“Let me order some labs, and then we’ll discuss where we go from there once I have the results.” I walk out of the patient’s room and right into one of my nurses. “Zoe, can we start that lady on pressors like we talked about? Her blood pressure is still low after the fluids. I need you to put the order in so the pharmacy can send it up.” I smile my assent. Got it — labs for room 11, then pressors for room 10. I reach my seat and see a sticky note on the keyboard — I have a new patient in room 4 who is requesting pain medicine. I move the sticky note only to have the results of a urine culture thrust in my face by the charge nurse. “Does this need an antibiotic? If so, would you write one real quick?” “Yeah, no problem, but it’ll be a minute.” Labs for 11, pressors for 10, pain meds for … room 5? No, room 4. Need to see why they’re here. And an antibiotic script. But let’s do the pressors first. I open the relevant chart and type in “Levoph…” right as my phone starts ringing. A colleague from a local clinic needs to tell someone about a patient they are sending in. I jot down a few notes and hop off the phone only for it to start ringing again immediately. Just then, an ambulance comes in the back door. “Hey, his heart rate got really slow right as we got here! Need some help! He’s not breathing great,” the paramedic shouts as they come barreling past. Naturally, they are headed into my resuscitation bay. I grit my teeth and finally fire off the Levophed order. The phone is still ringing, and I ignore it to go help with the new arrival. Thirty minutes later, I step out of the resuscitation bay after stabilizing my newest patient. I sit down at my computer, place some stat orders for him, then stare at the screen blankly for a moment. Do I need to order pressors on 10? I open the chart, but the order is already there. I try to reassemble my to-do list, but my mind feels sticky and slow. What else did I need to do? It might sound like I compressed that timeline of events for effect, but people who work in a hospital know that it gets precisely that busy quite often. Mostly I can handle lots of little tasks being thrown at me. The labs get ordered, the meds too. The trouble comes when I need to actually stop and reason through something. My mind gets stuck on my ticker tape list of order labs … print discharge papers … update family. And it’s hard to slow down and accomplish anything mentally complex. Then I try to get back to the list, and it’s like trying to pile marbles on each other. I can’t think! More than just fatigue, it feels like some critical process gets contaminated. I read an article a while back that sheds a little light on the matter. It turns out this problem is called attention residue, a term with deeply satisfying descriptive power. When we switch from one task to a second task, part of our attention stays on the first task, keeping us from top performance on the second one. Multiply that by a hundred or so over the course of a shift — no, really — and the mind is left holding fistfuls of sand, a hundred unruly fragments of unfinished work. Now try to hang onto that sand while painting a landscape. The difference between the two is what the article calls shallow versus deep work. Shallow work is the simple stuff I was dealing with above — order that, sign this. I do deep work when, for example, I focus on a patient’s unusual labs to figure out the underlying condition. The first is easily interrupted while the second is easily disrupted, especially by attention residue. In the article, they recommend decreasing shallow work and scheduling blocks of time for deep work; this obviously doesn’t apply to medicine. Sorry sir, you will need to come back in 20 minutes to have your ruptured aorta addressed; I have scheduled this time for thinking. Ma’am, you can’t have any medicine right now; today, I refuse to do menial tasks like placing orders in the computer. So what do we do when we have no control over the nature and pace of our workload, but we need to clear the decks to do some deep mental work or refresh our mental processes? I’m really asking. I can prioritize with the best of them, but I still have mixed success at work. I generally keep the ticker tape of little tasks up to date But on days like the one I described above, there’s no good solution. Sometimes I forget to put in a lab order or fill out a work note, and I have to be reminded. And I never get my charts done on time. My mental tool of last resort is a quick memory dump. I often need it at the least convenient times when the department is at its loudest and most chaotic, and half of my patients are people in their 80s with shortness of breath, and I can’t remember who needed the chest CT. I stop. I tell my charge nurse I’m taking five minutes, and I leave the department — maybe for a coffee from the doctors’ lounge, maybe outside to the ambulance bay for a breath of fresh air. It doesn’t matter. What matters is that I stop working on medicine entirely for a few minutes. Usually, when I get back, I find I have a better grasp on everything I need to do. I sit down and take a deep breath, order that CT on the correct person. I pick up a new chart. Someone hands me an EKG as my phone rings. The ticker tape flickers to life and starts running again. Source
