12 Employ patient-centered care and shared decision making. It makes patients and families happy and allows you to guide patients to appropriate decisions and away from unwarranted diagnostics. Here are four examples:

1. Lumbosacral spine X-rays for routine back pain: 1. No red flags. 2. Won’t change their management.
2. Chest X-rays: If you know patients do not have pneumonia clinically, tell them. They want an answer, not necessarily a test. If you have chosen to treat them with antibiotics and they don’t need admission, don’t order the X-ray.
3. CT for renal stone: 1. Previous stones with identical symptoms and no risk for abdominal aortic aneurysm (AAA), then don’t order the CT. 2. Young and healthy without risk of AAA and classic presentation, consider shared decision making and no CT.
4. Knee X-rays: With the exception of significant trauma, knee radiographs are rarely useful, so tell patients that. If you suspect internal derangement, then tell them that time is the best test. Most don’t benefit from imaging, but those without improvement may need an MRI.

13 Plan your shift.

1. Beginning of your shift:
   • Avoid taking more than two to three sign-outs.
2. End of your shift:
   • 90 minutes left: Begin expediting admissions (eg, some testing is incomplete but unlikely to impact disposition, so advise the admitting physician of outstanding items).
   • Make phone calls early (eg, admissions, outpatient follow-ups).
   • One hour left: Attempt to see easy dispositions one or two at a time.
   • Establish your system for chart and patient flow and stick to it.

14 Avoid diagnostic pathophysiology.

1. Consider the Frank-Starling curve. Stroke volume increases with increases in left ventricular end-diastolic volumes. However, there is a point at which more volume results in decompensation and reduced stroke volume. Our efficiency in the emergency department matches this theory. The more patients you acquire and the more tests you order, the more you accomplish until the wheels come off of the bus. Then errors are made, patients wait, diagnostics are not evaluated in a timely manner, etc. Know your point of decompensation.
2. Your brain is like a smart phone: Too many apps running, and your phone becomes slow and has no battery life. Patients and outstanding tasks are open apps in your brain. Open less by ordering less. Shut down apps by dispositioning patients as soon as possible.

References

1. Gladwell M. Blink: The Power of Thinking Without Thinking. New York, NY: Little, Brown and Company; 2005.
2. Chisholm CD, Collison EK, Nelson DR, et al. Emergency department workplace interruptions: are emergency physicians ‘interrupt-driven’ and ‘multitasking’? Acad Emerg Med. 2000;7:1239-1243.