There are six patients in the “to be seen” rack and you have three hours left of your single-coverage shift. You didn’t realize how quickly the charge nurse was able to clear out the waiting room and now she’s giving you the eye that says you’d better get moving . . . NOW. As an average emergency physician, you know you do about three patients an hour so you’re in for two hours of work. However, you also know that more will come, plus you still need to dispo your existing patients. The challenge is simple: be more efficient and dispo more patients in less time.
Enter the concept of “thin slicing.” First described by Malcolm Gladwell in his book Blink, thin slicing refers to the “gestalt” or “gut” feeling that we have when we know things intuitively. As a colleague recently illuminated, Gladwell’s quasi-scientific reasoning is a good complement to the hypothetico-deductive decision-making that EPs do daily. Think about the doc who comes into their shift and can clear off the ledge of charts that need to be seen in record time. These experienced EPs probably know the ED course and expected outcome and disposition within a minute or two of starting a patient’s H&P. This is an element of thin slicing, but it can be taken to another level.
Here’s the idea. Averaging three patients an hour, you might not see our hypothetical 6th patient for 90 minutes or more. Thin-slicing suggests that you see all of those patients over 20 minutes by going into the room, performing only a minimal H&P and then ordering tests based on your experience for the expected outcome.
When I do this, I preface my exam to the patient by explaining that the ED is very busy and I’m trying to expedite their evaluation. To do this, I want to do a brief exam to order the initial tests but I will be back to complete a more thorough exam.
You can think of this as doing a first pass before going back for a second and more complete exam. Typically, a physician can get through each patient initially in just a few minutes, thus allowing lab, radiology and medication orders to be started.
Now that you understand the concept, here’s my practical advice. For starters, averaging 3 patients an hour is really just an average. To achieve that during busy periods you’ll need to be able to increase your speed to 5 or 6 patients an hour. This is balanced by those hours where no one shows up, when you’re tied up doing critical care and not seeing new patients, and in the last hour of your shift when you’re mostly doing dispos. Consider evaluating the patient from the chart and the doorway, briefly talking to the patient and then returning when you have more time. This will stop the door-to-doc clock, a favorite metric of hospital administrators. If your OCD meter is so strong that it necessitates performing a complete evaluation on each patient one at a time, and you don’t multi-task well, you might have to ask yourself what you’re doing working in an emergency department.
As in our example above, you may be asked to see five or more patients very quickly. However, for thin-slicing, my rule of thumb is recycling after the third rapid evaluation. Thus, you have started three patients in 5 minutes (no kidding) and then you must go back to number one and do your complete eval. If you don’t, you will invariably find yourself adding on tests when you think the patient should be ready for discharge, thus giving away the length-of-stay benefit you gained up front.
There are dangers to thin slicing. The first is the failure to return to the patient in a timely fashion to complete a thorough H&P. While you likely got what you needed the first time, one day you will miss a critical piece of information if you don’t return. Plus, you promised the patient you’d return, and that’s a promise you need to keep. Otherwise, the patient may view you as only having completed a very superficial evaluation. The ability to properly thin slice and get to that critical data that will drive the work-up comes with experience. Residents and new attending physicians should use these techniques with caution. Another concern is that any existing bias you may have could subconsciously affect your decision making or perception. Everyone has heard the nightmare of the drunk patient who frequents the ED regularly. He’s put in the corner after a cursory “evaluation,” but no one looks close enough to notice his head trauma. Only after 10 hours when he doesn’t wake up does the staff perform a head CT and discover an intracerebral hemorrhage.
It’s still early for scientific backing for thin-slicing, but my gut tells me that if you get to patients earlier by not leaving them waiting, their evaluations will be completed faster, overall length of stay will decrease, patient satisfaction will increase, and your ED will have more patients to be seen. From an administrative point of view, these are all good end points. From a front lines point of view, it’s a very reasonable technique to get through those really busy parts of the day and keep more balls in the air successfully.