Thread by @jtsaxon

“Fast is slow, slow is smooth, smooth is fast”.

A🧵for interventional cardiology #ACCFIT

You’re likely to hear a variation of this phrase during your training in the cath lab. So what does it mean? And why do interventional cardiologists find it so compelling?

Let’s break it down.

Most sources attribute the phrase to the Navy Seals, a celebrated military group that takes pride in its culture and shared set of values.

Although cardiology and Navy Seals are vastly different professions, we can draw parallels among the two sub-cultures: both groups value efficient and effective decision making despite working in high-stakes, high-stress environments.

We can learn a lot from the Seals.

“Fast is slow.”

By definition, a cath lab procedure is not defined by a single skill, or a single step: the procedures are comprised by completing a series of steps, each linked together to complete a complex, linear task.

Consider how many steps are required to perform a PCI — from start to finish. If you try to list the steps in your head, it may seem rather daunting.

“PCI” is not a skill, it’s a *SKILLSET*.

This is true for other procedures. When you’re tasked with performing a bunch of steps back-to-back-to-back, there is a temptation to try to rush through some of the various steps — especially the steps that seem simple or straightforward, and especially if you’re in a hurry.

The classic example is primary PCI for a STEMI: the patient arrives in the cath lab, and everyone is running around and talking loudly (or yelling), and for some reason there are a bunch of extra people there, just to watch. The resulting tension in the room is super high.

You, as the IC fellow, may have gotten access thousands of times, but it’s a STEMI, so the stakes and tensions are higher, and Everyone is looking at you, waiting for you to do get the job done. And they expect you to get it done QUICKLY. So what do you do?

You start to rush.

Because you’re rushing, you don’t move your hands the way you normally would. Your movements are less controlled, less intentional, more erratic.

And you end up missing the access.

It’s no fault of yours, you were just in a hurry! Unfortunately the attending has to jump in and get access, so the procedure can move forward. And you feel… deflated.

Let’s imagine another scenario. What if, rather than rushing, you slow down, take a deep breath, and perform the steps of getting vascular access at your own pace? There’s a good chance you might not have missed it.

Missing the vascular access wasted precious seconds. Or even minutes.

Because you went fast, it ended up slowing down the procedure.

Fast…. is SLOW.

This can apply to any of the steps of a procedure. People want to look like they’re good. So they are tempted to… *go fast*. But when they rush, they don’t have controlled movements; they aren't purposeful. People who rush end up looking erratic — and unskilled.

Rushing is NEVER worth it. The fractions of a second you stand to gain by moving fast, are always outweighed by the time it takes to retrace your steps when you make a mistake, or the steps you have to repeat because they weren't done properly. All of this takes valuable time.

“Slow is smooth.”

In stead, when starting a complex procedure with a lot of steps, focus on taking your time and doing each step right the FIRST TIME.

Because the steps of the procedure have to proceed in a linear fashion (access > catheter advancement > coronary engagement > wiring > etc), the step you are currently on is a CRITICAL STEP in the procedure. We can’t move forward unless it’s done, and done right.

Focus on the *critical* step you’re on. Control your movements; move with purpose and intention no matter how seemingly inconsequential the task. No wasted motion. Nothing erratic. Even if it seems like you’re moving agonizingly slowly.

If you do this with intention, over time you will start to notice astonishing gains. Each individual step will go faster; the transitions from one step to the next will be seamless; and you will start to look very, very smooth.

But this process takes TIME. Don’t give into the temptation to rush. Keep getting better at the little things. Don’t worry about the finished product; worry about the PROCESS.

“Smooth is fast.”

Once you are smooth and thoughtful with your movements, many of them will start to become second nature. You will notice things that used to be hard will somehow, no longer require your active attention.

You will make far fewer mistakes, and you will spend much less time having to fix those mistakes. This will have a big impact on your *total* procedural time.

"Smooth… is FAST."

Put another way:

You must become *Proficient* before you can expect to be *Efficient*. Focus on proficiency at the little things, and the big picture will take care of itself.

Summary:

-Rushing leads to mistakes, which cost time
(Fast is slow)

-Move with purpose and intent
(Slow is smooth)

⁃Proficiency is the pre-requisite for Efficiency
(Smooth is fast)

Good luck in fellowship! #ACCFIT @ACCinTouch