Are you a Dr Big Workup or a Dr Minimalist?

[pulmoblast]

Remember the rules of the House of God, ...If a patient smells like someone who may sue (white entitled millennial prick, or a hood rat with Saul on speed dial) BUFF the chart and TURF the patient

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[Druggernaut]

On that note:

13. THE DELIVERY OF GOOD MEDICAL CARE IS TO DO AS MUCH NOTHING AS POSSIBLE.

 

[gro2001]

It's kind of funny how so many people think they are right about the middle. I guess it's like driving: anyone driving slower than you is an idiot and anyone driving faster than you is a maniac.

 

[GeneralVeers]

It's kind of funny how so many people think they are right about the middle. I guess it's like driving: anyone driving slower than you is an idiot and anyone driving faster than you is a maniac.

I'm not in the middle. I'm clearly in the Minimalist category, and very proud of it. I think it actually takes more brains and skill to be a minimalist than to work people up uselessly.

 

[Groove]

Sovereign immunity helps. I like hunting for the occasional zebras, don't enjoy sovereign immunity and hence, am somewhat more in the middle.

Case in point: I had a pt with a really sick atypical CAP/sepsis case last year with a few history components combined with an associated hyponatremia that tickled my brain and reminded me of an old USMLE study question back in the day on legionella and associated hyponatremia. (It's always the low yield info that sticks in the long term memory.) I actually ordered the antigen, which was a send out, admitted them and didn't think anything else about it. I got a call in the ED from a lab in NM the next week telling me it was positive. Made my day, lol.

 

[deleted547339]

Sovereign immunity helps. I like hunting for the occasional zebras, don't enjoy sovereign immunity and hence, am somewhat more in the middle.

Case in point: I had a pt with a really sick atypical CAP/sepsis case last year with a few history components combined with an associated hyponatremia that tickled my brain and reminded me of an old USMLE study question back in the day on legionella and associated hyponatremia. (It's always the low yield info that sticks in the long term memory.) I actually ordered the antigen, which was a send out, admitted them and didn't think anything else about it. I got a call in the ED from a lab in NM the next week telling me it was positive. Made my day, lol.

By which time the patient was discharged or dead, lol.

I actually think we run those at my hospital.

 

[GeneralVeers]

Sovereign immunity helps. I like hunting for the occasional zebras, don't enjoy sovereign immunity and hence, am somewhat more in the middle.

Case in point: I had a pt with a really sick atypical CAP/sepsis case last year with a few history components combined with an associated hyponatremia that tickled my brain and reminded me of an old USMLE study question back in the day on legionella and associated hyponatremia. (It's always the low yield info that sticks in the long term memory.) I actually ordered the antigen, which was a send out, admitted them and didn't think anything else about it. I got a call in the ED from a lab in NM the next week telling me it was positive. Made my day, lol.

Not to sound terrible, but who cares? At the point the patient is diagnosed with sepsis, order the "Sepsis Orderset" for your facility, admit the patient and move on. Once I've made a decision on admit versus discharge, my brain stops, and I immediately move on to another task. I don't want to be insulting, but your approach is precisely why some of my colleagues keep patients in the ED for 8 hours without a disposition.

 

[gman33]

Not to sound terrible, but who cares? At the point the patient is diagnosed with sepsis, order the "Sepsis Orderset" for your facility, admit the patient and move on. Once I've made a decision on admit versus discharge, my brain stops, and I immediately move on to another task. I don't want to be insulting, but your approach is precisely why some of my colleagues keep patients in the ED for 8 hours without a disposition.

Who cares?
The patient who maybe got better because a smart doctor ordered an appropriate test.

If a patient is truly sick, I think it's worth spending a few extra minutes thinking about what is going on.

I agree that you should not do that on every patient.
If you can help expedite appropriate care on a patient, I don't see how that's a bad thing.

 

[WilcoWorld]

Not to sound terrible, but who cares? At the point the patient is diagnosed with sepsis, order the "Sepsis Orderset" for your facility, admit the patient and move on. Once I've made a decision on admit versus discharge, my brain stops, and I immediately move on to another task. I don't want to be insulting, but your approach is precisely why some of my colleagues keep patients in the ED for 8 hours without a disposition.

When I read gman33's post I was pretty sure you were going to make the point that this was not an emergency. Fact is that you're correct - it wasn't. I really can't argue against your approach to EM on medical grounds. But I will say this, the way you practice seems joyless to me. On the other hand, it also sounds far less prone to frustration than the way I practice. To each his own...as long as you're not missing time-sensitive diagnoses and I'm not clogging up the ED getting knee MRI's.

 

[Groove]

Not to sound terrible, but who cares? At the point the patient is diagnosed with sepsis, order the "Sepsis Orderset" for your facility, admit the patient and move on. Once I've made a decision on admit versus discharge, my brain stops, and I immediately move on to another task. I don't want to be insulting, but your approach is precisely why some of my colleagues keep patients in the ED for 8 hours without a disposition.

For starters, mr. minimalist smart guy, legionella has to be reported to the CDC. So, if you're the only doc on the care team that thinks about it, you're certainly not doing the pts in your state a disservice by any means are you? You're pure locums though, right? If so, what do you care about your colleague's TAT times? The locums doc pontificating about the superiority of his (maximum brain and skill per your post) minimalist work ups and eschewing anything more as substandard while criticizing his colleague's practice patterns? Oh, please. Give yourself a reality check. Everyone has their own practice patterns, ddx and comfort levels and I find it insulting to insinuate all your fellow EM docs should conform to a minimalist approach. I honestly find it very difficult to run an ultra lean minimalist practice style with an ever growing ddx. It's actually rewarding to dx rare and interesting dx every now and then. That doesn't equate to lengthy work ups on each pt. You get that, right?

Some of our docs see 1.6pph. I see 2.2-2.5 comfortably. One guy sees 2.5-3.0 some shifts. You know what? They all practice differently, have unique strengths and weaknesses and are ALL smart and talented docs. I appreciate them greatly and certainly don't judge their practice styles or compare each other's TATs like we're standing around urinals in the bathroom. I promise you, there's room for all of us in the ED.

 

[GeneralVeers]

For starters, mr. minimalist smart guy, legionella has to be reported to the CDC. So, if you're the only doc on the care team that thinks about it, you're certainly not doing the pts in your state a disservice by any means are you? You're pure locums though, right? If so, what do you care about your colleague's TAT times? The locums doc pontificating about the superiority of his (maximum brain and skill per your post) minimalist work ups and eschewing anything more as substandard while criticizing his colleague's practice patterns? Oh, please. Give yourself a reality check. Everyone has their own practice patterns, ddx and comfort levels and I find it insulting to insinuate all your fellow EM docs should conform to a minimalist approach. I honestly find it very difficult to run an ultra lean minimalist practice style with an ever growing ddx. It's actually rewarding to dx rare and interesting dx every now and then. That doesn't equate to lengthy work ups on each pt. You get that, right?

Some of our docs see 1.6pph. I see 2.2-2.5 comfortably. One guy sees 2.5-3.0 some shifts. You know what? They all practice differently, have unique strengths and weaknesses and are ALL smart and talented docs. I appreciate them greatly and certainly don't judge their practice styles or compare each other's TATs like we're standing around urinals in the bathroom. I promise you, there's room for all of us in the ED.

You are correct in that there are greatly different practice styles. The docs who go on "Zebra hunts" on almost every patient, tend to bog down the ED. Yes it effects me, because if they tie up a room for 8 hours, that is nursing that they are tying up, which negatively impacts my patient care. It also means we can move fewer patients through the ED, which results in longer LOS for every patient, and as a consequence worse patient satisfaction, not to mention potentially negative outcomes, as that patient sitting in the waiting room for a bed could decompensate. Would it be cool to diagnose Legionella in the ED? Sure, but it's simply not practical in the 2-3 pt/hour shops I work at. Although a locums, I'm still tied to patient satisfaction, patient complaints, and RVU productivity just like any other full timer.

I see doctors beating their heads over and over on a diagnosis, or if they should order this/that CT scan. When they ask my advice, I say "Are you sending this patient home if everything's negative?" If they tell me that they are still going to admit the patient, I usually implore them to get the admission done, maybe get the CT or whatever other tests they want going, and move on to the next patient.

The future of medicine with Medicare and ICD-10, not to mention the new nationwide "quality metrics" are more and more going to turn us into factory workers churning out widgets. Impersonal? Yes. Joyless? Possibly. But it's coming, and if you're not okay with working in that environment, then it's probably best to go into academics or work at a slower-paced shop.

 

[Groove]

You are correct in that there are greatly different practice styles. The docs who go on "Zebra hunts" on almost every patient, tend to bog down the ED. Yes it effects me, because if they tie up a room for 8 hours, that is nursing that they are tying up, which negatively impacts my patient care. It also means we can move fewer patients through the ED, which results in longer LOS for every patient, and as a consequence worse patient satisfaction, not to mention potentially negative outcomes, as that patient sitting in the waiting room for a bed could decompensate. Would it be cool to diagnose Legionella in the ED? Sure, but it's simply not practical in the 2-3 pt/hour shops I work at. Although a locums, I'm still tied to patient satisfaction, patient complaints, and RVU productivity just like any other full timer.

I see doctors beating their heads over and over on a diagnosis, or if they should order this/that CT scan. When they ask my advice, I say "Are you sending this patient home if everything's negative?" If they tell me that they are still going to admit the patient, I usually implore them to get the admission done, maybe get the CT or whatever other tests they want going, and move on to the next patient.

The future of medicine with Medicare and ICD-10, not to mention the new nationwide "quality metrics" are more and more going to turn us into factory workers churning out widgets. Impersonal? Yes. Joyless? Possibly. But it's coming, and if you're not okay with working in that environment, then it's probably best to go into academics or work at a slower-paced shop.

You seem to have a fundamental misunderstanding of ED resource utilization. Your nursing staffing, section assignments and pt ratios are relatively fixed. The pt your colleague "nickel and dimes" or sits on that is not on a vent and/or already admitted to the ICU, is actually LESS resource intensive than the brand new pt just dumped into the room for the nurse to go see. So, it really should not be slowing you down. Unless, they are doing that for every pt and you have 20 in the waiting room, it should not affect your individualized metrics though the ED global metrics will naturally be affected. Those of us working admin in some capacity are really good at teasing out the individualized as well as the global metrics for the dept. I promise that I'm still able to see just "how good you are" compared to your colleagues. You see 2-3pph in your shops without diagnosing occasional zebras or flexing your brain very much? Great, so do I, and I'm still able to make the occasionally "more accurate" dx that hopefully helps improve ultimate pt care. It doesn't sound like you are any faster than me, so go see a new pt instead of comparing and criticizing my practice style. Obviously, I can't keep pts in rooms for 8 hours and maintain that pace. You seem to only allow for one extreme or the other and can't quite conceptualize "middle ground" which is what many of us mentioned was our practice pattern in this thread and is probably much more the norm.

Your metrics are quite honestly nowhere near as important as you think they are in the grand scheme of things as a locums. As long as you aren't killing people and/or pissing off admin, nurses, pt's, and can provide decent quality care, then you're good. You probably took awhile to credential and most will bend over backwards to express gratitude and make sure you are happy in your new gig. Ironically, I've seen it give some locums an overinflated sense of importance or self perceived abilities. Honestly, we're just trying to keep you happy so you can fill more emergency shifts should the need arise in the future. We realize you aren't invested in the site, hospital, or the community and are there for the paycheck at the end of the day. And hey...that's ok. Hell, I used to work locums.

If you want to be a factory worker churning out widgets, then go for it. It sounds rather jaded and...well, brainless.

 

[TheBlueBlazer]

I think the legionella example is a pretty crummy to exemplify as a win. I mean we normally put people on Abx that cover it with our typical empiric community bug coverage and most times, the urinary antigen is part of our hospitalists' admission set for anyone with a CAP. Maybe you decrease their eposure to CTX for one dose because it got sent a couple hours earlier? If it was part of your initial set of orders, no harm no foul, but if a nurse had to go back and collect a sample, that is slowing work down, and if you had to send it out, was it the serum antigen?If so, that would be quite wasteful.

 

[Arcan57]

I think the legionella example is a pretty crummy to exemplify as a win. I mean we normally put people on Abx that cover it with our typical empiric community bug coverage and most times, the urinary antigen is part of our hospitalists' admission set for anyone with a CAP. Maybe you decrease their eposure to CTX for one dose because it got sent a couple hours earlier? If it was part of your initial set of orders, no harm no foul, but if a nurse had to go back and collect a sample, that is slowing work down, and if you had to send it out, was it the serum antigen?If so, that would be quite wasteful.

The legionella example is a win in that the doc felt like they had made a difference in the patient's care and probably was a nicer person to be around for the next shift or two. Given the odds, putting your head down and just ploughing through patients is unlikely to result in harm to any individual patient but it's a pretty decent path to burn out.

 

[GeneralVeers]

You seem to have a fundamental misunderstanding of ED resource utilization. Your nursing staffing, section assignments and pt ratios are relatively fixed. The pt your colleague "nickel and dimes" or sits on that is not on a vent and/or already admitted to the ICU, is actually LESS resource intensive than the brand new pt just dumped into the room for the nurse to go see. So, it really should not be slowing you down. Unless, they are doing that for every pt and you have 20 in the waiting room, it should not affect your individualized metrics though the ED global metrics will naturally be affected. Those of us working admin in some capacity are really good at teasing out the individualized as well as the global metrics for the dept. I promise that I'm still able to see just "how good you are" compared to your colleagues. You see 2-3pph in your shops without diagnosing occasional zebras or flexing your brain very much? Great, so do I, and I'm still able to make the occasionally "more accurate" dx that hopefully helps improve ultimate pt care. It doesn't sound like you are any faster than me, so go see a new pt instead of comparing and criticizing my practice style. Obviously, I can't keep pts in rooms for 8 hours and maintain that pace. You seem to only allow for one extreme or the other and can't quite conceptualize "middle ground" which is what many of us mentioned was our practice pattern in this thread and is probably much more the norm.

Your metrics are quite honestly nowhere near as important as you think they are in the grand scheme of things as a locums. As long as you aren't killing people and/or pissing off admin, nurses, pt's, and can provide decent quality care, then you're good. You probably took awhile to credential and most will bend over backwards to express gratitude and make sure you are happy in your new gig. Ironically, I've seen it give some locums an overinflated sense of importance or self perceived abilities. Honestly, we're just trying to keep you happy so you can fill more emergency shifts should the need arise in the future. We realize you aren't invested in the site, hospital, or the community and are there for the paycheck at the end of the day. And hey...that's ok. Hell, I used to work locums.

If you want to be a factory worker churning out widgets, then go for it. It sounds rather jaded and...well, brainless.

Where did all the hate for locums come from? Whether or not I'm a locums is irrelevant to the discussion. I also worked full time/partner for 5 years and had the same issues with partners keeping patients in the ED too long for workups. And yes, keeping a patient in the ED for 8 hours does negatively impact work flow. I can't see how it wouldn't. By tying up that bed that could have been used to move 2-3 patients through in that time, you are inevitably going to slow things down. When a physician does this for 6-8 beds at a time, I've literally seen the ED grind to a halt. That is why LOS is going to become a metric, in fact I'm going to be bonused based on LOS starting this year. If your LOS if 120 minutes versus 240 it will absolutely change how many patients you can see in a given ED, assuming that nursing and physicians hours remain fixed. The only way it wouldn't affect things is if you always had a an available open bed, or were able to see/treat unlimited patients from the waiting room. Neither of my current facilities have these capabilities.

 

[Groove]

Where did all the hate for locums come from? Whether or not I'm a locums is irrelevant to the discussion. I also worked full time/partner for 5 years and had the same issues with partners keeping patients in the ED too long for workups. And yes, keeping a patient in the ED for 8 hours does negatively impact work flow. I can't see how it wouldn't. By tying up that bed that could have been used to move 2-3 patients through in that time, you are inevitably going to slow things down. When a physician does this for 6-8 beds at a time, I've literally seen the ED grind to a halt. That is why LOS is going to become a metric, in fact I'm going to be bonused based on LOS starting this year. If your LOS if 120 minutes versus 240 it will absolutely change how many patients you can see in a given ED, assuming that nursing and physicians hours remain fixed. The only way it wouldn't affect things is if you always had a an available open bed, or were able to see/treat unlimited patients from the waiting room. Neither of my current facilities have these capabilities.

Veers, I think you're using this discussion as a springboard to launch a diatribe against "slow docs", non minimalists, or ones with decision paralysis and their effect on ED performance and/or your personal performance. I'm actually not talking about that at all and you seem to keep twisting my words as well as forgetting your original statements.

The docs who go on "Zebra hunts" on almost every patient, tend to bog down the ED.

I never encouraged anyone to go on zebra hunts on almost every pt did I? I simply stated that I enjoy diagnosing, or "hunting" for the "occasional" zebra, and I do! Forget legionella as an example. Pick anything. Good grief, it's fun to have the opportunity to diagnose something that you simply don't get to see everyday...in the ED no less! That's a fun aspect to our specialty in my opinion. Who's talking about an 8hr LOS? I added that antigen test as an admission floor order. Apparently, I got lucky with a legionella diagnosis. Crucify me.

Yes it effects me, because if they tie up a room for 8 hours, that is nursing that they are tying up, which negatively impacts my patient care.

I simply corrected you in that it's not the actual nurse that is slowing you down in that scenario. The nurse is likely much more burdened with a critical pt or a new pt, not a stable one that a doc keeps adding orders to every half hour. Nobody on this thread is defending 8 hour turn around times. I think everyone understands and supports the concept that "too much of a work up" on every pt is a bad thing and affects the ED metrics in a negative way. When did I say otherwise?

Look, there is no locums hate. You just seem very critical of your colleague's practice patterns where they differ from your own (ones you prob just met, no less), especially in the context of speed, minimalism and in how that relates to your own concept of efficiency. Nobody is defending massive work ups on every pt. I just seem to feel much more tolerant, less judgmental, and much less critical towards my colleagues' metrics as long as the pt is getting the best quality care, and the metrics are reasonably acceptable and within our target goals. My point is that not everyone is a minimalist, for a variety of reasons. That's perfectly ok with me. The last thing I would want to do is pressure a doc to disposition a pt before he or she is ready.

The future of medicine with Medicare and ICD-10, not to mention the new nationwide "quality metrics" are more and more going to turn us into factory workers churning out widgets. Impersonal? Yes. Joyless? Possibly. But it's coming, and if you're not okay with working in that environment, then it's probably best to go into academics or work at a slower-paced shop.

I hope that's not the future of our specialty. However, if it is... you seem well suited for it.

 

[coachB]

I just seem to feel much more tolerant, less judgmental, and much less critical towards my colleagues' metrics as long as the pt is getting the best quality care, and the metrics are reasonably acceptable and within our target goals. My point is that not everyone is a minimalist, for a variety of reasons. That's perfectly ok with me. The last thing I would want to do is pressure a doc to disposition a pt before he or she is ready.



I hope that's not the future of our specialty. However, if it is... you seem well suited for it.

If there is that much variability, then a number of patients are not getting "the best quality care." End of story.

The future is here. And part of the problem is the attitude that "everyone does a good job" that you describe. We have completely failed to recognize physician value in emergency medicine.