Assigning patients from the waiting room

[TheTruckGuy]

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Is this standard at places where you work? Basically someone gets checked in, or is sitting in the waiting room, and people start signing up for them? Non-RVU based. Where I was at previously people didn't sign up till they were roomed.

I've noticed what's happening is people will sign up for 2-3 in the waiting room, and leave no one for me to pick up a couple hours before my shift ends. And when there is an empty room and a patient available for me to take, they have a full list and can't take any more, so I take it, even though my shift is almost ending. And what ends up happening is they basically sit on those patients and get out on time, while I picked up patients near the end of my shift because everyone else was already full, and I end up getting out late, and after people that were supposed to leave after me.

Is this normal at other places? I don't like picking up waiting room patients, or even some that haven't been fully triaged, because I don't know how long it'll be till they get roomed, and maybe I'll get busy with something else once they're roomed and I don't want them sitting in a room for forever. And it's not even like we're competing for RVUs. Not sure if they're doing it intentionally to stack their patient list early so they can sit on the same patients through the end of their shift or what.

Anyways, maybe was just a rant.

 

[emergentmd]

Weird. Never had people sign up in WR in RVU or non RVU models.

In my old RVU model, docs would sign up quickly for pts like it was some extinct animal. Didn't bother me, b/c in the long run it never was worth it. I just went to get some coffee.

But in a Non RVU model, people would wait for someone else to sign up for pts.

If I were you, don't change what you should do to get out on time. Pick up easy pts that you can get rid easily. Complicated pts should have labs ordered and passed on.

 

[Zebra Hunter]

You have patients that aren’t in waiting rooms?! Seems like I’ve been practicing waiting room medicine for the last 5 years. I wouldn’t see anyone if I didn’t sign up for patients in the waiting room.

 

[TheTruckGuy]

You have patients that aren’t in waiting rooms?! Seems like I’ve been practicing waiting room medicine for the last 5 years. I wouldn’t see anyone if I didn’t sign up for patients in the waiting room.

Well, it would be one thing is they went out there and saw the patient in the WR. But they wait till they come to a room, and have their name on them for 2-3 hours sometimes.

But we're lucky, most of the time the acuity isn't that bad, and we can get people upstairs or discharged in a reasonable amount of time. I also think waiting room medicine is dangerous and only rewards hospital CEOs for doing a bad job managing staffing, and gives the false sense that things are way better than they are. As long as it's not an actual emergency their wait times can go up.

 

[southerndoc]

They can pick up from the waiting room, but despite having a "full list" they are still responsible for picking up in the back as well. I would simply tell them "carry a lighter waiting room load next time, you're up and I'm putting your name on this one."

Either that or play their own game. Grab a bunch from the waiting room so they don't have any and then tell them the same thing when a patient is in the back.

 

[Brigade4Radiant]

yup we pick them up as soon as they sign in prevents cherry picking its rvu so most want to see more

 

[JacobMcCandles]

It makes the most sense to sign up when they get into a room unless you’re seeing them in the waiting room. Otherwise you’ll get a bonus of ambulances and the people you’ve signed up for will still be out in the waiting room and at it’ll just end up with somebody signed up on all the patients and not able to see them.

 

[emergentmd]

Man, I am glad I never cared to be in the rat rate. RVU or non RVU, I never had the need to pick up patients in the waiting room or chart watch so I can be the first to sign up. I worked with docs at RVU places who would pick up pts even with a full list. I just went to get some coffee.

 

[JacobMcCandles]

Didn't bother me, b/c in the long run it never was worth it. I just went to get some coffee.

I worked with docs at RVU places who would pick up pts even with a full list. I just went to get some coffee.

Are you getting coffee right now?

 

[Groove]

Yes, I'm your typical WR medicine doc who will pick up on WR patients. I see patients in the rooms and when they've all been seen I will dump orders in on WR patients and/or will pick up ones that seem like I can easily discharge from triage room or some cubby after evaluating them +/- covid or flu swab, etc..

One reason is non selfish and that's simply to improve departmental flow and decompress the WR.

The second reason is selfish and that's to cook my metrics. Every low acuity snipe in the WR that I pick up and subsequently discharge "cooks" my LOS and TATs as well as PPH+RVU/hr. That way, my metrics come out shining every month and that's just good for job security.

Yes, seeing patients like this can skew departmental numbers. If I'm aiming for 2pph during my shift and I chew through a threefer MVC and a twofer mom+kid URI then that's 5 patients in under an hour and odds are I can start slowing down and wrapping up before you can. Plus, these are low stress cases with pretty easy notes that I can knock out quickly.

Most docs hate going out to the WR and I completely get that. It's anything but optimal but the reality is that it really does make your numbers look good and is enormously helpful from a decompress/ED flow/logistical/pt satisfaction standpoint.

All that being said, I rarely see another doc do what I do. Most overwhelmingly wait for the pt to be roomed so I'm definitely in a minority.

 

[turkeyjerky]

I can’t stand people who assign themselves to pts in the WR and then don’t see them. It mucks up flow, screws up dept metrics (target vs measure etc) encourages bad medicine. Sometimes I’ll come into my shift rearing to go and do diddly squat for an hour, meantimes there’s like 6 patients who’ve been “seen” but actually won’t receive any care for another two hours…

If you want to help out and get things going, just put in obvious orders. It’s easy. No need to assign yourself to the patient. If you’re actually seeing them in the wr, fine, but don’t click on them with the intention of seeing them in 45 min. Plus, it forces others to do the same, and then a critical patient will come in, and then the wr patient will finally get roomed and then sit there for an hr.

I’ve seen this mostly from midlevels at poorly run (cmg, non-pod) places over the years. I’m sure they’re loved by the med directors though.

 

[emergentmd]

Are you getting coffee right now?

Yes had my morning coffee. Always come on shift right on time. If there is no one to see, I go get some coffee. If those who wants the RVUs badly can have it. In the long run, it matters little and creates a more stressful workplace when all docs board watch.

If I have the most pts on the board, I let the pts stay unassigned for 10 min then will pick it up. If I have the least, then I will pick it up. Always like to be fair and have a cordial environment.

 

[thegenius]

Is this standard at places where you work? Basically someone gets checked in, or is sitting in the waiting room, and people start signing up for them? Non-RVU based. Where I was at previously people didn't sign up till they were roomed.

I've noticed what's happening is people will sign up for 2-3 in the waiting room, and leave no one for me to pick up a couple hours before my shift ends. And when there is an empty room and a patient available for me to take, they have a full list and can't take any more, so I take it, even though my shift is almost ending. And what ends up happening is they basically sit on those patients and get out on time, while I picked up patients near the end of my shift because everyone else was already full, and I end up getting out late, and after people that were supposed to leave after me.

Is this normal at other places? I don't like picking up waiting room patients, or even some that haven't been fully triaged, because I don't know how long it'll be till they get roomed, and maybe I'll get busy with something else once they're roomed and I don't want them sitting in a room for forever. And it's not even like we're competing for RVUs. Not sure if they're doing it intentionally to stack their patient list early so they can sit on the same patients through the end of their shift or what.

Anyways, maybe was just a rant.

At a non-RVU place, what is the incentive to pick up these waiting room patients voluntarily? Where do they see them? In the WR?

Conversations in the waiting room:

"Sorry ma'am. You have a temp of 103.6, COVID, and the Flu. I recommend wearing this mask around others who have cancer, immunosuppressed, and the elderly." (2/3 of the WR get up and leave)

"Sir, you have a really stubborn, resistant form of gonorrhea. You need 'extra strength' antibiotics for 20 days!"

 

[Buddy.the.Elf]

Is this standard at places where you work? Basically someone gets checked in, or is sitting in the waiting room, and people start signing up for them? Non-RVU based. Where I was at previously people didn't sign up till they were roomed.

I've noticed what's happening is people will sign up for 2-3 in the waiting room, and leave no one for me to pick up a couple hours before my shift ends. And when there is an empty room and a patient available for me to take, they have a full list and can't take any more, so I take it, even though my shift is almost ending. And what ends up happening is they basically sit on those patients and get out on time, while I picked up patients near the end of my shift because everyone else was already full, and I end up getting out late, and after people that were supposed to leave after me.

Is this normal at other places? I don't like picking up waiting room patients, or even some that haven't been fully triaged, because I don't know how long it'll be till they get roomed, and maybe I'll get busy with something else once they're roomed and I don't want them sitting in a room for forever. And it's not even like we're competing for RVUs. Not sure if they're doing it intentionally to stack their patient list early so they can sit on the same patients through the end of their shift or what.

Anyways, maybe was just a rant.

My entire residency was waiting room medicine. I would say I saw about 60% of my pts in the WR during residency (2019-2022). We never had nurses to staff the ED rooms (60 bed ED in a state with mandated nursing ratios), so most of the ED rooms sat empty or we'd pull pts into them to do POCUS, DREs/pelvics, etc but back to the WR for the remainder of their workup. We allowed IVs in the WR and many got admitted from there. I work at a big county hospital system now and a good 1/3 of my pts still get their care from the WR including whole CP work ups, pelvic complaints, etc. We have little makeshift cubby chairs to pull them aside to offer some semblance of privacy.

 

[Janders]

We are ENTIRELY eat-what-you kill, and have had intermittent WR flow / boarding issues for some years.

As such, yes people pick up WR patients.

There are some ground rules that everyone follows to keep it Kosher.

We have aggressive triage RN based ordering protocols, and encourage the RNs to communicate actively with the MDs working if the patient clearly needs an US or CT head to keep things moving, so those fancy tests can be ordered and done in the WR. As such, while a lot of us surf the WR in epic to ensure tests are ordered, we don't sign up for those patients by definition. They will get EKG, labs, xrays etc without an MD signing up for them.

If its just "fast track I can d/c it from the WR", then its open season. We encourage the PAs to do this when they have open time too (eg nothing new in the back). You shouldn't pick up 3 at a time unless the other doc working is obviously very busy and not picking up any, so as to allow everyone a chance to feast on that WR glory. But if you see a ESI 4 nothing burger negative XR in the WR, you can pick it up and DC them, no issue.

If its "i can probably send it but I may need to order some tests after I see them" or "they look moderately ill and I'd rather see them now and get things started properly" or "we are in a code disaster and there is ZERO flow and the WR is larger than the department" typically we just ensure there is some conversation bt the MD/PA working and the resource RN, and that open season is declared on the WR. Then you can start picking up anything you want in the WR. Just know its hard to get IV meds going out there...

If its a usual flow day, and people aren't in the WR long, its considered a bit suboptimal to grab people from the WR (and cheat the other MD out of potential patients) unless you openly declare it...

 

[TheTruckGuy]

Most docs hate going out to the WR and I completely get that. It's anything but optimal but the reality is that it really does make your numbers look good and is enormously helpful from a decompress/ED flow/logistical/pt satisfaction standpoint.

I don't mind going to the WR. But little can get done unless they get roomed. But also, if I'm the only one doing it, I'm not going to burn myself out to make hospital admin feel as though they have enough staff/rooms because their ED to doc time looks better than it really is.

I can’t stand people who assign themselves to pts in the WR and then don’t see them. It mucks up flow, screws up dept metrics (target vs measure etc) encourages bad medicine. Sometimes I’ll come into my shift rearing to go and do diddly squat for an hour, meantimes there’s like 6 patients who’ve been “seen” but actually won’t receive any care for another two hours…

Yeah, that's the thing. Would be one thing to actually see the patient and start everything. But you never know when they're actually going to get roomed, and there maybe ambulance patients or sicker patients that come in after them. Or, you've just staked out your steady stream for the next 2 hours, meanwhile the other guy/gal is twidling their thumbs waiting for a patient.

At a non-RVU place, what is the incentive to pick up these waiting room patients voluntarily? Where do they see them? In the WR?

That's what I don't get. My only guess is that it allows them to stake out their steady flow.

My entire residency was waiting room medicine. I would say I saw about 60% of my pts in the WR during residency (2019-2022).

Yes, I also did a lot of WR medicine during residency. It had to get done. Thank goodness for techs who were willing to do nursing jobs. But I have zero desire to keep that up as I get older and more burned out. Not going to fight someone for patients. I can crush massive volume when I am lone coverage, but if someone wants to steal patients from me they can have them - especially since it's not RVU. Makes me think I'll never try to work at an RVU only place.

 

[Pinner Doc]

I’ve been at a non RVU place for the past ten years. People don’t pick up WR patients because there is not enough staffing to fulfill any orders made, aside from initial triage orders. We are on bare bones staffing as it is. The closest I’ve done is bird dog the charts of WR patients and let the charge nurse know if something needs to come back right away.

 

[EctopicFetus]

yup we pick them up as soon as they sign in prevents cherry picking its rvu so most want to see more

Also this is usually a gfreat way to scam your door to doc time is your hospital cares/tracks this.

For many it is done at the time of doc sign up. I know some others do it a different way.

 

[Tenk]

I don’t understand why people can’t just talk to their colleagues. I would just be like: “hey, I don’t have any patients right now so I’ll take these two. No worries.”

Then give them the good ol Leo meme:

 

[RustedFox]

This whole practice is lamesauce and it's primarily women that abuse this to game numbers, just like in the restaurant industry.

Anyone who has worked waiting tables in a high enough volume place knows that if the crew is primarily men, then nobody GsAF about the "tip pooling" nonsense. This is just that in the medicine world and slightly different.

 

[Janders]

This whole practice is lamesauce and it's primarily women that abuse this to game numbers, just like in the restaurant industry.

Please expand on how grabbing WR patients is a female-centric ploy to game numbers?

In my 15 years in a shop where its entirely eat-what-you-kill, and we do go in waves of having long WR holds and see WR patients…

… the ONLY providers who were borderline bad actors (specifically grabbing WR patients and not seeing them to claim them, or grabbing multiple without letting their coworkers grab any) were men.

Granted sample size is small and seems more individuals who really like money or who’s OCD tends towards collecting as many patients as possible… and never was a HUGE issue for us.

 

[Janders]

Now a few years back I was moonlighting at a place that had horrid flow (low RN staffing, enforced RN😛atient ratios in the ED, formal refusal to use hallway beds). I was straight hourly there.

By mid morning, the WR would start seriously backing up with loads of stuff that either could be seen and streeted, or CLEARLY needed X-ray/labs to start a workup. They had very minimal triage orders allowed to the nurses.

Anyway, oddly one very backed up morning the MD staff was me, and one of my full-time-Job buddies who was also moonlighting at the same shop. So we immediately applied our typical moves— ran the WR, dropped a lot of lab/imaging orders, and started seeing and streeting basic stuff like ankle sprains from the WR. Flow rapidly improved within an hour.

Within 2-3 hours we had a nursing director then multiple C-suite members show up in our doc box telling us to stop, that we were NOT allowed to order and see in the WR, were NOT allowed to d/c from the WR, and to just see things when they got brought back.

So we went back to being bored and making the same $/hr…

 

[RustedFox]

Please expand on how grabbing WR patients is a female-centric ploy to game numbers?

In my 15 years in a shop where its entirely eat-what-you-kill, and we do go in waves of having long WR holds and see WR patients…

… the ONLY providers who were borderline bad actors (specifically grabbing WR patients and not seeing them to claim them, or grabbing multiple without letting their coworkers grab any) were men.

Granted sample size is small and seems more individuals who really like money or who’s OCD tends towards collecting as many patients as possible… and never was a HUGE issue for us.

Sure.
But first; have you ever worked in a restaurant?

 

[TrailRun]

Isn’t it concerning, medico-legally, to assign your name to a patient if you’re not imminently about to see them?

 

[Janders]

Isn’t it concerning, medico-legally, to assign your name to a patient if you’re not imminently about to see them?

Right. Go see them if you put your name on them.

 

[Janders]

Sure.
But first; have you ever worked in a restaurant?

Not in the manner of a tipped waiter etc. more food stand like stuff.

 

[RustedFox]

Not in the manner of a tipped waiter etc. more food stand like stuff.

Okay.
Are you a woman?
EDIT: Are you an adult human female with an "XX" karyotype? This nonsense about "what is a woman" being a feeling or some other liberal horse$hit needs to stop.

 

[Janders]

Okay.
Are you a woman?
EDIT: Are you an adult human female with an "XX" karyotype? This nonsense about "what is a woman" being a feeling or some other liberal horse$hit needs to stop.

Nah, I identify as a guy. A 6ft tall white dude of privilege 🙂

 

[RustedFox]

Nah, I identify as a guy. A 6ft tall white dude of privilege 🙂

Okay. Pay attention.

I've had every position there is to have in a restaurant that's NOT "head chef".
Front of house. Back of house. Prep cook. Line cook. Server. Bartender. Host. Busser/DRA (DRA = "Dining Room Attendant"... the utility player). etc.

Say you work in a restaurant. Any upscale and decently "good enough" restaurant for the ebb and flow of diners to not be a problem.
Say you're the host. It is your responsibility to make sure that each of the servers' sections are "sat in turn", ensuring an equitable and near-uniform distribution of dining parties over the course of the evening's service. Double-"sit" one server (give them two tables at once), or fail to "sit" one server (skip one in the batting order), and you're gonna hear about it from them.

Let's say you have four servers for the night. Let's say all of them are women. They will all uniformly insist that all tips are "pooled" at the end of the shift and split evenly between them. In their minds, this measure guards against variations in "the seating of tables", the "big tipper/poor tipper" problem, and helps to ensure what they think is a "fair and equitable workload". This way, it's hard for Patty to b!tch and moan about Stacy not pulling her weight, etc. They will still b!tch and moan about who did or didn't do their side-work, who "needs to be cut first". Whatever. Suck a pickled egg, Patty.

Same restaurant. Same night. Now imagine all the servers are men. None of them will GAF about "pooling" the tips. They all know that they're gonna work, gonna get paid, and will go home. They also won't complain about who did more or less side-work. Sooner everything gets done; sooner everyone goes home. There are no petty-ass fights like there are when women insist on section-pissing and tip pooling and whatever.

Years and years in the restaurant world. This phenomenon has held true in every venue that I've been in. This concept extends to the ER world as well.

This whole "I cherrypicked a few in the waiting room earlier in my shift to pad my numbers and now I don't wanna see the higher complexity things later on" is simply an extension of this behavior - which is primarily exhibited by women who will spend more energy complaining about the perception of how much or how little work someone else has "done" than they will actually rucking up and working. Ashley makes sure to grab 3 patients from the waiting room and then doesn't want to see "72 year old syncope" two hours prior to end of shift because "her numbers are front-loaded".

Nursing staff does this nonsense too whenever there is the "perception" of one nurse "doing less work than the others". Penny is our charge nurse. You remember the charge RN from "THE PITT"? That's my Penny; cigarettes, bad attitude, sailor-mouth, and all.

She's awesome. She runs a tight ship here. Penny likes to spend some time during the nights (we only work nights; Penny and I) doing some schoolwork for whatever certification she is pursuing. OtherNurses see this and just can't stop themselves from bitching and moaning becuase "it looks to them like Penny is doing less work than they are". The site RN manager came to me to ask about this. I said, point-blank: "Penny gets everything done so she can chip away at her schoolwork. It has never become a patient care issue. The OtherNurses just want something to complain about. Leave Penny alone." Penny was left alone.

This actually happened to me: I'm working double coverage in the afternoon. During yesterday's shift, I saw a patient with acute pancreatitis. I recommended admission (little old lady, stoic, could use a little TLC), but she was adamant about going home. I told her to come back tomorrow if she wasn't feeling better, because I would be on-shift and would be happy to talk to her again. So, grandma comes back, nurse hands me grandma's EKG and says: "This is your grandma from yesterday."

"Rebeccah" takes the EKG out of my hand. Says to me:

"This will be easy. *I* want to front-load my patients so I get my numbers in early and yadda yadda yadda."

I said to her: "This patient is expecting to see me. I saw her yesterday. She trusts me enough to come back and listen to what I have to say, I really thin-"

Rebeccah interrupts me: "No no no, it will be easy, I can admit it. I want my numbers to be my numbers and the numbers will number."

My dude, I tell you: I came this close [holds thumb and forefinger 2mm apart] to saying back to her: "Ahh. It's true what the nurses say about you. It's Rebeccah's world and everyone else is just a supporting actor. I see why you're divorced."

I let Rebeccah have her way, but found grandma in the waiting room and explained that I would be going off-shift soon but had talked to the oncoming doc about her case.

So bro, I hear you when you say: "the problem players at my 100% RVU shop in the arena have both been men".
But I want to ask: "These men you speak of.... are they little b!tches? Because this is little b!tch behavior."

 

[Pinner Doc]

I’m female and worked in many restaurants up and down the east coast. Any time there has been pooled tips, and that was hardly ever, it was policy of the management.

Otherwise, tips have always been based on the cash (or credit card tips) you collected in your own guest checks. You sat down at the end of the night once your section was cleaned, had a beer, and did the math.

Cool story, though!

 

[RustedFox]

I’m female and worked in many restaurants up and down the east coast. Any time there has been pooled tips, and that was hardly ever, it was policy of the management.

Otherwise, tips have always been based on the cash (or credit card tips) you collected in your own guest checks. You sat down at the end of the night once your section was cleaned, had a beer, and did the math.

Cool story, though!

GOOD. That's the non-b!tch way to approach things.

 

[DocEspana]

Is this standard at places where you work? Basically someone gets checked in, or is sitting in the waiting room, and people start signing up for them? Non-RVU based. Where I was at previously people didn't sign up till they were roomed.

I've noticed what's happening is people will sign up for 2-3 in the waiting room, and leave no one for me to pick up a couple hours before my shift ends. And when there is an empty room and a patient available for me to take, they have a full list and can't take any more, so I take it, even though my shift is almost ending. And what ends up happening is they basically sit on those patients and get out on time, while I picked up patients near the end of my shift because everyone else was already full, and I end up getting out late, and after people that were supposed to leave after me.

Is this normal at other places? I don't like picking up waiting room patients, or even some that haven't been fully triaged, because I don't know how long it'll be till they get roomed, and maybe I'll get busy with something else once they're roomed and I don't want them sitting in a room for forever. And it's not even like we're competing for RVUs. Not sure if they're doing it intentionally to stack their patient list early so they can sit on the same patients through the end of their shift or what.

Anyways, maybe was just a rant.

I havent made my way down the comments yet, so idk where the conversation went from here... but I have exclusively worked at places that picked up from the waiting room and that was the expectation of all of the providers and the powers that be. Actually not exclusively, there was a locums job in WV I worked where you couldnt see patients in the WR on the EMR and you would just see someone pop into a room with a 45 minute LOS out of the blue. Always found that odd, but it was the culture and I couldnt buck it if I wanted to because they were essentially invisible on the physician EMR (which was cerner, but some customized one Id never used before) until roomed.

To be fair though I have worked at 1) residency in NYC where for at least part of my residency the wait time to be seen in a room was >>1 hour often >3 hours. That was changing near the end of my residency and wouldn't be surprised if they don't do waiting room medicine any longer. 2) tons of places in FL where there is an expectation baked into everyone's DNA, because of HCA having a stranglehold on the culture even at non hca location, that you'll be seen immediately and 3) a locums job in maryland that just had that waiting room medicine culture.

I never in a million years thought that snatching up people the second I see them hit the board would inconvenience anyone, but then again, everyone I work with is doing the same. And generally these are all flat-rate sites and not RVU driven.

 

[DocEspana]

Well, it would be one thing is they went out there and saw the patient in the WR. But they wait till they come to a room, and have their name on them for 2-3 hours sometimes.

But we're lucky, most of the time the acuity isn't that bad, and we can get people upstairs or discharged in a reasonable amount of time. I also think waiting room medicine is dangerous and only rewards hospital CEOs for doing a bad job managing staffing, and gives the false sense that things are way better than they are. As long as it's not an actual emergency their wait times can go up.

oh gross. my previous post was all examples of people going into the waiting room to meet the patient there and see/examine them when they sign up for them. Usually places I work at keep a room or two (theoretically triage rooms, but they're never used for that) permanently open to cycle waiting room patients in and out of to chat with, draw blood from, and disposition out of.

 

[DocEspana]

Okay. Pay attention.

I've had every position there is to have in a restaurant that's NOT "head chef".
Front of house. Back of house. Prep cook. Line cook. Server. Bartender. Host. Busser/DRA (DRA = "Dining Room Attendant"... the utility player). etc.

Say you work in a restaurant. Any upscale and decently "good enough" restaurant for the ebb and flow of diners to not be a problem.
Say you're the host. It is your responsibility to make sure that each of the servers' sections are "sat in turn", ensuring an equitable and near-uniform distribution of dining parties over the course of the evening's service. Double-"sit" one server (give them two tables at once), or fail to "sit" one server (skip one in the batting order), and you're gonna hear about it from them.

Let's say you have four servers for the night. Let's say all of them are women. They will all uniformly insist that all tips are "pooled" at the end of the shift and split evenly between them. In their minds, this measure guards against variations in "the seating of tables", the "big tipper/poor tipper" problem, and helps to ensure what they think is a "fair and equitable workload". This way, it's hard for Patty to b!tch and moan about Stacy not pulling her weight, etc. They will still b!tch and moan about who did or didn't do their side-work, who "needs to be cut first". Whatever. Suck a pickled egg, Patty.

Same restaurant. Same night. Now imagine all the servers are men. None of them will GAF about "pooling" the tips. They all know that they're gonna work, gonna get paid, and will go home. They also won't complain about who did more or less side-work. Sooner everything gets done; sooner everyone goes home. There are no petty-ass fights like there are when women insist on section-pissing and tip pooling and whatever.

Years and years in the restaurant world. This phenomenon has held true in every venue that I've been in. This concept extends to the ER world as well.

I wanted to dislike your theory, but I actually have no critiques of this summary based on my personal experiences also working many (fewer than you) jobs in food service for years before (and bartending during) med school.

Just confirming, not that you need it, that this is not only something I've seen but a phenomena I've heard other people talk about specific to waiting and service. Some people just want to earn their tips and get the work day over with and some people spend an exorbitant amount of time that could be spent earning tips, instead critcizing if everyone is truly 'being fair' and making sure that no one accidentally has an easy day. Unless its them, they can have an easy day - but god forbid there are two people like that on shift, then no one can have an easy day under any possible permutation because those two will be monitoring each other.

Does it have a gender bias? My n value that isnt evidence of anything beyond my n value says yes.

 

[DeadCactus]

Every place is different. It doesn't matter what people are doing in other emergency departments or what you did in previous places. There are some aspects of the culture that you don't want to be too far of an outlier on (wrapping up patients vs signing them out, PPH metrics, etc), but beyond that just do what makes sense to you and don't worry about other people.

I'll just say there is no way I'm staying late when the culture and norm is to wrap up and leave on time.

"I don't like picking up waiting room patients, or even some that haven't been fully triaged, because I don't know how long it'll be till they get roomed, and maybe I'll get busy with something else once they're roomed and I don't want them sitting in a room for forever."

Do you get paid to stay late? Has anyone ever thanked you for keeping patients from having to wait in a room too long? Does this improve some metric that puts more money in your pocket or keeps administrative heat off your back? My guess is no and you're just dying on some hill no one cares about. Just put your name on the patient, throw in any orders you can based on triage, and see them when you see them. Or don't and just sign out the late shift patients you see if that's acceptable in your shop. Or just don't sign up for patients if everyone else builds an off-ramp at the end of their shift. Plenty of alternatives to staying late.

Emergency physicians are a little too eager to get up on a cross sometimes and this sounds like one of those times.

 

[TooMuchResearch]

If we assign ourselves to waiting area patients, we see them. We have made some department changes that make this less necessary, sort of.

 

[turkeyjerky]

"I don't like picking up waiting room patients, or even some that haven't been fully triaged, because I don't know how long it'll be till they get roomed, and maybe I'll get busy with something else once they're roomed and I don't want them sitting in a room for forever."

No, I don’t want other people doing thisso that I can see this patient and dispo them, so that I can them move in to the next dozen rather than sitting on sdn.

Do you get paid to stay late? Has anyone ever thanked you for keeping patients from having to wait in a room too long? Does this improve some metric that puts more money in your pocket or keeps administrative heat off your back? My guess is no and you're just dying on some hill no one cares about. Just put your name on the patient, throw in any orders you can based on triage, and see them when you see them. Or don't and just sign out the late shift patients you see if that's acceptable in your shop. Or just don't sign up for patients if everyone else builds an off-ramp at the end of their shift. Plenty of alternatives to staying late.

Emergency physicians are a little too eager to get up on a cross sometimes and this sounds like one of those times.

If people just try to do what’s right for the patient and dept flow, rather than trying to make it look like they’re busy or hit some meaninglessness gamed metric, then it all works out.

 

[Janders]

Okay. Pay attention.
...
So bro, I hear you when you say: "the problem players at my 100% RVU shop in the arena have both been men".
But I want to ask: "These men you speak of.... are they little b!tches? Because this is little b!tch behavior."

Having paid attention, your theory / description just doesn't match my years working at my (entirely) eat-what-you-kill shop, or lesser experience working hourly at moonlighting places.

Perhaps being entirely eat-what-you-kill means everyone has some motivation to pick up WR patients? No one gives a **** about some magical "I saw 16 patients this shift so I don't need to see more" or "I saw 12 patients my first 2hr and thus I get a 2hr break". If you see patient, you get monies. If you no see patient, you get no monies but you sit in ER. If you stay late? Well either its your fault for being a distracted slow charter, or its because it was busy as hell and you saw 3-4 an hour for your last 3 hours and... you'll make $$$.

The potential bad of such a system-
(1) Cherry picking based on insurance or such... this would be a massive sin, its hard to see insurance info in our charts (most people don't know how) and is just so unkosher it hasn't been an issue.
(2) Cherry picking based on complaint / procedure / perceived ease-of-dispo to work ratio. This is also bad. Hard to entirely police. Likely solved by social pressors amongst providers (Hey dingus, that vaginal bleed has been skipped 3x already! stop grabbing ankle sprains). Also when flow is slow, you take turns grabbing patients. It IS obviously OK to spend your last hour seeing lower acuity unless critically needed to do other things. That being said, its not BAD to have some minimal competition to see patients, reduce dislocations, place splints, etc. In the end, it gets more patients speedy care.
(3) Going so fast to maximize revenue and ignore good care. This is my biggest fear of our system, and I think policing it requires a stable group, ethics, and people who are truly committed to quality and revue it.

Anyway... the "issues" we've had have been more men that have mismatched "aggression to go grab patients in WR" with "social graces to realize I need to share patients with my partners semi-equitably and communicate". Rather uncommon and self-policed.

So I continue to reject the theory that female EPs are somehow more apt to game systems and fudge numbers?

 

[bravotwozero]

At HCA you pretty much have to see patients in the WR, if there's nowhere else to put them. They track door to doc etc, so not really much of a choice

 

[AlmostAnMD]

At HCA you pretty much have to see patients in the WR, if there's nowhere else to put them. They track door to doc etc, so not really much of a choice

Sad

HCA should also track takeover-to-bankruptcy
times

 

[WhatJobDoIPick]

At HCA you pretty much have to see patients in the WR, if there's nowhere else to put them. They track door to doc etc, so not really much of a choice

The choice is to not work for them.

 

[RustedFox]

Having paid attention, your theory / description just doesn't match my years working at my (entirely) eat-what-you-kill shop, or lesser experience working hourly at moonlighting places.

Perhaps being entirely eat-what-you-kill means everyone has some motivation to pick up WR patients? No one gives a **** about some magical "I saw 16 patients this shift so I don't need to see more" or "I saw 12 patients my first 2hr and thus I get a 2hr break". If you see patient, you get monies. If you no see patient, you get no monies but you sit in ER. If you stay late? Well either its your fault for being a distracted slow charter, or its because it was busy as hell and you saw 3-4 an hour for your last 3 hours and... you'll make $$$.

The potential bad of such a system-
(1) Cherry picking based on insurance or such... this would be a massive sin, its hard to see insurance info in our charts (most people don't know how) and is just so unkosher it hasn't been an issue.
(2) Cherry picking based on complaint / procedure / perceived ease-of-dispo to work ratio. This is also bad. Hard to entirely police. Likely solved by social pressors amongst providers (Hey dingus, that vaginal bleed has been skipped 3x already! stop grabbing ankle sprains). Also when flow is slow, you take turns grabbing patients. It IS obviously OK to spend your last hour seeing lower acuity unless critically needed to do other things. That being said, its not BAD to have some minimal competition to see patients, reduce dislocations, place splints, etc. In the end, it gets more patients speedy care.
(3) Going so fast to maximize revenue and ignore good care. This is my biggest fear of our system, and I think policing it requires a stable group, ethics, and people who are truly committed to quality and revue it.

Anyway... the "issues" we've had have been more men that have mismatched "aggression to go grab patients in WR" with "social graces to realize I need to share patients with my partners semi-equitably and communicate". Rather uncommon and self-policed.

So I continue to reject the theory that female EPs are somehow more apt to game systems and fudge numbers?

You know somehow my brain missed that this is a 100% RVU shop.
If that's the case; then they shouldn't give a damn about the numbers; but they are being greedy and not distributing the patient load.
I still stand behind what I said about this being an extension of the feminine brain's fixation on perception and not reality.

 

[emergentmd]

Been out of the Pit for 7 years and things must have changed. Worked at a Part RVU place, and flat rate place. Been at Level 1, county, community so I would say I have experienced it all.

NEVER. I mean NEVER have I ever assigned myself to a waiting room patient. Never have I seen a pt in the WR (before Covid). Quadruple Never would I assign myself a WR patient and required to see them before my shift.

Admin tried to have our group see WR pts but we all balked and they hired APCs to do the dirty work.

You guys have given up or have becomes sheeps following C suite orders. See pts in the WR is dumb in so many ways and for some to find this is an acceptable way to practice just floors me.

What is next? Are you going to start to see pts in the parking lot?

 

[WhatJobDoIPick]

Been out of the Pit for 7 years and things must have changed. Worked at a Part RVU place, and flat rate place. Been at Level 1, county, community so I would say I have experienced it all.

NEVER. I mean NEVER have I ever assigned myself to a waiting room patient. Never have I seen a pt in the WR (before Covid). Quadruple Never would I assign myself a WR patient and required to see them before my shift.

Admin tried to have our group see WR pts but we all balked and they hired APCs to do the dirty work.

You guys have given up or have becomes sheeps following C suite orders. See pts in the WR is dumb in so many ways and for some to find this is an acceptable way to practice just floors me.

What is next? Are you going to start to see pts in the parking lot?

Most ER physicians are gutless and will do anything for a paycheck.

 

[Mount Asclepius]

Why is this an all or none discussion?

How many people are doing a version of a split flow, vertical/horizontal patient model?

Keep vertical patients vertical. Bring back to a room. Examine. Order labs and/or imaging if indicated. Draw labs. Return patient to waiting or internal waiting room pending imaging and testing results. Bring them back to a room when resulted. Then disposition.

Frees up rooms and allows you to not have to see patients in the waiting room.

 

[TeddyBoomBoom]

So…. maybe a partial counterpoint from a partner in a SDG.

I’m a partner in a SDG. We basically pay ourselves hourly and then split the profits throughout the year. There is a VERY minimal productivity incentive, but we’re taking to 0-$3K/month, so clearly not super impt.

In general, we don’t sign up for patients in the waiting room, although we will definitely put in armchair orders if it looks like it will speed things up.

I will very occasionally officially take pts from the waiting room if I have a specific reason (I got a call from an outside doc, I know the pt, or they’re a pain and i’m trying to jump on a grenade.) Of course I’ll take them if I can get them dispo’d from the waiting room (best case.)

Our pay is very egalitarian, so our motives are just to be as efficient as possible. My fellow partners basically share the load. Both we and our contracting hospital system seem pretty happy.

But again, that’s from the perspective of a partner in a group - I’m sure it would be wayyyyy different working as an employed hospital doc or working for a cmg.

 

[emergentmd]

Pull pts back, put them in triage, see them in the dept, put orders in, send them where ever you want to improve flow. Sometimes there is just no room and you do the best you can.

BUT, I am not assigning myself or putting orders in on a pt that I did not see. This to me is insane.

Imagine a shift that benign appearing 20 YO pt with a cough comes in with ok Vitals. Guess what, he actually complained of SOB but the triage nurse just clicked whatever was easiest. You sign up. She dies of a PE in the waiting room. Explain me how you could ever defend yourself.

I have been in MEC for 6+years and am always pro doc trying to find reasons for their care. In no way can I defend a doc who has their name on the pt for hours, never sees them, and there is a bad outcome. This is a disaster of a med mal case.

 

[Mount Asclepius]

I’ve heard medicolegal concerns expressed by many EPs regarding signing up for a patient in the waiting room, but not yet roomed, or getting testing started (either nursing collaborative orders ordered under your name by nursing or physicians directly ordering to get the ball moving). Has anyone ever heard of or been a part of a law suit that was successful for something like this? My suspicion is that while these are valid concerns, it really doesn’t happen. If any risk, I would think the facility would be at greater risk than yourself. If you made the argument that there wasn’t an open room to see the patient (perhaps due to lack of nursing staffing or inpatient boarding), but you were trying to help the patient even though they couldn’t be seen yet due to factors outside your control.

 

[turkeyjerky]

Why is this an all or none discussion?

How many people are doing a version of a split flow, vertical/horizontal patient model?

Keep vertical patients vertical. Bring back to a room. Examine. Order labs and/or imaging if indicated. Draw labs. Return patient to waiting or internal waiting room pending imaging and testing results. Bring them back to a room when resulted. Then disposition.

Frees up rooms and allows you to not have to see patients in the waiting room.

I’ll do you one better.

We see pts in the waiting room, put in all orders, then they get pulled back, stay in a room to get all the testing done (even if an mri that takes 5 or 6 hrs).

B/c we’re spineless and nursing doesn’t give a rats ass about flow.

 

[Mount Asclepius]

I’ll do you one better.

We see pts in the waiting room, put in all orders, then they get pulled back, stay in a room to get all the testing done (even if an mri that takes 5 or 6 hrs).

B/c we’re spineless and nursing doesn’t give a rats ass about flow.

Agree, nursing compensation is not tied to time metric pressures like physicians face and yet we have limited to no control over nursing staffing and productivity.

Seems like that process is backwards. Most of the time spent waiting is for testing to be performed such as imaging, which can happen from the waiting room in vertical patients, or for labs to result, which should be drawn immediately and then wait rather than just order and sit around waiting for a room so they can be drawn. In my opinion, better to get labs started processing and imaging ordered. Then relocate out of a room to wait for radiology to come get the patient for their study. This accomplishes flow in parallel more so than in series reducing queueing and bottlenecks.

Movement though takes efficient EVS and transport techs to be successful. Many hospitals don’t readily prioritize the staffing for these groups though despite unilaterally trying to impose metrics on physicians who have limited ability to influence without resources.