As Anton Chekhov wrote, “One must not put a loaded rifle on the stage if no one is thinking of firing it.” That is the essence of the incomplete macro manifesto.
Before I have even laid eyes on a patient, I often open the “assessment and plan” section of the patient’s chart and begin documenting.
This is, of course, mild blasphemy for a resident. Once in the chart, I insert an incomplete macro – a pre-programmed keyboard short cut that automatically insets a bolus of text I have previously written and saved as a keyboard shortcut. I pen the note and sometimes print it so I can bring it with me to the bedside as a reference or a checklist. Later, when I return to document the patient encounter, the incomplete macro awaits completion.
Like an itch waiting to be scratched, it demands attention. It must be addressed. Chekhov, a master of foreshadowing, would have approved. After all, he was not only one of the greatest writers of his time but also a successful practicing medical doctor. “Medicine,” he wrote, “is my lawfully wedded wife. Literature is my mistress.”
‘Before I have even laid eyes on a patient, I often open the “assessment and plan” section of the patient’s chart and begin documenting.’
The key to the incomplete macro is its very incompleteness. Instead of a long and unrealistic list of pertinent negatives that are cookie-cutter copy and pastes (that no emergency medicine resident can realistically fully assess during a short encounter), my macros have “yes/no” after each clinical feature or blanks that need to be filled. This means that later I will have to edit the macro to complete it.
This prevents auto-think (non-think) and encourages me not only to ask the right questions of my patients and perform the right exam, but to document my practices thoroughly. The incomplete macro enhances both the medical encounter and medical documentation. The incomplete macro primes and reminds.
Here’s an example for a patient we’ve all encountered in some form. Triage summary: 36-year-old female with chest pain. Heart rate 104. You click on the ECG already done in triage. It shows sinus tachycardia. The patient medication list says, “oral contraceptives.”
Well, if we are going to rule out pulmonary embolism, we might as well get it right. So, I click open the chart and type in two keyboard shortcuts, one for Jeff Kline’s Pulmonary Embolism Ruleout Criteria and one for the Wells Criteria for Deep Venous Thrombosis/Pulmonary Embolus. My macros are “.PERC” and “.Wells.” In a millisecond, a slew of text appears containing the nitty-gritty of these clinical decision rules that I typed up and saved as macros months and months ago. Right away, I know the patient does not “PERC out” because she has two disqualifying features I can already detect without even seeing her: the patient is tachycardic and takes estrogen pills.