work on your flow!!!

[knovecc]

What is the expectation for 2nd or 3rd year EM residents in terms of the number of patients seen in a typical 8-hr shift?
Let's say it's all combined/random, fast-track, patient on stretcher or in trauma room.

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[shoal]

Extremely variable, depends on your place of work and how much scut you have to do. Id say anywhere from 1.2 to 2.5 pph is reasonable.

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[EctopicFetus]

Ask your attendings.

 

[DeadCactus]

Ask your seniors.

 

[Chromatid]

During our shifts we pick up for 8hrs and are expected to see ~20. Some days I see 17 some its 23. We have PAs that cover fast track so we do not see any of those simple cases. So its 20 for 9.5hrs from walking in the pit to leaving. We also have to do double documentation (T system and dragon dictation). We have 1.5 hrs at end of shift to finish documenting and clear dispos, typically only sign out 1 patient. Our program really pushes volume and efficiency from day one, we notice this when we go out to other places and work with other residents.

 

[HooliganSnail]

During our shifts we pick up for 8hrs and are expected to see ~20. Some days I see 17 some its 23. We have PAs that cover fast track so we do not see any of those simple cases. So its 20 for 9.5hrs from walking in the pit to leaving. We also have to do double documentation (T system and dragon dictation). We have 1.5 hrs at end of shift to finish documenting and clear dispos, typically only sign out 1 patient. Our program really pushes volume and efficiency from day one, we notice this when we go out to other places and work with other residents.

I just don't see how that is possible. Especially if you take away the fast track patients, meaning most of your patients require some sort of workup. That means about 24 minutes per patient, and none of them are simple problems. At that pace, you are going to make mistakes, miss diagnosis, or do inadequate history and physical exams.

 

[WilcoWorld]

I'll start with the type of answer that the OP is looking for, and then I'll argue that you should ignore this answer.

Answer to OP: If you can't manage 1 pt/hr by the end of intern year, you're falling behind. If you can't manage >2 pt/hr by graduation, you're not ready to be an attending.

The real answer: This question comes up over and over again, and each time it demonstrates a fundamental misunderstanding of EM. Now, please don't take offense. This is a misunderstanding that I too had as a resident, and even as a fresh attending - gotta see 2.5 pph! Four hours into my shift I'd tally up my list - 10 patients so far…sweet, I'm right on track! Wrong. Why? Because the XYZ pph assumes that your work flow is consistent. Being able to reliably chug through 2.5 pph isn't what makes a good EM doc. It's far more important to be able to handle the surges. When 6 ambulances arrive within 30 minutes you can't keep up the 2.5pph pace. You need to shift to the 'eyeball 'em & enter orders based on vitals & chief complaint' pace until things slow down.

One of the best EM docs I know looks positively lazy when the room is slow to medium busy. He let's the PA's pick up patients and meanders from room to room, taking time to drink his coffee. But when things get busy the dude looks like Flash Gordon MD and dispositions come astonishingly fast. Compare him to Dr. Pencil Pusher who gets antsy if someone picks up an ankle sprain on his side when it's slow, because he's worried about maintaining his 2.5 pph. After 8 hours, they've both seen 20 patients, but you'd much rather get sign out from Flash Gordon than Pencil Pusher. Why? Because handling the surge has a much greater impact on the ED than maintaining a pace.

So, if you're a senior resident or an attending, how do I think you should be evaluating your pace? Look at two things: How long are your room-to-provider times? How does the waiting room look at the end of your shift? If patients get seen promptly, the waiting room shrinks during your shift, and you average 2.1 pph - please come work for my group. If a lot of your patients wait in rooms for >30 minutes before being seen and the waiting room swells during your shift then I'm not at all impressed that you average 2.6 pph.

 

[Birdstrike]

It's like anything else you've had to figure out, through pre-med, medical school, though residency. All you have to do is determine: Where's the curve?

What are the other 2nd and 3rd year residents seeing per shift, at your location?

Stay within the curve. Don't be the fastest. You could get the rep for not being careful, and making mistakes. Don't be the slowest or you'll get the rep for being inefficient or, well...just slow.

It's a shame that you have to obsess about these numbers, but the reality is that:

You will have to obsess about these numbers.

Long gone are the days that doctors can worry about only the science and the medicine of Medicine. These numbers are the business and monetary aspect of Medicine.

Tip: Cherry pick (I know, blasphemy!) just one or two super-quickies like an ankle sprain, ear ache or work note at the end of each shift and you'll bump from bottom third to the top third of the patients-per-hour curve. Some people resent these patients, but this viewpoint allows you to view them as a positive, in that they can help your numbers.

Take control of these numbers obsessions that your bosses will foist upon you, and use them to your advantage. It no different than any other specialty. Private-practice primary-care needs a certain number of patients per week to stay afloat. The same goes for hospital employed doctors who live and die by RVUs per hour. Nobody is immune to this.

Just stay somewhere in the middle, and you'll be fine.

 

[Siggy]

The real answer: This question comes up over and over again, and each time it demonstrates a fundamental misunderstanding of EM. Now, please don't take offense. This is a misunderstanding that I too had as a resident, and even as a fresh attending - gotta see 2.5 pph! Four hours into my shift I'd tally up my list - 10 patients so far…sweet, I'm right on track! Wrong. Why? Because the XYZ pph assumes that your work flow is consistent. Being able to reliably chug through 2.5 pph isn't what makes a good EM doc. It's far more important to be able to handle the surges. When 6 ambulances arrive within 30 minutes you can't keep up the 2.5pph pace. You need to shift to the 'eyeball 'em & enter orders based on vitals & chief complaint' pace until things slow down.

After doing medical school rotations at various hospitals and now doing an intern year at a busy county hospital, I'll say that this is the nice thing about my hospital's pod system. There's an intern assigned to each of the two 8 bed major medical pods with a senior covering both those pods and the 8 bed trauma bay and another senior and intern covering the 11 bed moderate medical pod/psych/jail check pod. The moderate/psych/jail check pod is extremely prone to surges due to the psych and jail aspect (hey look, 4 more jail checks just walked in...), so even the interns start to get decent at handling surges.

 

[Arcan57]

I'll start with the type of answer that the OP is looking for, and then I'll argue that you should ignore this answer.

Answer to OP: If you can't manage 1 pt/hr by the end of intern year, you're falling behind. If you can't manage >2 pt/hr by graduation, you're not ready to be an attending.

The real answer: This question comes up over and over again, and each time it demonstrates a fundamental misunderstanding of EM. Now, please don't take offense. This is a misunderstanding that I too had as a resident, and even as a fresh attending - gotta see 2.5 pph! Four hours into my shift I'd tally up my list - 10 patients so far…sweet, I'm right on track! Wrong. Why? Because the XYZ pph assumes that your work flow is consistent. Being able to reliably chug through 2.5 pph isn't what makes a good EM doc. It's far more important to be able to handle the surges. When 6 ambulances arrive within 30 minutes you can't keep up the 2.5pph pace. You need to shift to the 'eyeball 'em & enter orders based on vitals & chief complaint' pace until things slow down.

One of the best EM docs I know looks positively lazy when the room is slow to medium busy. He let's the PA's pick up patients and meanders from room to room, taking time to drink his coffee. But when things get busy the dude looks like Flash Gordon MD and dispositions come astonishingly fast. Compare him to Dr. Pencil Pusher who gets antsy if someone picks up an ankle sprain on his side when it's slow, because he's worried about maintaining his 2.5 pph. After 8 hours, they've both seen 20 patients, but you'd much rather get sign out from Flash Gordon than Pencil Pusher. Why? Because handling the surge has a much greater impact on the ED than maintaining a pace.

So, if you're a senior resident or an attending, how do I think you should be evaluating your pace? Look at two things: How long are your room-to-provider times? How does the waiting room look at the end of your shift? If patients get seen promptly, the waiting room shrinks during your shift, and you average 2.1 pph - please come work for my group. If a lot of your patients wait in rooms for >30 minutes before being seen and the waiting room swells during your shift then I'm not at all impressed that you average 2.6 pph.

I'm don't completely agree with you (2.6 pph in the absence of prolonged charting times after shift is impressive regardless of flow problems that may be inherent to the system) but you've articulated something that is crucial to how you are perceived in EM.

The main difference between "fast" and "slow" docs is going to be measured by average bed-to-provider times. PPH is easy to skew because most slow docs will compensate by picking up for longer periods of time than their speedier colleagues and just suck up the extra 2 hrs over they'll stay every shift. The fast docs can get hit by the tsunami and emerge from the wreckage with something approaching their baseline production. Slow docs take an extra hour+ to get back on their feet or (much worse) pretend that nothing happened as they continue their plodding new patient every 30 minutes pace. Residency was great for this because even though our LOS and backend was jacked up, most shifts would feature at least 1-2 periods where you would get 6 patients dumped on you at once.

Wilco nailed it: surge management is king in the ED.

 

[The White Coat Investor]

Surge control is important, but it is also important to realize that sometimes at the ER, people have to wait to be seen and you need to be okay with that. We have essentially no wait time (open rooms 95%+ of the time in our ED) almost all of the time. But if we get 15 in an hour, some people are going to wait before they see me. I can put in some orders based on the triage note and vitals and speed things up a little bit, and occasionally, someone is ready to disposition by the time I actually see them. But you've got to realize that it is okay sometimes that people wait. It's more important that the sick ones get taken care of right than that the ankle sprains are gone within 23 minutes. If you can do both, great, but remember why you're there in the first place and don't let the numbers become more important than your patient, your career, and your sanity. If it seems like they are, either change it or go somewhere else. There are places where no one cares if you average 2.5 pph. Our average last year was 1.3. And yes, we are hiring next summer.

 

[Birdstrike]

Surge control is important, but it is also important to realize that sometimes at the ER, people have to wait to be seen and you need to be okay with that. We have essentially no wait time (open rooms 95%+ of the time in our ED) almost all of the time. But if we get 15 in an hour, some people are going to wait before they see me. I can put in some orders based on the triage note and vitals and speed things up a little bit, and occasionally, someone is ready to disposition by the time I actually see them. But you've got to realize that it is okay sometimes that people wait. It's more important that the sick ones get taken care of right than that the ankle sprains are gone within 23 minutes. If you can do both, great, but remember why you're there in the first place and don't let the numbers become more important than your patient, your career, and your sanity. If it seems like they are, either change it or go somewhere else. There are places where no one cares if you average 2.5 pph. Our average last year was 1.3. And yes, we are hiring next summer.

This is how it should be. I hope this lasts for you as long as humanly possible.

 

[Birdstrike]

I'm don't completely agree with you (2.6 pph in the absence of prolonged charting times after shift is impressive regardless of flow problems that may be inherent to the system) but you've articulated something that is crucial to how you are perceived in EM.

The main difference between "fast" and "slow" docs is going to be measured by average bed-to-provider times. PPH is easy to skew because most slow docs will compensate by picking up for longer periods of time than their speedier colleagues and just suck up the extra 2 hrs over they'll stay every shift. The fast docs can get hit by the tsunami and emerge from the wreckage with something approaching their baseline production. Slow docs take an extra hour+ to get back on their feet or (much worse) pretend that nothing happened as they continue their plodding new patient every 30 minutes pace. Residency was great for this because even though our LOS and backend was jacked up, most shifts would feature at least 1-2 periods where you would get 6 patients dumped on you at once.

Wilco nailed it: surge management is king in the ED.

Ahh...."Surge Control." Sure everyone likes to work with "that guy." The ER doctor who swallows up the patient surges with near superhuman capacity. It's a difficult task to stay that guy over long haul.

 

[Arcan57]

Ahh...."Surge Control." Sure everyone likes to work with "that guy." The ER doctor who swallows up the patient surges with near superhuman capacity. It's a difficult task to stay that guy over long haul.

Agreed. There has to be some reward for sucking up the surge or that behavior goes away quickly. In RVU based systems it's the money, in hourly schemes it's usually ego-driven. The problem with lack of ability to handle surges is not so much that ankle sprains have to wait but that someone (c-suite) decides that you need another provide to cover the surge times and your compensation goes to crap because you don't have enough volume to support another 10 hr shift but nobody wants to come in for only 5 or 6 hours.

 

[The White Coat Investor]

This is how it should be. I hope this lasts for you as long as humanly possible.

Me too man. Me too.