Improving Your ED Efficiency: Upgrade This Elusive Skill

Improving Your ED Efficiency ALiEMU emergency department

No specialty in medicine requires “efficiency” more than Emergency Medicine (EM). Being able to seamlessly and quickly move between tasks is a necessary skill to function in the Emergency Department (ED). The controlled chaos and many moving parts can be overwhelming to new learners in the department and takes dedicated time and experience to overcome. Along with learning the necessary medical knowledge, efficiency expertise is crucial to becoming a high-performing emergency physician. Unfortunately, there is minimal formal training on how to maximize efficiency skills, leading many new EM learners (e.g. medical students and junior residents) having to troubleshoot and create these skills for themselves. 

ED Efficiency Themes

Research and anecdotal tips on being an efficient healthcare provider are sprinkled throughout the literature, but there are no established efficiency guidelines or consensus recommendations. Parsing through all available smattering of information in the literature, we identified 3 distinct “themes”: 

  1. Efficiency in workflow practices: This means learning skills that maximize a practitioner’s ability to see more patients throughout the shift. These skills work to help providers navigate patients quickly through the department, maintaining constant flow and maximizing resource utilization. By improving one’s workflow practices, tasks can be completed quickly and more patient’s can be seen overall.
  1. Anticipating roadblocks: Situational awareness of potential hurdles allows providers to more easily find workarounds to keep patients on a forward path. Understanding the intricacies of the health system and the functionality of a hospital allows for better anticipation and planning for future impedances to patient care and progress toward disposition.
  1. Effective team communication: Communication is an integral part of being an EM physician. By improving communication and learning to effectively work in a team, a provider can improve their overall efficiency in the department and can decrease provider mental burden. 

The ALiEMU 3-Course Series

As educators, we believe all skills can be taught. This includes efficiency skills. After distilling the available efficiency literature, we designed 3 courses, based on the above themes to best teach efficiency to new EM learners.

ED Efficiency ALiEMU badges emergency department

Our FREE curriculum uses the ALiEMU platform to simulate real-world scenarios, integrating the lessons in an interactive and fun way. Learners will discover strategies to optimize their time in the ED and begin their journey toward optimal efficiency. 

Examine how your ideas of efficiency fit with the strategies. These concepts may be new, or may already be a part of your EM practice. While operations vary for hospitals and EDs, the content taken as a whole represents the best practices found in the literature. These 3 themes should begin and guide your journey toward efficiency mastery. 

What are some of YOUR best tips for efficiency on shift? Contact us on Twitter (Dr. Guy Carmelli @GuyCarmelli) with any suggestions or feedback.

By |2021-12-16T14:34:48-08:00Dec 17, 2021|Academic, Life, Medical Education, Medical Student|

Teorías de la Educación en la Práctica (Education Theory Made Practical): An International Collaboration

spanish language book Teorías de la Educación en la Práctica

The vast majority of medical education materials (free or with cost) are available in the English language, a consequence of its hegemony as the language of science at a global level. In the world there are about 560 million people who speak Spanish, 460 million are native speakers, so Spanish is the language that has the second largest population of native speakers in the world after Mandarin. Although written English is understood by the Spanish-speaking community of health professionals, the best way to fully understand a text is reading it in the mother tongue!

It is therefore important to thank Teresa Chan from ALiEM and the clinical educators’ team that collaborate in the development of several texts on how to make educational theories practical, for their willingness to translate their material into other languages. The series “Education Theory Made Practical” (ALiEM Library) presents, with a simple but powerful strategy, educational clinical cases and reviews of the main educational theories for the consumption of students, resident physicians, and medical teachers around the world. These heroes and heroines of medical education have made this material available in free digital format, and with the Spanish translation of the first volume of this series (available at the Apple Bookstore and in ResearchGate) will help the community of Spanish-speaking medical educators with high-quality material for use in our countries. There is a great need for similar materials in Spanish, it is our fervent desire that the process of translation of these books continue, to help improve the quality of medical education globally.


La gran mayoría de los materiales de educación médica (gratuitos o con costo) están disponibles en el idioma inglés, consecuencia de su hegemonía como el idioma de la ciencia a nivel global. En el mundo hay cerca de 560 millones de personas que hablan español, 460 millones son hablantes nativos, por lo que el español es el idioma que tiene la segunda población de hablantes nativos en el mundo después del mandarín. A pesar de que la comunidad de profesionales de la salud hispanoparlantes entienden el inglés escrito, ¡no hay como leer un texto en la lengua materna para entenderlo cabalmente!

Es por ello importante agradecer a Teresa Chan de McMaster, Canadá y el equipo de clínicos educadores que colaboran en el desarrollo de varios textos sobre cómo hacer prácticas las teorías educativas, por su disposición para realizar la traducción de su material a otros idiomas. La serie “Teorías de la educación en la práctica” presenta, con un esquema sencillo pero poderoso, casos clínicos educativos y revisiones de las principales teorías educativas para consumo de estudiantes, médicos residentes y profesores de medicina de todo el mundo. Estos héroes y heroínas de la educación médica han puesto este material en formato digital y gratuito, y con la traducción al español del primer volumen de esta serie (disponible en la librería de Apple y en ResearchGate) ayudan a la comunidad de educadores médicos hispanoparlantes a tener un material de excelente calidad para su uso en los países hispanoamericanos. Hay una gran necesidad de materiales similares en español, es nuestro ferviente deseo que continúe la traducción de estos libros para mejorar la calidad de la educación médica en el mundo.


IDEA Series: Acute Venous Thromboembolism (VTE) Escape Room

escape room

Adult learning theory supports medical educators in moving away from long lectures with minimal engagement from the learners [1]. Core emergency medicine (EM) topics lend themselves well to interactive methods such as gamification [2]. Puzzle-based activities can successfully facilitate team building in medical education [3].

EM residents commonly encounter acute venous thromboembolism (VTE) in the ED and must know the spectrum of presentations and approach to evaluation and treatment, including the use of risk stratification calculators.

The Innovation

  • To improve teaching of acute VTE to EM residents, we created a puzzle-based activity called “Acute VTE Escape Room.” Two teams competed against each other to solve the theme case by unlocking clues with mini puzzles, similar to the format of commercial escape rooms.

The Learners

  • As this game comprised part of the intern core curriculum, all participants were interns, with the puzzles targeted to the expected knowledge base of a PGY-1 EM resident.

Group Size

  • Group size was 4-5 learners


  • Box with the ability to lock it
  • Numerical padlock
  • Tokens
  • Opaque envelopes
  • Laptop or tablet
  • Printed clues, questions and theme case components (Fig 1)
  • Note: If interested in obtaining printouts used in this activity, please contact Dr. Elspeth Pearce on Twitter (@ElspethKPearce)

escape room vte IDEA series

Figure 1. Game Materials

Description of the Innovation

Interns were split into 2 groups to compete against each other and race the clock to solve the case within 45 minutes. Two senior residents, one per group, assisted with the question-and-answer portion of the game. The interns had access to smartphones during the activity, and were encouraged to utilize them to access risk stratification tools during the first mini puzzle.

A theme case of obstructive shock secondary to catastrophic thrombosis of an IVC filter [4] was presented in pieces as the teams unlocked additional components of the case. The teams were given the case stem introducing the patient, chief complaint, and vital signs. They then had to unlock a box using a 4-digit passcode. This first mini puzzle had 3 cases with risk stratification scores that could be deduced. Once they calculated the risk scores they were able to unlock the box and were given the theme case history of present illness, physical exam, and instructions for the next puzzle.

The groups then had to order diagnostic laboratory and imaging tests to further evaluate the patient described in the theme case. Results were made available for tokens, with the cost of the tests similar in scale to what patients might encounter in the ED. This corresponded to an added educational objective to teach residents about resource utilization and cost of care. Labs and ECG cost 1 token and more expensive diagnostics cost 3-5 tokens. The teams earned the tokens by answering written board exam style questions (some sourced from existing board review question banks and others written by the instructor) from volunteer senior residents. Participants received the results of the tests in envelopes after they purchased them with tokens. The envelope for the lower extremity Doppler ultrasound included an additional puzzle necessitating completion in order to obtain the results.

The final mini puzzle included 4 ECGs that could be seen in acute pulmonary embolism with four questions to answer. Participants filled in the answers in boxes. Highlighted boxes yielded a passcode required to access a PowerPoint that then revealed a video of a positive ultrasound for DVT. The interns were expected to interpret this ultrasound, apply this result to the case components they had obtained, and report the final diagnosis and treatment to the instructor. A prize was awarded to the winning team.

Both groups had 45 minutes to complete the activity, allowing the instructor roughly 10 minutes to debrief, answer questions, and deliver a brief lecture on acute VTE. After completion of the activity, the participants filled out a survey evaluating the activity.

Figure 2. Learners Solving Mini Puzzle 2


Figure 3. Learners Solving Mini Puzzle 3



This activity was completed in-person during the hour designated for the intern core curriculum prior to the start of the resident didactic conference. Nine out of ten (90%) interns completed the acute VTE escape room and 6 (66.7%) completed the post event survey (Fig 2). Both groups finished in the time allotted with one group requiring help from the instructor to finish on time. All participants agreed or strongly agreed that the time was used effectively, and the material was presented in a clear and organized manner. Five participants (83.3%) strongly agreed that the material was delivered in an enthusiastic and stimulating way. The comments on the activity were overwhelmingly positive: “Fun and engaging way to learn about the topic”, “I LOVED this activity and really enjoyed it! Thanks for organizing it!”

IDEA Escape Room survey results

Figure 4. Survey Results

Lessons Learned

We successfully developed this game for a small group of residents at approximately the same level of medical knowledge. Adjusting the activity to target a more heterogeneous knowledge base would allow for participation by EM residents of all levels. The questions used for obtaining tokens (mini puzzle 2) and the ECG reading (mini puzzle 3) could be adjusted to the level of learner. We would recommend small group sizes as we discovered the printouts were hard to share amongst the whole group. The debrief session at the end provided a key opportunity to address any remaining questions among learners and clarify any ongoing knowledge gaps. Both groups needed some explanation of the theme case given that it involved a rare and difficult diagnosis to make. As both groups answered some of the most difficult board review questions incorrectly, future iterations may seek to better target questions to the level of the learner.

Theory Behind the Innovation

Gamification, as described by Bíró in 2014, was used as the educational theory foundation for this escape room style activity [5]. Each learner working with a team could create their own path to the correct answers. The groups and the competitive environment provided the motivation to quickly learn and adapt to the puzzles presented. 

The debrief session at the end allowed us to address existing gaps in medical knowledge and unpack emotions experienced by participants during gameplay. Debriefing theory allows the instructors of an activity, usually simulation, to create an emotionally charged event within a safe space for learning [6]. Through the debrief, instructors can identify and address gaps in clinical knowledge uncovered during gameplay.


Read other IDEA Series innovations.


  1. Cooper AZ, Richards JB. Lectures for Adult Learners: Breaking Old Habits in Graduate Medical Education. Am J Med. 2017 Mar;130(3):376-381. Epub 2016 Nov 28. PMID: 27908794.
  2. IDEA Series: Toxicology Virtual Escape Room during COVID-19. Academic Life in Emergency Medicine. Accessed September 22, 2021.
  3. Zhang XC, Lee H, Rodriguez C, Rudner J, Chan TM, Papanagnou D. Trapped as a Group, Escape as a Team: Applying Gamification to Incorporate Team-building Skills Through an “Escape Room” Experience. Published online 2018. doi:10.7759/cureus.2256
  4. Pearce EK. An Uncommon Cause of Shock: Acute Thrombosis of the Inferior Vena Cava. J Emerg Med. 2021 Jul;61(1):67-69. Epub 2021 May 8. PMID: 33972133.
  5. Bíró GI. Didactics 2.0: A Pedagogical Analysis of Gamification Theory from a Comparative Perspective with a Special View to the Components of Learning. Procedia – Soc Behav Sci. 2014;141:148-151. Doi: 10.1016/j.sbspro.2014.05.027
  6. Fanning RM, Gaba DM. The role of debriefing in simulation-based learning. Simul Healthc. 2007 Summer;2(2):115-25. PMID: 19088616
By |2021-11-26T16:53:23-08:00Nov 24, 2021|IDEA series, Medical Education|

How I Work Smarter: Mark Ramzy, DO EMT-P

One word that best describes how you work?


Current mobile device

Samsung Galaxy S20


Samsung Notebook 9

What is something you are working on now?

Ultrasound Teaching Curriculum (both image review and interpretation) that can be made virtual and in very small group sessions with focused teaching and infographics.

How did you come up with this Idea/Project?

We performed a needs assessment in ultrasound learning across different divisions and specialties (IM, Anesthesia, etc) within the hospital. This didn’t just include medical students and residents/fellows, but also included attendings and faculty members with a longitudinal component to teaching. Also planning to make infographics easily referenceable on shift for quick review.

What’s your office workspace setup like?

Well since I’m a fellow, I don’t quite have an office at work. My office (and also recording space) at home consists of a custom-built desktop computer that is essentially a replica of my laptop.

What’s your best time-saving tip in the office or home?

Chunk or group together your work, especially similar tasks. If you have articles or content to review across different slack work groups, try to do it all at the same time so that you can develop a flow to your focused work. Have similar rules for work and home. For example turn off your phone notifications when “chunking”, then when you dedicate time to yourself/family/friends, also turn off your phone and be as present as possible.

What’s your best time-saving tip regarding email management?

Don’t just get your inbox to zero, have an organized system to keep everything straight. Whether that is a folder, labels, or specific inboxes, make sure you can easily find information. Also, utilize the snooze button in GMail as it helps you prioritize emails that you need to respond to but are unable to right away if viewing on your phone.

What apps do you use to keep yourself organized?

  • OneNote AND Evernote (I think the former has drawing/writing features, allowing me to take handwritten notes and easily search them
  • Business Calendar
  • Feedly

How do you stay up to date with resources?

  • Push specific content to me (ie. Utilize email notification system on PubMed and Journals for articles on specific topics)
  • Make customized lists on Twitter following particular people and hashtags

What’s your best time-saving tip in the ED?

Count your steps and limit them when you can to ultimately see more patients and save time. Also in addition to nursing staff, make every possible effort to learn the names of the unit clerk, environmental services, and any other ancillary support staff in the ED.

ED charting: Macros or no macros?

Macros for sure. I re-read it every single time on every single patient and make sure it applies to the patient after slight modifications as needed.


  • What’s the best advice you’ve ever received about work, life, or being efficient?

    • Double-dip when working on a project. Writing an article? Turn it into a blog post as well! Spin it into a deep discussion with an expert to also make it into a podcast.
    • Find a way to make your work easily accessible on shift (with or without an internet connection), Evernote and OneNote are both great options for this.
  • What advice would you give other doctors who want to get started, or who are just starting out?

    • Treat your staff (and patients) BETTER than you would want to be treated. Actively work to know their names and develop a working relationship with them so everyone can better help take care of patients together as a team.
    • Don’t gossip or talk about others no matter how tempting it is to get pulled into the “drama”
    • Be that doctor, who staff are excited to see when you come on shift and say things like “Oh Thank God it’s you…”
  • Is there anything else you’d like to add that might be interesting to readers?

    • Make sure to have one or more hobbies outside of medicine that really push your creative boundaries. For me, it’s things like graphic design, infographics, baking cheesecakes, and artistically decorating. It’s an added bonus if others can benefit from your hobby too!

Who would you love for us to track down to answer these same questions?

  • Paul Young (@DogICUma)
  • Zaf Qasim (@ResusOne)
  • Zack Shinar (@ZackShinar)
  • Joshua Niforatos (@ReverendofDoubt)
  • Shreya Trivedi (@ShreyaTrivediMD)

Read other How I Work Smarter posts, sharing efficiency tips and life advice.

By |2021-11-11T07:33:34-08:00Nov 12, 2021|How I Work Smarter, Medical Education|

How I Work Smarter: Katie Holmes, DO FACEP

One word that best describes how you work?


Current mobile device

iPhone 12 Pro


Macbook Air

What is something you are working on now?

Updated Curriculum for our EM Clerkship, VSAS, Conference Material, Intern Orientation planning, and more

How did you come up with this Idea/Project?

We are always trying to improve our curriculums to make them better based off of feedback from previous years!

What’s your office workspace setup like?

My kitchen counter or my office at the hospital.

What’s your best time-saving tip in the office or home?

Keep a To Do list and divide into “right now” and “ideas for later”.

What’s your best time-saving tip regarding email management?

Start with the longest sitting email and work your way up, but always respond quickly to urgent emails, even if it’s to recognize you saw it.xt

What apps do you use to keep yourself organized?

iPhone To Do lists, Notepad shared with my team, Google Docs/Sheets

How do you stay up to date with resources?

Twitter, podcasts, subscribed emails

What’s your best time-saving tip in the ED?

Epic’s Work space, Updating ED Course frequently, Epic messaging, multitasking constantly

ED charting: Macros or no macros?

Minimalist Macros unless I have a complex patient, then it’s story time with M-Modal


  • What’s the best advice you’ve ever received about work, life, or being efficient?

    Always make time for the things you love. Travel hard. What you do matters. Don’t engage difficult people. Don’t take yourself too seriously… you just have to laugh it off sometimes. Take care of patients passionately. Encourage others around you always. Work can and should be enjoyable, if it’s not… you’re doing something wrong.

  • What advice would you give other doctors who want to get started, or who are just starting out?

We have the best job in the world, but you must truly love what you do to sustain a long and happy career in medicine.

  • Is there anything else you’d like to add that might be interesting to readers?

Surrounding yourself with motivated, helpful and kind people who are passionate about what they do is the best thing you can do in this demanding job! I don’t know what I would do without my people.

Who would you love for us to track down to answer these same questions?

  • Dr. Anant Patel, DO  @anantpatels

Read other How I Work Smarter posts, sharing efficiency tips and life advice.

By |2021-07-28T04:41:51-07:00Jul 28, 2021|How I Work Smarter, Medical Education|

Education Theory Made Practical: Listen to the New Podcast Series

education theory made practical books into podcast

The Education Theory Made Practical (ETMP) set of 3 e-books were published starting 2017, reviewing key education theory principles and practically framing the abstract into practical scenarios. This series was produced by the ALiEM Faculty Incubator in collaboration with the  International Clinician Educator (ICE) blog. These e-books can be downloaded for free in the ALiEM Library.

We were surprised, humbled, and honored that Dr. Daniel Harper wanted to convert the popular e-books into a podcast series, with each chapter turned into short 10-20 minute podcast. As a pilot test, he converted Volume 1 into a set of 10 podcasts. Take a listen, put on your educator-scholar caps, and let us know what you think.

Podcast Series: Education Theory Made Practical (Volume 1)

Podcast Team

Daniel Harper

Host: Daniel Harper, MD

Senior Resident
Dual Interventional Radiology and Diagnostic Radiology
Ochsner LSU Health Shreveport

Host: Surbhi Raichandani, MD

Senior Resident
Department of Radiology
University of Arkansas Medical Sciences

Guest Voice:

  • Loren James Perley (electrical engineer)


Chan TC, Gottlieb M, Sherbino J, Boysen-Osborn M, Papanagnou D, Yarris L. Education Theory Made Practical, Volume 1. San Francisco, CA: ALiEM Publishing, 2017. [ISBN 978-0-9992825-0-2, PDF]

By |2021-07-20T06:21:16-07:00Jul 16, 2021|Academic, Medical Education, Podcasts|

How I Work Smarter: Gus M. Garmel, MD, FACEP, FAAEM

gus garmel how i work smarter

One word that best describes how you work?


Current mobile device




What is something you are working on now?

Multiple projects, presently Microaggressions & Civility in the Workplace, Communication and Success in EM, and Coaching/Mentoring in EM.

How did you come up with this Idea/Project?

These are important topics; not a lot of information is available about these topics related specifically to EM despite the need.

What’s your office workspace setup like?

Standing wrap-around adjustable desk with good lighting, multiple computer monitors, and sufficient space to work so that I can keep needed materials close and accessible in my work area. I have few distractions in my workspace, which allows me to focus best on the work I am doing.

What’s your best time-saving tip in the office or home?

Limit distractions and work on one thing at a time, which reduces inefficiencies and errors that often occur with multitasking.

What’s your best time-saving tip regarding email management?

I have several tips, although I have found that turning off email notifications and checking email infrequently (or on YOUR schedule when time allows) are perhaps the best recommendations I can share (again, this relates to multitasking inefficiencies, limiting distractions, and error prevention).

What apps do you use to keep yourself organized?

Ical, Notes, and email all help me stay organized. I also use SUPER-STICKY Post-It notes. They come in a variety of colors if you purchase them in bulk, which some people use to help with organization through color-coding (I don’t use this strategy, but it is a good one).

How do you stay up to date with resources?

Staying current and updated (medical and non-medical) is challenging and takes time. I have a few key websites bookmarked, and still get some materials through the mail on paper. I schedule time for keeping up. Some aggregated links direct me to articles of interest, and I receive TOCs directly from society journals (EM and non-EM). I make a conscious effort to keep up, and spend very little (or no) time on Facebook, Twitter, and other social media platforms.

What’s your best time-saving tip in the ED?

Always think DISPOSITION (every patient needs one). I teach that if you don’t have a good idea about a patient’s disposition, you should ask more targeted questions and do a better physical examination before leaving the room. I recommend planning for test results that can only be normal, abnormal, or indeterminate. Imagine what you would do for (and with) each patient if the test results are all negative (or normal). Have a plan for indeterminate results, for positive findings, or what to do if there is a worsening in the clinical course (including persisting pain, dizziness, vomiting, shortness of breath, etc.). I also think and teach to consider what information is necessary before it is appropriate to call a consultant that I or the patient needs anyway. Often consultants appreciate hearing about a patient “early” even before all the results return (especially if it is near the end of their day while they are still in the hospital).

ED charting: Macros or no macros?

Macros, but only after I see the patient and with attention to modifying the EMR as necessary. I am meticulous about adding detail and removing anything that is incorrect from the Macro. I never use Macros in my free-text HPI.


  • What’s the best advice you’ve ever received about work, life, or being efficient?

    FOCUS – that’s key. Make every minute (or moment) count. Whenever possible, try to “finish” one task before starting another, which keeps your “to do” list as short as possible and prevents errors and inefficiencies related to multitasking or task switching.

  • What advice would you give other doctors who want to get started, or who are just starting out?

My best and most frequent advice to all physicians (especially new physicians) is to work hard (and smart), be a team player at all times, show compassion and demonstrate empathy as often as possible (always is best), and strive to improve your communication and professionalism skills. Clinical knowledge is expected. Your efficiency will improve with experience and with practice. Be kind to as many people as you can as often as you can. These are important strategies for professional success, patient satisfaction, and personal wellness.

  • Is there anything else you’d like to add that might be interesting to readers?

Enjoy your career in EM, which will be challenging yet extremely rewarding. Strive to achieve Joy and Meaning in Medicine by working with purpose. Use people’s names frequently and correctly (patients, staff, consultants, colleagues), and express genuine interest in them as people and professionals. Learning something personal about your patients and colleagues (in and outside of EM) is a sign of respect. Expressing gratitude and saying “thank you” with sincerity are always beneficial.

Who would you love for us to track down to answer these same questions?

Anyone who has demonstrated consistent long-term success in EM, and is able to share his or her successes, failures, and strategies in a clear manner.

Read other How I Work Smarter posts, sharing efficiency tips and life advice.

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