We all ‘kick the can down the road’ – delay acting on a problem or decision with the hope that it will be easier to address in the future.” Or maybe we hope that benign neglect will make it go away. Alas, if only life were so easy.
In this pod we dig into the reasons behind on-shift procrastination and strategies for overcoming it. We also present a few practical steps to recognize and address decision deferral, techniques for managing aversion to some decisions, and how to pre-load accountability.
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We Discuss:
What does it mean to kick the can down the road?
- “Kicking the can down the road” means delaying or postponing a problem or decision with the hope that it will be easier to address in the future.
- This idiom signifies temporary avoidance rather than a solution.
How procrastination shows up on a clinical shift
- Common scenarios include patients with multiple nebulous complaints or complex underlying diseases, making it difficult to decide on a course of action.
- Elderly patients with pan-positive reviews of systems or patients with a concerning chief complaint can lead to deferred decisions due to the lack of clear diagnostic answers.
- Difficult personalities or tasks that may disrupt the rest of the shift, such as complex procedures or discharges, increase the likelihood of procrastination.
- Despite having all the necessary information to make a decision, the tendency to delay persists due to discomfort and unease.
- Avoidance behaviors stem from the desire to relieve the immediate discomfort and uncertainty of a difficult decision.
- Avoidance does not eliminate the problem but merely postpones the inevitable need for action. In the end, the problem may end up bigger later down the road.
Why does procrastination happen?
- Procrastination often occurs because the task is linked to a negative emotion like anxiety, fear, stress, or aversion.
- The act of avoidance temporarily alleviates the negative feelings, reinforcing the procrastination behavior.
- Procrastination is not just about poor time management but also about managing emotions related to the task at hand.
It doesn’t take much dread for can-kicking to occur
- Even a small amount of dread can lead to procrastination.
- A minor sense of dread, discomfort, or anxiety, can cause a task to be deprioritized during a busy workday and push a task one slot down the priority list.
Avoidance Awareness
- The first step in addressing procrastination is recognizing when it is happening.
- Inner tension or a subtle pull to avoid a decision is often present and must be identified.
- Procrastination can manifest as a physical sensation and/or a mental narrative.
- Understanding the situations, cases, and patients that trigger procrastination is crucial.
- Awareness is the foundational step in overcoming the habit of decision deferral.
Decisional Interrogation
- Regularly ask yourself if you have enough information to make a decision on patients who have been lingering.
- If the answer is no, identify what specific information is needed to decide.
- Emphasize the need for concrete and actionable information, avoiding unnecessary tests that merely delay the decision.
- Determine what action will result from the additional information, whether positive, negative, or neutral.
- Plan what you will do if the additional information does not provide clarity.
- If the answer is yes, you have enough information, ask what is stopping you from deciding.
- Personal barriers to decision-making, such as fear of missing something or intuition about an underlying issue, need to be identified and addressed.
- Balance the need to dig deeper on cases with genuine concern against the risk of keeping every patient too long due to indecision.
- Recognize when shared decision-making is appropriate or when further testing may be more harmful than beneficial.
- Continuously evaluate and adjust your approach to reduce unnecessary delays and improve decision-making efficiency.
Kicking the can because deciding will set off a cascade of more work
- Making a decision can trigger a cascade of events requiring significant attention and time.
- In emergency medicine, discharging a patient often involves more work than admitting them.
- Discharge involves numerous steps, including paperwork, patient conversations, and ensuring proper follow-up.
- The need for extensive documentation and coordination with primary care or care facilities adds to the workload.
- The anticipation of these tasks can lead to procrastination, as the effort required feels overwhelming.
Avoiding the infinite test of time
- Using the “test of time” as a reason to delay decisions can become a form of procrastination.
- Without a specific time constraint, it serves as a blank check for the procrastination brain.
- Setting a clear time frame for observation ensures the test of time is used effectively.
- Defining outcomes based on the patient’s condition at the end of the observation period helps make decisive actions.
- The test of time can sometimes hinder efficiency and effectiveness if not appropriately managed.
Identify how, when, and where you’ll make high-level decisions
Long term guests | How is it that decisions can finally be made when the shift is over?
- Long-term guest: A patient who you see early in the shift and is discharged after your shift has ended.
- Discharges are sometimes deferred, not because of needed information but because the end of the shift forces a decision.
- Procrastination can occur due to task saturation and prioritizing other activities over high-level decision-making.
- Frequent interruptions and tasks during a shift make it difficult to allocate time for complex decisions.
- Effective decision-making at the end of the shift is aided by having no other tasks competing for attention.
- Establishing boundaries, such as setting specific criteria for when to be interrupted, can create the necessary space for high-level thinking.
- Communication with the team about these boundaries ensures that critical tasks are prioritized without unnecessary interruptions.
- Identify how, when, and where you’ll process high level information
Chunking
- By the nature of your work, you are a world class decision maker.
- Despite being highly skilled decision makers, , even the best experience moments of subpar performance, requiring practice to address.
- Procrastination also occurs in personal life
- Identifying a manageable task from the to-do list and deciding how, when, and where to act on it can help break the cycle of procrastination.
- Breaking down large, overwhelming tasks into smaller, manageable steps, each taking less than 10 minutes, can reduce the feeling of distress and facilitate action.
- Even small tasks may involve difficult conversations or interactions, but addressing them incrementally helps prevent avoidance and further delay.
Kicking the can at work: pick one thing and identify YOUR decision points
- Changing the habit of procrastination in one day is difficult due to deep-rooted dread, angst, or habits.
- Complex topics, patients, and systems make sustainable change challenging.
- A better approach is to identify one specific area where decisions are regularly delayed or deferred.
- Writing down all the steps involved in evaluation, diagnosis, treatment, and disposition helps identify decision points.
- Recognizing the exact moment when discomfort and decision delays occur is crucial.
- Create a detailed pathway for that decision point, considering all steps and potential outcomes.
- Research and understand the literature to become an expert on the process, ensuring confidence in decision-making.
- Common delayed decisions often occur in gray areas without clear textbook answers, like certain pregnancy or neurologic complaints.
- Developing departmental protocols and engaging with other services to manage common pain points can improve consistency and reduce delays.
- Documenting and sharing these pathways with the group ensures everyone follows the same process, reducing individual hesitation and improving overall efficiency.
Preloading accountability
- Preloading accountability involves discussing uncertainties and potential outcomes with patients and families during the initial evaluation.
- In cases of procrastination, there is often a lack of clear communication and expectation setting with patients.
- Clear communication is more likely with straightforward cases than with complex or vague cases.
- Setting clear expectations helps avoid the need for decision delays later on by having predefined plans and outcomes.
- Preloading accountability reduces hand-wringing and rumination at critical decision points, as expectations are already established.
- While this approach may not work every time, it can significantly reduce procrastination and improve decision-making efficiency.
Perfectionists get caught in a tree when they’re actually in a tunnel
- Perfectionists strive to make the best decisions possible, but it’s often impossible to know if a decision is the best one.
- In high-stakes work, significant decisions are made based on limited information.
- Concerns about potential lawsuits, complaints, quality reviews, or M&M can exacerbate the pressure to make perfect decisions.
- In the moment, decision-making is like being in a tunnel, where one decision clearly follows another in a singular route.
- Retrospectively, the decision-making process looks like a tree with multiple branch points
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