How to deal with a perfect storm

[Pure Anergy]

I recently had an especially bad shift that was compounded by my slowness on top of my colleague's slowness. Don't get me wrong, I will be the first to admit that I'm not the speediest doc in the group. But I showed up to eight people waiting to be seen, some of whom had been waiting for as long as three hours in their rooms after coming back from triage. My colleague SlowDoc never went to see them, didn't write for pain meds, zofran, etc. (The nurses said they even asked SlowDoc to at least write for meds and SlowDoc wouldn't, because SlowDoc had decided to stop picking up any more new patients for the last three hours of the shift!) Of course everyone was royally POd about waiting so long, which was not a nice way for me to start my shift. I was trying to see people as fast as I could and get them out as fast as I could, but I couldn't even get close to getting caught up until the very end of my shift.

I know I need to work on my own efficiency, and I am. But I also need to come up with a game plan for what to do from now on when I work next after SlowDoc. I like this job overall, and I want to stay here, but the stress of having half a dozen angry nurses and patient families descending upon me like a cloud of hornets the second I show up for my shift greatly erodes my ability to function well (or provide good patient care). I'm not delusional enough to think I can change SlowDoc in any way, so I'm hoping some of you veterans can give me suggestions on what I can do to decrease my own stress levels and cope with the situation more effectively. So far the best idea I've come up with is to show up for my shift an hour early when I know SlowDoc is on before me. I'm more than willing to do that if it will prevent another perfect storm like the last shift, but if anyone else has additional ideas, I'm game to try almost anything that seems reasonable.

(For the record, I don't consider complaining about SlowDoc to my boss as reasonable.)

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[EctopicFetus]

First why complain to the boss. Let slowdoc know.

I think the type of practice you are in will have a lot to do with the action you should take. Is it a CMG? Private group? Whats the culture. Do they track metrics?

You can always fall on the easy "patient safety" "Patient satisfaction" etc.

I wouldl highly advise NOT coming in an hour early. What happens is that he will stop working even earlier.

We have this in my group. We have one doc who is known for showing up 30-45 mins earlier. This just makes the other docs stop working even sooner.

 

[Pure Anergy]

First why complain to the boss. Let slowdoc know.

Not to be dense or argumentative, because I really appreciate you taking the time to respond, but what exactly am I supposed to be letting SlowDoc "know"? That SlowDoc's shift doesn't end three hours early? That patients were in the rooms waiting to be seen all that time? That patients/families/nurses were upset about how long the patients had been waiting in those rooms? That it made my shift horrific?

I'd forgotten about this until just now, but I had one patient's family member tell me (during a different shift) that they were going to file a complaint about SlowDoc for this same exact issue. Obviously I don't know what became of that, but I strongly doubt any of this is because SlowDoc doesn't know when the shift ends or that patients were waiting to be seen. Nor do I think that SlowDoc particularly cares about me taking the fallout because the patients are upset.

I think the type of practice you are in will have a lot to do with the action you should take. Is it a CMG? Private group? Whats the culture. Do they track metrics?

Private group. They do track metrics, but I'm not sure what happens yet. I've only been working here a few months so far.

You can always fall on the easy "patient safety" "Patient satisfaction" etc.

If you mean talking to SlowDoc about this stuff, I doubt they care.

I wouldl highly advise NOT coming in an hour early. What happens is that he will stop working even earlier.

We have this in my group. We have one doc who is known for showing up 30-45 mins earlier. This just makes the other docs stop working even sooner.

Shoot, that's a good point and one I hadn't thought of. Unfortunately, you're probably right. I guess I'm back to the drawing board then for ideas.

 

[Apollyon]

I recently had an especially bad shift that was compounded by my slowness on top of my colleague's slowness. Don't get me wrong, I will be the first to admit that I'm not the speediest doc in the group. But I showed up to eight people waiting to be seen, some of whom had been waiting for as long as three hours in their rooms after coming back from triage. My colleague SlowDoc never went to see them, didn't write for pain meds, zofran, etc. (The nurses said they even asked SlowDoc to at least write for meds and SlowDoc wouldn't, because SlowDoc had decided to stop picking up any more new patients for the last three hours of the shift!) Of course everyone was royally POd about waiting so long, which was not a nice way for me to start my shift. I was trying to see people as fast as I could and get them out as fast as I could, but I couldn't even get close to getting caught up until the very end of my shift.

I know I need to work on my own efficiency, and I am. But I also need to come up with a game plan for what to do from now on when I work next after SlowDoc. I like this job overall, and I want to stay here, but the stress of having half a dozen angry nurses and patient families descending upon me like a cloud of hornets the second I show up for my shift greatly erodes my ability to function well (or provide good patient care). I'm not delusional enough to think I can change SlowDoc in any way, so I'm hoping some of you veterans can give me suggestions on what I can do to decrease my own stress levels and cope with the situation more effectively. So far the best idea I've come up with is to show up for my shift an hour early when I know SlowDoc is on before me. I'm more than willing to do that if it will prevent another perfect storm like the last shift, but if anyone else has additional ideas, I'm game to try almost anything that seems reasonable.

(For the record, I don't consider complaining about SlowDoc to my boss as reasonable.)

I don't know why you don't feel that speaking to your boss is reasonable. You can easily address this as a patient safety issue (without that being a "buzzword"). Does he know where he stands? Absolutely. And, if the nurses are angry, they tell the charge nurse - who tells the nurse manager - who either sends it upstairs to the CNO, and/or to the president of your group (or whomever is the assigned liaison). As such, everyone knows. Talking to him won't change anything.

Tell your boss that you are new, and you are not completely up to snuff with the patient sat stuff (which is true). Tell the boss that the patients waiting in rooms were difficult to satisfy. And, as you say, it affects your ability to provide good patient care. What if one of the patients had an acute closed angle glaucoma? That's an easy $2-3million loss for loss of an eye.

And, if the family member was going to file a complaint, why didn't they?

And, yes, do NOT come in 1 hr early. That is enabling behavior.

 

[Birdstrike]

Pure Anergy,

I hate to be the one to say it, but this is completely normal. For one, you can tell your director the SlowDoc is slow as molasses, but I can bet you he knows that painfully well, already. But here's the rub. Even if you make a effort to get rid of, reform, or speed up SlowGuy, any EM group will always have a speed/efficiency bell curve. There's always "the slowest guy." The names may change, but there's always someone at the bottom. Just don't let it be you.

Also, realize now, that you cannot single handedly fix the US ED overcrowding crisis, one shift at a time. Even if you could, your bosses want it that way. They want demand high, they want unlimited customers, they want the volume. They also want you to do the impossible and constantly get faster to accommodate it. This assures their own job security.

SlowDoc is no dummy. SlowDoc knows it's a long career. SlowDoc knows there either is, or will be, a billboard on the main road directing more patients into your ED no matter how fast any of you go. In fact, the faster you go, the lower the wait time will be on the billboard, driving more patients in to your ED, requiring you to always be going "just a little bit" faster. This is not an aberration. This is not a real "crisis." This is the way they've set up the system. Everything is in place, and working just the way those in control want it to.

See all 8 patients who are in your ED when you arrive in their goal times and next week there will be 10. See all 10 quick as lightening and next week there will be 12, and so on.

So work hard, but not too hard. Try to be around your group's average patients and RVUs per hour. Don't be the fastest or the slowest. Provide good patient care, and let the rest take care of itself. Don't come in early, don't stay late. Don't change anything you do other than what you're already doing to work on reasonable efficiency. Keep your house in order. But also realize you will never solve the ED overcrowding crisis anytime in your career, and that the powers that be, have a vested interest in perpetuating that false crisis, and making everyone else believe that if they work just beyond their breaking point, that they may see a brief pause in it. It's a lie.

 

[Cheese Whiz]

thank you guys for contributing experience and thoughts to threads like this one/MLP supervision thread/etc. as a new attending, this forum is a great support group and guide.

 

[USCDiver]

Tell your director you'd love to develop nursing protocols to start work ups in triage including complaint based labs, meds, and imaging.

 

[two guys]

I would take things slow for the first year or so before pissing anyone off.

Slow doc prolly is slow, but I bet he/she's within 0.5 patients per hour of your speed. In other words, those eight patients waiting to be seen would've been there with another doc, it would have probably just been 5 and 3 of them would have had some initial orders written.

I wouldn't take the nurses word that he stopped seeing patients 3 hours prior to leaving, maybe he did or maybe they exaggerated a little because they don't like him. I would wager that you will have a shift where there are more people waiting to be seen when you're signing out then the next guy likes. It shouldn't be a regular occurrence but it will happen. I try my best not to judge what the outgoing guy could've done. For all I know he did a peripartum c-section, coded the child, talked with the father, saw the CEOs daughter for chest pain, had 5 chronic pain patients come in all at once and 4 worried moms with all 3 kids each wanting a screen for ebola. Truth is, I know that is unlikely but my mind space is better if I just assume he got his tail handed to him. That works better for me than if I assume he doesn't give a damn about me and is just sitting around.

Do you have some double coverage shifts or other shifts where you can bring this up in a non confrontational manner. You have already guessed that slow doc isn't going to like Dr New Partner telling him he is slow. But next time you're on a shift with anyone (slow doc or otherwise) you could ask: When do folks usually start to wrap up? Do you put in orders on patients at the end of your shift to help out the new guy? Of course you probably already know the answer to both of these but asking it gives you a chance to open up a discussion without complaining. They might say "yeah we all put in orders except Dr Slow, we've all already complained" or "we are working on trying to get an overlap between shifts for this reason" or "some of us really don't like when other docs have put in orders on patients they haven't seen."

A little more aggressive but possibly necessary is to mention whenever you sign out to slow doc that you went ahead and put in some orders on the patients waiting "I hope you don't mind, I just didn't want you to start off your shift with 5 people angry at you."

 

[TooMuchResearch]

Tell your director you'd love to develop nursing protocols to start work ups in triage including complaint based labs, meds, and imaging.

How common are extensive triage lab/imaging protocols?

I've had patients transferred to our ED after an extensive (expensive), weird workup from outside ED. Some of those patients get transferred to us simply for too many abnormal lab values without a clear cause (i.e. labs that should not have been checked). Many seem to get ?wtf CTAs of the chest. Often no explanation for these weird workups in the physician's note. Later discovered these EDs use nursing protocols.

 

[xaelia]

I would take things slow for the first year or so before pissing anyone off.

Probably the most useful advice so far.

Go to work nice/look nice/be nice/smell nice for awhile, vent on SDN.

 

[xaelia]

How common are extensive triage lab/imaging protocols?

From an administrative/risk management standpoint, why bother trusting docs not to miss a critical diagnosis? Thus, the triage protocol with EKG/troponin/BNP/d-dimer on the 22 year old with left hand numbness a week ago.

So, then your patient hits the room with non-specific complaints and an elevated D-dimer, and the last thing anyone wants is to be in the boss' office as the guy who sent home the PE with elevated dimer staring them in the face. Besides, everyone involved gets more $$$ when you can keep the CT scanner heating up leftovers all day and all night.

Perfect storm of disincentives for practicing appropriate medicine.

 

[erdoc00]

This is our specialty... and why >50% dread going into work.

 

[Arcan57]

This is our specialty... and why >50% dread going into work.

What's our specialty and where are you getting the 50% number? Birdstrike's comment was pitch-black but at least he offered a reasonable rationale for his world view. I don't necessarily agree with it (his conclusions, his premise is dead on) but there's something there to ponder. Are you talking about docs stopping long before their shift ends? About reliance on nursing protocols which leads to unnecessary testing in the name of meeting arbitrary metrics? About just shutting up and soldiering through without trying to make things better?

To the OP, 8 waiting on the early AM shift is rough but it's nowhere near as bad as it gets. My first job used to be walking into 10-14 patients four mornings out of five. I would talk with slowdoc about putting in protocol orders or shotgunning labs and that you'll do the H&P when you see them. He/she may give some BS excuse about they don't want to be responsible/don't feel comfortable ordering labs on patients they aren't going to see. In which case I'd let it go, but there's a chance they'll say sure.

 

[Birdstrike]

Birdstrike's comment was pitch-black but at least he offered a reasonable rationale for his world view. I don't necessarily agree with it (his conclusions, his premise is dead on) but there's something there to ponder.

What do you mean "pitch black," ie, gloomy? If so, you should be vaccinated to my gloom and doom by now. Lol. Honestly, I don't think I even said anything that earth shattering in the post. Basically, I told him, "It's always going to busy, so take the pressure off yourself, just relax and don't try to save the world." Maybe I should have just boiled it down to that one sentence, but what did I write that was so "pitch black"? I honestly don't think my post really said anything you or anyone else didn't already know. It was basically a, "Dude, chill" post.

 

[Birdstrike]

This is our specialty... and why >50% dread going into work.

Explain, please.

 

[erdoc00]

Explain, please.

The job is one ongoing chaotic clusterf**k. You have no control over any aspect of your day and there are endless people/entities that can make your day increasingly more miserable at any time.

The OP's post is a perfect example of this. The day doc is getting slaughtered and tries to slow down so he's no leaving 3 hours post shift. The oncoming doc is now 8 pts in the hole. These docs both now get **** on by all the pissed off patients for things completely out of their control.

The only incentive to work harder/faster is to generate less complaints. But this is a foolish proposition since as you pointed out, you can't beat the system and it'll only increase volume... and the cycle repeats. Eventually, all you're doing is working harder and faster to achieve the same original outcome.

The staffing model for your typical ED is absolutely laughable from a patients-per-hour perspective. Everyone's trying to get rich as possible so we're left with these minimalist staffing models that are barely sufficient for day to day volume and then become dangerous-bordering-on-impossible-to-manage during boluses.

 

[TooMuchResearch]

From an administrative/risk management standpoint, why bother trusting docs not to miss a critical diagnosis? Thus, the triage protocol with EKG/troponin/BNP/d-dimer on the 22 year old with left hand numbness a week ago.

So, then your patient hits the room with non-specific complaints and an elevated D-dimer, and the last thing anyone wants is to be in the boss' office as the guy who sent home the PE with elevated dimer staring them in the face. Besides, everyone involved gets more $$$ when you can keep the CT scanner heating up leftovers all day and all night.

Perfect storm of disincentives for practicing appropriate medicine.

I know you're in academia, but do you have a sense for how common these protocols are in the community? It's going to limit my job options since I do not want to work in a practice environment where I am essentially unnecessary and patients get substandard care to help line my pockets.

 

[Hercules]

I know you're in academia, but do you have a sense for how common these protocols are in the community? It's going to limit my job options since I do not want to work in a practice environment where I am essentially unnecessary and patients get substandard care to help line my pockets.

I have worked in EDs where the nurses don't have any standing order sets and those places are miserably inefficient and painful to work in. Do you really need to lay eyes on each 75 year old chest pain with multiple stents to know that they are going to need an EKG, CXR, troponin? I don't. And when we're slammed it helps me greatly to be able to walk into that room get the story and already have my labs back so I can call with the admit as soon as I walk out.

If you don't like the protocols or standing orders, rewrite them. Make them what you and your group feel like is appropriate. I think the key here is not to avoid EDs that are efficient enough to have nursing order sets but instead to have those order sets written by the docs who are going to be seeing the patients.

 

[KarlPilkington]

Be careful if you decide to talk to your boss:
1. You guys may be totally understaffed, and "slow doc" may be doing what they need to do to not get in over their head in terms of volume. Your boss likely knows this is an issue and is choosing to allow this problem to exist.
2. "Slow doc" is actually not that slow in terms of overall metrics, if they're killing it for the first 2/3 of the shift, they may see enough folks to phone it in for the last part of the shift. Clearly folks know that this happens and have chosen to let this person continue to pick up shifts.

I'm sure your boss knows what is happening, and has some reason that they allow it to continue.

 

[EctopicFetus]

This thread saddens me. My group when I started would often have people in a room for 1 hour plus until the next doc arrived. We had group discussions and agreed that this wasnt reasonable. You now what happened? We changed.. the whole group. We would basically ask our partner why a patient hadnt been seen if they were in a room for over 30 mins.

They better have a good excuse too. No one was at risk of termination but it was simply the respect one owed their colleague.

Honestly if you use an EMR and scribes starting a workup on patients is simple. If you are pure RVU thats different.

Sounds like there is more to this than whats in your post.

Lastly, I woould agree with the device above if you are in year 1. I wouldnt rock the boat.

 

[Apollyon]

You want to know why I say about talking to the boss? Because I was there. At a one year review, I elucidated various concerns, and the group president asked me why I hadn't come to him earlier. My answer was, "I didn't want to rock the boat, because I was new". His answer? "We can't fix it if we don't know, and, if you don't feel comfortable talking with administration because of worries about how you'll be seen, then you should be looking for somewhere else to work" (meaning, they supported it - not telling me to get another job).

Not everyone can have a perfect job that will have them out on permanent Margaritaville at 50. Recall, also, what is it - 40% that change jobs in the first 2 years?

 

[Pure Anergy]

And, if the family member was going to file a complaint, why didn't they?

I don't know if they did or not. I'm not privy to patient complaint data.

And, yes, do NOT come in 1 hr early. That is enabling behavior.

Duly noted.

So work hard, but not too hard. Try to be around your group's average patients and RVUs per hour. Don't be the fastest or the slowest. Provide good patient care, and let the rest take care of itself. Don't come in early, don't stay late. Don't change anything you do other than what you're already doing to work on reasonable efficiency. Keep your house in order. But also realize you will never solve the ED overcrowding crisis anytime in your career, and that the powers that be, have a vested interest in perpetuating that false crisis, and making everyone else believe that if they work just beyond their breaking point, that they may see a brief pause in it. It's a lie.

Good advice, thank you.

I would take things slow for the first year or so before pissing anyone off.

I'd rather not piss anyone off regardless of how long I've been here, but you're right that no one wants to hear griping from the new guy.

I wouldn't take the nurses word that he stopped seeing patients 3 hours prior to leaving, maybe he did or maybe they exaggerated a little because they don't like him.

Entirely possible.

Truth is, I know that is unlikely but my mind space is better if I just assume he got his tail handed to him. That works better for me than if I assume he doesn't give a damn about me and is just sitting around.

True. Regardless of what else is going on, the one thing you can always control is your own attitude.

A little more aggressive but possibly necessary is to mention whenever you sign out to slow doc that you went ahead and put in some orders on the patients waiting "I hope you don't mind, I just didn't want you to start off your shift with 5 people angry at you."

I like this idea and will try it.

Go to work nice/look nice/be nice/smell nice for awhile, vent on SDN.

Well, I suppose there's some venting component to it too, but I really am interested in practical suggestions for things I can do to try to improve the situation.

Be careful if you decide to talk to your boss:

As I said in the OP, I am not going to complain about SlowDoc to my boss.

This thread saddens me. My group when I started would often have people in a room for 1 hour plus until the next doc arrived. We had group discussions and agreed that this wasnt reasonable. You now what happened? We changed.. the whole group. We would basically ask our partner why a patient hadnt been seen if they were in a room for over 30 mins.

They better have a good excuse too. No one was at risk of termination but it was simply the respect one owed their colleague.

I like this idea. It offers a solution instead of just making me part of the problem, and it doesn't single out SlowDoc. This isn't an interpersonal issue, and I'm not looking to make it into one. Any suggestions for how to initiate a discussion like this?

Lastly, I woould agree with the device above if you are in year 1. I wouldnt rock the boat.

Even to start a group discussion like the one your group had?

You want to know why I say about talking to the boss? Because I was there. At a one year review, I elucidated various concerns, and the group president asked me why I hadn't come to him earlier. My answer was, "I didn't want to rock the boat, because I was new". His answer? "We can't fix it if we don't know, and, if you don't feel comfortable talking with administration because of worries about how you'll be seen, then you should be looking for somewhere else to work" (meaning, they supported it - not telling me to get another job).

Again, I'm not looking to be part of the problem or to make it a personal thing about SlowDoc. If I could approach my boss with a real potential solution, as in, "Hey, I noticed we have this problem of people waiting in the rooms for 1+ hours sometimes, and it makes everyone really angry and stressed. Maybe we could make it a group policy to do a quick check/start workups/give pain meds/antiemetics/etc. on all these patients prior to signout to smooth things over for the next person/improve patient flow/satisfaction?" then that is something I'd be willing to do.

 

[EctopicFetus]

Ill just say this. You need some credibility and buy in from your group leadership. To make it impersonal you can point to your group times on the CMS website and compare it to the hospital across the road.

Its also weird that you dont have triage/standing orders. Seems a good place to start to improve the efficiency of your department.

 

[USCDiver]

From an administrative/risk management standpoint, why bother trusting docs not to miss a critical diagnosis? Thus, the triage protocol with EKG/troponin/BNP/d-dimer on the 22 year old with left hand numbness a week ago.

So, then your patient hits the room with non-specific complaints and an elevated D-dimer, and the last thing anyone wants is to be in the boss' office as the guy who sent home the PE with elevated dimer staring them in the face. Besides, everyone involved gets more $$$ when you can keep the CT scanner heating up leftovers all day and all night.

Perfect storm of disincentives for practicing appropriate medicine.

If your protocols call for those labs to be done on a 22 year old with hand numbness a week ago then you need to re-write the protocols.

 

[xaelia]

If your protocols call for those labs to be done on a 22 year old with hand numbness a week ago then you need to re-write the protocols.

A little bit of hyperbole – but, again, if you run much of a waiting room ... and then have a couple folks LBWS to a neighboring ED and get diagnosed with an "emergent condition" ... and get an EMTALA fine ... you'll see sensitivity, not specificity, rule your triage protocols ....

 

[Groove]

Work for a CMG or SDG that is heavily or 100% productivity based and you won't mind slow doc anymore. I absolutely love it when I work with slow docs. The only days I get pissed are when I'm working with an overstaffed ED full of fast docs.

 

[WilcoWorld]

A little bit of hyperbole – but, again, if you run much of a waiting room ... and then have a couple folks LBWS to a neighboring ED and get diagnosed with an "emergent condition" ... and get an EMTALA fine ... you'll see sensitivity, not specificity, rule your triage protocols ....

It is absolutely ridiculous that an ED can get fined for an EMTALA violation when someone chooses to LWBS.