EM Mindset – Goal Setting and Decision Making

Author: Jeffery Hill, MD, MEd (Assistant Professor / Assistant Residency Director, University of Cincinnati) // Edited by: Alex Koyfman, MD (@EMHighAK) and Brit Long, MD (@long_brit)

On a macroscopic scale, I’ve often likened our job in the Emergency Department to that of someone who mows grass for a living.  Just like the grass always grows, patients always show up in the ED.  Day in and day out, patients come in, get diagnosed with a medical problem, get treated, and get their care coordinated.  Day in and day out the cycle repeats, the grass grows, weeds trimmed, patients arrive, need treatment, the lawn is cut, the patients are cared for.  It’s not just that our task is Sisyphean, it’s more so that the Emergency Department and the patients we see and the lives unfolding are so much bigger than us.  The metaphor, of course, falls apart on a more microscopic view, the blades of grass are different each day and whereas the blade of the lawn mower leaves a transient impact on the blade of grass, the impact we have on our patients is lasting and can be powerful and life-changing.

One of the many challenges we face as we head to work each day is how do we find meaning and motivation for each and every shift.  And this is especially important when we are early in our training.  When the job that we do can seem so Sisyphean, and when we have thin faith in our own skills as Emergency Medical providers, how do we approach each shift with the joyful industriousness and confidence necessary to be successful?  I want to talk about 2 skills that I have found (and continue to find) helpful in my practice and growth.

The first skill I want to talk about it is goal setting.  We hear a lot about goals over the course of our training.  We get questioned as to what our 5-year or 10-year goals are.  We get asked what are our goals for the year or the month or the shift.  And, if you’re like me, you’ve always been terrible about setting goals.  My goals were either terribly non-specific or overly specific (yet unachievable and lacking a broader vision).  Think of the goal of aspiring to read 1 chapter of Rosen’s a week in your residency training (a goal I set for myself on more than 1 occasion).  Sure it’s specific, but in the setting of working 4 to 5 shifts a week with Grand Rounds, with day-night transitions, with trying to keep life at home in order; reading 20 pages of dry, small font text and actually integrating that knowledge never happened for me.  And failure to achieve those goals just leads to a feeling of hopelessness.

Why is goal setting so important?  When done well and when intentionally focused, setting goals provides you with greater internal motivation, focuses your attention and effort, and can make you better than you ever thought you could be.  Goal setting theory has been well established in the organizational psychology literature (1).  The distillation of this literature is that the broader goals you set should be “high goals” or “stretch goals” as these lead to greater effort than easily achieved goals.  Within each of these stretch goals, you can use a SMART framework (Specific, Measurable, Attainable, Realistic, Timeline) to define subgoals to help you accomplish the greater stretch goal.  Setting the stretch goal of becoming the most efficient provider in your practice group may include the specific sub goals of improving your time in room with each patient, improving time to documentation, time to orders placed, etc.  Goal setting helps provide focus and purpose for every shift and every patient interaction.

The second skill I wanted to cover is probabilistic thinking/Bayesian decision making. This may seem completely unrelated to the first skill covered, but for me personally improving my decision making and thinking has been a consistent goal as I have progressed through my career.  We have all heard much about System 1 and System 2 thinking, so I won’t rehash them here.  However, as I was watching an episode of Game of Thrones recently, I was struck by how applicable a quote from Petyr Baelish was to our practice and thinking in the ED.

“Fight every battle everywhere, always, in your mind. Everyone is your enemy, everyone is your friend. Every possible series of events is happening all at once. Live that way and nothing will surprise you. Everything that happens will be something that you’ve seen before.”

How does this apply to the Emergency Department? Well, one of the things that makes you efficient in the ED is knowing what to do the moment you get diagnostic results, to know what the next 2 steps in the care of your patient will be based on your history/physical/diagnostics.  Much like you consider Schrodinger’s cat to be both alive and dead until you open the box, it is helpful then to consider that the patient you are working up for a PE both has a PE and doesn’t have a PE. In this way, when the CTPA results back you know exactly what to do if it is positive or negative.

Similarly, when considering therapeutic treatments early in the care of patients where there is considerable diagnostic uncertainty, it is extremely helpful to consider the effects of a prospective treatment in the multitude of possible disease states.  Take for example a patient presenting with dyspnea and significant work of breathing.  They are hypoxic and have crackles and wheezes heard throughout their lung fields.  They have a history of heart failure and COPD but, on presentation, are febrile to 101 with a productive cough.  Early on in their care pneumonia, COPD, and acute heart failure all are possible diagnoses. Should you aggressively treat their initially hypertensive blood pressure with nitrates (or order up some furosemide?*).  If they are septic from a pneumonia, nitrates are potentially harmful to the patient.  Likewise, pounding that patient with fluids should they have acute heart failure is also potentially harmful.  Considering all of the possible outcomes and possible diagnoses can help you decide when it is appropriate to institute a treatment and help you determine when you simply don’t have enough information.**

*No, don’t do this; fix the hemodynamics first (3)

**The true answer here (IMO) is to pull the ultrasound to the bedside and assess for pulmonary edema, cardiac function, and IVC diameter (4)

References / Further Reading

1. Locke, E. & Latham, G. New Directions in Goal-Setting Theory. Current Directions in Psychological Science. Vol. 15, no 5, 265-268.

2. Kovacs, G & Croskerry, P. (1999) Clinical Decision Making: An Emergency Medicine Perspective. Academic Emergency Medicine. vol 6, no 9. 947-952.

3. Felker, G., O’Conner, C., & Braunwald, E. (2009) Loop Diuretics in Acute Decompensated Heart Failure. Necessary? Evil? A Necessary Evil? Circulatory Heart Failure. vol 2; 56-62. DOI: 10.1161/CIRCHEARTFAILURE.108.821785

4. Papanagnou, Dimitrios et al. “Clinician-Performed Bedside Ultrasound in Improving Diagnostic Accuracy in Patients Presenting to the ED with Acute Dyspnea.” Western Journal of Emergency Medicine 18.3 (2017): 382–389. PMC. Web. 15 Aug. 2017.