the year “if there’s money left over.” There never is. So think about teaching first, before attacking the first case. Unless one of your patients is coding, this brief delay won’t make a difference. Trust me.

3) Make your agenda transparent. Give the team a rough outline of your pie chart, how you’re planning to spend the time on rounds. Make sure they endorse the general plan.

4) Call attention to time when necessary. Keep an eye on the agenda, and be willing to say, “I’d love to spend more time on that, but I’m mindful of the clock. Let me talk to you later about that.” Encourage the med students to keep a log of questions that you didn’t get to.

5) See if one of your team members will agree to be a designated smartphone looker-upper. On my team this week, Marcus, one of our awesome interns, took on this role. During walk rounds, we were trying to decide whether to continue anticoagulation in a patient with a left ventricular thrombus and a severe coagulopathy; the latter made anticoagulation riskier than usual. The decision hinged on the probability that the LV thrombus would throw off a systemic clot. Armed with his iPhone and UpToDate, Marcus looked it up and gave us the data we needed (7.5 percent risk per year, too low to merit anticoagulation) in about 30 seconds, a fantastic example of real-time learning.

6) Speaking of asking the team members to help, if you’re not a great timekeeper yourself (because you’re too nice to cut someone off, or this involves too much multitasking), ask another member of the team to take on that role (“I just wanted to let you know that it’s 9:15, we’ve spent 25 minutes on Mr. A and there are 4 more patients we wanted to see”). Rotate this task among the team members.

7) When events on the fly force you to think about changing the agenda – and they will – think about the time you allocated for each remaining activity on your pie chart. When considering whether to spend another 3 minutes (beyond what you’ve allotted) discussing a non-crucial patient care issue or for making a teaching point, ask yourself, “Is this important enough to cut the time from the slices we allocated for the other patients and tasks?” If it is, use your contingency or adjust your schedule (and tell the team that you’re doing that). If it isn’t, respectfully deflect the question or move it to the parking lot for later consideration.

OK, call me R2-D2, but there you have it. In my experience, everyone who is any good at running rounds – or meetings – hews to a version of what I’ve described (even if they don’t articulate it so robotically). They think through their agenda beforehand. They allocate the appropriate amount of time to each task, based on the goals and the minutes available. They build in a reasonable contingency, but try hard not to use it. They generate robust discussions and then efficiently move to closure, developing and articulating an action plan if appropriate. They find a comfortable way to push things along, including mastering the fine art of cutting someone off without being nasty.

And they virtually never save the most important issue – or the sickest patients – for last.

Robert Wachter, MD, professor of medicine at UCSF, is widely regarded as a leading figure in the patient safety and quality movements. He edits the federal government’s two leading safety websites, and the second edition of his book, “Understanding Patient Safety,” was recently published by McGraw-Hill. In addition, he coined the term “hospitalist” in an influential 1996 essay in The New England Journal of Medicine and is chair of the American Board of Internal Medicine.  His posts appear semi-regularly on THCB and on his own blog, Wachter’s World.


2 replies »

  1. My residents spend most of the time on rounds clicking away on the EMR to find results hidden someplace and to enter orders after searching for the unusual descriptions of common medications and tests that are as user unfriendly as all get out.