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.

I am going to have to apply Wells criteria if I am going to avoid sending this patient directly to CT. I quickly read the Wells criteria which are now conveniently on my screen along with their point values. I either print the list out or jot them down on my notepad for approximately the thousandth time (I always seem to forget to ask about hemoptysis and objectively measuring leg circumference unless I do this).

The macro reminds me yet again to carefully measure for objective leg swelling. Because the chair of my department humbled me once with a great pickup of a pulmonary embolism, I have adapted the practice of either using a tourniquet and a pen for extremity measuring and comparison or, preferably, I use an actual tape measure for determining accurate circumferences. In fact, I have no choice but to do this or else my macro will be incomplete, useless, and unfulfilled. Chekhov would not approve!

My Wells macro forces me to be deliberate and careful when I suspect PE. But mostly it forces me to follow through on my intentions, a hallmark of a decent writer: if you foreshadow, you must fulfill.

Another beauty of incomplete macros is that they can aid in my clinical decision-making by reminding me of known risk percentages associated with my findings that I have not yet memorized. Once I have easily and accurately documented the components of a clinical decision rule, the statistical probabilities associated with my findings are right in front of me.

My Wells score macro spits out the following. Total score: [blank]. For my patient, I fill in 1.5 points (for tachycardia). Next, I consult my list of known risks, which look like this: Risk: <2 points = low risk (mean probability = 3.4%), 2-6 points = moderate risk (mean probability = 27.8%), >6 points = high risk (78.4%). With 1.5 points, I know my patient is in the lowest risk category.

But given the overall pre-test scenario, I am likely going to have to get a D-dimer to reassure myself that the patient is not in a hypercoagulable state. But for now, I’ve avoided a CT because my suspicion is sufficiently low. Regardless of what happens, if I or anyone else were to look back at this case, my thought process and care would be clear to any reader.

My list of incomplete macros is ever growing. Sometimes, I make new ones at the end of shift, usually by cutting and pasting out of a note I have just written. I have an incomplete macro for “Red Flags of Headache (.RFHA). I have a macro for the differential diagnosis for each quadrant of the abdominal pain (.DdxRLQ, for example). I have a macro for the Clinical Institute Withdrawal Assessment scoring and treatment decision algorithm (.CIWA).

My incomplete macros contain percentage odds and sometimes cite literature. But most importantly, they crystalize my thinking and encourage thoughtful deliberation. For any chest pain patient, my incomplete macro (.ChestRisk) reminds me to document why I am assured that this pain is unlikely to have an aortic dissection, pericarditis, esophageal rupture, pneumothorax, acute coronary syndrome, pulmonary embolism, or pneumonia.

Those blanks remind me to follow up my lab results, look at the ECG one more time, think about the history and risks, run and document my clinical decision rules like Wells and PERC, think about doing a bedside sonogram if indicated, and to read that chest x-ray myself and then document my thoughts.

A good macro does not put my mind at ease but rather keeps my mind working vigilantly with a clear goal in mind.

My incomplete macros can serve as bookends to my patient encounters. When I receive signout from another resident, my “.SBAR” macro creates a formatted progress note with the patient’s known demographics, and predesigned sections for “situation, background, assessment, and recommendation.”

I simply fill in the blanks. More than a few times, this thought process has forced me to reassess the assessment, and led to changes in the plan – including a couple of pick-ups that gave me a little bit of intern pride! And when I go to “.Discharge” my patient, my incomplete macro not only states that I discussed the discharge instructions but asks me whether I have discussed reasons to return to the emergency department with the patient. If I haven’t, I do it.

To prime and to remind. To foreshadow and to fulfill. These are the tenets of the incomplete macro manifesto. To become better doctors, we also must become better writers. And like any skill in medicine, we all need good guidance and mentorship. So for a little inspiration, try channeling someone who might as well have been the patron saint of doctors who know how to write: Anton Chekhov.

Dr. Faust is an emergency medicine resident at Mount Sinai Hospital, New York, and tweets about mE.D.icine and classical music @JeremyFaust.