Emergency Medicine Resident Multitasking and Improvisation


  • Related articles appear on pages XXX and XXX.

  • Supervising Editor: Carey Chisholm MD

There’s lots of ways of playing. There’s a way of playing safe, there’s a way of using tricks, and there’s the way I like to play, which is dangerously, where you’re going to take a chance on making mistakes in order to create something you haven’t created before.1

—Dave Brubeck, Jazz Artist

When I first learned to play the trombone, one of the most difficult concepts was understanding and performing improvisation. Even the same song played twice sounds unique and is always personalized by the performer’s distinct musical touch. A time and key signature are the set boundaries, and the artist is free to roam anywhere in between. One of my favorite songs is Dave Brubeck’s Take Five, a song written in the less familiar 5/4 time signature. Brubeck is an artist who is famous for his various tonalities and contrasting rhythms. Just as musicians thrive on the uncertainty of improvisation, this process is in many ways similar to learning multitasking as a resident in the emergency department (ED).

Previous studies have shown that emergency physicians (EPs) are frequently interrupted in their daily tasks. As the number of patients increases, so do task interruptions.2 This past PGY-2 academic year I was especially challenged in the skill set of multitasking. I am at a stage in my professional development where I have learned the basic time and key signatures of emergency medicine (EM). I know what a sick patient looks like and feel confident in basic procedural skills. I can manage a steady influx of simultaneous patient encounters, but continue to practice managing patient surges. The transition between internship and PGY-2 year has pushed me to take a leadership role in the ED. While large academic EDs provide a tremendous exposure to high patient volumes during training, this advantage can become a disadvantage if not managed properly. There can be a false sense of safety with other doctors around, minimizing effort to “pick up the slack” and see the next patient. On the other hand, with plenty of backup, it is also a safe environment to test “losing control” and expand boundaries of comfort zones.

In 2001, the American Academy of Emergency Medicine passed a position statement that included a recommendation for EP staffing ratios, that the rate of patient influx not exceed 2.5 patients per physician hour.3 Surge of patients is frequently discussed in the news and is one of the skills emphasized in EM residency training. Reflecting back on early PGY-2 year, I remember one of my busiest shifts. I was working 1:1 with an attending physician on the critical care side of our high-volume department. In a period of about 50 minutes we received 12 high-acuity-triaged patients, including a STEMI, a cardiac arrest, and an active aortic dissection, among other sick patients. While a continuous rate of patient influx would be ideal, rarely do patients trickle in on a scheduled basis. Watching other faculty manage 10 or 15 patients at a time is inspiring. It is like listening to J.J. Johnson or Miles Davis perform and wondering how they make it sound so exhilarating. Perhaps I should not stare in awe. Instead, I should take note of the things that make this possible.

While multitasking is something we strive for as residents, some argue that multitasking is not possible. Douglas Merril, PhD, is a former Google executive and has training in cognitive science. In a recent interview with National Public Radio he stated, “Everyone feels like they’re tremendous multitaskers. It’s a little bit like Lake Wobegon—everyone thinks they’re better than average, but you’re not. You can’t multitask. When you shift from one context to another, you’re going to drop some things.”4 I agree with Dr. Merril that loss of fidelity and details occur with increasing amounts of task. However, multitasking is possible and occurs in many other professions besides EM. One must be aware of the potential loss for information with simultaneous tasks. An exceptional EP has the ability to stretch the balance between detail and efficiency. All of us are humans with limits and capacities. We only have so much emotional, intellectual, and physical energy to give each shift. Difficult and complex patients can be energy-costly, but they don’t always have to be with the right approach. A superior, multitasking EP knows who to spend this on and how much to give at each encounter.

Along these lines, every EP has techniques and strategies that work for his or her individual practice. Residency is very similar to an apprenticeship. After 3 or 4 years, residents are a mixture of their own self-directed education and lessons absorbed from others along the way. While there are several strategies and recommendations for improving patient flow in EDs,5 evidence-based medicine is limited in the arena of multitasking because there is no one cookbook recipe for success.

Two personal traits that prohibit expansion of multitasking are my obsession with details and fear of making mistakes. “Pay attention to the details” is a voice I hear my old music teacher saying over and over. Just like I have accidentally played a note in the incorrect key, I am scared to miss some important detail that could potentially jeopardize a patient’s care. Medicine is a little different than music in that the mistakes have real consequences other than producing a clashing phrase. Perhaps adding to this fear is the legalistic culture in which we practice. Doctors are sometimes publically crucified for mistakes. Those mistakes can follow an entire career with potential financial and professional consequences.

A 2009 study in Academic Medicine analyzed EM resident multitasking abilities, using the collaborative author’s creation of a multitasking assessment tool. Interestingly, one of their conclusions states that this assessment tool was perhaps measuring ability “independent of achievement, experience, and education.”6 While all of those things are important, perhaps an immeasurable characteristic is the courage to test uncharted waters. How then do I test these uncharted waters? Following Brubeck’s philosophy and what I have learned playing trombone requires courage to let go, with the possibility of messing up. I will continue to expand my background medical knowledge, studying, and practicing my scales of algorithms and mnemonics of differential diagnoses. Less of my focus will be on the technical aspects of how it works, with more focus on the “overall sound.”

An article by Dr. Ronald Epstein, entitled “Mindful Practice,” addresses the art of medicine as similar to a performing musician, “whose task is to perform and listen at the same time, attending simultaneously to the technical challenges, emotional expressions, and overall theoretical structure of the music … if the musician were to attempt to control each finger movement while simultaneously analyzing the harmonic structures, rhythms, and silences that constitute expressive playing, playing would become impossible. Thus, focal awareness on the music is accompanied by subsidiary awareness of technique and analysis—a mix of peripheral vision and semiautomatic action that is highlighted only when the unexpected or difficult occurs.”7 The practice of EM is indeed an art-filled practice. It cannot simply be studied and imitated. It must be practiced, reconstructed, and adapted in an ever-changing nature. Then in the joyful chaos of the unpredictable ED, a truly unique song is born.