In 2014, Academic Life in Emergency Medicine (ALiEM) introduced a blog series titled “How I Work Smarter” where Emergency Physicians described the life-hacks they use to work smarter, not harder. On April 18th2019, a thematic review of this series was published describing the strategies used by these physicians to increase productivity, improve work-life balance and decrease burnout.
“The parts I truly love about the work I do in my non-clinical time are all creative. I am not painting exquisite portraits, but the impulses and the rewards feel the same to me. Unfortunately, for every hour I can create there are 10 hours of maintenance, upkeep, and busywork to make the creative work possible. I dream of finding ways to significantly increase that ratio. I spend a bunch of time searching for those ways; I imagine many of us are in the same boat.“
What they did...
Utilizing a snowball sampling technique, a total of 46 Emergency Physicians were nominated by their peers who were felt to be particularly successful and efficient. The mean age of interviewees was 39.5 years of age with an average of 11 years in practice. 34% of those responding to the questions were female, and 66% male. Subjects were asked a standardized set of questions to look for common patterns of Emergency Physician productivity.
Here are some of their responses...
What's your office workspace setup like?
"If you prefer having physical screens, then try Duet. This allows you to hook up your iPhone or Ipad up to your Mac and turn it into another display. I’ve been using this a lot recently and I love it. Pair it up with a Mountie and this will turn your laptop into a powerful workflow device."
"Mac “sticky notes”: I have different notes for short-term must-do; lists of ongoing/pending/future projects; and lists of revisions I want/need to make for my grants. My devices. My can’t-live- without applications: Twitter, Dropbox, Evernote, Stata, NVivo."
"I don’t have any special method of organization except a folded piece of paper that I carry in my pocket and write notes on when something needs to be done…a paper to-do list. It’s just paper."
"The cloud. My satchel carries a laptop or iPad, phone, portable laptop speaker, earphones, remote clicker, iPhone microphone adaptor, and adapters for lightning to everything AV, and occasionally lipstick."
"Double screens are the best for document editing and writing."
"I can work wherever and whenever I like, to be honest, as cloud computing, mobile devices, and 4G telecoms mean that I can access pretty much anything I want, when I want, where I want".
"Backup everything on SugarSync, so I can access my files everywhere."
"Flubox Molubile charger. Large Capacity Memory Stick or Portable External Hard-Drive and Travel router. Some hotels only allow one device to link to their network at a time, but this is a huge problem if you have multiple devices that need wifi access. So, when I travel, I always bring a portable travel router. I use the Satechi Smart Travel Router. For traveling Lecturers: Bring multiple versions of your presentations and a wireless remote: the R800 by Logitech for several reasons: 1) it has a great range so I can walk around the room without losing the signal, 2) it has green laser which is easier for people to see than a red laser, 3) it has a built in count-down timer that you can set and vibrates when you have 5, 2, and zero minutes. The R800 fits comfortably in my hand and is very lightweight for travel. Video Adapters for your own computer. Business cards: Email, blogs, and social media are the new business cards for networking, but I still have some business cards."
What's your best time-saving tip in the office or home?
"I use aText ($5) on my Mac, although I recently learned that you might be able to do this for free in the most recent Mac OS (System Preferences > Keyboard >Text). I have keystrokes for my various emails, work and non-work email signatures, phone numbers, and some stock phrases. For instance, typing “eee” inserts my work email automatically. These few saved seconds save lots of time in the long run."
"Set goals for the each day and each week. I keep a running list of goals on a piece of post-it paper (yes, written with pen… I know) attached to my computer. That way I see it every time I open it. The pen and paper gives me the satisfaction of crossing though when tasks are completed and crumpling the paper when I finish a list. I love that feeling."
"I set up my day with 3 tasks – a “must do,” a “should do” and a “nice to do.” Get those done and the rest is gravy (and I feel like a superhero)."
"If you listen to podcasts (or any educational audio) at normal playback speed, the following tip will transform your efficiency: Increase the playback speed! Make sure you have an audio player that allows this option (most do, but some don’t)."
"I frequently find myself needing to fill-in and sign PDF forms emailed to me (hospital credentialing, anyone?). Instead of downloading the PDF, printing it, filling it out, scanning or faxing it… enter OS X Preview. Just open the file in Preview, then go to the Tools > Annotate > Text Menu to add text to a file. Tools > Annotate > Signature to sign your PDF. When done, hit Command-S to Save, then always “Print to PDF” to save the combined file. Email it back to the sender. You just saved some trees and obviated the need for fax machines."
"I do use Dropbox, Any.Do, and Mozy back up to manage projects/ activities/ documents."
"Setting up one calendar with color coding and reminders. Since I have a Mac, I use iCal and have synced all my emails and other calendars onto one. I have my calendar divided into administrative work, clinical work, vacation, birthday reminders, and personal life."
"Only allow a certain amount of time for each task. When that time is up, move onto the next task regardless."
"Whenever someone is offering you an opportunity, ask yourself if the event was coming up or the chapter was due next week; and you had 10 other things that you were in the midst of, and your kid was sick; would you still be excited to be doing this thing. If the answer is yes, go for it—otherwise say no."
"Give yourself defined blocks of time to achieve your tasks. If you know you have 1 hour, you’ll get it done in 1 hour."
"To take it to the next level, get boomerang. Boomerang allows you to push a thread out of your inbox, to return whenever you want, or, if you’re composing an email, to send it whenever you want instead of right now."
"An academic physician needs to focus on particular niche, be passionate about it, and then repeat. The Achilles heel of the emergency medicine physician is that we tend to like too many things, and as a result, it is easy to become unfocused academically."
"I use the Dragon app on my phone to dictate long emails, parts of papers, or new ideas while I am walking on the treadmill, watching my kids play in the yard, or otherwise not near a computer, so I don’t lose the wording/ thoughts/ etc."
"To only have one system to use in all locations. This avoids lots of duplication and looking for information."
"Never open your email box unless you have time to deal with it."
"When going on holiday put the following message on your out of office assistant: ‘I am on holiday until **/**/****. Your email has been automatically deleted. If the matter is important then please contact me after this date. If the matter cannot wait please contact ******** in the interim’. This has a dramatic effect on email quantity and makes coming back from holiday a much more pleasant experience. It is also a salutary lesson that the world does not stop when you are not there."
"Tools like Slack, Basecamp, GoogleDrive, and Evernote (I use all of them– you have to be amphibious to be collaborative across ecosystems) allow for truly collaborative work and diminishes the number of overall meetings while improving efficiency and productivity. Never repeat any task that can be automated (automatic Pubmed citation generator). Using keyboard shortcuts helps me streamline my computer work, as they are always faster than mouse clicks."
"For the home, try to touch non-work related paper (e.g. mail and kid’s school stuff) only once – pay it, RSVP, log it, set up reminder, etc. – do whatever you need to do with it and be done with it."
What's your best time-saving tip regarding email management?
"I am an advocate of David Allen’s Getting Things Done philosophy and “Inbox Zero” philosophy by Merlin Mann, although I honestly haven’t been able to achieve it yet. Currently, I have 21 messages still in my inbox! Nonetheless, I have rigged my Gmail so that I can quickly sort my inbox immediately into actionable items of: To Do Today, To Do Soon, Scheduled for Meeting, Awaiting Reply, Non-Urgent Tasks."
"I always answer at least 1 email while going to the bathroom, and 2-3 if doing number two… Think about that the next time you open an email from me."
"Run e-mail like running the department – disposition-focused. Delete as much as possible, respond immediately by phone when practical, and otherwise “run the list” of recent e-mails a couple times a day when the opportunity arises."
"Many folks mistake the internet meme of “Inbox Zero” as having no messages in your email inbox. That is not quite it; instead the key is to have no messages there that you have not already made a decision on. That is what kills us about opening our email—all these reminders of decisions we don’t want to make or work we don’t want to do."
"Cluster times for email at the beginning and end of the day, so it doesn’t dominate the whole day."
"Seriously, teach your Siri to understand you while you’re running. You’d be amazed at how many emails you can answer like that. A good mic on your headphones helps."
"Delete most. Ferociously ‘unsubscribe.’"
"I used this tutorial to create “multiple inboxes” through smart uses of labels. Plus it’s important to learn keyboard shortcuts in Gmail to quickly move messages around."
"Do not open your email until you have time to process it, and process it immediately. Either delete, take action, or flag for follow up. Save email time for when you need a mental break. Batch email processing, and don’t constantly check during the day."
"I use Gmail with the ActiveInboxHq add-in ($39.95/yr). The add-in allows me to assign statuses to emails very efficiently so they are quickly created into to-dos. I can also mark them to be watched if I am waiting on a response, send an email later (so it does not look like I am really working at 3 am), and assigned labels with ease."
What's your best time-saving tip in the ED?
"Try and build relationships with everyone, so you can delegate effectively and safely to junior staff, nurses, orderlies and even patients."
"Document as much as possible up front, immediately after the patient encounter. I don’t document during the encounter. I’d rather have an effective, efficient patient encounter and charting session in series, rather than do both tasks simultaneously, but poorly. Then, left to the end of shift, documentation quality both degrades and requires longer to create."
"Tell patients how long things are going to take so that they do not ask you. Whatever time you think something will take, double it. Leads to fewer interruptions."
“I find that charting at the time of interview or resident/student presentation allows for better documentation, and lets me focus more on medical decision-making.”
“Only order the tests you need (things that change your decision making based upon the result).”
"I created my Paucis Verbis cards to maintain a repository of topics that I commonly need to look up (e.g. vasopressor doses, PECARN for pediatric blunt head trauma) or commonly use to teach students/ residents on shift. These on-demand resources save me tons of time."
"Lists! (Do you sense a theme here?) Seriously though, I carry around a clipboard with me to keep track of who I’ve seen, who I’ve charted on, whose primary care physician (PCP) I still need to call, etc."
"I’ve found Siri is more than capable of scheduling reminders – or even meetings (and if you use Omnifocus, your Siri reminders can end up in your Inbox)."
“Documentation suffers if we delay between the encounter and charting.”
“Always take all the necessary tools you’ll need when examining a patient into the room with you. Sore throat? Make sure you have a tongue depressor. Abdominal pain? I bring the ultrasound in with me.”
"Run the board every time you come back to it to figure out what you’re missing or what you’ve forgotten. Dispos’ are usually waiting on you, not the other way around. Minimize excess movement by combining trips to multiple adjacent rooms at a time."
"If you have any control over the environment, then work towards reducing flow-destroying interactions and circumstances. When we are in flow-state we perform better and leave the shift elated rather than drained. Flow-destroying situations include task interruptions, unnecessary alarms, fights with other services, and poor physical plant/work set-ups. All these are preventable and fixable with forethought and a group of colleagues that want change."
“Always make an active decision. You should not be constipated about decision making or you will harm your patient. Sometimes the active decision might be to do nothing. That is ok - it is still a decision. On the other hand, doing nothing because you never got around to making a decision is not.”
“I have one favorite app … and I know where and how to search it well.”
ED charting: Macros or no macros?
"No macros. Write less."
"Macros, but cautiously."
"Definitely macros, but you need to be exceedingly careful about how and when you use them. Let’s stop pretending that charting does anything good for our patients. If we cared about that, we would spend all our time writing the 3 lines that described why they came and what we did. That would be the whole chart. Charting in its current form is for two reasons only: Billing and Avoiding Lawsuits. So be as savvy as possible to accomplish those two goals. Macros can help with that a bunch."
“My MDM [medical decision making] is how I remember the patients in my brain. Even if every back pain has ALMOST the same MDM… there’s always a little bit that’s different. And the sheer fact of typing ‘no signs/sxs of epidural abscess, cauda equina, trauma…’ makes me double-check in my brain that they really don’t have signs or symptoms of these life threatening disorders.”
What's the best advice you've ever received about work, life, or being efficient?
"Before taking on a new project, think about whether it is aligned with your long-term professional goals. If so, commit to a finite amount of time whereupon then you can re-new your commitment, if time allows."
"Exercise every day. This will refresh you physically and mentally. You will ultimately get more done and be able to handle more stress."
“Figure out what means the most to you in your life, and schedule those things in first, along with things that are necessary for your health and well-being (sleep, family time, exercise, etc.)"
"On time means being ten minutes early. My Dad taught me this. This isn’t just for clinical shifts but it applies to every deadline. I always shoot for coming in a couple days ahead of schedule. It shows people that you deliver on what you promise and that you take their project seriously."
“I actually do most work on a spinning bike at home because I can’t concentrate well with my heart rate below 100.”
“I find that people who really have a passion for something will end up being successful. You have to love what you do every day to be consistently good at it and maintain that drive without burning out.”
"D'elegate! I used to think it was a badge of honor to just do everything myself and plow through. Then I realized I really stink at a lot of things and it would be much more effective if I let people better than me do some of the tasks that need to get done. Focusing on my strengths and others strengths really makes for a much more productive team."
“[Allow] colleagues to support you and [permit] them to be creative as a means of becoming more efficient. . . . [T]his means that when I task people I ask them to deliver the outcome, rather than micromanage the task processes. This is much more time efficient for me and I often find that they develop their own systems which are better than your original idea.”
Is there anything else you'd like to add that might be interesting to readers?
"I make sure I spend time with the family and workout. I don’t watch much TV. I sleep 5-6 hours/night. When I travel, I work on the plane and in the hotel, I workout, eat room service, and get caught up on sleep."
"I strongly feel it is our ethical responsibility to patients and society at large to order precisely the indicated tests and therapies – no more, no less. Being judicious with limited resources is an incredibly difficult challenge – but the alternative is simply lazy, thoughtless, wasteful medicine. I also find involving patients in decisions at every step of the process, with explanations of goals of care, diagnostic strategies, and estimates of costs – results in interesting and revealing conversations of substantial value in directing care."
"I strongly feel it is our ethical responsibility to patients and society at large to order precisely the indicated tests and therapies – no more, no less. Being judicious with limited resources is an incredibly difficult challenge – but the alternative is simply lazy, thoughtless, wasteful medicine. I also find involving patients in decisions at every step of the process, with explanations of goals of care, diagnostic strategies, and estimates of costs – results in interesting and revealing conversations of substantial value in directing care."
"Knowing the evidence can improve our practice and help set realistic expectations. It is about choosing wisely which usually means choosing fewer tests not more. It takes less time to explain why something is not needed than it does waiting for the investigation to be performed and results to be reported. This allows you to see another patient who is also waiting anxiously to have their problem addressed."
"Learn to say no . . . but not early on in your career. Saying yes is vital to development. Even projects that don’t seem particularly interesting may lead to relationships with people that you’ll want to work with later on."
"As much as I’ve blabbered on above, my greatest secret to productivity is a very carefully compounded mixture of caffeine, Bengal tiger blood, and methamphetamines. Mix it wrong and it’s deadly, but get it right and you’ll work productively for days straight."
"I like the Getting Things Done method of time management, and also find good tips and resources on Unclutterer.com."
"Choose projects, jobs, and talks all based on who is involved – mates should always take precedence over prestige."
"Whiteboard for home office for brainstorming and planning projects and making checklists (white showerboard panels (can get from Home Depot or Lowe’s)."
"In an effort to organize my life, I have created a “Dashboard” that I check once week. The dashboard is inspired by my research on ED tracker boards, and uses a colour coding system. Just like the ED tracker board, I run this list periodically and complete my “reassessments” of existing projects (i.e. sending off emails, checking up on results or progress on manuscripts, etc). Here is a template copy of my little dashboard file. Feel free to download and make it your own!"
"In an effort to organize my life, I have created a “Dashboard” that I check once week. The dashboard is inspired by my research on ED tracker boards, and uses a colour coding system. Just like the ED tracker board, I run this list periodically and complete my “reassessments” of existing projects (i.e. sending off emails, checking up on results or progress on manuscripts, etc). Here is a template copy of my little dashboard file. Feel free to download and make it your own!"
Conclusion
The personalities of Emergency Physicians vary just as much as the pathology we encounter. We are known for our abilities to improvise and adapt to our current situations. Efficiency is an art built on experience and shaped by the tools we are given. We can all use these tools to improve our productivity, both in and out of the Emergency Department.
References
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Azan B, Innes M E, Thoma B, et al. (April 18, 2019) How I Work Smarter: A Qualitative Analysis of Emergency Physicians’ Strategies for Clinical and Non-clinical Productivity. Cureus 11(4): e4499. doi:10.7759/cureus.4499
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Azan B, Lin M. “How I Work Smarter.” Academic Life in Emergency Medicine (ALiEM) Blog, July 18, 2014. Available at https://www.aliem.com/category/non-clinical/how-i-work-smarter/
Nicholas McManus
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