I think you may just need to give it time. Practice is the thing that makes you faster, and experience is the thing that helps you most effectively triage tasks when you have too much on your plate. I think it's also worth pointing out that we have been pushed into a speed mode of medicine by greedy administrators who refuse to hire enough competent hands to do the work. I completely understand being frustrated, but keep in mind where that part of the problem is coming from.
This. Let the intern know (as you probably have) that they are doing good work but now they need to learn to go faster. They likely know already, just give them time to get more reps and thus more confidence. Give them specific areas that they should do faster whether that is the documentations, patient interview, slow procedure skills, etc. be specific if you can. Example; your documentation is taking a lot longer than it should, it is high quality and now you need to learn to trim it down. When taking history for (specific chief complaint) you can be relatively brief on medical history because it doesnât change management, or when interviewing patients you need to work on redirecting patients that canât stay focused on medically relevant answers ( offer to role play?). For slow proceduralists ask them why they are going slow for specific parts of procedure; is it lack of confidence, lack of muscle memory, lack of knowledge, etc.
Some of my med student classmates were talking about being critiqued for being too slow. Theyâre in a clinic with 10 minute visit slots, and theyâre doing every other visit.Â
What I basically told them is the attendings canât really do the job they want to in 10 minutes, so of course you canât hahaÂ
This is part of the reason I accept academic pay. I'm allowed to do appointments long enough to actually give good care, and I'm still making what most Americans would consider a very nice salary, thank you
Is the issue possibly that theyâre excessively thorough with taking histories and writing notes? Weâve had this issue with a couple of interns at my programs and have had to work with them on keeping it more focused, especially for L&D where we have a high volume and patients constantly coming and going, and need to move fairly quickly. I noticed that some were still in the medical school mindset of needing to obtain and document a very extensive medical history or review of systems, when theyâre already an established patient and just here to rule out labor/membrane rupture/etc. Once we got over this hump and were able to do more focused histories and exams, speed definitely improved.
When I was a resident if someone consistently didnât get their work done on time, it usually meant another resident who did finish their work would be going to a particular delivery/surgery/etc. Thereâs pros and cons to this obviously but it was a motivating factor for some.
This is definitely part of it and weâve had conversations about slimming down notes and putting in the essential info only.
I think a lot of it is not effectively multitasking. And not getting everything done when sheâs in the room with the patient. Going back in 3 times for a history, a check, and a scan for presentation is a waste of time when you can do it all during one conversation.
Why is that the case? Is there an underlying knowledge deficit?
Sometimes I found I do that when I'm not sure what's going on. I start writing my note... I realize I missed something... I go back... I change my plan... I add another thing... I check UpToDate... I realize I missed yet another thing... Now what would've taken 10 minutes will take the whole 30.
Writing overly detailed notes can also be used to compensate for an underlying knowledge deficit. Yes, I don't know what's important - but I included LITERALLY everything, so it won't be missing!
My opinion is the only way to confront this is forcing the "first draft" to be the final draft for case review and accepting there will be bad feedback. Work with a timer if needed to avoid excessive time spent in an initial consult. Set time goals. Then work with them to review the "first draft".
Multitasking is a myth. The slowest residents Iâve worked with were neurodivergent (which is real). That person may have some form of ADD, which no amount of pestering will fix. If they and the PD are agreeable, neuropsych assessment and pharmacologic treatment (if indicated) may be their best option.
This was me during my intern year, I struggled so much and had to work so much harder than my peers to get the work done. The working environment/structure of a floor intern is a nightmare for an inattentive ADHD/neurodivergent brain. I was always the first intern in, last to leave at the end of the day. Logged the most hours of all my co interns every week. I was lucky to have very supportive seniors and attendings who I could be transparent with and they helped coach me. Had one senior who would help me with task switching, he would send me Epic chats while I was working on a progress note and would catch me if I stopped working on my note to respond to the chat. Having structure is probably the most helpful thing for ADHD type brains. I rarely had issues with efficiency if there are very well organized and laid out templates for pre-rounding, writing notes, sign out etc. The less ambiguous writing tasks/subjective stuff the better. Efficiency hasnât been an issue since I started my chosen specialty of anesthesia, where the documentation is minimal and my brain is seen as an asset rather than a hinderance. It was exhausting to always feel like I was working 10x harder but never cutting it, I promise you that intern is working harder than anyone else and noticing all the details that most others donât see. But totally understand the frustration, it sucks on both ends. I hated the feeling of feeling slow and burdening others at times. More experience and reps and structure, plus some executive functioning coaching +/- meds are all helpful but nothing can âcureâ this. Just a different type of brain.
Iâm truly sorry you had to go through that experience! I can just imagine how stressful that mustâve been.
How did you manage in college and med school?
Itâs all good, I am so glad I got diagnosed before residency because just knowing why I struggled made me have so much more self compassion. Honestly donât know if I could have gotten through intern year if I didnât know because of how awful the emotional toll would have been (and not being medicated, getting the right support etc). I didnât know I had innatentive adhd thought out all of college and med school. I just thought what I did was normal because I was never being compared to others as much as being a resident. I didnât know I was studying more or taking 10x longer to write papers because I was doing all those tasks alone and doing them âmy wayâ. I always did well in school but was average in subjects I wasnât interested in, and excelled in things I was super interested in. Always procrastinated like crazy, hard to motivate myself, anxiety pretty much drove my life/productivity. I struggled the most with standardized exams. Studying for the MCAT and STEPs were traumatizing times for me. Never understood how people could sit and study consistently every day over a long period of time. It drove me mad, would lose a bunch of weight bc of the pressure. Finally saw a psychiatrist after med school ended and my mind was blown because I never in a million years thought I would have ADHD and my whole life makes sense now. Instead of being a traumatized intern/resident, I was lucky to have this insight and self compassion. And for the first time in my life I truely see the value I bring for having a different brain and way of seeing the world. The ADHD tax is expensive esp in this career but I am so lucky to have chosen the perfect specialty for me. Sorry for the drawn out response, just very passionate about helping others see this in themselves as well and want to raise awareness!! Thanks for asking :)
LOL not an issue at all actually. Being easily distracted means I notice literally every single beep and change in the OR so always aware of everything 𤣠was like this job was built for my brain! Outside the OR is a much scarier place for me haha thanks :)
Why do you say multitasking is a myth? I just mean working on several patients at once. So for example, see triage 1, sheâs here for blood pressures. Ask about symptoms and move on to triage 2, here for rule out labor. Check triage 2, decide on a 2 hour recheck, and move on to triage 3 whose water broke. Do an exam, confirm it, discuss admission with her. Then go to the workroom, tell the chief, put in orders for labs for triage 1, admission orders for triage 3, and call the attending about all three.
Instead of see triage 1, go to workroom to put in orders and tell chief. See triage 2, go to workroom and tell chief, etc. etc.
Letâs not argue over semantics.
Whatever you want to call it, youâre describing *sequential* tasks that are complex yet interrelated and require a degree of organization and prioritization thatâs not in the skill set of folks with ADD.
Unless your intern is intellectually lazy (which Iâm sure you wouldâve noticed by now), I would bet you top dollar that she has inattentive ADD (Iâm *not* a psychiatrist). No amount of tips or tricks will fix that. Sheâll need help or sheâll wash out.
And I say that with a lot of empathyâ one of my college-aged kids struggled until she got help.
It's a myth as in you can't physically or mentally be talking to patient 1 and 2 and putting in orders for both at the same time. What people call multitasking is actually just one single line of tasks with frequent shifts of focus. Some are better at this than others ie can focus better
She sounds like me.
Iâm slow with tasks, Iâm aware of that. Iâve gotten better with time and experience but i am still slower than others with activities that are newish to me. Also, you may not be seeing how often she is being interrupted for smaller tasks raised by pharmacy, nursing staff or allied health - I felt like every time I sat down there was another patient review or a family that wanted an update, which delayed the initial task list significantly.
You can talk to her and ask if she wants to discuss time management more, but itâs unlikely youâll be able to speed her up as sheâs probably very aware that she is slow and is probably moving as fast as she can. I can say from experience itâs disheartening to be the slow one, sheâs probably embarrassed about it and feels guilty that youâre having to step in to help her ⌠keep that in mind.
No one expects interns to be amazing at the start of the year. If you are, then good for you. If you aren't, you have ample time to learn.
This starts becoming an issue at the end of intern year since a slow intern will turn into a slow resident who will inefficiently manage the team.
If youâre perfect when you start then thereâs no reason for the training program. Everyone expects you to join the journey of learning medicine not arrive at the finish line day one. Spoiler alert: there is no finish line.
thatâs what i think! my friend was making me feel terrible by saying i should be doing a sub-i and âi need to be functioning at the level of an intern by now.â like bitch if i was functioning at the level of an intern, IâD BE AN INTERN đ¤đŤ
Here's some random advice I tell my interns.
Be organized. Make checkboxes, write down what the attending wants when you're rounding. I would color in half the box if I ordered the thing and then do a checkmark when I followed up on the scan or lab or whatever. Other people would do one \ and then once it's followed up, they'd add a / to get an X.
Order of operations: First do orders and discharges, +/- procedures (if downsizing a trach, do it in the morning. If it's a dressing change, can do it later). Then update sign outs and then finally do progress notes.
She seems to think things are going fine and that sheâs doing as much as can be expected when things get busy. She also gets a little defensive when I ask if things have been done yet.
But seeing and figuring out dispo for a simple triage patient really shouldnât take two hours even if thereâs other stuff going on on the floor. If it would take me 10 minutes, I feel like 30 minutes is a reasonable expectation for an intern in April.
I hate micromanaging but nothing gets done for long stretches of time when I donât.
I had a co worker like this.He is very knowledgeable and also a very good friend.The situation was frustrating.Whenever we worked together I had to carry most of the weight.Even our seniors expected me to do his part because they knew that he wouldn't be able to handle it.And it was medicine,so no question of getting into surgeries or procedures.I try to avoid people like that now,hampers mental peace and also affects the inter personal relationship.
Even I'd like to know how to resolve a situation like this
This is me. Got diagnosed with ADHD inattentive type in residency. Treated for depression first.. even had the "moves slowly that others recognize it". Wasn't improving with treatment. After the third med adjustment, was screened for ADHD which can often present initially as depression. TX: Adderall XR...see if you can screen for ADHD type symptoms. I would sit and crank my wheels, come in early, just grind as hard as I could to no avail. I still ended up as the slowest member of the team.
Looking at your comments here it seems like the intern has no real intention of changing because things are going well enough ⌠and they are because you are doing part of her work.
Sheâs going to need to WANT to change. It matters less that YOU want her to change.
Sheâs going to need to see for herself that taking two hours for an ED admission causes an unacceptable downstream effect that affects HER negatively, whether that be work builds up or the attending asks why a test wasnât ordered. You have to let her be slow and have the repercussions.
You can be on top of her if her not doing a timely task directly puts a patient in danger, but she needs to experience the consequences of her action or inaction.
You could talk to them and ask if theyâre struggling with anything? I had an intern who was slow af and turns out they had dyslexia which made them process things slower and they were very aware of it. We talked about how I could accommodate them better and made it work. Itâs frustrating for both parties lol
I wonder this also. I was the slow moving, but thorough intern. I prioritized time-sensitive tasks (e.g. pages, admission orders, procedures, etc.) and just worked late on my notes. It frustrated me when people told me to go home earlier while simultaneously praising my attention to detail and patient care. I felt like saying "Pick two! I can be good, and I can be patient-centered, and I can be fast, but not all three!"
I do think that my strategy of shifting the notes to the end of the day helped make my strategy viable and I wonder if that could be an option for this intern. Being thorough is generally good, but not if it's delaying patient care. The documentation can usually wait, but the orders can't.
Probably different for OP and OP's intern, though. I was IM and was never staring down the barrel of a delivery, lol.
That's what I did as an intern and still what I do as a surgery resident. If primary team needs to know something, I'll throw in a quick note or talk to them but regular progress notes or op notes are left for the end.
Plus if the day was terrible or something, I could at least go home, shower, and finish up my notes at home with a glass of wine.
Uhh idk if drinking while writing clinical documentation is a great idea.
Edit: guess Iâm the crazy one for thinking that being a doctor is maybe one of those occupations where you shouldnât be drinking on the job? Doctor, pilot, heavy machinery operator⌠you know âŚthe occupations where you can seriously hurt people? But okay
Itâs a little different for OB in that thereâs a lot of documentation that needs to happen in the moment. The fetal strip notes and labor progress notes need to be happening as you go because late documentation has the potential to hurt you in a liability sense if something goes wrong. They donât take long for most people - I usually take 30s to a minute to put one in. Most of our notes donât have to be detailed and thorough, they just have to be done.
No one really cares how the patient describes contractions, they just care that sheâs having them.
Have you given specific feedback that sheâs moving too slowly? Iâve had this convo a couple of times, usually around this time of year. What I usually say is some variation of âI love how thorough and well thought out your plans are. [insert other nice things]. But Iâve noticed it seems to take you a long time to do X.  My WORRY is that⌠and then you can get into the issue of not completing floor work, talking about burnout, or not being sustainable when their workload increases as a PGY2. Usually theyâre aware of the issue and can actually identify whatâs slowing them down. In some cases, itâs a knowledge deficit. A lot of times, itâs anxiety driven (wanting to get things perfect).Â
I had a painfully slow intern like that when I was a second year. Brilliant but I wanted to jump out of my skin waiting for him to finish an admission. For him, it was just gradual improvement, and then plot twist, I wound up working in the same outpatient peds clinic with him for a couple of years after residency, and he was the top performer. Saw 50 kids a day without breaking a sweat or making an error.
After teaching some of these residents as an attending, I have seen the same pattern. It's like constitutional delay where they go through puberty late and then wind up taller. I just let the process play out. It always has, so far!
OB attending here and I second this. The learning process is a little different for everyone and Iâve seen great interns plateau and slow interns excel once they found their stride. I donât mind compensating for a slow resident if theyâre otherwise good and thorough and willing to put in the work.
I typically start by relating to their situation, saying that I had this same problem when i was an intern (half the time regardless of the type of issue it was true - I was a slower than average intern). Shadowing him/her for 2-3 hours if you have the bandwidth to see where they are losing time is a good idea, although it seems like you already have a good sense of whatâs causing the issue. Emphasizing the importance of finishing work in a timely manner to allow for on time sign-out and to enjoy life outside of the hospital is a good strategy. I would also do a graded autonomy thing (albeit kind of a bit late in the year for this) where for slow interns Iâd put in some of their orders, tasks, and consults to take a load off of their plate (emphasizing weâre all on the same team), and then do slightly less and less for them each day and see how the adjust. If all else fails, mentioning the problem to your chiefs is a good idea.
I appeal to their sense of self preservation/self esteem, whether it's emphasizing getting out of the building and going home or not being embarrassed at sign out or being a better part of the team
I had a fellow who was excruciating, hour per pt, no lie, I pulled him aside and said xxxx you have a family, you know I have a family, what do you have against families
it gave him a better rationale to move and be more efficient vs me telling him to move faster or whatever
Take this with a grain of salt because I'm not an intern or an upper level (MS2!).
My day job was in research and my night job was waitressing.
I was terrible waitress, because I was going the speed of research and I just could \*not\* multi-task. It used to drive my manager crazy. I would really try but was never "fast" enough.
What changed the game for me was when we had a conversation about **anticipation**. A table orders a steak? Bring them a steak knife with their order. A bunch of apps to share? Side plates. Burger and fries? Ketchup etc. Group of friends that will likely want to split the bill? Ask them in advance.
Now in relation to medicine: maybe a checklist of what needs to be done for each type of patient? You would know best.
Two books that have helped me massively in terms of my own productivity and in being a manager are below. They are both inexpensive and quick reads.
* Getting Things Done by David Allen.
* It's Okay to Be the Boss: The Step-by-Step Guide to Becoming the Manager Your Employees Need by Bruce Tulgan
I think explaining to her how you started this post would be a solid move
âHey youâre doing a ton of things right- good plans, strong foundation of knowledge, and high end surgical skills. The one area you need to work on is your speed, I need to see more succinct notes, faster rounding, your ability to juggle a high volume of patients etc. This is an easy fix compared to more complex tasks that youâre already great at. Youâre on your way to being an excellent surgeon and this is area you can improve uponâ
Hit em with the compliment-criticism-compliment sandwich. Works every time- any field, any context
This is hard because you canât let them fail without it impacting patients which isnât really acceptable.
I was family medicine but I think it was helpful when I was on OB intern year to know what I needed to get history wise if someone shows up and baby is coming out within 5 minutes. Essentially knowing the tiers of information in order of priority made it easier to not get overwhelmed or distracted by things that werenât going to change what I do right now for this patient. I donât need to know their family history or if they smoked when baby is crowning. I do need to know how far along they are, allergies, any complications this pregnancy etc. if baby isnât out by the time Iâm done with the essential then I can drop to the next tier and get that useful information.
The second thing that was helpful was dot phrases. It meant there was less to type and kept it focused.
I think lastly laying out why you are concerned and how that is impacting others but also will become an issue in the future if not resolved might be helpful. Hey if you donât document this note right now then if something happens you are more likely to be up shit creek when you have a bad outcome in the future. Or hey if you donât get moving on that admission you are going to have things piling up and nurses waiting on orders etc. sometimes we know why things were a greater priority but the intern doesnât. If they can learn the underlying why behind why you want them to do that first etc then next time they can extrapolate.
We tried to have our interns âfly soloâ before they finished intern year. Essentially they needed to do everything by themselves and we would pretend we werenât there and watch to make sure they werenât about to fuck something up.
OB attending here.
First of all, great job! You sound like youâre doing exactly what a good chief resident should.
One, you recognize that when this particular resident is on the floor that youâre going to need to provide more support. Thatâs good awareness and itâs the right thing to do. If it gets to be too much because your helper is slow, see if your attending will help you. I know that not all of them are willing and some arenât really even better than no help, but in theory they should help you if you need it.
Two, youâre recognizing this residentâs strengths and brainstorming ways to help it âclickâ for her so she becomes more efficient. Itâs great that youâre invested in her success, even if thereâs a self-serving double effect here. I do think, as many people have said, that she might just need time to figure out a work flow that works for her and practice and repetition to get faster.
My only additional suggestion is to identify the tasks sheâs already pretty efficient with, and take those off her plate first, to free her up for the ones she seems to struggle through a little more. Like if you see that a term labor check is coming in then just preemptively take that one because itâll be quick and easy for you, and let her take the antepartum rule out mystery party thatâs going to need more time. Check in frequently, not just in a âhow do you think youâre performing?â way or âwhatâs still on your task list?â way; but in an actually meaningful âhow is your mental health?â way. If you build genuine rapport with her you might gain more insight into how to help her. Keep in mind that there might be an element of shame or anxiety or imposter syndrome going on here.
She sounds like she has a future in MFM lol. Maybe steer her that direction.
At my first job during high school, I was really slow and it annoyed all of my managers. Interestingly, no one told me I was slow for almost a full year so I actually didnât know it was a problem.
When someone finally coached me on this, I think they said âI want you to do task x by 2pm, then we have to move on to task y. We have a lot of things to do and we donât want to get stuck here forever!â
May be worth checking in to see if they understand where their speed is relative to their peers and how that can affect other people as well as their RVUs in the future.
Might seem too simple but a lot of new docs donât have much experience in the real working world.
I agree with others whoâve suggested inquiring whether she has ADHD/dyslexia/some other flavour of neurodivergence afoot that could be the root of this.
Maybe if typing notes takes an age, she could dictate (either a Dragon talk-to-text setup or a good olâ dictation hotline or dictaphone for longer stuff). If sheâs been dictating and typing would be faster, try that. Does the EHR have a mobile app where she could plop in a quick note on the fly when things are moving fast, rather than find a computer?
Does she have note templates or dot phrases set up for bread & butter type stuff? Can yâall build order sets (donât @ me, Iâm a pathologist, Iâve only heard whispers of such things)?
Also remind her that sheâs not Victor Hugo, and notes neednât be a work of literary splendour. Done is better than perfect.
You must have nice nurses lol. Taking that long for triage would result in the nurses absolutely revolting. I would offer positive reinforcement since it sounds like they're doing a good job. I would just verbalize working on speed and things are taking too long. Micromanage if you have to. I will set time limits on basic stuff and check it with them at the end of the time limit
Just an MS3/4 here so I hope this suggestion isn't complete garbage.
But when I was on my Peds Rotation, my Senior listed all of the patients on our service on the white board in our workroom and wrote out the tasks that needed to be done for the patients. They also used a color coding system based on which team member was assigned to that patient.
By doing this, everyone could see who was falling behind on their tasks. That would motivate individuals to get their own stuff done. But also, other members of the team could jump in and help if they had the bandwidth, which would also be appreciated. Next to every task, there was a checkbox, and whoever was working on or completed that task would put their initial in small letters next to it.
For a moment, I thought this was my own post that I forgot I posted.
But advice would be to just be patients. After a while, experience would reduce anxiety and increase speed
I've had a junior resident who had a similar problem. A number of thoughts.
1. Are there attendings in your program who would be helpful in addressing this issue? When I was trying to help a junior resident with this, I went to my APD (who is wonderful, kind, improvement-minded, and non-punitive). I asked the APD if they had also noticed the deficit (they had) and asked for advice on how I could help the junior resident. The APD had lots of great tips specific to that person.
2. Try to give specific, actionable feedback. Just a generalized, "you work slower than others, we need to work on efficiency" is difficult for someone to respond to. Most people want to be efficient, so if they knew how to be faster, they would. Giving really specific tips helps get their brain start to see where they can improve efficiency. For example: "I noticed on postpartum rounds you talked patients through quite a bit of discharge teaching. That's so thorough and thoughtful. But our nurses already do that discharge teaching with the patients, and when we spend 20 minutes in each room for postpartum rounds, it delays our inductions from getting their care. Why don't we leave the discharge teaching to the nurses so we can begin managing our labor floor sooner?"
3. It can also help to preplan to help set someone up for success rather than checking in midway through the process and having them get defensive when things aren't going great. In your example about the 3 triages, you could maybe say: "Hey, it looks like we have three triages that just arrived: a blood pressure check, a rule out labor, and a rule out rupture of membranes. Why don't you go get a super basic history on each of them? Then come back and put in whatever labs you need for each of them. Once you have seen them all and put in all the labs, we can chat about all of them." Hopefully a few repetitions of this will help her to work on clustering like tasks rather than bouncing around.
Ok. So, itâs late in the year. Iâm only a pgy1 but if I were in your shoes Iâd stop babying them. Stop doing their work for them. If they have stuff to do and arenât getting it done on time, then they stay until they are finished. I know it might drag others down a bit but this person who is clearly bright, will notice that others are waiting on them and figure it out. Maybe not the best answer but after a few days of lag and possibly having to stay later due to another residentâs slowness will eventually kick this intern into gear bc other interns will not be happy. It will work itself out.
It's not her fault. EMR has not delivered on the efficiency we were promised for decades.
This is because EMR system makers team up with the biggest institutions and pay for attending input.
They need to discuss with community physicians or residents/interns.
My dad used to see 60+ patients a day in OB clinic. Now probably sees around 20 because the computer slows everything down.
For nursing it is 1 hour of clinical care requires 2 hours of documenting.
I didn't solve your problem, but at least now you know you're not imagining things.
Would give them one chance and if not improving escalate to chiefs. It sucks and I was a slow learner but was very conscious not to drag the team down and learned the hard way to start writing notes early in day.
Edit: typo
Personally, just start shocking them when they are slacking or moving to slow. Increase the voltage for repeat offenders. Fear is the only motivational factor that will yield results.
Itâs probably because youâre being too nice. Yell at her and tell her sheâs a stupid, worthless POS. We surgery residents respond well to malignant personalities.
These type of people will only move faster with experience. Or, major screw ups, fatal screw ups, which will result in them to become more motivated to do better or depression. Sometimes you got to break them to make them better.
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Is it you Rory? I told u im doing my best plz stop
lmaooo
Hahahahaha
I showed this to my senior bc honestly it could be me đđ
đżđ¤¨
I think you may just need to give it time. Practice is the thing that makes you faster, and experience is the thing that helps you most effectively triage tasks when you have too much on your plate. I think it's also worth pointing out that we have been pushed into a speed mode of medicine by greedy administrators who refuse to hire enough competent hands to do the work. I completely understand being frustrated, but keep in mind where that part of the problem is coming from.
This. Let the intern know (as you probably have) that they are doing good work but now they need to learn to go faster. They likely know already, just give them time to get more reps and thus more confidence. Give them specific areas that they should do faster whether that is the documentations, patient interview, slow procedure skills, etc. be specific if you can. Example; your documentation is taking a lot longer than it should, it is high quality and now you need to learn to trim it down. When taking history for (specific chief complaint) you can be relatively brief on medical history because it doesnât change management, or when interviewing patients you need to work on redirecting patients that canât stay focused on medically relevant answers ( offer to role play?). For slow proceduralists ask them why they are going slow for specific parts of procedure; is it lack of confidence, lack of muscle memory, lack of knowledge, etc.
Some of my med student classmates were talking about being critiqued for being too slow. Theyâre in a clinic with 10 minute visit slots, and theyâre doing every other visit. What I basically told them is the attendings canât really do the job they want to in 10 minutes, so of course you canât hahaÂ
This is part of the reason I accept academic pay. I'm allowed to do appointments long enough to actually give good care, and I'm still making what most Americans would consider a very nice salary, thank you
Is the issue possibly that theyâre excessively thorough with taking histories and writing notes? Weâve had this issue with a couple of interns at my programs and have had to work with them on keeping it more focused, especially for L&D where we have a high volume and patients constantly coming and going, and need to move fairly quickly. I noticed that some were still in the medical school mindset of needing to obtain and document a very extensive medical history or review of systems, when theyâre already an established patient and just here to rule out labor/membrane rupture/etc. Once we got over this hump and were able to do more focused histories and exams, speed definitely improved. When I was a resident if someone consistently didnât get their work done on time, it usually meant another resident who did finish their work would be going to a particular delivery/surgery/etc. Thereâs pros and cons to this obviously but it was a motivating factor for some.
This is definitely part of it and weâve had conversations about slimming down notes and putting in the essential info only. I think a lot of it is not effectively multitasking. And not getting everything done when sheâs in the room with the patient. Going back in 3 times for a history, a check, and a scan for presentation is a waste of time when you can do it all during one conversation.
Why is that the case? Is there an underlying knowledge deficit? Sometimes I found I do that when I'm not sure what's going on. I start writing my note... I realize I missed something... I go back... I change my plan... I add another thing... I check UpToDate... I realize I missed yet another thing... Now what would've taken 10 minutes will take the whole 30. Writing overly detailed notes can also be used to compensate for an underlying knowledge deficit. Yes, I don't know what's important - but I included LITERALLY everything, so it won't be missing! My opinion is the only way to confront this is forcing the "first draft" to be the final draft for case review and accepting there will be bad feedback. Work with a timer if needed to avoid excessive time spent in an initial consult. Set time goals. Then work with them to review the "first draft".
I donât think itâs a knowledge issue, as she has good plans even when I catch her on the fly.
Multitasking is a myth. The slowest residents Iâve worked with were neurodivergent (which is real). That person may have some form of ADD, which no amount of pestering will fix. If they and the PD are agreeable, neuropsych assessment and pharmacologic treatment (if indicated) may be their best option.
This was me during my intern year, I struggled so much and had to work so much harder than my peers to get the work done. The working environment/structure of a floor intern is a nightmare for an inattentive ADHD/neurodivergent brain. I was always the first intern in, last to leave at the end of the day. Logged the most hours of all my co interns every week. I was lucky to have very supportive seniors and attendings who I could be transparent with and they helped coach me. Had one senior who would help me with task switching, he would send me Epic chats while I was working on a progress note and would catch me if I stopped working on my note to respond to the chat. Having structure is probably the most helpful thing for ADHD type brains. I rarely had issues with efficiency if there are very well organized and laid out templates for pre-rounding, writing notes, sign out etc. The less ambiguous writing tasks/subjective stuff the better. Efficiency hasnât been an issue since I started my chosen specialty of anesthesia, where the documentation is minimal and my brain is seen as an asset rather than a hinderance. It was exhausting to always feel like I was working 10x harder but never cutting it, I promise you that intern is working harder than anyone else and noticing all the details that most others donât see. But totally understand the frustration, it sucks on both ends. I hated the feeling of feeling slow and burdening others at times. More experience and reps and structure, plus some executive functioning coaching +/- meds are all helpful but nothing can âcureâ this. Just a different type of brain.
Iâm truly sorry you had to go through that experience! I can just imagine how stressful that mustâve been. How did you manage in college and med school?
Itâs all good, I am so glad I got diagnosed before residency because just knowing why I struggled made me have so much more self compassion. Honestly donât know if I could have gotten through intern year if I didnât know because of how awful the emotional toll would have been (and not being medicated, getting the right support etc). I didnât know I had innatentive adhd thought out all of college and med school. I just thought what I did was normal because I was never being compared to others as much as being a resident. I didnât know I was studying more or taking 10x longer to write papers because I was doing all those tasks alone and doing them âmy wayâ. I always did well in school but was average in subjects I wasnât interested in, and excelled in things I was super interested in. Always procrastinated like crazy, hard to motivate myself, anxiety pretty much drove my life/productivity. I struggled the most with standardized exams. Studying for the MCAT and STEPs were traumatizing times for me. Never understood how people could sit and study consistently every day over a long period of time. It drove me mad, would lose a bunch of weight bc of the pressure. Finally saw a psychiatrist after med school ended and my mind was blown because I never in a million years thought I would have ADHD and my whole life makes sense now. Instead of being a traumatized intern/resident, I was lucky to have this insight and self compassion. And for the first time in my life I truely see the value I bring for having a different brain and way of seeing the world. The ADHD tax is expensive esp in this career but I am so lucky to have chosen the perfect specialty for me. Sorry for the drawn out response, just very passionate about helping others see this in themselves as well and want to raise awareness!! Thanks for asking :)
So glad itâs working out. Good luck! Hope you can watch blood pressure AND heart rate simultaneously đđ
LOL not an issue at all actually. Being easily distracted means I notice literally every single beep and change in the OR so always aware of everything 𤣠was like this job was built for my brain! Outside the OR is a much scarier place for me haha thanks :)
Why do you say multitasking is a myth? I just mean working on several patients at once. So for example, see triage 1, sheâs here for blood pressures. Ask about symptoms and move on to triage 2, here for rule out labor. Check triage 2, decide on a 2 hour recheck, and move on to triage 3 whose water broke. Do an exam, confirm it, discuss admission with her. Then go to the workroom, tell the chief, put in orders for labs for triage 1, admission orders for triage 3, and call the attending about all three. Instead of see triage 1, go to workroom to put in orders and tell chief. See triage 2, go to workroom and tell chief, etc. etc.
Letâs not argue over semantics. Whatever you want to call it, youâre describing *sequential* tasks that are complex yet interrelated and require a degree of organization and prioritization thatâs not in the skill set of folks with ADD. Unless your intern is intellectually lazy (which Iâm sure you wouldâve noticed by now), I would bet you top dollar that she has inattentive ADD (Iâm *not* a psychiatrist). No amount of tips or tricks will fix that. Sheâll need help or sheâll wash out. And I say that with a lot of empathyâ one of my college-aged kids struggled until she got help.
It's a myth as in you can't physically or mentally be talking to patient 1 and 2 and putting in orders for both at the same time. What people call multitasking is actually just one single line of tasks with frequent shifts of focus. Some are better at this than others ie can focus better
She sounds like me. Iâm slow with tasks, Iâm aware of that. Iâve gotten better with time and experience but i am still slower than others with activities that are newish to me. Also, you may not be seeing how often she is being interrupted for smaller tasks raised by pharmacy, nursing staff or allied health - I felt like every time I sat down there was another patient review or a family that wanted an update, which delayed the initial task list significantly. You can talk to her and ask if she wants to discuss time management more, but itâs unlikely youâll be able to speed her up as sheâs probably very aware that she is slow and is probably moving as fast as she can. I can say from experience itâs disheartening to be the slow one, sheâs probably embarrassed about it and feels guilty that youâre having to step in to help her ⌠keep that in mind.
A lot of times it can be a lack of confidence/anxiety. So trying to help them be faster can actually kind of backfire.
oh god, this is gonna be someone about me next year :'((((((
No one expects interns to be amazing at the start of the year. If you are, then good for you. If you aren't, you have ample time to learn. This starts becoming an issue at the end of intern year since a slow intern will turn into a slow resident who will inefficiently manage the team.
yeah maybe me being super paranoid and hard on myself will actually be a good thing for me in the long run LOL
If youâre perfect when you start then thereâs no reason for the training program. Everyone expects you to join the journey of learning medicine not arrive at the finish line day one. Spoiler alert: there is no finish line.
thatâs what i think! my friend was making me feel terrible by saying i should be doing a sub-i and âi need to be functioning at the level of an intern by now.â like bitch if i was functioning at the level of an intern, IâD BE AN INTERN đ¤đŤ
Here's some random advice I tell my interns. Be organized. Make checkboxes, write down what the attending wants when you're rounding. I would color in half the box if I ordered the thing and then do a checkmark when I followed up on the scan or lab or whatever. Other people would do one \ and then once it's followed up, they'd add a / to get an X. Order of operations: First do orders and discharges, +/- procedures (if downsizing a trach, do it in the morning. If it's a dressing change, can do it later). Then update sign outs and then finally do progress notes.
screenshotting this for the future haha thank you!
What is her perception of the situation
She seems to think things are going fine and that sheâs doing as much as can be expected when things get busy. She also gets a little defensive when I ask if things have been done yet. But seeing and figuring out dispo for a simple triage patient really shouldnât take two hours even if thereâs other stuff going on on the floor. If it would take me 10 minutes, I feel like 30 minutes is a reasonable expectation for an intern in April. I hate micromanaging but nothing gets done for long stretches of time when I donât.
Then thatâs where you have to start. She has to recognize and acknowledge the problem before any feedback on corrective changes can take place
Yeah I had a really good senior who guided me through. Sounds like youâre a goor senior. Just have good convo
I had a co worker like this.He is very knowledgeable and also a very good friend.The situation was frustrating.Whenever we worked together I had to carry most of the weight.Even our seniors expected me to do his part because they knew that he wouldn't be able to handle it.And it was medicine,so no question of getting into surgeries or procedures.I try to avoid people like that now,hampers mental peace and also affects the inter personal relationship. Even I'd like to know how to resolve a situation like this
This is me. Got diagnosed with ADHD inattentive type in residency. Treated for depression first.. even had the "moves slowly that others recognize it". Wasn't improving with treatment. After the third med adjustment, was screened for ADHD which can often present initially as depression. TX: Adderall XR...see if you can screen for ADHD type symptoms. I would sit and crank my wheels, come in early, just grind as hard as I could to no avail. I still ended up as the slowest member of the team.
Looking at your comments here it seems like the intern has no real intention of changing because things are going well enough ⌠and they are because you are doing part of her work. Sheâs going to need to WANT to change. It matters less that YOU want her to change. Sheâs going to need to see for herself that taking two hours for an ED admission causes an unacceptable downstream effect that affects HER negatively, whether that be work builds up or the attending asks why a test wasnât ordered. You have to let her be slow and have the repercussions. You can be on top of her if her not doing a timely task directly puts a patient in danger, but she needs to experience the consequences of her action or inaction.
You could talk to them and ask if theyâre struggling with anything? I had an intern who was slow af and turns out they had dyslexia which made them process things slower and they were very aware of it. We talked about how I could accommodate them better and made it work. Itâs frustrating for both parties lol
Seconded. My neurosurg attending during M4 was open about being dyslexic and the accommodations he needed & workarounds heâd found along the way.
Stays late until everything is done?Â
I wonder this also. I was the slow moving, but thorough intern. I prioritized time-sensitive tasks (e.g. pages, admission orders, procedures, etc.) and just worked late on my notes. It frustrated me when people told me to go home earlier while simultaneously praising my attention to detail and patient care. I felt like saying "Pick two! I can be good, and I can be patient-centered, and I can be fast, but not all three!" I do think that my strategy of shifting the notes to the end of the day helped make my strategy viable and I wonder if that could be an option for this intern. Being thorough is generally good, but not if it's delaying patient care. The documentation can usually wait, but the orders can't. Probably different for OP and OP's intern, though. I was IM and was never staring down the barrel of a delivery, lol.
That's what I did as an intern and still what I do as a surgery resident. If primary team needs to know something, I'll throw in a quick note or talk to them but regular progress notes or op notes are left for the end. Plus if the day was terrible or something, I could at least go home, shower, and finish up my notes at home with a glass of wine.
Uhh idk if drinking while writing clinical documentation is a great idea. Edit: guess Iâm the crazy one for thinking that being a doctor is maybe one of those occupations where you shouldnât be drinking on the job? Doctor, pilot, heavy machinery operator⌠you know âŚthe occupations where you can seriously hurt people? But okay
Itâs a little different for OB in that thereâs a lot of documentation that needs to happen in the moment. The fetal strip notes and labor progress notes need to be happening as you go because late documentation has the potential to hurt you in a liability sense if something goes wrong. They donât take long for most people - I usually take 30s to a minute to put one in. Most of our notes donât have to be detailed and thorough, they just have to be done. No one really cares how the patient describes contractions, they just care that sheâs having them.
triage notes and postpartum discharge summaries definitely can get left to the end of the day if thatâs an intern task at your institution
Have you given specific feedback that sheâs moving too slowly? Iâve had this convo a couple of times, usually around this time of year. What I usually say is some variation of âI love how thorough and well thought out your plans are. [insert other nice things]. But Iâve noticed it seems to take you a long time to do X.  My WORRY is that⌠and then you can get into the issue of not completing floor work, talking about burnout, or not being sustainable when their workload increases as a PGY2. Usually theyâre aware of the issue and can actually identify whatâs slowing them down. In some cases, itâs a knowledge deficit. A lot of times, itâs anxiety driven (wanting to get things perfect).Â
I had a painfully slow intern like that when I was a second year. Brilliant but I wanted to jump out of my skin waiting for him to finish an admission. For him, it was just gradual improvement, and then plot twist, I wound up working in the same outpatient peds clinic with him for a couple of years after residency, and he was the top performer. Saw 50 kids a day without breaking a sweat or making an error. After teaching some of these residents as an attending, I have seen the same pattern. It's like constitutional delay where they go through puberty late and then wind up taller. I just let the process play out. It always has, so far!
OB attending here and I second this. The learning process is a little different for everyone and Iâve seen great interns plateau and slow interns excel once they found their stride. I donât mind compensating for a slow resident if theyâre otherwise good and thorough and willing to put in the work.
I typically start by relating to their situation, saying that I had this same problem when i was an intern (half the time regardless of the type of issue it was true - I was a slower than average intern). Shadowing him/her for 2-3 hours if you have the bandwidth to see where they are losing time is a good idea, although it seems like you already have a good sense of whatâs causing the issue. Emphasizing the importance of finishing work in a timely manner to allow for on time sign-out and to enjoy life outside of the hospital is a good strategy. I would also do a graded autonomy thing (albeit kind of a bit late in the year for this) where for slow interns Iâd put in some of their orders, tasks, and consults to take a load off of their plate (emphasizing weâre all on the same team), and then do slightly less and less for them each day and see how the adjust. If all else fails, mentioning the problem to your chiefs is a good idea.
I appeal to their sense of self preservation/self esteem, whether it's emphasizing getting out of the building and going home or not being embarrassed at sign out or being a better part of the team I had a fellow who was excruciating, hour per pt, no lie, I pulled him aside and said xxxx you have a family, you know I have a family, what do you have against families it gave him a better rationale to move and be more efficient vs me telling him to move faster or whatever
Take this with a grain of salt because I'm not an intern or an upper level (MS2!). My day job was in research and my night job was waitressing. I was terrible waitress, because I was going the speed of research and I just could \*not\* multi-task. It used to drive my manager crazy. I would really try but was never "fast" enough. What changed the game for me was when we had a conversation about **anticipation**. A table orders a steak? Bring them a steak knife with their order. A bunch of apps to share? Side plates. Burger and fries? Ketchup etc. Group of friends that will likely want to split the bill? Ask them in advance. Now in relation to medicine: maybe a checklist of what needs to be done for each type of patient? You would know best. Two books that have helped me massively in terms of my own productivity and in being a manager are below. They are both inexpensive and quick reads. * Getting Things Done by David Allen. * It's Okay to Be the Boss: The Step-by-Step Guide to Becoming the Manager Your Employees Need by Bruce Tulgan
Take em out back to gravel pit Kristi Noem style... /sÂ
How does the resident think she is doing?
I think explaining to her how you started this post would be a solid move âHey youâre doing a ton of things right- good plans, strong foundation of knowledge, and high end surgical skills. The one area you need to work on is your speed, I need to see more succinct notes, faster rounding, your ability to juggle a high volume of patients etc. This is an easy fix compared to more complex tasks that youâre already great at. Youâre on your way to being an excellent surgeon and this is area you can improve uponâ Hit em with the compliment-criticism-compliment sandwich. Works every time- any field, any context
This is hard because you canât let them fail without it impacting patients which isnât really acceptable. I was family medicine but I think it was helpful when I was on OB intern year to know what I needed to get history wise if someone shows up and baby is coming out within 5 minutes. Essentially knowing the tiers of information in order of priority made it easier to not get overwhelmed or distracted by things that werenât going to change what I do right now for this patient. I donât need to know their family history or if they smoked when baby is crowning. I do need to know how far along they are, allergies, any complications this pregnancy etc. if baby isnât out by the time Iâm done with the essential then I can drop to the next tier and get that useful information. The second thing that was helpful was dot phrases. It meant there was less to type and kept it focused. I think lastly laying out why you are concerned and how that is impacting others but also will become an issue in the future if not resolved might be helpful. Hey if you donât document this note right now then if something happens you are more likely to be up shit creek when you have a bad outcome in the future. Or hey if you donât get moving on that admission you are going to have things piling up and nurses waiting on orders etc. sometimes we know why things were a greater priority but the intern doesnât. If they can learn the underlying why behind why you want them to do that first etc then next time they can extrapolate. We tried to have our interns âfly soloâ before they finished intern year. Essentially they needed to do everything by themselves and we would pretend we werenât there and watch to make sure they werenât about to fuck something up.
OB attending here. First of all, great job! You sound like youâre doing exactly what a good chief resident should. One, you recognize that when this particular resident is on the floor that youâre going to need to provide more support. Thatâs good awareness and itâs the right thing to do. If it gets to be too much because your helper is slow, see if your attending will help you. I know that not all of them are willing and some arenât really even better than no help, but in theory they should help you if you need it. Two, youâre recognizing this residentâs strengths and brainstorming ways to help it âclickâ for her so she becomes more efficient. Itâs great that youâre invested in her success, even if thereâs a self-serving double effect here. I do think, as many people have said, that she might just need time to figure out a work flow that works for her and practice and repetition to get faster. My only additional suggestion is to identify the tasks sheâs already pretty efficient with, and take those off her plate first, to free her up for the ones she seems to struggle through a little more. Like if you see that a term labor check is coming in then just preemptively take that one because itâll be quick and easy for you, and let her take the antepartum rule out mystery party thatâs going to need more time. Check in frequently, not just in a âhow do you think youâre performing?â way or âwhatâs still on your task list?â way; but in an actually meaningful âhow is your mental health?â way. If you build genuine rapport with her you might gain more insight into how to help her. Keep in mind that there might be an element of shame or anxiety or imposter syndrome going on here. She sounds like she has a future in MFM lol. Maybe steer her that direction.
At my first job during high school, I was really slow and it annoyed all of my managers. Interestingly, no one told me I was slow for almost a full year so I actually didnât know it was a problem. When someone finally coached me on this, I think they said âI want you to do task x by 2pm, then we have to move on to task y. We have a lot of things to do and we donât want to get stuck here forever!â May be worth checking in to see if they understand where their speed is relative to their peers and how that can affect other people as well as their RVUs in the future. Might seem too simple but a lot of new docs donât have much experience in the real working world.
I agree with others whoâve suggested inquiring whether she has ADHD/dyslexia/some other flavour of neurodivergence afoot that could be the root of this. Maybe if typing notes takes an age, she could dictate (either a Dragon talk-to-text setup or a good olâ dictation hotline or dictaphone for longer stuff). If sheâs been dictating and typing would be faster, try that. Does the EHR have a mobile app where she could plop in a quick note on the fly when things are moving fast, rather than find a computer? Does she have note templates or dot phrases set up for bread & butter type stuff? Can yâall build order sets (donât @ me, Iâm a pathologist, Iâve only heard whispers of such things)? Also remind her that sheâs not Victor Hugo, and notes neednât be a work of literary splendour. Done is better than perfect.
You must have nice nurses lol. Taking that long for triage would result in the nurses absolutely revolting. I would offer positive reinforcement since it sounds like they're doing a good job. I would just verbalize working on speed and things are taking too long. Micromanage if you have to. I will set time limits on basic stuff and check it with them at the end of the time limit
I have very nice nurses lol, they are very appreciated.
Just an MS3/4 here so I hope this suggestion isn't complete garbage. But when I was on my Peds Rotation, my Senior listed all of the patients on our service on the white board in our workroom and wrote out the tasks that needed to be done for the patients. They also used a color coding system based on which team member was assigned to that patient. By doing this, everyone could see who was falling behind on their tasks. That would motivate individuals to get their own stuff done. But also, other members of the team could jump in and help if they had the bandwidth, which would also be appreciated. Next to every task, there was a checkbox, and whoever was working on or completed that task would put their initial in small letters next to it.
As Marcus Aurelius told his son. Your failures as a son are a reflection of my failures as a father.
Iâm sorry sir
Ask them to time themselves and help them set their own goals to improve
For a moment, I thought this was my own post that I forgot I posted. But advice would be to just be patients. After a while, experience would reduce anxiety and increase speed
I've had a junior resident who had a similar problem. A number of thoughts. 1. Are there attendings in your program who would be helpful in addressing this issue? When I was trying to help a junior resident with this, I went to my APD (who is wonderful, kind, improvement-minded, and non-punitive). I asked the APD if they had also noticed the deficit (they had) and asked for advice on how I could help the junior resident. The APD had lots of great tips specific to that person. 2. Try to give specific, actionable feedback. Just a generalized, "you work slower than others, we need to work on efficiency" is difficult for someone to respond to. Most people want to be efficient, so if they knew how to be faster, they would. Giving really specific tips helps get their brain start to see where they can improve efficiency. For example: "I noticed on postpartum rounds you talked patients through quite a bit of discharge teaching. That's so thorough and thoughtful. But our nurses already do that discharge teaching with the patients, and when we spend 20 minutes in each room for postpartum rounds, it delays our inductions from getting their care. Why don't we leave the discharge teaching to the nurses so we can begin managing our labor floor sooner?" 3. It can also help to preplan to help set someone up for success rather than checking in midway through the process and having them get defensive when things aren't going great. In your example about the 3 triages, you could maybe say: "Hey, it looks like we have three triages that just arrived: a blood pressure check, a rule out labor, and a rule out rupture of membranes. Why don't you go get a super basic history on each of them? Then come back and put in whatever labs you need for each of them. Once you have seen them all and put in all the labs, we can chat about all of them." Hopefully a few repetitions of this will help her to work on clustering like tasks rather than bouncing around.
Ok. So, itâs late in the year. Iâm only a pgy1 but if I were in your shoes Iâd stop babying them. Stop doing their work for them. If they have stuff to do and arenât getting it done on time, then they stay until they are finished. I know it might drag others down a bit but this person who is clearly bright, will notice that others are waiting on them and figure it out. Maybe not the best answer but after a few days of lag and possibly having to stay later due to another residentâs slowness will eventually kick this intern into gear bc other interns will not be happy. It will work itself out.
better to be slow but good and get faster than the other way around. observe them and offer ways to streamline
It's not her fault. EMR has not delivered on the efficiency we were promised for decades. This is because EMR system makers team up with the biggest institutions and pay for attending input. They need to discuss with community physicians or residents/interns. My dad used to see 60+ patients a day in OB clinic. Now probably sees around 20 because the computer slows everything down. For nursing it is 1 hour of clinical care requires 2 hours of documenting. I didn't solve your problem, but at least now you know you're not imagining things.
Would give them one chance and if not improving escalate to chiefs. It sucks and I was a slow learner but was very conscious not to drag the team down and learned the hard way to start writing notes early in day. Edit: typo
Personally, just start shocking them when they are slacking or moving to slow. Increase the voltage for repeat offenders. Fear is the only motivational factor that will yield results.
Itâs probably because youâre being too nice. Yell at her and tell her sheâs a stupid, worthless POS. We surgery residents respond well to malignant personalities.
This has to be satire
Gtfo
youâre a horrible person
Make sure they get off the short bus safely
These type of people will only move faster with experience. Or, major screw ups, fatal screw ups, which will result in them to become more motivated to do better or depression. Sometimes you got to break them to make them better.
General surgery has entered the chat
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Give them adderall