Maintaining Order in the Midst of Chaos

HP Lovecraft's Azathoth at the center of Ultimate Chaos.  "Azathoth". Licensed under CC BY-SA 3.0 via Wikimedia Commons.
HP Lovecraft’s Azathoth at the Center of Ultimate Chaos. “Azathoth“. Licensed under CC BY-SA 3.0 via Wikimedia Commons.

There are few jobs more chaotic than that of physician, at least based on my own experience. Yes there is a schedule of sorts: hospital rounds, procedures, office patients. Unfortunately things rarely go as planned. There is a particularly sick patient on rounds who needs a temporary pacing wire placed. There are more consults than expected. The procedure that was planned to take up to 2 hours takes 4 hours because of unexpected difficulties. Office patients are double booked. And then there are the phone calls. Referring doctors wanting advice or asking if a particularly tough patient can be seen quickly in the office. Nurses calling to clarify orders or to tell about a patient who isn’t doing well. Calls from Medicare or insurance company minions asking why a particular patient was still in the hospital and hadn’t been discharged yet. Other non-patient care related duties take up precious time. There are hospital staff requirements to take infantile online courses on Hazmat or Fire Safety. There are recurring CME (continuing medical education) and new MOC (maintenance of certification) requirements. Finally, believe it or not, doctors usually have a family life too. There have the same school concerts, hockey games, and sick kids that other working parents deal with.

As there are only 24 hours in a day, the net effect of all this running around was that I was perennially late for everything: late in the office, late for procedures, late, late, late.  I myself hate going to an appointment and waiting.  Most of my patients were understanding and good-natured about it, which only made me feel more guilty about being late.  But there didn’t seem to be much that I could do about it.

When things got really busy, interruptions would themselves have interruptions. For example, while writing my patient documentation in the office on my computer, my medical assistant would come in to talk to me about a different patient. While talking to her, a phone call would come in. I would take that call, then go back to the conversation with my MA, then finally back to the patient documentation — at least in theory, assuming I hadn’t forgotten where I was. This interruption process was so common that I began to analyze it — being the geek that I am — in computer terms. Computers also have “interrupts.”  A computer will be processing some task, say sorting a list, when you press a key on the keyboard. This generates an interrupt.  The current state of the task is stopped and pushed onto a certain area of memory called the “stack.” The keystroke is then processed, after which the original task is “popped” off the stack and resumed. Interrupts can also have interrupts with the result that multiple tasks are pushed onto the stack in backwards order (last in — first out).  It works for computers, but unfortunately human memory is fallible, so despite my analysis of the situation, I still often lost track of what I was doing when interrupted multiple times.  Utter Chaos!

Organization is the antithesis of Chaos. Like many people overwhelmed by disorder, I read a lot about the principles of organization. One book that I read in 2008 and that I highly recommend is David Allen’s Getting Things Done (GTD). Even if you don’t implement his entire system of organization, which is actually fairly complex, it would be hard not to come away from this book without some useful tips. A fundamental idea of GTD is to write things down. The whole GTD system is centered on having a “trusted system” to enter tasks so you don’t have to remember them yourself. This trusted system could be a notebook, index cards, scraps of paper, or, more high-tech, computer programs or apps designed to record notes. By writing everything down you can spend time actually doing tasks rather than worrying about what you are forgetting to do.

There is a lot more to the GTD system than just this and I encourage you to read the book. But even if you don’t implement the whole system, just getting things written down is a mind-lightening experience, almost zen-like. In the context of working as a doctor, I used a decidedly low-tech approach to implement a trusted system. I would have a piece of paper with me all day long — usually my hospital rounding list. I would use this to check off the patients I rounded on, adding diagnoses and billing level codes in tiny print. I would write down new patients on the list, including new consults and admissions, as well as patients I received calls about. I would write down little todo tasks, such as, check a troponin level or electrocardiogram, adding a little box that I could check when I completed the task. I could even handle nested interruptions with the list, jotting down a brief note about what I was doing at the time of each interruption so that I could resume where I left off. At the end of the day everything on the list should have been checked or crossed off, and I could discard it. Obviously my todo list often grew beyond one sheet of paper, in which case I would staple a blank one to the original. I realize that many physicians use such a system anyway, and this system is only in the most sketchy sense an implementation of the GTD system. Yet it upholds the spirit of the GTD system, which is to write your tasks down, with frequent reviews and updates.

Since I retired, I have had fewer tasks to organize and more time to develop more elaborate methods of organization. In the hectic world of medicine, nothing was faster or more effective than just writing things down with pen and paper. Nowadays, I gravitate more towards digital forms of organization. I don’t have just one program or app that I use for this. For ephemeral unimportant lists (like a shopping list) I like simple list making apps, such as Wunderlist [Update 2022:  Wunderlist is defunct].  For entering notes or clipping webpages, I find Evernote is useful. As mentioned above, I am a longstanding computer geek and programmer. Ultimately the best organizational tool I have found is something called Org Mode which runs in the old-fashioned programmers text editor Emacs (I use that editor to write almost everything, including these posts). Unfortunately Emacs has a very steep learning curve, so I can’t recommend it (unless you too want to write computer programs). There are many other apps and tools to choose form nowadays to implement any organizational system imaginable.  So there are no excuses.  Life today is very complex and chaotic.  Everyone should work out their own organizational system and use it. With such a system, even in the field of medicine, order can come out of chaos!

By mannd

I am a retired cardiac electrophysiologist who has worked both in private practice in Louisville, Kentucky and as a Professor of Medicine at the University of Colorado in Denver. I am interested not only in medicine, but also in computer programming, music, science fiction, fantasy, 30s pulp literature, and a whole lot more.

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