The Pediatric Milestones are now being used to guide the ongoing evaluation of trainees in all rotations. Certainly the most important Milestones vary from rotation to rotation. In the Pediatric Emergency Department (as in many others) being organized can help make you an efficient provider, Effective prioritization allows you to move from one patient to the next seamlessly.
This post in the Art of Medicine series therefore delves into what we, as evaluators are looking for when we assess residents in terms of how they organize and prioritize in the Pediatric Emergency Department.
The Pediatric Emergency Department is a place where solid time management skills, good multitasking and efficiently dealing with interruptions are key skills to master as early as possible. In the ED we experience frequent interruptions that lead to lapses in our tendency to get things done. Basically, if you are interrupted more often and get distracted by these interruptions you’ll have to multitask more. Experienced emergency medicine attendings will respond to interruptions then go back to their pre-interruption task. They can take new interruptions (a nurse asking for a Tylenol order) and compare them with what they are doing (writing discharge instructions) and determine that the latter is going to free up a room faster, and thus move things along quicker for the department as a whole. So, they discharge the kid first, then write the Tylenol order. This efficiency is enhanced by clinical experience and their achieved ability to multitask. Inexperienced residents may be interrupted but fail to return to the pre-interrupted task (write the Tylenol order – but then move onto something else with that patient, neglecting to return to discharging the other patient).
It is important to note that earlier in their clinical development residents are more likely to have prolonged or permanent breaks in task completion in response to an interruption even when the interruption is less important. Advanced trainees are more likely to respond to an interruption with a brief break and return to the pre-interruption task. That is, there is less latency in moving from task to task. This seamless movement form patient to patient is one of the hallmarks of an experienced ED provider, and is not generally achieved until at least midway through residency. Context is important too – sicker, and more complex patients are more likely to leave novices lost in the weeds regarding how to proceed.
As a supervisor, in order to effectively assess this milestone we suggest that you:
- Try to understand how a resident is prioritizing their work. Ask them what they have on their task list. Find out how they are staying organized. Are their using the EMR or scraps of paper? Figure out where they can be more efficient – writing down the history on paper then transcribing to the EMR is inefficient. Maybe have them chart in room for instance.
- You should also always direct nurses and other care providers to the resident first with questions/issue about their patients. Eavesdrop, then assess how the resident dealt with the interruption.
- It can be challenging, but please attempt to discern what makes a resident less efficient. Is it volume? Acuity? Interruptions? All of the above? The easiest way to get at this is to ask the resident themselves. This often opens up a bridge to discussing ways to become more efficient and new insights for you as the evaluator and preceptor.