Dangerously Busy?
Started by Old_Mil
D
deleted109597
What's the question? To moonlight or to work?
How much physician coverage? Admitting percentages?
How much physician coverage? Admitting percentages?
I'd stay away from any place that makes you do "floor procedures". The maximum I'd accept is covering codes in the hospital and intubating. Any other procedures should be figured out by the patient's primary.
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Our group covers several small rural CAH (critical access hospitals). We do cover codes on the floors. Do not accept anything else. You will get taken advantage of. And don't think collegiality will work: if something goes wrong, you'll be the first on the hook.
Do the math. Single coverage I assume.
$22K/year = 60 per day, or 20 per 8 hour shift or 30 per 12 hour shift. That's about 2.5 an hour, but it will be heavily skewed toward the times that the PA is there. If you assume the PA sees 20 of those 60, then you're down to 20 per 12 hour shift, a relatively comfortable 1.67 per hour assuming a reasonably efficient department (a big assumption.) Floor codes tend to come with the territory. I'd flesh out the "floor procedures" in the contract, but it might not be that bad, especially if real ICU patients don't stay in the hospital. But if it means doing it most shifts, that's not going to work. I'd also avoid it if it means you're the OB until the OB gets there. Too much liability.
$22K/year = 60 per day, or 20 per 8 hour shift or 30 per 12 hour shift. That's about 2.5 an hour, but it will be heavily skewed toward the times that the PA is there. If you assume the PA sees 20 of those 60, then you're down to 20 per 12 hour shift, a relatively comfortable 1.67 per hour assuming a reasonably efficient department (a big assumption.) Floor codes tend to come with the territory. I'd flesh out the "floor procedures" in the contract, but it might not be that bad, especially if real ICU patients don't stay in the hospital. But if it means doing it most shifts, that's not going to work. I'd also avoid it if it means you're the OB until the OB gets there. Too much liability.
D
deleted6669
I work per diem at a place with a similar arrangement but only 8 hrs of pa coverage.
sometimes the docs love it(when it's slow) but sometimes they are seeing 3-4/hr for their entire 12 hr shift.
acuity is very high as it is a retirement community. 9 mo of the yr the avg pt age is > 65 with an influx of tourists in the summer only. we have a hospitalist in house during business hrs and available after hrs for non-emergent floor issues or new icu admissions. overall the docs are very happy and I could see myself working there if I was a doc. surgery, ortho, and ob are available on alternate days so many pts are transfered on off days. the docs there use their critical care skills more often than the docs at my level 1 trauma ctr job because there is no trauma team, resident service, etc.
sometimes the docs love it(when it's slow) but sometimes they are seeing 3-4/hr for their entire 12 hr shift.
acuity is very high as it is a retirement community. 9 mo of the yr the avg pt age is > 65 with an influx of tourists in the summer only. we have a hospitalist in house during business hrs and available after hrs for non-emergent floor issues or new icu admissions. overall the docs are very happy and I could see myself working there if I was a doc. surgery, ortho, and ob are available on alternate days so many pts are transfered on off days. the docs there use their critical care skills more often than the docs at my level 1 trauma ctr job because there is no trauma team, resident service, etc.
Routinely where I work (50K volume L3 trauma with 50 ICU beds), I get calls from lazy intensivists who want central lines put in their ICU patients upstairs. I politely refuse, and magically they get done somehow. Just have to polite but firm.
If a patient is coding or otherwise under my care I don't have a problem, but I'm not touching the chart of non-critical patients who are under the care of others.
Thanks for this!
House supervisor here, who works in a small rural hospital, and I get the hospitalists calling me all the time to go get the ER doc for: nasal packing, ekg reads, sutures, central line placements (that should have been done hours before, upon admission, not at 0100 when trouble is coming), and I politely refuse, and give them the ED's number so they can call the ED doc themselves. magically, they don't ever call, and the procedure gets done.
Nursing (or ED docs) has no business in the middle of inpatient medical management (unless it's emergent, then I still believe the hospitalist should come in)
I'm in the minority: "we've been doing it for years" is what I hear, but I also know the ED doc likely won't get reimbursed, and is now on the hook for the EKG he just (graciously) read
I refuse to ask the ED docs to do any of that
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Seriously??? Are there really hospitalists, or do you have community attendings that round? If I got a call regarding a patient in the middle of the night, I may beg one emergency docs to give a quick look regarding the need for me to get out of bed, but I would never call him to read an ECG... I would never call at all if I was a hospitalist. That's just crap.
I wish it was just a story...Almost every shift, really.
Yes hospitalists and community attendings all behave the same way (out of the goup of 10 hospitalists, only 2 do central lines and their own intubations)
no intensivists...non teaching, rural hospital
Their (hospitalists, signed off by the board) rule is that, unless it is an 'emergency' (left for the doc to decide) the hospitalists don't (have to) come in at all (and don't even field admit calls from the ED docs) after 1900, PERIOD.
So (oncoming next day) hospitalists get a list of admitted patients at 0700, and they get a status update about the pt's progress (or lack therof) from the nursing staff
Unbelievable stuff really, but reality to those "born and bred" here
Hospitalists were asking med surg RNs to read (read:interpret) their EKGs, having ED docs do nasal packing, suturing, placing central lines, on inpatients, DURING DAY SHIFT hours
We get called to intubate patients all the time in the ICU. The ICU pulmonologist will often be at bedside requesting a specific tube size. I don't know if it's laziness, or lack of procedural qualifications or both that makes them behave like this.
hospitalists at my new shop don't do ANY procedures... lung/belly taps are all done by IR. not sure who does floor central lines, but recently i tubed and resuscitated a ginormously obese lady. nurses had 2 18g iv's. pt's bp was borderline and responded to fluid bolus. i had called hospitalist 90 min prior about icu admit, talked to pulm/cc doc... she was even off the ED board.
hospitalist finds me to ask me to put in a central line... 10 min before the end of my shift. (talked to the nurses - he was afraid to call the icu doc). i told him very nicely to call the icu doc b/c the pt was about to roll upstairs. smdh....
hospitalist finds me to ask me to put in a central line... 10 min before the end of my shift. (talked to the nurses - he was afraid to call the icu doc). i told him very nicely to call the icu doc b/c the pt was about to roll upstairs. smdh....
I had one hospitalist say that she hasn't done a LP in years.
That's not your problem, that's her problem. Certainly she can call a neurologist, order an IR study, or transfer the patient out if she can't get it done.
D
deleted6669
or ask the PA to do it.....🙂
I despise you.
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D
deleted6669
This is sdn. get in line.
Not shocking at all. Hospital I'm at IM residents do gobs and gobs of central lines but I've never seen or heard of one doing an LP. IR consult all the way . . .
Is there a list of required procedures for specialties other than EM ?
All residencies have a list of required procedures that I have recently found out change with time. As in I'm supposed to be logging all my I&Ds, pelvic exams, and lac repairs. They also call medical stabilization a procedure...which can only be interpreted as you wish. No specific guidelines. I tend to log medical stabilizations as transfers and ICU admits or I would be logging all day long.
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Dangerous to whom?
1) Your health and sanity?
2) Your marriage?
3) Your Press-Ganey score?
4) Your malpractice claims history?
5) Your patients health and well-being?
In my opinion, the danger is less as you go from 1-5. I don't think the situation as your describe it constitutes an immediate threat to patient safety - but the resulting stress may well have very negative effects on you and your family.
1) Your health and sanity?
2) Your marriage?
3) Your Press-Ganey score?
4) Your malpractice claims history?
5) Your patients health and well-being?
In my opinion, the danger is less as you go from 1-5. I don't think the situation as your describe it constitutes an immediate threat to patient safety - but the resulting stress may well have very negative effects on you and your family.
12 or 24 hr shifts?
22k doesn't work out to an excessive amount of pts/hr, but especially in rural hospitals there is not a normal distribution of when patients arrive. See if you can find out the breakdown of patient arrivals by hour of the day. I wouldn't be suprised to find out that 40 of their 60 patients arrive between 4 and 9.
I don't know, I think if you are the only doc in the ED and you are physically somewhere else (like in the ICU doing a central line) you could be held responsible if someone sick comes into the ED. What if a trauma comes in? If you are in the ER and it's busy you are only seconds away from a given room. If you are upstairs somewhere it's a bit more dodgy.
I would certainly get in writing a liste of "procedures" you are expected to cover. If the list is too extensive, and includes much more than intubation, codes, and lines on unstable patients then I'd seek employement elsewhere. If the hospital or group won't give you the list then run elsewhere.
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We should expect the pay that the hospitalists or ICU docs get for night call go to us if we have to "come in" to the ICU.
HH
When I moonlight, I looked for volumes of less than 15K or more than 30K. The less than 15K is not bad to manage as a well trained EM physician. As you approach the 30K, you end up double physician coverage at least part of the day and perhaps a midlevel as well..
I do not like the 18-25K places with only a midlevel... I would not want to work there as 'my career'.. The few times I worked those places, it sucked. Maybe I just had bad days.. I dunno.
Most of these sized shops, you are expected to cover code situations throughout the hospital as you are probably the ONLY doc there at night. I moonlit A LOT the last two years of residency and I probably went to a total of 3 codes..
If its a code situation, I dont think its a huge deal as its rare. If you are having to do all the lines, and non emergent procedures... I would tell someone to pound sand... or have a set price for each that you do.
I do not like the 18-25K places with only a midlevel... I would not want to work there as 'my career'.. The few times I worked those places, it sucked. Maybe I just had bad days.. I dunno.
Most of these sized shops, you are expected to cover code situations throughout the hospital as you are probably the ONLY doc there at night. I moonlit A LOT the last two years of residency and I probably went to a total of 3 codes..
If its a code situation, I dont think its a huge deal as its rare. If you are having to do all the lines, and non emergent procedures... I would tell someone to pound sand... or have a set price for each that you do.
That's what I'm worried about. This is for an attending/career job, not moonlighting. Floor work would include codes, tubes, lines, LPs, vent adjustments because the admitting hospitalists are not in house 24/7. The more I find out about it, the more it sounds like a place that uses the ER doc as a well paid scutmonkey and the single coverage + PA is the staffing model that has been chosen so that all the wallets above the pay grade of physician can get their pound of flesh. It's a place that really should have two ED docs.
Run away!!!
Unless this is in some uber desirable spot to live and you would give your left n** to live there... I would run away.. there are MUCH better jobs out there...
I agree with the others. Do not take this job. Unless there is a guarantee of over $200 plus benefits, it's not worth it. The other docs can, and will abuse the ER physicians if they can get away with it.
There are enough jobs available that any BC/BE physician shouldn't have to do this.
There are two ways to work it: first is that you come up with an insane number for pay - like twice as much as they offer. They would be insane to take it. However, if they DO go for it, the job suxx, but you make buckets of cash.
If you lowball it, you screw yourself. If you offer something like a 10% higher number, they'll take it, and you have shot yourself squarely in the groin.
The other way is to pound salt, and tell them, professionally and politely, that you are trained EM physician; you are not a procedure monkey or a red-headed stepchild.
If you lowball it, you screw yourself. If you offer something like a 10% higher number, they'll take it, and you have shot yourself squarely in the groin.
The other way is to pound salt, and tell them, professionally and politely, that you are trained EM physician; you are not a procedure monkey or a red-headed stepchild.
I would seriously look into why this place is hiring.
I'll venture that the previous ED docs left. Prob early. Ask about the previous turnover, ohh, for like the last 10 years.
I'll also venture that the hospital docs likely get paid more.
You will be the scut monkey. Enjoy your intern years, forever.
This definitely isn't a lifestyle job.😀
I'll venture that the previous ED docs left. Prob early. Ask about the previous turnover, ohh, for like the last 10 years.
I'll also venture that the hospital docs likely get paid more.
You will be the scut monkey. Enjoy your intern years, forever.
This definitely isn't a lifestyle job.😀
Doing further research, a group called ECI has several simiarly sized ERs that they seem to cover with two docs AND a PA. Don't know much about them specifically, but that sort of puts into perspective how bad a deal this could be. I'm passing on the site visit. 👍
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We cover all that at one of our smaller hospitals (where hospitalists aren't in-house during the night). I've only responded to one code on the floor and intubated one person. I've never had to do an LP on the floor, suture someone, etc. there.
Ok - just to play devil's advocate...
These types of departments are not a bad deal to work in if they are relatively lower acuity (admit% <25) and have relatively stable daily volumes. Midlevel coverage is great in these cases. The reality is there are only 60 patients per day split between three providers, or 20 patients per provider. As mentioned above, most of this volumes peaks later in the day shift, and ends later in the night shift. I assume the PA is scheduled to cover historical peak hours (noon or 1pm to 10 or 11 at night) and sees the same number of patients as the physicians.
Nights at these places can be relatively predictable, and will often allow sleep (yes - sleep) between the hours of 2-3am and 6am - although not a guarantee.
From a medical staff perspective, especially if this is a location where you see yourself staying for 4-5 years, the opportunities are almost endless. Small hospitals give you a great opportunity to become known as a strong physician, a problem solver, and a reliable contact. Your ability to move up in the ranks of medical staff is good, and it will only help your career.
Also, as most hospitals today will be feeling the crunch to meet their bottom line, they will surely plan to expand their volume and service lines over time, which is a great opportunity for you to grow with the hospital, and eventually increase coverage and change how things are done. Check to see what their plans for volume expansion are.
Not sure if this is your bag or not, but if it is even a remote consideration, you may think twice about this type of setup. I also agree with Veers - a rate above 200/hr plus bennies would be nice. $230 as an independent contract would be ideal, especially if you can negotiate a set "call rate" for in house procedures. As also mentioned above, you won't have many calls for floor procedures. In reality, you'll probably have plenty of time seeing 1.66 patients per hour to put in your own lines and do most of your own procedures before patients even leave your department...
These types of departments are not a bad deal to work in if they are relatively lower acuity (admit% <25) and have relatively stable daily volumes. Midlevel coverage is great in these cases. The reality is there are only 60 patients per day split between three providers, or 20 patients per provider. As mentioned above, most of this volumes peaks later in the day shift, and ends later in the night shift. I assume the PA is scheduled to cover historical peak hours (noon or 1pm to 10 or 11 at night) and sees the same number of patients as the physicians.
Nights at these places can be relatively predictable, and will often allow sleep (yes - sleep) between the hours of 2-3am and 6am - although not a guarantee.
From a medical staff perspective, especially if this is a location where you see yourself staying for 4-5 years, the opportunities are almost endless. Small hospitals give you a great opportunity to become known as a strong physician, a problem solver, and a reliable contact. Your ability to move up in the ranks of medical staff is good, and it will only help your career.
Also, as most hospitals today will be feeling the crunch to meet their bottom line, they will surely plan to expand their volume and service lines over time, which is a great opportunity for you to grow with the hospital, and eventually increase coverage and change how things are done. Check to see what their plans for volume expansion are.
Not sure if this is your bag or not, but if it is even a remote consideration, you may think twice about this type of setup. I also agree with Veers - a rate above 200/hr plus bennies would be nice. $230 as an independent contract would be ideal, especially if you can negotiate a set "call rate" for in house procedures. As also mentioned above, you won't have many calls for floor procedures. In reality, you'll probably have plenty of time seeing 1.66 patients per hour to put in your own lines and do most of your own procedures before patients even leave your department...
This very scenario happened in our hospital last week (Our ED, from 0700-1300, and from 2300-0700, runs with one doc alone, and sometimes it's an FP guy)
CP came in (active MI), pt was delayed ten minutes into cath lab, 'cause ED doc was upstairs in cath lab (ironically enough) tubing a pt who went south on the table. Oh, and best part was, it was during the day - 1100, during the week, while anesthesia (surgery is next door to cath lab) lined up to watch ED doc (an FP doc BTW) struggle with the intubation.
Hospital admin had repeatedly ignored my pleas to not let ED doc leave the ER for procedures during DAY SHIFT HOURS (when other capable docs are crawling around the place)
But the cath lab RN called the ED charge RN (tool 1 calling tool 2) to get our ED guy up to tube the dead guy.
Before that day, despite my pleas, no one had ever conceived of any problems, as 'they have always done it that way' (and since then, solo ED doc has been called away yet again, to do a nasal packing, at 0930 yesterday morning, as the hospitalist 'didn't know how') leaving the ED unmanned by any doc
This reason alone should be enough to scare one away from an ED gig whose hospital admin allows its hospitalists to not do certain procedures, and puts the ED doc at risk for liability, period.
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Yup, that's all it takes, the perfect storm of negative events.
I have no illusions that if something went wrong, the ED doc will be thrown under the bus.
I have no illusions that if something went wrong, the ED doc will be thrown under the bus.
I worked at a number of single coverage setups in rural Texas. I was responsible for any codes 24 hours, and emergent intubations. Both were fairly rare, since most unstable patients got transferred out. As far as any other procedures, we were not responsible and I would tell the hospitalist such. Need that nose packed? Transfer him out to a place with ENT. Need an LP? Transfer out to a place with neuro and/or IR.
This job still sounds frightening to me.
