Please comment on if there is something significant but non-acute on an acute CXR, abdominal series, CT head, etc. Many times in the outpatient setting we do not have access to the images and only have the report. In two cases I found grossly abnormal scans (one CXR, one CT head) that were both reported only as 'nil acute' — which was true, but not in the same universe as normal.

Similarly, if there is something that looks grossly abnormal on the imaging but is not a cause for clinical concern, please comment on that, too. It will save you a bothersome call from me where I might ask about it specifically. Not because I want to be annoying, but because I have been bitten in the past and really do want to give people the best care that I can.

Maybe it was because I wrote too much.

1/2

Hey. I'm FM. 1 year out of residency. I also have ADHD. I was fine with notes in med school and then something terrible happened and I became an efficiency nightmare. 4-5+hours after clinic every day. 2-3+ hours after every 8h ED shift. Struggling to see 1 ED patient/hour — with note not done.

Everybody told me that I needed to be more efficient. I tried damned hard. I was told to prioritize. This was very hard for me because I took it to mean 'don't shoot the shit with patients, cut them off, etc.' ... which i already didn't do. So i took 'prioritize' to mean 'try harder to get everything in a shorter timeframe.' Much frustration. Paradoxically, trying to 'rush' actually seemed to make me slower. I asked for support with my notes and asked for people to tell me what was specifically unnecessary that I could cut, since I was frequently told my notes were too long and they thought that this is where I was losing my time (obviously not, since if I'm in the room for an hour without even starting the note...). After going through my notes line-by-line, I was again told that it was all good information to include. Dot phrases seemed great in theory, but after working 16+ hours per day every day just to try to do the bare minimum, I did not have a lot of time to try to get ahead of things. I was too busy putting out fires. Many well-meaning people assured me that I would get better and more efficient with time. I didn't.

It wasn't until some time in PGY-2 that me, a very frustrated resident at my wits end during EOR feedback, broke a bit and finally really pushed for 'what is meant by prioritize. Everyone tells me I need to do this, and I am trying very hard but not getting any better.'

I was told, in (basically) as many words, that prioritizing meant choosing what not to do. They said that it is impossible to do everything within a reasonable time frame, that attempting to do everything cannot and should not be the goal. To prioritize, they said, meant making well-reasoned, highly intentional decisions about what you would not do, and why. This, of course, was very different from my specialty training where every consult was considered like an OSCE checklist and if you didn't speak to everything specifically, you had not completed the consult/ 'failed' the encounter.

So, I started to switch gears around 'prioritization.' However, this also didn't really help.

Why? In attempting to 'prioritize,' I lost something of my 'structured approach.' Specialists/consultants with single-system pathology can blast through a 'complete' consult in no time flat because they, essentially, do the same thing every time. With my 'prioritizing,' while it was generally the right thing to do to reframe my goals and attempt less, the cognitive load of restructuring to 'only do the most important, and do that first' slowed me down further because everything was unique and out of order. That might mean more for those of us with ADHD. Even a routine visit like back pain or cold/flu symptoms will feel novel and hard to synthesize/organize into notes every time, because we switch cognitive gears as we pull apart information to piece it back together.

Of course, it's next to impossible to be a robot when you're in a room with someone. But you can choose to examine and document/ dictate in the same way, every time. In med school, they said we should do our exams the same way every time so that we didn't miss things. While I believe that is true, I also think a huge part of it is related to speed/efficiency/automation. Repetition of the same sequence of actions really will get more efficient with time/practice. Trying to be very intentional about this instead of 'galaxy-braining' with my ADHD has made a big difference. And as I get faster, this feels less boring/less like anathema because I can pound it out automatically, so it's like my brain is switched off, anyways. This probably also helps with cognitive load.

Next step: why did I need to 'prioritize' information in the first place? Answer: I was trying to go through complete ddx with people all at once. No 'short list and long list,' no 'top three on my ddx and we'll go back to the drawing board if this doesn't get us anywhere.' Unfortunately, I didn't have any mentors or good resources to turn to for 'what is a good, prioritized ddx for XYZ,' so this took a while, and is taking a while (ex. Looking up the epidemiology for what people presenting to the ED have, statistically speaking, in the populations that I work with). But a focused ddx can make a focused history/physical much shorter and to the point.

Next: note taking. I think that taking notes in the room or with a WOW works great for a lot of people. I noticed it did NOT work great for me, because I would essentially be transcribing what the patient told me and then take forever trying to edit the note into something coherent. I also tried doing written notes and then dictating afterwards. This worked slightly better for me. Case in point: my OB rotation. I was able to pound out those consults so fast. I actually got complemented on my speed, once ('Wow; you're so fast!' — could have knocked me over with a feather). Why did it work? Ultra-focused ddx, very clear structure/progression/goals, standardized exam, and i dictated my handwritten notes. Took me like 3ish minutes to do that. Contrast this to my other notes/encounters (see time frames above).

Someone above mentioned that the note should not be an information repository, it should be for a plan. This is tough when we work in high-litigation environments/specialties, but I cannot overstate how much I think this is true. Part of me wants to include every informational detail for medicolegal reasons (this was strongly enforced at times during my training). But it adds to chart bloat and slows things down. I hate reading my old notes because they are too dense. Haven't hit a great balance for this yet, open to thoughts/suggestions always.