Sensitivity is the number of people who have a test that is positive that have the thing you are looking for.  In medicine, this is usually a disease.  We like sensitive tests in medicine.

The flip side of the same coin is the specificity of a test.  This is the ability of a test, if it is negative, to allow you to confidently assert that the patient does not have a disease.  We like specific tests in medicine too, we really like them in Emergency Medicine.

Both of these things can be defined numerically.  That can be helpful when thinking about the result, as essentially both the sensitivity and specificity of tests are closely related to the incidence of the thing you are looking for.

The more common a disease (the higher the incidence) the less false positives and negatives matter (as you get less of them).  Generally speaking as you calibrate a test if you push the sensitivity to 100% (fewer false negatives), the specificity falls (more false positives).

So what?

Well, when we study tests we define the population we are looking for really tightly, and exclude people who might not fit, or might generate confusing results (like women – seriously the data gap here is terrifying), or people we might not be able to follow up well.

We then use this published evidence to inform our search for diseases, and often we will not look back at how or why we are using the test again. 

Then the test starts getting used for more and more stuff, more and more tangentially, to the point we really have no idea how it is actually performing.  This is happening with pro-calcitonin right now, and happened with BNP before.

All very well you may say, that’s just academic vs ‘the real world’. There is always going to be indication creep, test biases and testing creep as the people that sell us the assay find more and more ‘useful’ uses for it.

But as we creep, we create a problem for ourselves as doctors in general, and our speciality in particular. This leads to poor care, overcrowding, and exhaustion.

This is the sensitivity trap, and I’m not sure we are talking about it.

We work in a regulatory, governance and legal environment that is pushing for, and demanding, close to 100% sensitivity.  We as a profession have bowed our heads, nodded, as this is absolutely the best thing for patients isn’t it?  We need to find everything.  Smarter doctors, more subtle findings, earlier diagnosis, so much better for patients.

But is it?

100% sensitivity is a wonderful goal, but for many clinical conditions it is impossible to attain.  Yet we are treating many tests as if they are 100% sensitive.  This has dangerous consequences for our systems.

If we aim for higher and higher sensitivity, our specificity drops.  This means we fail to rule out more and more patients, which means they need further, more invasive, tests.  These tests have risks for the patients themselves, but also have risks associated with the next patient, as we delay investigation when it is necessary because the infrastructure to manage 100% sensitivity medicine hasn’t been built (at least in this country –we could look to the US, to see where this thought experiment leads). 

As we fall into this cognitive trap, we assume that all false negatives are preventable, and related to poor clinical care, that the doctor, or nurse was stupid, that they didn’t notice a sign.  So we ratchet up the sensitivity yet further, we make more senior clinicians responsible for an ever high density of test interpretation decisions, or we create pathways which generate an ever decreasing amount of pathology, like an exhausted mining seam.  Just to pick up that 1 diagnosis a year, that we ‘missed’.

NICE performs relatively exhaustive technology assessments of new drugs or interventions to make sure they are cost effective.  Trusts and ICBs do not do the same when it comes to their pathways, is this SDEC working?  How many heart attacks has the rapid access chest pain clinic prevented?  Instead, governance systems, specialty interests, HM coroner and now the HSIB push institutions and clinicians to abandon specificity in the interests of sensitivity, because False negatives are seen as more important than False positives. 

This serves to flood your GP clinic, SDEC, ED, AMU, and 2 week wait clinic with more false positives, as we aren’t allowed to miss a single false negative.  This is overwhelming us, and it leads, I think to a change in clinical reasoning.

How many times have you heard the phrase “I cannot rule it out…”?

We have found ourselves in the position that if a constellation of symptoms or history could potentially fit with an unusual presentation of a clinical emergency (in particular) even if it is felt to be incredibly unlikely an onward referral is made, or further testing is arranged.

Yet at no point have we had a discussion about the infrastructure required by this approach.  Trusts, ICBs and organizations are discussing the utility of of 24 hour MRI lumbar spine testing because of this very problem.  Cauda Equina Syndrome is incredibly difficult to diagnose, but because of some exceptionally ill-informed case law, we must not miss a single case.  This results in many referrals a day for spinal services, which doesn’t result in a demonstrable increase in pick up of CES, or better management for people with lumbar back pain.  A bit like where we are with CTPA now (rates of PE are static, rates of CTPA especially in countries like the US are sky high with yields as low as 1-5%¹).  We do a bit better in the UK with the RCR wanting us to manage > 15%², we hit that (just!) where I am.

This is the tension between providing what we think of as gold standard care for an individual (because remember we don’t care about the harm of false positives) versus the good of the entire population.

We could, for example, trust a negative CT head for SAH in a patient that is GCS 15, and not admit them for confirmatory LP (SHED Study).  We could trust a single 3 hour high-sensitivity troponin at under 5³, as specific enough to rule out an MI, or we could accept a less risk averse calibration and go for 40, how many MI’s would we miss?  Doing these things would reduce short stay admissions a little, reduce time in the department a little, and would we really miss that many MIs?  Would we miss any important SAHs?  Probably not, but we would have to turn to His Majesty’s Coroner, and our peers and go ‘this is good enough’. 

There is periodically a push for choosing wisely for tests and treatments that are of no benefit to patients to be stopped.  Do we need to think about choosing more wisely for systems too?

1. https://www.ahajournals.org/doi/10.1161/CIRCOUTCOMES.119.005753
2. https://www.rcr.ac.uk/career-development/audit-quality-improvement/auditlive-radiology/appropriateness-of-usage-of-computed-tomography-pulmonary-angiography-ctpa-investigation-of-suspected-pulmonary-embolism/
3. https://pubmed.ncbi.nlm.nih.gov/24428678/

As an EM Doc you do a lot of tests.  You know about them, and you know that negative tests don’t always rule out a disease, you know that positive tests can be false positives (patients don’t have the disease you are looking for, but the test suggests they do).  You have seen this normogram about likelihood ratios, and maybe even used it once at a teaching day.

That Normogram (Faagan’s normogram) is your friend, because it defines the relationship between the possibility of the disease before and after you test for it, based on what you think.  This depends on three things, the quality of the test, how likely you think the disease is, and whether you are trying to diagnose it (rule in) or exclude it (rule out).

If you have a really low pre-test probability (<1%), and your test has a decent LR of say 10, you still only manage to get a 5% post-test probability that you’ve found pathology.  Most tests don’t have a +veLR of 10, most of them run from 0-10, so if after looking at the patient, talking to them, and examining them you really don’t think it’s X, and maybe you think there is 1 % chance its X to rule the diagnosis in with a test you need an amazing test, one with a LR of over 200 to get you to a coin-toss likelihood (seriously print out a normogram and draw the lines!).

Now this is hard to get our heads around, mostly because we don’t trust ourselves, we have the entire medical establishment telling us not to miss things, but paradoxically only ever refer things we’ve found, and never admit someone who turns out not to have high consequence disease X. The other thing that people don’t realise is that big ticket, high consequence genuine medical emergencies are rare events.  They are rare events in the ED population, and they are even rarer in the general population.

This means that if you test lots and lots for these rare events you are going to find more false positives than true positives.

So if it doesn’t sound like X, and you don’t think it’s X, and the patient doesn’t think it’s X, why do the test? (Please don’t do the test!).

We also need to talk about ruling-out here.  Unless you’ve got a really good rule out test like (for example CTA for AAD) if you don’t think its AAD, doing the scan isn’t going to change the post-test probability in the slightest.  This is counter-intuitive, so I’ll go step by step.

1. You’ve seen someone.  You’ve “Thought Aorta”.  They look ok to you.  You estimate a <1 % chance of AAD.
2. You do your CTA.  Lets say CTA has a -LR of 0.01
3. Well done your post-test odds are now 0.2% (but you thought that was the case already…), and now your patient has a 1 in 300 lifetime risk of cancer (according to our radiology requesting system)– you’re a monster…

Essentially if you’ve seen a patient and you don’t think they’ve got the disease they probably haven’t got it.  If you’ve seen a patient and think there’s a good chance they might, then you do the test and see, but for most tests your pre-test probability has to be above 1% at least, and probably higher.  If you’ve seen the patient and it clearly is X, then why do the test?  This is the problem with super rare, high consequence medical conditions.

Also:  your pre-test probability will almost certainly be an over-estimate.

INDEX OF SUSPICION

Should it be low? Should it be high? It is a term that peppers lectures and learning modules about specific conditions all the time. Have you noticed? It should always be high or low, it can never be right. It’s probably worth thinking about, and what I think people really mean when they talk about it, is your gain.

I mean gain in terms of amplification  – “the factor by which power or voltage is increased in an amplifier or other electronic device, usually expressed as a logarithm”

Now if we think of ourselves as detectors of pathology (which is incredibly pretentious but bear with me) we can increase or decrease our sensitivity to signals (in this case pathology) depending on a variety of factors.  These could be patient factors, or factors associated with the clinical question that has been asked.  For example we all know that neonates can have very subtle signs when they have a serious underlying infection.  So, we are careful, and exceptionally risk averse when assessing them.  Similarly, we should be careful in elderly patients with frailty for the same reasons.  Presentations are non-specific and can mask pathology that can be of high consequence (I’m planning on writing about non-specific presentations later).  We all do this to a certain degree, this can be seen with referral and admission patterns in the elderly and in the very young (higher conversion rates to admission).  However we probably don’t need to be similarly alert to subtle signs in a 24 year old man.

I think people find it difficult to switch modes here.  The likelihood of finding significant subtle pathology in a normally healthy person with nothing overt in the history to point you in any particular direction is so low that you probably don’t need to spend as much time with them as you would with the other categories of people I’ve described.  Now a number of doctors do this instinctively, but the majority I see use the same mental model, and the same ‘gain’ for every patient interaction.  This is inefficient, it will be too low for the cases that require subtlety and far too high for our ambulatory majors area. 

It is theoretically possible that with your gain turned down, you might be more likely to miss something; however, the sub-populations (Farmers anyone?) you are working within here are different as well.  The risk is probably smaller than you think, because the prevalence of subtle stuff in our young healthy population is less than in the elderly and frail.

So this is what comes with experience, you can see people incredibly quickly if you understand the population they are coming from, and the relative likliehoods of the pathology they or their GP are worrying about.  Now most people who work in EM have a good but tacit understanding of this.  They know for example that ACS is incredibly unlikely in a 24-year-old who attends with chest pain and are more wary of a 54 year old woman with ‘heartburn’ who is feeling tired all the time.  So this is probably a combination of gestalt and that term (that I hate) ‘index of suspicion’ or, as I’ve described, your gain.

So if after assessing someone you feel they are low risk, you aren’t really obliged to do any confirmatory or rule out testing.  You can send them home.  Equally if you have assessed someone and the diagnosis is clear, you don’t have to go through a risk stratification or Boolean algorithm to get to the diagnosis.  That wastes time.  Just skip to the end.

Speed and efficiency for doctors and AHPs starting out in ED.

Lots of people are worried about their speed in EM.  This is the time it takes to see a patient.  In the bad old days (maybe in some places still) junior doctor’s productivity is measured, and commented upon, with prizes for faster doctors (terrible idea) or euphemistic ‘extra support’ available for those who are ‘slow’.  Junior doctors are also generally a relatively high achieving bunch, they want to be seen to be ‘good’ this generates some anxiety, and nearly every doctor I have supervised have said they are worried that they are ‘too slow’.  Speed is important (I explain why in another post) and it’s right to want to be able to be efficient when you need to be, but how do you do it in EM?  How do you do it in EM when you are just starting out?  Especially when the entire system is in free-fall?

First off you shouldn’t expect to be fast, or try particularly hard to be quick.  You should be working on efficiency here, and that’s different.  So instead of being fast try to avoid behaviours that are going to get you tied in knots.  This is sometimes counter intuitive!

The best piece of advice I can give is to spend more time with the patient. In the age of electronic patient records, summary care records, and electronic discharge summaries it is really really easy to get sucked into reading about a patient’s past medical history to ‘prepare’ yourself to see them. This is rarely helpful, remember you’ve got a patient in front of you with a ‘thing’ the ‘thing’ may or may not be related to what you’ve read about, and you’ll likely have to go back and read stuff again if its relevant after you’ve seen the patient. There are exceptions to this, patients with care plans, and patients who have RECENTLY been discharged from hospital, but generally speaking after checking the ambulance sheet, triage note, and obs, just go see the patient!

The thing the patient can tell you is why they are here.  That is the most important bit of the history.  That is the bit to nail down and invest some time in.  The second most important part of the history is social history and functional status, as this is going to tell you if you can send them home, or not.  Don’t spend ages getting a PMH or DH from the patient, it’s hard for them to remember in many cases, and it will be inaccurate, you can do PMH from the Summary Care Record, or even the Drug history.  Spending the time to see if your patient can walk is time better spent than them trying to remember if they had their appendix out in 1978 or 87.   So see if your patient can stand and walk.

If after taking a history, ordering the obvious tests and writing your notes you do not know what to do go and ask. 

Do not:

• Wait for the bloods THEN ask
• Decide to do some bloods, or another test because you aren’t sure, THEN ask

These are behaviours that can get you tied into knots.  It’s ok to ask Middle Grades/SPRs and Consultants for advice.  They’ve got more experience about what is the likely trajectory of your patient, and it is what they are paid to do!

I think some people think that asking at this stage is akin to failure, but finessing your plan at this stage allows you to discuss the decision making that needs to occur after and around the tests that may or may not be needed.  This is valuable educational time, and will make you more efficient in the long run.  Our unit has a large cohort of F2 doctors making up a slim majority of our SHOs.  Now generally speaking in F2 you’ve not had that much exposure to decision making of the density or complexity that happens in ED (on the wards it’s often deferred to more senior docs).  Its ok that that bit (‘the plan’ part) of seeing patients is the bit that you need the most support for.

Deciding if someone needs hospital admission is something that can usually be ascertained from the history, and sometimes some examination findings.  Blood tests in general don’t help with many specific presentations, though there are a myriad of exceptions (like an amylase in pancreatitis, or those lovely high sensitivity troponins).  This means that once you’ve seen your patient, and examined them you should have a pretty good idea of which direction things are going in, and if at that point you aren’t sure it is ok to ask.

Chasing is another low yield behaviour for admitted patients waiting for beds.  Technically in most departments once someone is referred to another specialty most of the work of that chasing and case synthesis falls to the admitting team, but I see a lot of people chasing all of the extant investigations.  This rarely changes the patient’s trajectory, and consumes a lot of your brain power, as you are forced to maintain a long list of every patient you’ve seen.  The trick is working out what YOU need to chase and what can be left for the clerking doctor.  The thing here is that if blood tests aren’t going to help you decide what to do, then you don’t really need to do them.  Especially if the person in front of you looks well, and there is nothing in your differential diagnosis that blood tests will help you decide.  What blood tests do sometimes do is give you a 2-3 hour window in which to observe a patient ‘while they wait for the bloods’ and you can see if the symptom that’s bothering them (or you) goes away. 

I remember quite vividly as an F1 dealing with surgical referrals always, ALWAYS being happier seeing an ED referral than a GP referral because I had less work to do.  Even if the clerking bit of the ED notes was comically perfunctory usually all the ‘work’ (the Bloods, the cannula, the antibiotics) had usually been done, I just had to finesse the ongoing management.  The GP referrals (by their very nature) meant I had to start from ‘scratch’.

So in general – spend more time with the patient, and less time with electronic records.  Ask earlier for help with plans.  This will make things smoother, and that will make you faster in the long run.  Your notes (and I cannot stress this enough) do not need to be perfect, you are not writing a letter to your Gran, you don’t need to keep a handover sheet, all that information should be in the clinical record.  Spending time writing a little handover sheet or keeping a book is wasted time.

Inter-speciality referral fights are still a thing, and can bog down any doctor.  Don’t ever try to deal with these on your own.  Come find a SPR or Consultant who will be able to cut through whatever issue is holding things up.  Referral criteria and automatic referral pathways really help here (we’ve got lots of them where I work).  Many hospital specialties say they don’t like them, but a number of things happen if you pick up the phone to speak to a specialist when you don’t need to that can slow down the care for that patient and make a department overcrowded.

• Asking for another specialty to review prior to them coming to the ward.  This comes in two flavours:
  1. The safety check, asking for an ICU r/v or an anaesthetic r/v prior to transfer,
  2. The check it’s not the other specialities ‘problem’ before they come to the ward
• Both of these things can happen on a ward, and if you thought they needed ICU you’d probably have called them yourself.  If you aren’t sure if your patient needs ICU or an anaesthetic review ask an ED senior, they’ll know
• Asking for test Y or treatment X prior to going to the ward
  • This helps the speciality, and sometimes the patient, but does mean they stay in the department longer, and sometimes when they ask you to order the test you can get into a tangle with a radiologist.  Usually it’s best to ask them to order the test they want.  If radiology are ready while the patient is in ED, brilliant.  If not they can have it on the ward.  Doing the test in ED takes up valuable nursing and portering time, and that time might be better used doing something else.
• Asking for a review from speciality X before test Y can be done
  • If this is the agreed pathway then the accepting specialty can do all of that on their ward. 
• Refusing a referral, this needs to be brought to the attention of the SPR or the consultant, because it’s against the rules in most institutions.
• Accepting the referral, but saying they’ll see the patient in the ED because ‘they might’ discharge the patient.  This snarls up space in the ED unnecessarily, I know for example that over 90% of our referrals are admitted, so seeing the patient in the ED rarely results in a discharge.    
• This does depend a little bit on your local set up, sometimes some orthopedic patients, and surgical patients can go home with further specialist follow up or reassurance

It’s also important to note that inter-speciality disagreements always involve two very stressed people trying to manage an unmanageable workload. If you are going to call another speciality, at least for the first few times I would recommend talking to an ED senior first. They might know of local pathways or procedures for the situation you have found yourself in.

Ongoing care and handovers

If you are seeing a patient towards the end of your shift and know they are going to need to be handed over, it’s worth putting a bit of effort into your plan and documentation to make it easier for the person receiving it. 

Ideally; you need to handover a patient like this:

 I have seen them, I am waiting for X if X is Y do Z if X is T do B

Don’t handover a patient if you’ve seen them but don’t have a plan.  Find a SPR or a consultant and you can make a plan to handover.  Don’t ever handover a patient with the plan of ‘discuss with senior’ because what that means is that the person you are handing over to has to go and see the patient AGAIN and then discuss with the senior.

It is better to hand over 5 tidy patients than 6 partially seen patients with no plan.

It is best to handover up the chain of seniority.  I am unable to convince all my colleagues of this (though more and more are coming round to my way of thinking).

The patient no-one wants to see

They sit there on the board like a dam, maybe there are language difficulties, maybe it’s a regular attender, maybe it’s a problem no one particularly ‘likes’ to see.  Maybe you can see from the triage note it’s an intractable problem that you cannot solve. 

Most of the time these are simpler problems than you think. 

Language barriers are less of a problem than they used to be, and a short call with a telephone interpreter service can yield loads of useful information.  Also sometimes the problem is simple enough for that not to be required.

If you pick up that patient, I guarantee that within seconds the board will look better as the dam will have been broken, your behaviour here makes everyone faster.  You see you can be sneaky here as well.  You can go and see the patient, then after you’ve done your notes go and ask for help.  Every registrar and consultant is going to be happy you’ve taken the plunge and done the hard bit, and no one is going to question the need for help!   One of my colleagues calls this patient the ‘domino patient’.

Summary

Try to be efficient rather than fast.  Don’t rush, just don’t do things you don’t need to do.

Ask for help. The best time to ask for help is after you’ve seen the patient and written your notes.

Your history should be focused on understanding why they are in the ED, and what has happened to them.  You don’t need to do a clerking (please don’t do a clerking!).

Chase things that matter, nothing else.

We have all experienced the ED in the dire state it is in in the morning with a dejected broken night team filing into the handover room, giant waits on the tracker screen, apologies, unsaid recriminations, and the day team.  Girding their loins to sort out THEIR mess.  No one wants us to be in that situation, but this is where we find ourselves every day.

We fight against a broken IT system that is literally from a generation ago, specialities that think we are stupid and can be covertly or overtly obstructive, overcrowding caused by dangerously long bed waits, and the constant unrelenting arrivals from the waiting room the ambulance forecourt from a community care system broken by austerity.  We are constantly asked to do more for our patients, blocks, frailty scores, delirium scores, pressure sore assessments, and at no point does anything get taken away.

None of us want to discover a STEMI or sepsis at 6, 8, or 12 hours, and we worry that someone in the giant queue of patients is sick, and needs our help and we don’t know and worry we won’t get there in time.  That moral injury hurts us all, and our nursing colleagues probably more.  Nearly all of us have found someone who would have done better if seen sooner, and we carry the weight of that knowledge with us.

The easy way out is to discuss the barriers to speedy assessment, our knowledge, our IT system, the lack of space, the lack of engagement of other specialties, the time it takes to get to XR, the time it takes to get that scan reported, but that’s easy.  These are systemic problems, and I’m sure we will touch on them too, but that doesn’t touch on us, on how we operate, and why we do what we do.

It also doesn’t help, the above problems which are obviously the big drivers of our own inefficiencies require a system wide approach to solve, and though the management team in every ED in the world are trying to fight the good fight and some slow changes are happening it doesn’t help the patient you see next week, or next month.

It would therefore be easy then to gaslight everyone reading this, as we can’t fix the systemic problems, so we need to be faster somehow, I have no intention of doing that, and if it feels like I am, I apologise right now.  My intention is to get us all thinking about what we do, and how we do it.  A LOT of medical practice is ingrained, taught by observation, and through hidden curricula, and very little of it is actually genuinely beneficial to the people who are our patients.  It is also important to note in that vein that nearly everything I am going to discuss here is my opinion, and as such should carry the weight of the feather of a pixie fairy fighting a dragon.  I am, I believe, an outlier with these opinions, so by all means laugh, challenge, and ignore. 

This was originally a teaching session and it is adapted from my talking notes.  It is in two parts, the first I will make my case for speed, and the second part I hope will be a more practical discussion of thought processes, task management, and how and where it is safe be fast. But first I must make my case…

Why is being fast important?

EM doctors are important, yet we are derided within medical subculture as stupid, obnoxious, lazy, risk averse, jaded, broken and burnt out.  This is because all the other specialties don’t understand what we do, when you don’t understand something you fear it.  Emergency medicine isn’t easy, converting an undifferentiated presentation into something more clear and obvious is really difficult, prone to a lot of error, and poorly understood by our colleagues.  Yet they rely heavily on the work we do, and don’t fully understand how we turn an undifferentiated presentation into a patient with a problem list or a list of differential diagnoses.

You as an EM doctor are important, the system has made it so.  EM doctors are at the tip of the spear when it comes to providing treatment and diagnosing patients.  You have privileged access to the best diagnostic tests we have, and some of the best nurses on the planet.  You work in a close-knit team that functions every hour of every day to look after people when they need it most.  You are right nearly all of the time, despite having NO TIME to think.  You have license to do ANYTHING – prescribe whatever antibiotic you choose (even if it needs a code), put whatever chest drain in you feel like, summon a team of the most senior specialists in the hospital with a single phone call, and STOP the hospital to pivot to your patient.  If you can do ANYTHING, and you can do it faster and more efficiently than anywhere else you breed behaviours that become counterproductive, (more on that later).

Anyone can come to us, we have access to certain blood tests, and diagnostics faster than anywhere else in the NHS, and certainly faster than a member of the general public, or a doctor in a clinic can muster.  Even faster than private work.

The public know this.  Our colleagues know this. So despite us viewing our system from the inside as degraded, broken and inefficient, people outside marvel at it’s brilliant efficiency compared to everywhere else.

So we are important, ok.  But why should we be fast?

The biggest issue we face is our queue, the line of people waiting to be seen.  Waiting for the decision maker, which is us, to decide what the problem is and how they can be helped is something only you can do.

Countless studies have tried to work out what constitutes an ‘inappropriate ED attendance’ but the fact of the matter is that only after we’ve looked at someone do we know with any degree of certainty whether they need us or not.  The faster we can move through the queue, the faster we can find the people who truly need us. 

The faster we can move through the queue, the fewer people who are in the queue, the less overcrowded the department is, the easier it is to see the next patient.  The faster we all move, the better it is for all of us.

Now many things stop us being fast, I’ve alluded to the environment, the IT, and the other systems that slow us, but there are deeper, broader forces at work, demanding a variety of things from you that slow you down.

At no point in anyone’s medical training has anyone ever been given any teaching about how to manage a queue of tasks or decisions, we learn through experience, trial and error, or by watching others.

If you’ve got a queue of 15 things of varying levels of complexity is it best to manage the quick things first and do the things that will take longer afterwards?  Is it best to tackle the complex issues first, and then whip through the fast things at the end?  (Actually, if you tend to tackle the harder issues first you might end up generating more tasks for yourself or for others, so it’s probably best to tackle the quick things first!).  This is before we even start thinking about delegating tasks to others.

There is also, I think its fair to say, an atmosphere of fear that lingers over acute care in every sector.  The long shadow of a variety of GMC and other cases that castigate clinicians for making mistakes inside broken systems but fail to recognize the broken system in which they are operating.  It doesn’t take a genius to see that this actually forces a slower approach for each patient.  This makes the queue longer, and makes overcrowding worse.

You *have* to be thorough, you aren’t allowed to miss anything, even if deep down you know that the likelihood of serious illness is laughably low we have to go through the motions just in case we might be wrong.  This is because we are frightened our organization won’t support us, and our regulator will deprive us of our ability to earn a living. 

I have no answer for this, other than that we need to be brave, as the more of us who are brave, the less of an issue this becomes –   that’s the Bolam or Bolitho principle.

I think that this sometimes leads to that phenomenon where you feel you need to enter someone into a diagnostic pathway but feel a bit dirty doing so because they don’t fit.  The CT head ‘because they are here’ the first trop begetting the second trop (which heamolyses) and before you know it the patient has been present in the department for 12+ hours, and clearly isn’t having an MI, but is very very tired.

Part of this is that the people who write guidelines never think about their effect on the system that they operate in. There is also the phenomenon where we feel obligated to use a diagnostic pathway following the request of another clinician, for ED that’s often those in primary care.

The thing is, we forget our own agency.  We can STOP things like this, should you or I choose to, this sometimes requires more effort than just letting the metaphorical diagnostic ball roll down the hill. 

The patient who gets to go home earlier may thank you, and yes, there is undeniably a slightly increased THEORETICAL risk to them if you’ve not exited that pathway properly, there is also, undeniably an increased risk open to you as you’ve ‘gone rogue’.  However, was that pathway really the right choice?   If you choose wisely, and share the risk with your patient how much increased risk is there?  Really?  What is the downstream effect of that patient going home and freeing up a cubicle space and yourself to get to the next patient faster?  The next patient you see won’t thank you, they may even complain about their wait.

But it will be safer for them.

Sometimes being faster will mean we do LESS for the patient in front of us, but this isn’t always the case, sometimes it just means doing the key bits.  We should embrace this, we should only do what must be done, and never anything more.  However we are all under constant pressure to do more for these patients.  Especially the admitted ones.  This is because we are being abused by the inpatient specialities.

• ‘Can you just order this scan?’
• ‘Can you just put a catheter in?’
• ‘Can you just send of a serum cortisol?’

We work in the most efficient part of the hospital, so the hospital tries to get us to do the hospital’s job too.  Resisting this is hard.  Your job is the decision, and the critical interventions to keep people alive.  It might include a diagnosis, but it does not have to.

Refusing to do something that a patient obviously needs never feels good, and it feels like your friend the specialist (who is also up against it) will suffer, as will your patient, as the next bit of care is delayed slightly.  Win-win to do it here?  Again the patient in front of you doesn’t suffer, but your next patient does, as it takes you an extra 30 minutes to get to them.

You are so important and your time is so precious, yet you are forced to act like you aren’t important, that what you do with your time doesn’t matter but it absolutely does.

Nearly every single F2 and some of the HST’s I supervise worry about ‘not being fast enough’.  I think there is a widely held belief that some doctors are just faster than others, and that this inherent.  I hear people say things like ‘I’m not like that’; now if we think of speed just as a collection of behaviours, then it’s just another cognitive skill, which we can learn and refine.  The reason some doctors are faster than others is because they like being fast, and they work at it.  So if you can learn to be fast, and get faster if you want to, then anyone can.

Saying ‘I’m not fast, it’s just not who I am’ becomes a bit like saying “I’m not doing maths its just not who I am.”  Now we don’t teach ‘speed’, in fact the overt and subliminal  messages you are bombarded with as you try to learn emergency medicine are that you need to look for ever more subtle pathology, and ever rarer clinical syndromes, so we are teaching you to be slow, and you are working in a regulatory environment that wants you to be slow, and no one is teaching you how to be fast.

Yet our patients need us to be fast, and our colleagues need us to be fast too.

A group of doctors who can throttle up their speed to seeing 2 patients an hour for 3-4 hours would make the difference between a 11 hour wait in the morning and a 2 and a half hour wait.  So here we see speed is a patient safety issue. 

The other thing to think about is how ‘being fast’ gets turned into being a binary thing.  You are fast or you are slow, however this is of course very silly.  Speed of seeing patients is of course an analogue value, and just as there is a normal distribution of averages for cycle times for seeing patients, each individual will have times when they are faster or slower.  Speed is analogue, and just like a car you can push your own accelerator to go faster or ease off and go slower based on the terrain you find yourself in.  You have control of this.

Many doctors I see have one speed, whether it’s night time or day time, regardless of their location.  They apply the same approach to seeing a patient in a decisions unit, to a patient in ambulatory majors, to a patient in resus regardless of the presenting complaint.  These patients generally need different approaches, if you are aware of the different approaches you can take, you can modify it based on information you are receiving as you go.

You see we are up against a variety of systemic pressures that push us to be slow, and make being fast hard, requiring concentrated effort, complex thought, and practice.  It requires you to think further down the line for your patients than many of us are comfortable with and it requires us to use evidence and clinical reasoning in ways that are diametrically opposed to how we often are instructed to operate, and to how we’ve been trained.

It would be easy to talk about ways ‘we can better’ we can always be smarter, and in some respects, being cleverer and ‘better’ than every other doctor in the hospital is often what this boils down to.  However that is the most intellectually bankrupt solution to speed, but it is often bandied around in some way or another. 

So what can we do to be fast?

Know thyself – you need to be rested, hydrated, alert and comfortable.  Take your breaks.  Do you have specialized knowledge from somewhere else?  Use it.  Always.  Share it with others.  EM Clinicians love learning new skills and new approaches to the same old problems.

Adapt

Right approach for the right patient, complex obvious admission? Stop them dieing and move on.  Stuff that clearly doesn’t matter, ignore.  Obviously on the right pathway?  Execute the pathway and allow them to leave.

Letting go of patients you’ve seen is difficult, but going back and re-checking things including investgations often doesn’t yield much.  Remember how precious your time is.  Decide what you are chasing and why.  Only chase that.

Cheat

GP note says they’ve got this and it fits?  They’ve got it.  Hospital discharge note says this has happened before, great.  Do the same thing again (if it doesn’t seem silly).  Patient thinks they’ve got it (and it fits) they are right.

If a patient is on a trajectory that is going to require an investigation no matter what, order it (a good example of this is pregnant patients who might have a PE).

Trust

The downstream teams to do their job.  Don’t clerk the patient for them.  If the downstream team need a test, trust them to arrange it. We work in a big system, and are a big team. [You can insert a sports analogy here if you like]. 

Plan

If you need something before you can make the decision for that patient make that happen next.  While you are waiting for that to happen see another patient (or do a quick thing).  If you find a senior doctor they may not require the test for the decision.  Start to think about what tests alter decision making.

Remember:

Common emergencies are relatively rare events, even in the ED, our big tertiary referral trauma centre sees on average:

• 1 aortic dissection a month
• 1 NSTEMI/STEMI/ACS a day
• 1 PE a day
• 2 Cases of genuine ACTUAL sepsis a day

Out of roughly 400 type 1 adult patients a day.