Improving efficiency as attending

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Jimmy1

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I am a new attending at a busy (120K) center. I have been working there for about a month, and I am really struggling to see more than 2 pts/hr. The average here is 3/hr (no residents/PAs), and we have a completely separate fast track area.
Any tips on improving efficiency?

I usually pick up 2pts, go see them, come back to the desk and order labs/xrays, chart, check on other pt's tests, finish charting on pts, dispo some people, then eventually pick up 2 more. My problem seems to be with the frequency that I pick up patients, and that time at the desk between seeing new patients seems to be really long.

Would it be better to pick up a lot of pts (like 5?) then spend an entire hour at the desk doing all of the charting, xr/ct, dispo? I've found that if I try to discharge people in boluses the patients and nurses get antsy during the wait.
Also, I find that if I have more than 8 active pts, I start to feel like I need to make dispos. Other docs seem to carry 15+ with no problem. Any advice for this as well?

Thanks.
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I also just started as an attending in a new hospital system (in fact three very different hospital environments) and was told my efficiency (RVUs per hour) were at the bottom of the curve. When we looked per month, there was a steady improvement each month. I wonder if the same may be true of yourself?

About picking up many charts, I would fear like you do that if you took five charts and stopped as a whole to finish all of them, the rest of the staff and the waiting room would probably not be happy with you.

Do you think it is the documenting that is the rate limiting step? Is it the return of your labs? Is it nursing? Because that might help you target areas for efficiency. Some things I changed in my practice, was I started writing orders first, and then discharge summaries (which in one of my places have to be typed) I started writing as soon as I know they are going home. Then while the nurse is discharging the patient, I finish the rest of my documentation for the patient. By doing this, there is a new patient being settled into the room just as I am done with my documenting.

The last thing I have considered in my practice is following the attendings with the highest efficiency for a shift or two on my own time to see how they do it...just something to consider.

If you find out any other solutions, please let me know as I would be very interested too!

Good luck,
TL
 
I work in a busy facility as well, and my average is usually 2.5 to 3.2 patients per hour.

I wouldn't necessarily strive for 3 patients per hour, as I notice my time with patients, and possibly their care suffers when seeing that money.

Typically when I start my shift I pick up 4, 5 or more patients if they are ready to be seen. I take the charts with my into the room and order the labs/x-rays as I'm talking to them. Often I'm carrying 15+ patients by myself when the department is busy. I only take 5-10 minutes for lunch, and sometimes don't take a bathroom break.

Our group actually offers an "Efficiency Academy". You may want to find out if your group does the same.
 
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If you're seeing 2.5 or 3 patients per hour, you're in a sweatshop. You may burn brighter, but you won't burn as long. If they throw Press/Ganey or Gallup on top of that, unless you're the "Teen Angel" or "Mr. Perfect", you're going to suffer.
 
With more time, you'll get faster. As it's only been about a month, you're still learning the ropes of your department. It might not seem that way, but you are.

In your downtime, prepare your discharges. For example, order that ankle X-ray, fill out your DC papers for ankle sprain, and write your scripts. When the XR is done, you're done. And if that XR actually shows a fracture, well, just change your papers. More often than not, though, you know what that XR shows.

There'll be a bunch of other similar scenarios. While your lac tray is being setup, type up your laceration repair/discharge instructions. Same goes with abscesses.

Eventually as you know your consultants, you'll call earlier because they know they can trust you. You'll start calling Rads periodically to get your CT/US reads for certain studies faster (especially when you're at the end of a shift and your study just got done!).

For now, take it all with a grain of salt. One month at a new job isn't long enough to get down on yourself.
 
Thanks for the input! SDN = not just for students.

I'm definitely waaay at the bottom for RVUs per hour. The thing is, I am busy the entire shift, no downtime. So I think in order to be faster I need to streamline my routine in the dept. I think I spend too much time on documentation, and checking labs then rechecking them because everything was back except for the BMP, or UA, or whatever
 
Unless the patient is critical and you have to be at bedside discipline yourself to go see another patient while you are waiting for those labs - don't sit there rechecking and rechecking. Take that 5 minutes and see another chest pain.
 
A little off the subject, but I think applicable. When do you chart? My attendings end up charting for ~2hrs after each shift and our residents are similar. We commonly get part of the HPI charted and labs ordered, then present to the attending and go pickup another patient (we use EPIC). We type when we can but usually the pt is discharged or admitted and only the HPI and pertinent findings on the PE are completed. We can print discharge instructions separately, so the chart is no where near finished by the time the pt has left.

As a community physician are your able to get all your charting done during the shift or do you commonly have more to do at home. I'm thinking that your RVUs would increase if you did less charting during the shift and saw more patients, but in return you would lose personal time to documentation.
 
I find the key to efficiency is prioritizing dispositions. No one can actually move 15 patients. It's a lot easier to keep track of 5. By the time you've seen the 5th one, the 1st is ready to be dispositioned unless you have a horribly slow lab or radiology. It's pretty unusual for me to be carrying more than 8. Usually in a department where you're carrying 15 it's because it takes forever to get patients admitted.

You can chart as you go (I find that much easier and safer as everything is in my head and I go over everything prior to discharge.) Or you can chart after your shift. But I think it's stupid to say you saw 3 patients an hour when you did an 8 hour shift, saw 24 patients, and stayed over 4 hours to finish charts and dispositions. In reality you saw 2 an hour.

Another key to efficiency is to have someone else do everything that you don't absolutely have to do yourself. The clerk birddogs your labs and manages the calls. The nurses/techs bring charts to you when all the labs and x-rays are done. Wounds are prepped and anesthetized when you see them with lac trays open waiting for you. The nurse is with you at the time of the initial exam to help you do the pelvic and rectal. A scribe does your charting. Consultants write the admission orders. The chaplain hunts down the medical examiner. The psych tech or crisis worker finds the psych bed. Unfortunately, most of us work in places that are understaffed, so we find ourselves doing far too much work that could be done by others.

It also helps if you're the type who doesn't spend much time talking to patients and who doesn't order large work-ups, and when you do, you do them shotgun style rather than serially.

Good luck. Don't get too efficient. It takes some of the joy out of it.
 
Picking up more charts at once usually leads to batching which is the enemy of efficiency. We used to have a couple of docs that did this and you'd see half their side waiting to be seen on the tracking board. Then they'd sign up for all the patients at once, see the patients, then order labs. Strangely enough, most of the labs would then come back at the same time and there would then be a queue to d/c them. Keep in mind, the docs feel busy because they are always in the process of having just picked up 5 patients at once or having to dispo 5 people at the same time.

Unless your ED has a horribly inefficient system for entering orders (like a bad EMR that takes >1 minute to log into and logs you out after 10 minutes of inactivity), you're not going to gain efficiency by waiting on orders. In fact, seeing two patients at once may be slowing you down if you're thinking about both simultaneously. What you need to do is work on reducing your cycle time in between patients. See a patient, write orders/communicate with nursing staff regarding plan, document on patient, see next patient. If there is downtime between patients, see what you can get ready to expedite disposition (finishing up charting, writing out scripts and d/c instructions). If I am pod-locked, I prioritize discharges over seeing new patients. If I have plenty of available beds and have <12 active patients I'll see a new patient versus discharging an old one. However, our shop places a high value on door to MSE and not so much on total LOS.
 
I'm not sitting around checking & rechecking labs between patients, maybe that came across in my post...but I meant that I feel like I am wasting time checking up on labs & studies that are incomplete when I check them.

I am getting faster, it is just taking some time!

I still find that after I have about 8 patients, I need to start dispo'ing patients. I don't know how other docs are carrying 15+ patients at a time. I have tried picking up around 5 patients, seeing them all, then coming back to write orders/discharge/etc, but I'm not sure if that is a faster method.

Thanks for the tips.
 
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I'm a fairly new attending, and work in a 100K+ center as well.

I find i can manage a fairly large workload (although we have scribes) easiest when I can consistently keep rounding in my head. I see a patient, and then constantly re-assess what's going on with my other patients- i'm waiting on a lab test, or an imaging or a phone call. If i've got a call out to an attending, i keep the triage note in my pocket to remind me about whats up with the patient so i can duck out of a room when they call (we have portable phones for each doc). I've always got a mental map of the pod i'm in running through my head so I know where everyone stands at any given minute. As long as I have that map, I can keep picking people up and stay efficient.

Getting into a routine where youre 'assessing and re-assessing constantly helps with efficiency. I see about 2-2.3 pts/hr (we work 9's), and have pretty short time to dispo's (averaging about 2 hours or so, according to the data we get), and I attribute it to finding a routine and sticking to it.
 
I am seeing about 2.5/ hr. Can't seem to break into that 3+/hr range, which is the average.
 
Jimmy1 said:
I am seeing about 2.5/ hr. Can't seem to break into that 3+/hr range, which is the average.
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Wow. There really shouldnt be a place where you have to average 3 pt/hr. That is just crazy.
 
GeneralVeers said:
At 2 out of 3 hospitals in my system I average between 2.5 - 3.5 patients per hour. This evening I saw 3.25 patients/hour. It sucks.
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I am amazed at people who see numbers like this. Are you actually doing procedures when you see this average (lac repairs, LPs, etc) or are you seeing more low-acuity patients, or more lab/imaging driven complaints? (This isn't directed at GeneralVeers specifically, but at people who can see this number.)
 
Pinner Doc said:
I am amazed at people who see numbers like this. Are you actually doing procedures when you see this average (lac repairs, LPs, etc) or are you seeing more low-acuity patients, or more lab/imaging driven complaints? (This isn't directed at GeneralVeers specifically, but at people who can see this number.)
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Maybe in an academic setting you can see 3 fairly easily if you are with a couple of strong residents. Otherwise, seeing 3/hr on your own means you either have scribes, have suture techs, splint techs, and all the other bells and whistles at your disposal. But really if it's that busy, there should be another body to divide the work I think.
 
Pinner Doc said:
I am amazed at people who see numbers like this. Are you actually doing procedures when you see this average (lac repairs, LPs, etc) or are you seeing more low-acuity patients, or more lab/imaging driven complaints? (This isn't directed at GeneralVeers specifically, but at people who can see this number.)
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There was also a recent thread about this - I said how there was a guy I worked with that saw 46 in 12 hours on one shift, and people started piping in left and right how they saw those volumes, which I found to be quizzical - it's just unsustainable, and, as you mention, if you're sewing people and working up complex cases (and when people say they threw a code in there, too, I wonder if it's just a "look at it and call it"), either you are really, really cutting corners (literally and figuratively), or you're a damn straight miracle worker. I'm not bringing in the blind and crippled to those people; I don't believe the miracle workers are there.
 
takotsubo said:
Maybe in an academic setting you can see 3 fairly easily if you are with a couple of strong residents. Otherwise, seeing 3/hr on your own means you either have scribes, have suture techs, splint techs, and all the other bells and whistles at your disposal. But really if it's that busy, there should be another body to divide the work I think.
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Not saying it's safe, but our attendings have been known to crest 6 per hour with their residents. Of course, they're supervising 3 or 4 at a time. I agree that there is more work than they should be doing.

I've seen more than 3 per hour plenty of times on the low acuity side, and have seen more than 2 per hour on the high acuity side while admitting more than 50%. And this is during residency.

I'm not an outlier or anything either. Frankly, very few of the patients need you to do a whole lot other than talk to them and order stuff, then interpret it later. Even on the vag bleed hallway, pelvic exams (once started, which is a hangup) only take a few minutes. Maybe our patients are better at not getting hurt(unlikely), but I probably suture something less than once per week. Abscesses are more frequent, but they still take less than 10 minutes.
Of course, if you have to sedate someone, your speed gets shot.

The thing about speed is, once you hit that efficiency (or convince yourself that you have), you breeze through things in a hurry. I may not sit and chat with every patient about their crop this year, or how their dad is doing, but I have my exam and questions and can rattle them off fairly expediently. Then you go out, order stuff, and write the note. The note takes maybe 5 minutes if you do it right then. Then you go see the next patient. Its funny because you'll basically be done with a patient and be ready to see another one, and suddenly you've picked up 3 or 4 that hour without actually sweating (barring any of them needing a procedure).

As others have mentioned, if you batch and try to see 4 patients at once, then sit down and remember which one had the murmur, who had the insignificant umbelical hernia, and what rash was where, you start losing time. Also, all the dispos come at once, which really sucks.

The real part where I slow down is when I feel I have too many active patients. If they're all waiting for their pelvic ultrasounds or psych consults, they don't bother me much. It's keeping track of 8 people's cardiac enzymes. I don't know what a max should be, but I've never seen anyone with double digit patients do a great job on each individual one. I think this is why the pod system works out so well. Our shop has the two aforementioned sides, and one has 35 beds. For 4 hours of the day, it has single resident coverage, and for 3 more on either side of that, double coverage with an intern. Most of the time the volume is low, but there are (more frequent now) days when upwards of 20 new patients are there, and it isn't feasible to expect 1 resident to see all of those, but that's what they do here. I guess it forces you to become fast, but at the same time, it does stress you.

However, even with those problems, nobody sees the 40 patients in a shift that the other thread alluded to. Simply because once you get to 10-12 active patients, you can't see a new one before someone else's results are back and you have to call someone. Then the next are back, and before you know it, you've been on the phone for a solid hour dispositioning patients.
 
Pinner Doc said:
I am amazed at people who see numbers like this. Are you actually doing procedures when you see this average (lac repairs, LPs, etc) or are you seeing more low-acuity patients, or more lab/imaging driven complaints? (This isn't directed at GeneralVeers specifically, but at people who can see this number.)
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Most are minor complaints that are treat and street, or need one X-ray. Usually throw in 5-6 chest pains, 1-2 lacs, and a few abdominal pains.

The key to efficiency, especially with abdominal pains is to order everything up front. If you're female with lower abdominal pain, you're getting a CT, pelvic ultrasound, labs, UA and pregnancy test immediately. You get one visit from me when you arrive, and another visit when everything's back and you are getting discharged for your 10/10 menstrual cramps.

It is impossible to see 3/hour and not cut corners somewhere. For me it's time spent with patients, as I rarely spend more than 5 minutes even with admitted patients.

To make matters worse is administration is forcing us to do a "new" triage protocol where we have to drop anything we are doing and run out to triage every time a patient comes in, just to greet them and get stuff started. As you can imagine that's going to be really help my efficiency. "Sorry Mr. Heart Attack, I have to interrupt our conversation because the nurse wants me to see Ms. Stuffy Nose out front".
 
Dr.McNinja said:
I've seen more than 3 per hour plenty of times on the low acuity side, and have seen more than 2 per hour on the high acuity side while admitting more than 50%. And this is during residency.
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We have the advantage of familiarity with our patients, however. As the largest hospital in the region, nearly everyone who walks in the door has been there before - often within the last week - so our EMR gives us a head start on our history even before we walk in the room. It cuts out several minutes of yelling questions at a deaf 85 year-old about her cath results from last week.

But, I'm with Veers - a lot of complaints need fewer than 5 minutes in the room to blitz the relevant HPI, minimum level 5 ROS, and basic exam. Spend the next 5 minutes at the computer, sip some coffee, chat with the nurses, get bored, go see the next patient.
 
I am honestly amazed at people seeing 3.5 pph. I work in a busy level 1 trauma center (one of the 3 hospitals i am in) and if i bust my tail i see 2.5 pph. We admit about 30% of our patients as urgent cares siphon off the easy stuff.

I am near the top of my group and honestly I see probably close to 2pph. Im not trying to bad mouth anyone elses job but as someone mentioned.. 3.5 patient per hour will have you quitting this business pretty soon. Question is do you guys who see this insane volume work for a private group of a large EmCare/TeamHealth place.

I think if the people making you see that many patients had to do it themselves change would happen.
 
Good discussion, I really enjoy hearing what other people think about what is reasonable volume during a shift.

I work for a private democratic group in a very busy community hospital. We work 8's and seeing 16 a shift is toward the slow end. Avg is about 20 during the day. Nights are single coverage and I usually average around 22-24 which leaves you feeling like road kill at the end of it. We're the only game in town and I've probably tubed 6 people in 3 weeks, multiple traumas, acute arterial occlusions etc so our acuity is quite high.

As far as female pelvic pain/abd pain goes I virtually never order a pelvic us unless they are pregnant. Some of the other docs do it, and I've never seen it reveal any pathology other than "ovarian cysts" which people latch onto that diagnosis like its terminal cancer. It takes long enough to work up female abd pain without the us, so I just don't order it.
 
xaelia said:
In what population do you consider ovarian torsion?</offtopic>
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Agreed completely. Ovarian torsion is the ONLY thing I'm concerned about in the non-pregnant female with no vaginal discharge or fever. To not document that you have ruled it out is taking a big risk.

The other big advantage to doing the ultrasound is you can give the patient a diagnosis (like ovarian cysts). In my experience most female pelvic pain with no discernible pathology has a large psychiatric component to it. If you can give the patient a reason for their pain, they are generally easier to discharge, plus you can send the patient to an OB/GYN for further workup of their menstrual/psychosomatic pain.
 
Interpolfanclub said:
Good discussion, I really enjoy hearing what other people think about what is reasonable volume during a shift.

I work for a private democratic group in a very busy community hospital. We work 8's and seeing 16 a shift is toward the slow end. Avg is about 20 during the day. Nights are single coverage and I usually average around 22-24 which leaves you feeling like road kill at the end of it. We're the only game in town and I've probably tubed 6 people in 3 weeks, multiple traumas, acute arterial occlusions etc so our acuity is quite high.

As far as female pelvic pain/abd pain goes I virtually never order a pelvic us unless they are pregnant. Some of the other docs do it, and I've never seen it reveal any pathology other than "ovarian cysts" which people latch onto that diagnosis like its terminal cancer. It takes long enough to work up female abd pain without the us, so I just don't order it.
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Interesting.. For those of you seeing 2.5+ per hour.. Scribes? Dictation?

Share with me.. we are just trying out scribes but I am pretty sure we will be expanding that (which I love). Then as people retire we just wont hire more.. We have ~10 docs 50+.
 
EctopicFetus said:
Interesting.. For those of you seeing 2.5+ per hour.. Scribes? Dictation?

Share with me.. we are just trying out scribes but I am pretty sure we will be expanding that (which I love). Then as people retire we just wont hire more.. We have ~10 docs 50+.
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Scribes definitely help. We use T-sheets, and usually will hit around 2.5 for overnights. The main thing that helps with the rate at night is a lot of times the hospitalist will just want us to make a list versus calling on every patient. Considering we're admitting 35% of our patients that is a significant time savings.
 
GeneralVeers said:
Agreed completely. Ovarian torsion is the ONLY thing I'm concerned about in the non-pregnant female with no vaginal discharge or fever. To not document that you have ruled it out is taking a big risk.
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I've seen lots of people with pelvic pain and rarely am I concerned about ovarian torsion. If the pain is rather sudden, severe and one sided I'd consider it. I usually get a CT if I'm worried and if it doesn't show a large ovarian cyst I don't consider torsion any longer. I read a paper during residency which said something to the effect that women with normal ovaries on CT almost never torse. The one patient I've seen with torsion was in severe pain, vomiting, doubled over. But it's something I certainly plan on reading more about.

Back on track, our group doesn't use scribes. We have paper charts we can zip through. But we still call our own consultants, I wish we could just leave a list for the hospitalists. We recently went to a zoned system which is reducing the amount of walking we do during shifts. One doc wore a pedometer in our old system and walked over 7 miles. Ugh. Friends of mine working with scribes really enjoy it.
 
We don't have scribes. We have a separate fast track/minor care area so I am talking about the main ED. Honestly, I feel a little uncomfortable with trying to see so many patients! don't want to miss something because I am rushed.
 
Jimmy1 said:
We don't have scribes. We have a separate fast track/minor care area so I am talking about the main ED. Honestly, I feel a little uncomfortable with trying to see so many patients! don't want to miss something because I am rushed.
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I think that's the point some of us are making. There are plenty of ways to see 2-3 patients per hour and not feel "rushed". If I have to, I slow down. I don't let the waiting room dictate my speed, I do what I think I need to. Just so happens the vast majority of people don't need much.
On the other hand, there are a few people here who are apparently scared of everything, and because they order so many CTs, they frequently get incidentalomas that reinforce their behavior.
I can go a couple days without ordering CTs, but that's rare. I definitely order less than most.
 
I agree w you, but obviously many people ARE seeing that many patients.
 
I have seen at one of our sites 27 patients in 4.5 hours with a scribe and PA. It wasnt too terrible. I dont know if I am more cautious (though I order fewer CTs than most in my group) our acuity is high. I can tell you I cant imagine a shift without me ordering a CT or US on a decent percentage of patients. We dont do much Urgent Care stuff.. maybe thats why. Mylast shift I ordered a CT on the 1st 5 patients I saw and got signed out 2 CT's and an MRI from the doc before me. Again this is a level 1 trauma center with ~30% admission and 5-7% critical care.
 
I think the right number to see per hour is as many as you can efficiently, safely, and thoroughly see. I wouldn't worry too much about that number, but somewhere between 2 and 3 per hour sounds about right. I think it's also important to put up fair comparisons, ie. chart as you go - it doesn't count as seeing 37 patients in 8 hours if you see the patients and then spend 4 additional hours dictating. If you get paid for that additonal time, or earn by RVU's, then fine, but call it 37 in 12 hours. I estimate that with good real-time charting, you'd probably be just over 2/hr. Those are my 2 cents.
 
Reviving this thread because I'm now a newly minted attending.

I'm really trying to work on my efficiency. I've had one shift where I saw 2pt/hr, but am just coming off a couple of slower shifts where I still felt pushed at far less than this because of the frustrating nature of the complaints.

I thought that in the community there would be much less "smoldering potential for badness," as I like to say, but really I've found it's not the case. The chief complaint is rarely one item, the ROS is positive for multiple things, and the patients have several comorbidities that make the differential broader and takes time to weed through. I think the average pts my group sees on an 8 hour shift is around 20, but I'm nowhere near there.

When I read (above) about doctors going into a room, spending 5 minutes, and then ordering a bunch of tests followed by speedy dispo, I wonder how you weed through all that? Do you just shotgun things? Take your chances and not order the CT? Where are you cutting down on the time?
 
What impact does being on the lower end of patients per hour have on you professionally? Does the guy consistently seeing 2-2.5/hour in a group that averages 3/hour need to worry about keeping his job or making partner? I imagine it depends on the practice, but in general?
 
DeadCactus said:
What impact does being on the lower end of patients per hour have on you professionally? Does the guy consistently seeing 2-2.5/hour in a group that averages 3/hour need to worry about keeping his job or making partner? I imagine it depends on the practice, but in general?
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Yeah, I'd say depends on the practice, the feedback from administration, whether you're RVU-based, etc.
 
Pinner Doc said:
Yeah, I'd say depends on the practice, the feedback from administration, whether you're RVU-based, etc.
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Unfortunately "Shotgunning" may be a necessary method in many patients, especially those with multiple complaints or who are poor historians.

Example: A 56 year old woman with chest pain, abdominal pain,and dyspnea.

It may be nearly impossible to drill down on exactly where the pain is, or why she's dyspneic. Therefore you are going to want to evaluate heart, abdominal emergencies, and lung emergencies. Easiest way is to order cardiac labs, abdominal labs, CT of the Chest and Abd/Pelvis. This may not seem efficient, however by ordering all these tests up front, you can eval for heart attack, PE, appendicitis, and numerous other complaints rather quickly.

When I see a patient in the room I can pretty quickly tell whether the history and/or physical exam is going to narrow down my differential. It's the rare patient who's both a good historian, and has an unequivocal finding link McBurney's Point tenderness.
 
GeneralVeers said:
Unfortunately "Shotgunning" may be a necessary
Example: A 56 year old woman with chest pain, abdominal pain,and dyspnea...Easiest way is to order cardiac labs, abdominal labs, CT of the Chest and Abd/Pelvis.
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Do you regularly order CT scans neck-to-pubis? Is this standard of care for poor historians in the community setting? I'm not judging, it is just very different from the way we are trained to work up the vague historian with multiple complaints in my residency.

At our shop this lady would get EKG, cxr, cbc, panel, and *maybe* a d-dimer or rescue myotrop depending on how she described her pain and what attending was on that day (varying opinions on the both d-dimers and single myotrops where I'm at). She would also get a bedside RUQ u/s if she still had a gallbladder and and I'd probably take a quick look at her heart at the same time to evaluate for gross abnormalities in her systolic fxn and to look for RV strain. If this was all unremarkable with normal or near-normal vitals and no peritoneal signs this patient would be sent home. Most of these pt's at our ED (county facility) don't get scanned.

I can't remember the last time I saw a CT Chest and Abd/pelvis ordered at the same time in a non-trauma pt.

Again, not judging. We see TONS of these types of patients and I'm still trying to figure out how much of a workup I'm comfortable with and how things are done out in the "real world".
 
old_boy said:
At our shop this lady would get EKG, cxr, cbc, panel, and *maybe* a d-dimer or rescue myotrop depending on how she described her pain and what attending was on that day (varying opinions on the both d-dimers and single myotrops where I'm at). She would also get a bedside RUQ u/s if she still had a gallbladder and and I'd probably take a quick look at her heart at the same time to evaluate for gross abnormalities in her systolic fxn and to look for RV strain. If this was all unremarkable with normal or near-normal vitals and no peritoneal signs this patient would be sent home. Most of these pt's at our ED (county facility) don't get scanned.
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In the non-county world, a 56 yr old with chest pain doesn't go home. Even if they also complain of abdominal pain. One set of troponins will never stand up in court, even if their pain has been there for a week. You've got to trend them.
Also, bedside US still takes up your time, when simply ordering it and having the lower paid, less important ultrasound tech frees you to continue seeing patients. It may extend the patient's stay a little longer, but we aren't talking about LOS, we are talking about efficiency.
Also, out in the real world, you'll order more CTs. One reason is because it is now your ass on the line. Another is that because Press Ganey and now CMS have decided that patient satisfaction=good care, and patients think CT=good care, thus CT=satisfaction. It's sad, but it happens. You also get a lot of pressure from your director because plenty of PMDs will send people to the ED to get scans done, and if you don't do them, you'll get flack because "the staff doctors are what make this hospital money", and EDPs are not staff doctors. This is why direct admissions don't exist, and everything goes to the ED.
 
Dr.McNinja said:
In the non-county world, a 56 yr old with chest pain doesn't go home. Even if they also complain of abdominal pain. One set of troponins will never stand up in court, even if their pain has been there for a week. You've got to trend them.
Also, bedside US still takes up your time, when simply ordering it and having the lower paid, less important ultrasound tech frees you to continue seeing patients. It may extend the patient's stay a little longer, but we aren't talking about LOS, we are talking about efficiency.
Also, out in the real world, you'll order more CTs. One reason is because it is now your ass on the line. Another is that because Press Ganey and now CMS have decided that patient satisfaction=good care, and patients think CT=good care, thus CT=satisfaction. It's sad, but it happens. You also get a lot of pressure from your director because plenty of PMDs will send people to the ED to get scans done, and if you don't do them, you'll get flack because "the staff doctors are what make this hospital money", and EDPs are not staff doctors. This is why direct admissions don't exist, and everything goes to the ED.
Click to expand...

Agree.

Good medicine != real medicine. When I teach my residents something, it's frequently with the caveat "However, out in the community...."
 
old_boy said:
Do you regularly order CT scans neck-to-pubis? Is this standard of care for poor historians in the community setting? I'm not judging, it is just very different from the way we are trained to work up the vague historian with multiple complaints in my residency.
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Yes. Generally the poorer a historian the more testing gets ordered. Some people are genuinely unable to articulate why they are in the ER, and thus leaves us with a harder job to do. In order to rule out emergencies and get these people either admitted quickly, or out of the ER a shotgun approach is needed.

If you're in a busy place, whether the department functions or whether it crashes and burns may depend on how efficient you are. If you keep those patients in beds for 6-8 hours doing multiple rounds of testing, then chances are you won't make much money, (or you'll stay 2 hours after your shift) and the nurses will hate you.
 
old_boy - I understand and commend your desire to avoid unnecessary testing. I think everyone on this forum likely wishes that we could practice EM more like that. However, I need to go on a bit of a tangent/rant here about the increasing over-estimation of ultrasound's utility. As a bit of background, I trained at a residency program that was big on US and has trained some of the bigger names in the field, so I do respect the utility of US in the ED. However, what is the sensitivity of an EM-resident-performed cardiac and GB US for ruling out pathology in a 56 year old with poorly defined symptoms? Not very good, is my estimation. Lately I've seen residents use a negative FAST to decide not to do a CT on a blunt abdominal trauma patient. This is a clear misapplication of the FAST.

The way I see it, US has two types of purpose in the hands on an EM physician:

1) In patients with pathology: To look for a specific, clearly identifiable finding (free fluid, gallstones, AAA, IUP, procedural guidance, etc).

2) In patients without pathology: To trick them into thinking they've gotten a fancy test when what they really need is to be discharged without any tests.

The fancier uses are fun and interesting, but they quickly start to fall off the other side of the diminishing returns curve.

So, if your H&P convinces you that someone has something you can find on US - have at it. If your H&P convinces you that a patient is fine, but you want to make them happy by showing them their gallbladder, well that's OK too. If you're in a murky clinical situation and you aren't asking a clearly defined and answerable question with the US - then relying on it is fraught with pitfalls, and it's a waste of your time.
 
Dr.McNinja said:
Also, out in the real world, you'll order more CTs. One reason is because it is now your ass on the line. Another is that because Press Ganey and now CMS have decided that patient satisfaction=good care, and patients think CT=good care, thus CT=satisfaction. It's sad, but it happens. You also get a lot of pressure from your director because plenty of PMDs will send people to the ED to get scans done, and if you don't do them, you'll get flack because "the staff doctors are what make this hospital money", and EDPs are not staff doctors. This is why direct admissions don't exist, and everything goes to the ED.
Click to expand...

I'm a new attending, coming from an academic program and now in the community. I've been told in 2 short months that I 'tend to order more scans than most,' and gotten feedback from the nurses that I'm overly cautious (better than cavalier I suppose?). So, I've actually found the opposite is true about ordered more CTs in the community, at least by my partners. Maybe that's why they're turning patients over faster.
 
Pinner Doc said:
I'm a new attending, coming from an academic program and now in the community. I've been told in 2 short months that I 'tend to order more scans than most,' and gotten feedback from the nurses that I'm overly cautious (better than cavalier I suppose?). So, I've actually found the opposite is true about ordered more CTs in the community, at least by my partners. Maybe that's why they're turning patients over faster.
Click to expand...

There is no right or wrong number. I tend to order fewer CTs then the majority of my partners, and my efficiency is higher as well. It all comes down to your comfort level and your individual algorithm for certain complaints.
 
You will find your own sweet spot in regards to efficiency. It takes time.
I think being very cautious out if the gate as an attending as very appropriate abs probably very common.
I think we all know there is a $&$) storm on the horizon for us with regard to Cts. Seems like most if us are taking the ostrich approach.
I hope the rads have a strong ass lobby in DC cuz the whole radiation risk and costs are real problems and only the tip of the iceberg.


---
I am here: http://maps.google.com/maps?ll=39.875841,-75.237799
 
TrumpetDoc said:
You will find your own sweet spot in regards to efficiency. It takes time.
I think being very cautious out if the gate as an attending as very appropriate abs probably very common.
I think we all know there is a $&$) storm on the horizon for us with regard to Cts. Seems like most if us are taking the ostrich approach.
I hope the rads have a strong ass lobby in DC cuz the whole radiation risk and costs are real problems and only the tip of the iceberg.

I am here: http://maps.google.com/maps?ll=39.875841,-75.237799
Click to expand...

The key is liability reform. For most abdominal pain it's completely reasonable to order labs, discharge the patient home and have them return in 12 hours if they still have pain, thus avoiding unnecessary CTs. Unfortunately the threat of liability for "missing" an acute appendicitis or other surgical problem makes this reasonable disposition impossible and requires us to CT most abdominal pain.
 
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