attending to attending sign outs

[unchartedem]

So I was just wondering how it's like for everyone else, but signing out is a huge pain in the ass for me. There are a couple of attendings in my group that are a little too "nosy" in the patient I'm signing out if that makes any sense. I sort of trust in myself that if there's something the other attending needs to know about my patient then I will tell him or her. I want to get to the point of each patient and then be done and move on, not to be asked a ton of questions. When I receive sign out from other attendings I don't overly dwell on the case at hand nor do they offer anymore info. and I'm fine with that.
Is there a way I should be signing out my patients to sort of forceably avoid going too in depth? To play my own devil's advocate I understand that asking more q's at sign out can only better pt. care but I'm confident enough in myself to tell only what needs to be told. I'm confident in the other attendings as well. Am I being overly dramatic or do other people here sometimes have the same problem?

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[jendc08]

How long have you been there?

 

[RustedFox]

I'm in the opposite camp. When I get sign-outs, I wish that (some) fellow attendings would tell me MORE about their thought process.

 

[Apollyon]

Are you still a resident? (Your status says so.)

If you are now in practice, I'll tell you that you treat the oncoming attending like you do consultants - whatever they want to know, you tell them. For whatever reason - have been burned before, conservative, obsessive, whatever - they want to know minutiae, give it to them. Your post gave me an initial feeling of being haughty - "I know what they need to know or not". You also have a contradiction, as you acknowledge that more questions lead to better care.

If you are fresh out, this isn't the way to start. If you aren't, then you should already be getting some feedback. What will sucker punch you is if one of these colleagues from whom you are withholding information finds that information on their own - now, you are "that person" that is not thorough.

 

[unchartedem]

I've been there for over a year. When I was in residency I guess my exposure was different. When I saw other attendings signing out to each other it wasn't like they were presenting each case like they were talking to an accepting physician at another hospital. I'm not trying to be cocky or sound haughty, but I do believe we should all by the time of practice have some sort of focused sign out. If a patient that I saw myself is stable, there is nothing pending or to follow-up on, there is no potential for decompensation, why do I need to state something that has no bearing to the fact? I mean I'm fairly certain that no one here signs out their patients with C.C., complete ROS, complete PE, PSH, allergies, etc... we all at some point carve things out to make things relevant. I wouldn't consider that haughty.

 

[Apollyon]

Then I don't know what to tell you. If you are signing out patients, something is left to follow up. If your colleagues are pimping you for patients admitted ("bed 7 is uncomplicated pancreatitis, admitted to medicine"), then that is a whole other issue. But, if the patient is not dispositioned, then the doc who is getting the patient from you, I believe, has a right to whatever they want to know, no matter how trivial.

 

[Arcan57]

Are they like that with everyone or just you?

 

[WilcoWorld]

Sometimes people irk me by asking a lot of seemingly irrelevant questions during sign out, but I agree with Apollyon that it's their right to do so, and it's in your best interest to be forthcoming (and polite) with the info.

And as Arcan may be getting at, it's worth asking yourself if you've given them reason to act this way.

 

[EM_Rebuilder]

Are they like that with everyone or just you?

This.


And, do you sign out MORE patients than other folks? How are you paid, is there an RVU bonus given to the person who only FIRST sees the patient?

We seldom have signouts since we do not take new patients the last hour, plus we have a small RVU component that goes to the discharging doctor, so its often worth sticking around 30 minutes or less if you can get them dispo'd in that time. On the flip side, I LOVE getting a 'follow up CT signout' as I can see that CT and typically d/c them on consult and I get that RVU component...


It makes me wonder if the rest of the group feels like you 'leave them a bunch of crap' that they have to go clean up for you. It might be worth while to talk to your director in a private setting to see if there is a problem that YOU need to fix. Again, I dont want to point fingers, but often a little self reflection is a good starting point....

 

[edgesofsanity]

Keep in mind you are medicolegally on the hook for patients that have been signed out to you. If they end up having a bad outcome, regardless of their dispo, you will be named in the lawsuit.

Given that, I think it's understandable that some members of your group want more information - the risk tolerance of practitioners in our discipline varies widely.

 

[southerndoc]

The person who receives sign out is ultimately responsible for the patient's outcome. He/she should be free to ask every question available. We have one doc in our group who wants sign out at bedside with the patient listening to the plan. I could care less because he's doing me a favor to allow me to leave on time or early. Nothing says that the oncoming physician must accept a sign out.

EDIT: Are you talking about signing out things pending or patients already admitted? I'm assuming with things pending as telling another doc about patients being discharged or admitted isn't what I was thinking when you said sign out.

 

[deleted109597]

And, do you sign out MORE patients than other folks? How are you paid, is there an RVU bonus given to the person who only FIRST sees the patient?

Usually it's the opposite (in my experience). The last name on the chart gets the dollars.

 

[Arcan57]

Usually it's the opposite (in my experience). The last name on the chart gets the dollars.

We get nothing if we sign out a patient. This leads to a lot of waiting around for CTs to be read, etc. because we can't trust the in-patient side to follow-up on studies (even ones they ask for).

 

[deleted109597]

We get nothing if we sign out a patient. This leads to a lot of waiting around for CTs to be read, etc. because we can't trust the in-patient side to follow-up on studies (even ones they ask for).

Yep.

 

[Doctor Bob]

I'm at an academic place so maybe it's different... if it's a case with residents then the incoming attendings usually want 1-2 sentence blurbs with a 1 sentence plan for disposition. If it's an attending primary patient they want more detail. And everyone's different in the amount of detail. Usually the risk-minimizers/test-maximizers ask the most questions and the test-minimizers/risk-maximizers ask the fewest.

 

[dotcb]

From doing an EM residency and then going into practice, you will have several thousand patients signed out to you. Giving and receiving sign-out it a skill just like anything else in the profession. Hopefully you will get good at it, but there's some personal style to it as well. I happen to be someone who prefers less information beyond a clear plan of things to follow up and disposition. But you have to be attuned to someone who's signing out a bomb to you, and get more info when necessary. It's also very appropriate to ask someone to clean up their dispo plan a little more before you take over the patient. For me the bottom line is: don't be one of those people who it's a pain to sign out to, but also don't allow yourself to get taken advantage of. On the flip side, do your best to complete patient care tasks and have tight sign-out plans for the teams that follow you.

 

[AmoryBlaine]

What I have noticed as an attending is that there is a great deal of "what can I do to get you out of here?" and that question in utterly insincere at least 50% of the time. The one time I tried to sign out 2 fairly early, undifferentiated patients the oncoming attending was openly hostile saying things like "you shouldn't be doing this."

It is amazing to me because we still have M+M and the occasional med mal case in our department, but for many of the attendings if you say, "this patient needs some reassessment" they are immediately hostile and angry.

It's not what I expected at all. Granted small # of people.

 

[Arcan57]

What I have noticed as an attending is that there is a great deal of "what can I do to get you out of here?" and that question in utterly insincere at least 50% of the time. The one time I tried to sign out 2 fairly early, undifferentiated patients the oncoming attending was openly hostile saying things like "you shouldn't be doing this."

It is amazing to me because we still have M+M and the occasional med mal case in our department, but for many of the attendings if you say, "this patient needs some reassessment" they are immediately hostile and angry.

It's not what I expected at all. Granted small # of people.

I was thinking of this last night. In residency (especially post-night shift), there would be a patient at the end of every 4 shifts or so that I didn't really know what was going on with them. When I was signing them out, I'd tell the on-coming resident that they needed to be seen as a new patient. Now, I'll pop in briefly, get labs started, and not sign up for the patient on the board.

 

[deleted109597]

What I have noticed as an attending is that there is a great deal of "what can I do to get you out of here?" and that question in utterly insincere at least 50% of the time. The one time I tried to sign out 2 fairly early, undifferentiated patients the oncoming attending was openly hostile saying things like "you shouldn't be doing this."

This is why I wouldn't pick up certain complaints less than 90 minutes prior to shift change. You know what is easier than signing out with a "you need to follow up this CT and reassess the abdomen"? Not seeing the patient in the first place.

 

[Apollyon]

So, the OP is MIA, after checking in once. Either she (I thought the OP was a woman) is working A LOT, or someone hit the nail squarely on the head.

 

[southerndoc]

This is why I wouldn't pick up certain complaints less than 90 minutes prior to shift change. You know what is easier than signing out with a "you need to follow up this CT and reassess the abdomen"? Not seeing the patient in the first place.

In community practice this is hard to do. Not only for Press-Ganey, but also for liability reasons. Not seeing a patient that looks stable but has a bad outcome can be a litigation nightmare if they show it took more than an hour for the patient to be seen (even if you didn't treat the patient).

 

[AmoryBlaine]

This is why I wouldn't pick up certain complaints less than 90 minutes prior to shift change. You know what is easier than signing out with a "you need to follow up this CT and reassess the abdomen"? Not seeing the patient in the first place.

Agree in principle although I'd say more like 60 min. The problem with this as a solution is that I'm the new guy in the group and I don't want to get the rep as someone who checks out 1.5 hours early. I've definitely noticed that some of the older guys really start slowing down in the last 2 hours of their shift.

 

[deleted109597]

Agree in principle although I'd say more like 60 min. The problem with this as a solution is that I'm the new guy in the group and I don't want to get the rep as someone who checks out 1.5 hours early. I've definitely noticed that some of the older guys really start slowing down in the last 2 hours of their shift.

I didn't slow down. And since they order quite a bit in triage, there were some patients that I could pick up during that time frame. But the undifferentiated EMS abdominal pain? Not hardly. If only because picking it up meant staying there until the CT came back. And our rads guys wouldn't let us do the "no PO contrast" stuff because they argue that even though the studies show it equal, they feel it isn't. Another win for EBM.

Of course, I could order it without contrast, only to have them recommend some ridiculous triple contrast study to be repeated, doubling the radiation.

 

[la gringa]

Agree in principle although I'd say more like 60 min. The problem with this as a solution is that I'm the new guy in the group and I don't want to get the rep as someone who checks out 1.5 hours early. I've definitely noticed that some of the older guys really start slowing down in the last 2 hours of their shift.

AMEN... then you get the brunt of the patients who have been waiting now over 2 hrs to see you.

we have no overlap and it's expected you don't sign out much. i'd rather have a pt stay an extra hr or 2 to make sure they are dispo'ed correctly and won't come back than shooing them out the door quickly w/o a full w/u (think, rlq pain, stone study neg, no pelvic done, dc home as abd pain. i see them 8 hrs later, clearly adnexal, u/s shows cyst. pt very happy to have an answer and didn't come back).

ergo, i don't have many return visits and i am not the most "efficient" when you look at rvu/hr. i have partners who turn the board over faster, but have a ton more return visits. makes the #'s look better i guess it's one of the most frustrating things about my job.