#046 How to structure your workflow for maximum efficiency and quality

"They want to talk to you."

My hands were working under the microscope just after midnight. I was at the end of my training and on call for emergencies. A sprightly 70-year-old had suddenly become paralysed by a spontaneous blood clot around his spinal cord. His only treatment option was to have his spinal cord decompressed to have a chance at recovering.

The bony spinal column is very similar to the skull in some ways. Neither contains any extra space for visitors. When pathology arrives - like blood, infection, or tumours - the fragile neural tissue inside the spinal column gets put under pressure, often losing its function.

In stroke medicine, there is an aphorism – "time is brain." Every minute counts when treating patients who have had a stroke from the blockage of an artery. But on this night, time was spine. Every minute that my patient's spine remained under pressure, cells were dying.

The phone call had come from a distant hospital where a child with a ventriculoperitoneal shunt had presented with a headache. A shunt is a tube that takes fluid from one place to another.

A ventriculoperitoneal shunt takes fluid from the brain known as the ventricles, to another place, the peritoneum - the fluid space around the organs in the abdomen. A shunt is a treatment for hydrocephalus - the build-up of fluid within the brain - and no other invention in neurosurgery has saved so many lives.

Frustrated at being interrupted, I stopped operating and took a look at the child's scan. There was nothing for me to do and I advised them to admit the child and look for another source of the headache. I returned to the microscope and finished the operation with no problems.

Few times have I been so grateful for the mystery that is "gut feeling". As I wrote my operation note I had a nagging feeling about the referral I had taken mid-operation. I looked at the child's scan and my sympathetic nervous system kicked into overdrive. Sweating, tachycardia and a sprinkling of nausea for good measure ensured.

I had looked at an old scan and given the wrong advice. Their current scan showed enlarged fluid spaces in the brain - a clear sign that their shunt wasn't working. Shunts save lives by maintaining normal pressure in the brain. If the pressure goes too high there is a predictably catastrophic series of events – headache, vomiting, confusion, blindness, seizures, coma and finally death.

I called the referring hospital and the child was flown down immediately. Thankfully they had not deteriorated during the short delay. Their operation went smoothly and they were discharged a few days later.

This event stuck in my mind like a splinter for months. I kept revisiting it over and over, never wanting it to happen again.

This is why it happened and how the lessons extend far beyond the operating room.

Context Switching

Context-switching is our tendency to switch from one task to another. It is an essential ability to navigate day-to-day life. There are different degrees of context-switching that is, I can't put this any other way, context-specific.

When switching from operating to taking a referral, I went from using a psychomotor skill to visual data interpretation, to verbal communication, and then back to psychomotor. That's three switches in the space of a few minutes.

The problem with context-switching is that it comes with a cost, and the greater the difference is skills required between tasks, the greater that cost is.

Attention Residue

Attention residue is the cost of context-switching. It is an inbuilt element of how our minds work. For a time, when I stopped operating and looking at the child's scan I was still thinking about the operation.

When I returned to operating, part of me was still thinking about the scan. This is why my gut told me something wasn't right as I wrote my operation note. The residue of the scan was thick and yet to clear from my brain. This is the evolutionary benefit of attention residue – a safety net for decision-making.

However, the danger of attention residue is that it prevents you from giving 100% of your focus to the task at hand. And when attention is degraded, efficiency and quality go down.

Decision Fatigue

"You need to focus your decision-making energy. You need to routinise yourself." - Barack Obama

If you have been making decisions for a prolonged period - like taking emergency referrals and operating - the quality of your decisions becomes worse with time. This is decision fatigue.

When attention and cognitive horsepower are viewed as currency, decision fatigue makes you poor. It's why Steve Jobs wore the same clothes every day and why Barack Obama's mornings were always the same.

Systems Error

The final hole in this Swiss cheese of events was a systems error. The imaging system I used did not automatically load the most recent scans for patients.

Normally I would notice the wrong date on a scan, but when combined with context-switching, attention residue and decision fatigue, I failed to notice this familiar inbuilt error.

Here are three principles you can take from my near-miss and apply to maximising the efficiency and quality of your work.

Interruption Barriers

After my not-so-fun night of operating, I created a simple interruption barrier. If a phone call came while I was operating I asked the theatre staff to forward it to the Consultant on call with me.

This took maturity and experience to do. At the start of training, I was very conscious of not being able to do everything as being perceived as a sign of incompetence. But after seeing the fallout of degraded attention, I wanted to give my total focus to my responsibility in the moment.

There are 2 ways you can set up interruption barriers. The first is external. Let people know you don't want to be disturbed for a set time. This can be a friendly chat or a sign on your door.

The second is internal. You are your own worst source of interruption. Emails, social media and WhatsApp are all designed to steal your attention. Here, simple heuristics can serve as barriers. Firstly, flight mode on your phone instantly cuts off 90% of your options. Secondly, not opening your messages unless you're ready to act on them will keep you in good stead.

You have to cultivate an environment that promotes the best in you. Creating barriers to interruptions and distractions is the first step.

Time Blocking

A simple step to limit context-switching is defining your work by skillset, not the outcome. For example, if you have 3 projects on the go and need to make short calls for each, don't scatter the calls throughout the day. Block all 3 into one hour.

This way you have gotten into the flow of listening and talking. The first call might be a bit clunky, but by the time you're done and are on to the second and third, you'll be flying. This makes quality and efficiency go up.

Once the calls are done move to your next skillset block. Switching tasks is a necessary part of any workflow, but by blocking your work bouts by skillset you can drastically decrease the number of switches in your day.

Rest and Recovery

Rest is a state of inactivity. Stopping work and doom-scrolling at your desk for 15 minutes is rest. When you return to the grindstone, there's no guarantee the quality of your work has returned to your best.

Recovery is returning to a better state. When you are recovered you will produce the same, if not better, quality of work.

Paradoxically, when recovering, context-switching is useful. If you've been slogging at a desk, go for a walk. If you've been on your feet talking for an hour, sit down and listen to a podcast. Take a break and actively recover by passively using a disparate skillset.

Some signs that you need to take a break are making more simple errors than usual and hunting for distractions.

A simple question to know if you're recovering or resting is to ask yourself - how do I feel now I have to get back to work? If you've rested it will feel like a chore. If you've recovered you'll be up for the challenge.

The take-home message from this post has nothing to do with work, mistakes, or productivity.

It's this.

Effective solutions cannot be found in the same field where the problem resides.

No textbook of surgery would have deconstructed why I made this mistake or how to stop it from happening again. The answers came from psychology, neuroscience and the pursuit of getting better.

Read widely. Find your own solutions.

You will know you're on to something when it solves more than one problem.

P.S.

If you struggle to find enough hours in the day for work and family, I can help you out.

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