southerndoc

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Is anyone else about to throw the hat in for all the conflicting requirements we have?

AUC is likely to start 1 Jan 2018. Basically you would need an "appropriate use" to order a CT. I already use clinical decision rules (Canadian head CT, Ottawa SAH, etc.), but sometimes cave in for people demanding CT's due to Press-Ganey constraints.

With each passing year, I feel more inclined to give up my clinical practice and concentrate on other consulting jobs.

Let's review the conflicts imposed on emergency physicians:

  • AUC vs EMTALA - sometimes an emergent condition isn't identified until after a CT
    • Order an inappropriate CT and your hospital doesn't get reimbursed, bad for your salary and stability
    • Don't order a CT and patient has untoward outcome, may be EMTALA violation because patient wasn't appropriately screened (most physicians don't realize screening includes "all available options" which sometimes means CT's)
  • Appropriate care vs patient satisfaction
    • We all know patient satisfaction surveys aren't statistically significant and can be biased sometimes based on bad experiences
    • Recent studies show patient satisfaction surveys are tied to higher risk, mortality, and expense
    • Conflict to try to do what's best for the patient vs what the patient wants
    • Often tied to physician pay or physician job/group contract stability
  • Opiate prescriptions
    • Do what's right for the patient and not prescribe to drug seekers, but they write letters complaining against the physician (thus risking his/her job)
    • Get a patient satisfaction survey 1-2 weeks after their visit
    • Threat of physical violence (see separate thread)
    • Threat of state medical board sanctioning for inappropriate use of opiates or for failure to query the prescription drug database prior to prescribing
  • Increasing CME, letter badge course requirements, etc.
    • Every where you turn around, there is 16 hours for trauma, 12 hours for stroke, an hour for hospital computer order entry, 10 hours of this, etc.
    • Try to balance that with clinical time and family time
  • Threat of lawsuit
    • Some states have good malpractice laws, but many have been successfully challenged
    • Order a CT and it's not indicated? shame on you. Don't order a CT and miss something? shame on you, and that'll cost you a few hundred thousand dollars. Thank you sir!
  • Metrics
    • This one that bothers me most. We are held to standards that are affected by multiple departments (lab, radiology, other consultants, etc.)
    • Conflict between door-to-door and door-to-floor times with increasing pressure to not admit patients (do a repeat troponin and send them home; a 3-hour repeat troponin makes your door-to-door time go down the drain)
  • Increasing threat from APP's and nursing
    • Online DNP programs
    • More nursing "leadership" in health systems wanting to acquire Magnet status
    • Physicians having less involvement with administration
  • EMR's
    • Spend 2-3 times more time documenting than actually speaking to the patient
Luckily my hospital isn't imposing all of these, but CMS seems to be pushing many that the hospital has no choice to impose.

Perhaps the time has come for me to move on to another career... Anyone else feel the same way or am I just being overly winey?
 
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WilcoWorld

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Is anyone else about to throw the hat in for all the conflicting requirements we have?

AUC is likely to start 1 Jan 2018. Basically you would need an "appropriate use" to order a CT. I already use clinical decision rules (Canadian head CT, Ottawa SAH, etc.), but sometimes cave in for people demanding CT's due to Press-Ganey constraints.

With each passing year, I feel more inclined to give up my clinical practice and concentrate on other consulting jobs.

Let's review the conflicts imposed on emergency physicians:

  • AUC vs EMTALA - sometimes an emergent condition isn't identified until after a CT
    • Order an inappropriate CT and your hospital doesn't get reimbursed, bad for your salary and stability
    • Don't order a CT and patient has untoward outcome, may be EMTALA violation because patient wasn't appropriately screened (most physicians don't realize screening includes "all available options" which sometimes means CT's)
  • Appropriate care vs patient satisfaction
    • We all know patient satisfaction surveys aren't statistically significant and can be biased sometimes based on bad experiences
    • Recent studies show patient satisfaction surveys are tied to higher risk, mortality, and expense
    • Conflict to try to do what's best for the patient vs what the patient wants
    • Often tied to physician pay or physician job/group contract stability
  • Opiate prescriptions
    • Do what's right for the patient and not prescribe to drug seekers, but they write letters complaining against the physician (thus risking his/her job)
    • Get a patient satisfaction survey 1-2 weeks after their visit
    • Threat of physical violence (see separate thread)
    • Threat of state medical board sanctioning for inappropriate use of opiates or for failure to query the prescription drug database prior to prescribing
  • Increasing CME, letter badge course requirements, etc.
    • Every where you turn around, there is 16 hours for trauma, 12 hours for stroke, an hour for hospital computer order entry, 10 hours of this, etc.
    • Try to balance that with clinical time and family time
  • Threat of lawsuit
    • Some states have good malpractice laws, but many have been successfully challenged
    • Order a CT and it's not indicated? shame on you. Don't order a CT and miss something? shame on you, and that'll cost you a few hundred thousand dollars. Thank you sir!
  • Metrics
    • This one that bothers me most. We are held to standards that are affected by multiple departments (lab, radiology, other consultants, etc.)
    • Conflict between door-to-door and door-to-floor times with increasing pressure to not admit patients (do a repeat troponin and send them home; a 3-hour repeat troponin makes your door-to-door time go down the drain)
  • Increasing threat from APP's and nursing
    • Online DNP programs
    • More nursing "leadership" in health systems wanting to acquire Magnet status
    • Physicians having less involvement with administration
  • EMR's
    • Spend 2-3 times more time documenting than actually speaking to the patient
Luckily my hospital isn't imposing all of these, but CMS seems to be pushing many that the hospital has no choice to impose.

Perhaps the time has come for me to move on to another career... Anyone else feel the same way or am I just being overly winey?
You are not being overly whiney. Internal inconsistency is one of the few things that no amount of corporate double-speak can justify.

Me? I sit on the metrics committee and cry "WOLF!" when I see it. Beyond that I resign myself to:
a) knowing the rules so I can play the game
b) doing what I think is right
c) accepting that some of my bonus pay may be sacrificed in the service of b

If I ever get to a point where I can't do what's right, or doing so is such a pain in the a$$ that I'd rather teach Junior High Science...peace out.
 
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dchristismi

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Dec 4, 2003
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I hear you.

I got (along with most of my main group) a series of texts admonishing us to not forget the mandatory phone call to any ortho patient's surgeon if you have to admit them within 90 days of any orthopedic surgery, or 30 days for CV surg, even if you're admitting them for something completely unrelated. But I can't get the hospital operator to page the general surgeon who took out my patient's gallbladder 5 days ago, because "he's not on call."
Also, bounceback go back to whoever admitted them in the last 15, no 30, no 15 days. But consult care management to make sure that they *have to* be admitted. ("Yes, Bed 8 is intubated. He's not going home.")
Dr X admits his own patients unless it's Wednesday. Then ABC Hospitalist covers.
Don't forget the sepsis rescus note, even though you can't ever get the nurse to put in the second temperature. And god forbid you click the Sepsis orderset before the nurse has the weight in, so the 30cc/kg will input correctly...


I *just* wrote a resignation letter to one of my part time hospitals because I just can't keep everything straight, and each hospital EMR is just different enough to screw with you. I figure that if I have to review notes before I work a shift at a hospital to remember the stupid little stuff, and it's only 1-2 shifts a month, it's just not worth it.

The medicine is complicated enough, but its the nagging little stuff that is killing me. And I've cut my hours way back. Always try to do the right thing for the patient, but the bureaucracy is more and more painful.
Yeah Southern, I hear you. And there are certainly days I contemplate throwing in the hat. I'm not sure what's going to happen, because my patients just seem to get sicker and sicker.

The whole medical system feels like it's hanging by a thread. When I'm the one who orders the abdominal CT on a lady who not only has a PCP, but has been referred to pain management for her "back pain" with marked bony tenderness who has also lost 60 lbs, is cachectic as hell and has a firm enlarged liver... and tells me her doctor has been trying to get a CT approved... and there's metastatic badness everywhere (oh, yeah, those are bony spinal mets. No wonder your back hurts...), shouldn't that have been caught well before me?

I'm not sure if it's better to rant, or if that just makes it more depressing.
 
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Veil

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I'm with you. I'm a young attending and will defer to those more experienced, but I quickly learned that the idea behind the good ol' serenity prayer applies. I increasingly feel that all I can do is, in notes in charts, justify why I did what I did such that I go home feeling comfortable with what I've done and said in documentation. 30 cc/kg was unreasonable, and here's why. I prescribed Norco, here's why. I didn't prescribe Norco because it wasn't indicated. I ordered a CT because I thought about this. I didn't order that head CT because of this, and this, and this, and in fact, Joe McMigraine and I talked about why we didn't and that he knows to get right back here if anything's wrong in even the slightest.

Pain in the ass that medicine has devolved into this, but I don't know what else can be done to allow us some modicum of enjoying this goat rodeo.
 
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BAM!

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I'm with you. I'm a young attending and will defer to those more experienced, but I quickly learned that the idea behind the good ol' serenity prayer applies. I increasingly feel that all I can do is, in notes in charts, justify why I did what I did such that I go home feeling comfortable with what I've done and said in documentation. 30 cc/kg was unreasonable, and here's why. I prescribed Norco, here's why. I didn't prescribe Norco because it wasn't indicated. I ordered a CT because I thought about this. I didn't order that head CT because of this, and this, and this, and in fact, Joe McMigraine and I talked about why we didn't and that he knows to get right back here if anything's wrong in even the slightest.

Pain in the ass that medicine has devolved into this, but I don't know what else can be done to allow us some modicum of enjoying this goat rodeo.
Problem is, when admin sees you've ordered 100 head CTs last month, they're not looking at your notes. They don't care about your justification. They just see patient data pulled from the EMR and that you ordered an "unnecessary head CT." They see you didn't order the 30ml/kg bolus. They see you didn't order antibiotics. You get dinged regardless of your justification, because some nurse who's job it is to crunch numbers 9 to 5 doesn't understand your note. And doesn't care either.
 

Dr.McNinja

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I just ignore most of it. They are welcome to fire me.
Yep. Smile and nod when the speak to about it and they get to put the checkmark on their little clipboard. If you argue, you get marked as noncompliant.
If it comes to a formal issue, then maybe consider resigning before you get fired and have to report it. Typically those are professionalism complaints though.
 

Veil

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Problem is, when admin sees you've ordered 100 head CTs last month, they're not looking at your notes. They don't care about your justification. They just see patient data pulled from the EMR and that you ordered an "unnecessary head CT." They see you didn't order the 30ml/kg bolus. They see you didn't order antibiotics. You get dinged regardless of your justification, because some nurse who's job it is to crunch numbers 9 to 5 doesn't understand your note. And doesn't care either.
I know it. But I can't change the bull****. All of our jobs have their issues, but I'm fortunate to be somewhere that has a minimum of such things. I've gotten dinged on a couple things. But it's also still a good market for us -- our admin actually seems to get that people will leave if you piss them off enough. It's weird.
 

bravotwozero

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I know it. But I can't change the bull****. All of our jobs have their issues, but I'm fortunate to be somewhere that has a minimum of such things. I've gotten dinged on a couple things. But it's also still a good market for us -- our admin actually seems to get that people will leave if you piss them off enough. It's weird.
Same here. Plus I've got a decent ED director that has been somewhat successful in deflecting the kind of crap that comes down from hospital admin all the time..


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Birdstrike

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Dec 19, 2010
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Is anyone else about to throw the hat in for all the conflicting requirements we have?

AUC is likely to start 1 Jan 2018. Basically you would need an "appropriate use" to order a CT. I already use clinical decision rules (Canadian head CT, Ottawa SAH, etc.), but sometimes cave in for people demanding CT's due to Press-Ganey constraints.

With each passing year, I feel more inclined to give up my clinical practice and concentrate on other consulting jobs.

Let's review the conflicts imposed on emergency physicians:

  • AUC vs EMTALA - sometimes an emergent condition isn't identified until after a CT
    • Order an inappropriate CT and your hospital doesn't get reimbursed, bad for your salary and stability
    • Don't order a CT and patient has untoward outcome, may be EMTALA violation because patient wasn't appropriately screened (most physicians don't realize screening includes "all available options" which sometimes means CT's)
  • Appropriate care vs patient satisfaction
    • We all know patient satisfaction surveys aren't statistically significant and can be biased sometimes based on bad experiences
    • Recent studies show patient satisfaction surveys are tied to higher risk, mortality, and expense
    • Conflict to try to do what's best for the patient vs what the patient wants
    • Often tied to physician pay or physician job/group contract stability
  • Opiate prescriptions
    • Do what's right for the patient and not prescribe to drug seekers, but they write letters complaining against the physician (thus risking his/her job)
    • Get a patient satisfaction survey 1-2 weeks after their visit
    • Threat of physical violence (see separate thread)
    • Threat of state medical board sanctioning for inappropriate use of opiates or for failure to query the prescription drug database prior to prescribing
  • Increasing CME, letter badge course requirements, etc.
    • Every where you turn around, there is 16 hours for trauma, 12 hours for stroke, an hour for hospital computer order entry, 10 hours of this, etc.
    • Try to balance that with clinical time and family time
  • Threat of lawsuit
    • Some states have good malpractice laws, but many have been successfully challenged
    • Order a CT and it's not indicated? shame on you. Don't order a CT and miss something? shame on you, and that'll cost you a few hundred thousand dollars. Thank you sir!
  • Metrics
    • This one that bothers me most. We are held to standards that are affected by multiple departments (lab, radiology, other consultants, etc.)
    • Conflict between door-to-door and door-to-floor times with increasing pressure to not admit patients (do a repeat troponin and send them home; a 3-hour repeat troponin makes your door-to-door time go down the drain)
  • Increasing threat from APP's and nursing
    • Online DNP programs
    • More nursing "leadership" in health systems wanting to acquire Magnet status
    • Physicians having less involvement with administration
  • EMR's
    • Spend 2-3 times more time documenting than actually speaking to the patient
Luckily my hospital isn't imposing all of these, but CMS seems to be pushing many that the hospital has no choice to impose.

Perhaps the time has come for me to move on to another career... Anyone else feel the same way or am I just being overly winey?
What to do about all the 'conflicting requirements' we have?

Well...We're now deep in the trenches of a highly regulated, and increasingly heavily regulated industry with the government's groping hands all over it. (We're not the only ones, there's Wall Street, aviation, insurance market and others)

Solution?

1) Either play the game to get paid, or

2) Get out of the game (either go to outpatient direct-pay/cash-pay medicine, or leave medicine all together) or

3) Run for office and try to change the system.

Most people will choose #1, less will choose #2 and even less will choose #3,
as the path of least resistance also follows that order.


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WilcoWorld

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I do not mean to defend these encroachments. Yes, a lot of the metrics are stupid. But I've got good news for you - you are smart! If you read these things carefully and get a good understanding of them, you can usually continue to practice the way you want without getting "dinged".

So, while it is a hassle, I think this indicates that there is a 4th option to add to the above list:

4) Learn how the game works so that you can outsmart it.
 
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bravotwozero

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So you think I can weasel my way out of a 30 ml/kg bonus on the septic dialysis patient with an ef of 20% ?


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WilcoWorld

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So you think I can weasel my way out of a 30 ml/kg bonus on the septic dialysis patient with an ef of 20% ?


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Yes. Document the contraindication(s) in your MDM. Add those confounding conditions in as secondary diagnoses for a bonus.

If you're doing that and you're still getting "dinged" it's time to let your compliance office know that they're doing it wrong.
 

Old_Mil

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Is anyone else about to throw the hat in for all the conflicting requirements we have?

AUC is likely to start 1 Jan 2018. Basically you would need an "appropriate use" to order a CT. I already use clinical decision rules (Canadian head CT, Ottawa SAH, etc.), but sometimes cave in for people demanding CT's due to Press-Ganey constraints.

With each passing year, I feel more inclined to give up my clinical practice and concentrate on other consulting jobs.

Let's review the conflicts imposed on emergency physicians:

  • AUC vs EMTALA - sometimes an emergent condition isn't identified until after a CT
    • Order an inappropriate CT and your hospital doesn't get reimbursed, bad for your salary and stability
    • Don't order a CT and patient has untoward outcome, may be EMTALA violation because patient wasn't appropriately screened (most physicians don't realize screening includes "all available options" which sometimes means CT's)
  • Appropriate care vs patient satisfaction
    • We all know patient satisfaction surveys aren't statistically significant and can be biased sometimes based on bad experiences
    • Recent studies show patient satisfaction surveys are tied to higher risk, mortality, and expense
    • Conflict to try to do what's best for the patient vs what the patient wants
    • Often tied to physician pay or physician job/group contract stability
  • Opiate prescriptions
    • Do what's right for the patient and not prescribe to drug seekers, but they write letters complaining against the physician (thus risking his/her job)
    • Get a patient satisfaction survey 1-2 weeks after their visit
    • Threat of physical violence (see separate thread)
    • Threat of state medical board sanctioning for inappropriate use of opiates or for failure to query the prescription drug database prior to prescribing
  • Increasing CME, letter badge course requirements, etc.
    • Every where you turn around, there is 16 hours for trauma, 12 hours for stroke, an hour for hospital computer order entry, 10 hours of this, etc.
    • Try to balance that with clinical time and family time
  • Threat of lawsuit
    • Some states have good malpractice laws, but many have been successfully challenged
    • Order a CT and it's not indicated? shame on you. Don't order a CT and miss something? shame on you, and that'll cost you a few hundred thousand dollars. Thank you sir!
  • Metrics
    • This one that bothers me most. We are held to standards that are affected by multiple departments (lab, radiology, other consultants, etc.)
    • Conflict between door-to-door and door-to-floor times with increasing pressure to not admit patients (do a repeat troponin and send them home; a 3-hour repeat troponin makes your door-to-door time go down the drain)
  • Increasing threat from APP's and nursing
    • Online DNP programs
    • More nursing "leadership" in health systems wanting to acquire Magnet status
    • Physicians having less involvement with administration
  • EMR's
    • Spend 2-3 times more time documenting than actually speaking to the patient
Luckily my hospital isn't imposing all of these, but CMS seems to be pushing many that the hospital has no choice to impose.

Perhaps the time has come for me to move on to another career... Anyone else feel the same way or am I just being overly winey?
I punched out last year. Good luck with your decision.
 

goodoldalky

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A few points:

1. AUC has exceptions for inpatients and patients undergoing a medical screening exam (i.e.: ED). We are largely excluded on this.
2. The EMRs that we use will likely change to incorporate more clinical decision support (some would say, to be more annoying). AUC is not going to be able to be implemented until third party EMRs catch up which is unlikely to occur by Jan 2018. It is difficult to say for sure whether Trump's stay on the issue will be extended, but I would say there is a high probability this will be delayed further.
3. The game is certainly changing. Fee for service is going away. MIPS, MACRA, ACO's, bundled payments... they are here to stay. FFS you may consider as a 40 year experiment that has proved too costly and there is ZERO chance that it survives except for an exceedingly small proportion of cash-based specialists in affluent areas who see no medicare or medicaid, and do not rely on patients in pediatric or elderly demographics for procedures, and can survive on zero commercial insurance/cash only (dermatology, cosmetic plastics). In my hospital system, even the surgical sub-specialists have been looped into performance based contract metrics. It's not as though this is an EM-based or even replaceable vendor-based phenomenon, and I suspect with financial pressures in the future further consolidation is going to be the only way to survive, leading even the last insurance-based sub specialist holdouts into new payment models.

You can look at this one of two ways: 1) Sky is falling, or, 2) things are going to change, BUT, there is a tremendous shortage of physicians, which is guaranteed to get worse (particularly if the last hold outs of aging physicians hang it up when FFS fully goes away), and that changes in your practice may allow you to succeed well into the future. Doing the same thing you have always done will certainly lead to failure, but I do not think that success with the right adaptation is out of the question.

In my opinion, in order to make this all tolerable, you need to have a supportive admin, reasonable hospital/healthcare system partner, and probably some forward thinking/experimentally minded leaders in your organization that might be able to formulate profitable, survivable, equitable solutions to evolve into the future.

I personally have no idea what is going to happen with healthcare. I can't leave at this point, and although I've certainly hedged my bets, am planning on seeing where we can take it.
 

bravotwozero

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Sep 19, 2004
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No, he went over to the land of hockey and maple syrup..:


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