Do your hospital sites let residents discuss whether patients warrant admision with the ED?

[VA Hopeful Dr]

BS, they get all the facilities fees and subsidies. They arent subsidizing a hospitalist 130k a year, between the facility RVUs (not just wRVU) they are billing out like 2 million a year for average hospitalist. The whole '130k' subsidy is a BS accounting trick. We make money, not lose it.

Billing =/= collecting.

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[Nocturnist]

Any physician who thinks they won't get sued because they "did everything right" needs to think again. As someone who does peer review and expert witness work, I can tell you that all that elaborate criteria doesn't need to be met. 99% of the time cases end in a settlement so there is very little "proving I practiced bad medicine".

Case: non-hemodynamically significant PE in a middle aged firefighter. Patient was admitted to telemetry, next day codes and dies. Patient was appropriately anti-coagulated and no one did anything wrong. Everyone was named, including the residents. It went on for 5 years before it was settled.

Patient dies after being discharged when another physician recommended to admit? Forget about the suit, just sign where they ask you to.

Sure, mate- nobody's thinking they'll never get sued for doing everything right, just like nobody's thinking they'll never get in a car accident for obeying all traffic laws. But we just went from me driving without a seatbelt to essentially a "you can wear your belt, helmet, scuba gear and fire suit but lookie here my friend's cousin's grandfather's catsitter still got hit by a lightning bolt while driving so why would you ever get inside that death trap?". What am I supposed to do with that information and how should my practice change?

Here's a chart of annual malpractice percentage claims by specialty. Anything ending with 'urgery is paying for the lawyer's private school bills. You can see ER and internal medicine have essentially identical rates of both claims and payments and are both under average. ER on average admit 26% of their visits and so send 3 of 4 patients out into the great abyss, never again to be seen again until returning lawyered up. How then by your logic does a specialty that lets the vast majority walk out come out neck and neck with a specialty that admits nearly everyone, monitors them for days, often with multiple specialties involved? And if it's such a liability why wouldn't the ER cut its to psychiatry levels by just admitting everything with a pulse walking through their door? Either you're telling me they're somehow just damn near 100% accurate at picking every needle in the haystack, or it's simply decoupled from admitting vs discharging and there's just a baseline "cost of doing business" to this job you just have to accept while doing your best to practice high quality evidence based medicine, doing due diligence, documenting your thought process, and not losing sleep over things out of our control.

I admit patients when indicated and when I have something to offer them in the hospital that can't be done at home or can't wait a couple days. I order tests and consults when indicated. Statistically most of us will get sued one day, and maybe my naivete will be shattered the first time that happens, but until that day I'm going to keep doing the right thing.

 

[Nocturnist]

BS, they get all the facilities fees and subsidies. They arent subsidizing a hospitalist 130k a year, between the facility RVUs (not just wRVU) they are billing out like 2 million a year for average hospitalist. The whole '130k' subsidy is a BS accounting trick. We make money, not lose it.

Every year on SDN I've only ever been reading about how much I'm losing the hospital and how soon midlevels are coming for my job.

Every year I've made more than the last and my job satisfaction has skyrocketed from midlevels handling my cross coverage and triage.

Can't believe everything you read on the internet.

 

[CCM-MD]

BS, they get all the facilities fees and subsidies. They arent subsidizing a hospitalist 130k a year, between the facility RVUs (not just wRVU) they are billing out like 2 million a year for average hospitalist. The whole '130k' subsidy is a BS accounting trick. We make money, not lose it.

Whatever makes you feel better.

 

[CCM-MD]

Sure, mate- nobody's thinking they'll never get sued for doing everything right, just like nobody's thinking they'll never get in a car accident for obeying all traffic laws. But we just went from me driving without a seatbelt to essentially a "you can wear your belt, helmet, scuba gear and fire suit but lookie here my friend's cousin's grandfather's catsitter still got hit by a lightning bolt while driving so why would you ever get inside that death trap?". What am I supposed to do with that information and how should my practice change?

Here's a chart of annual malpractice percentage claims by specialty. Anything ending with 'urgery is paying for the lawyer's private school bills. You can see ER and internal medicine have essentially identical rates of both claims and payments and are both under average. ER on average admit 26% of their visits and so send 3 of 4 patients out into the great abyss, never again to be seen again until returning lawyered up. How then by your logic does a specialty that lets the vast majority walk out come out neck and neck with a specialty that admits nearly everyone, monitors them for days, often with multiple specialties involved? And if it's such a liability why wouldn't the ER cut its to psychiatry levels by just admitting everything with a pulse walking through their door? Either you're telling me they're somehow just damn near 100% accurate at picking every needle in the haystack, or it's simply decoupled from admitting vs discharging and there's just a baseline "cost of doing business" to this job you just have to accept while doing your best to practice high quality evidence based medicine, doing due diligence, documenting your thought process, and not losing sleep over things out of our control.

I admit patients when indicated and when I have something to offer them in the hospital that can't be done at home or can't wait a couple days. I order tests and consults when indicated. Statistically most of us will get sued one day, and maybe my naivete will be shattered the first time that happens, but until that day I'm going to keep doing the right thing.

Pushing back on admits and discharging when the ER wants to admit involves taking on a lot of liability. That’s the only point I’m trying to make. I never asked you to change your practice or called you a bad physician. Don’t take it personally.

 

[collegestud2013]

BS, they get all the facilities fees and subsidies. They arent subsidizing a hospitalist 130k a year, between the facility RVUs (not just wRVU) they are billing out like 2 million a year for average hospitalist. The whole '130k' subsidy is a BS accounting trick. We make money, not lose it.

Unless it's a VIP patient that is paying the hospital cash for the whole stay, the hospital gets a more or less a fixed amount (based on DRGs) per stay from the patient's insurance, which doesn't change no matter how long the patient stays. This has been they way since around the 1980s and was done to control healthcare costs. This has to cover all the hospital's costs of providing care during that stay (eg nursing, electricity, food, imaging, etc....). Whether the hospital profits or loses depends largely on how long they stay or how much resources are used. The whole idea of getting hospitalists was so they can get the patient out faster. Of course if you're patient population has a high rate of uninsured patients then it's pretty hard to profit (in that case you should be working at public safety net hospital that gets subsidized to provide charity care).

If you're only counting the amount of money hospitalists bring in via billing E/M from their notes, then it's true that in most cases hospitalists require a "subsidy" to cover their pay, benefits, and other practice expenses like malpractice. But hospitalists can make the hospital money in addition to just what they bill for E/M if they get patients out quickly (and thus profiting from DRGs with short LOS), and refer to other specialties for the higher margin tests and elective procedures.

 

[aafisahar]

Doesn't it?

If you cut hospitalist pay/benefits by 25%, you're saving money.

Only if the hospitalists stay on and accept it. If they walk away, then the hospital is screwed.

This is the same **** anesthesia deals with. On paper, they are a pure "cost". However, when you try to lowball them or replace them with cheaper substitutes, you risk ruining all your surgical revenue. It's penny wise pound foolish.

 

[VA Hopeful Dr]

Only if the hospitalists stay on and accept it. If they walk away, then the hospital is screwed.

This is the same **** anesthesia deals with. On paper, they are a pure "cost". However, when you try to lowball them or replace them with cheaper substitutes, you risk ruining all your surgical revenue. It's penny wise pound foolish.

Right, if being the key word there.

 

[AlteredScale]

At my current hospital site all the residents are explicitly forbidden from any kind of pushback against ED admits. This leads to some pretty absurd stuff - for example I recently admitted a patient in the ED who was already improved to baseline s/p IVF, just to be told to write their discharge about an hour later when the attending saw them at the floor. Another example would be a LOL in NAD denied at their usual hospital because they "dont accept admits for placement"...admitted here. Multiple admits for ACS ruleout this week with negative trops, normal EKG and no cardiac history but still having their "weird chest feeling" after GERD treatment.

At the other hospitals I've rotated through theres usually some ability for residents to push back on this kind of thing to stop the unwarranted admission in the first place - what's your experience been like? Anyone else out there with a strict policy to accept any and all admits?

That is weird. My program absolutely has good conversations with the ED residents regarding appropriate disposition/admission. At our university hospital, this is mainly run by fellows/attendings but if I as a senior resident feel sketched out I will tell the attending and ask the ED resident to maybe do more workup. Our VA is insane with the weird admits but again, we can push back and are not aggressively discouraged.

 

[aafisahar]

Right, if being the key word there.

If this worked every hospital system would be doing this. If anything, hospitalist salaries are going up not down.

 

[end stage fibro]

If this worked every hospital system would be doing this. If anything, hospitalist salaries are going up not down.

I remain bullish re. the hospitalist job marketand salaries. Healthcare systems do anything they can to minimize and stabilize the cost center that is the hospital. Furthermore, we may be 2x more expensive than a midlevel, but I would says I'm at least w.5x as efficient. Another place hospitalists earn their keep(If your system has their own insurance as well) is minimizing consults and getting people out of the hospital, both of which are key to saving money

In short, if you don't mind being the medical mop man and can chug some extra shifts, hospitalist life style isn't bad and job security not precarious

 

[collegestud2013]

I remain bullish re. the hospitalist job marketand salaries. Healthcare systems do anything they can to minimize and stabilize the cost center that is the hospital. Furthermore, we may be 2x more expensive than a midlevel, but I would says I'm at least w.5x as efficient. Another place hospitalists earn their keep(If your system has their own insurance as well) is minimizing consults and getting people out of the hospital, both of which are key to saving money

In short, if you don't mind being the medical mop man and can chug some extra shifts, hospitalist life style isn't bad and job security not precarious

Hospitalist salaries have definitely gone up in the past decade. According to this report (Key trends in hospitalist compensation from the 2020 SoHM Report) it went from median of $215k in 2010 to $307k in 2020. Even after adjusted for inflation, that's about a 21% increase in pay over a 10 year period. If this trend continued you would expect the median hospitalist compensation to be around $370k in 2030 (in 2020 dollars).

Not sure if that trend will continue for the next decade though. There are a few things going against further large increases in hospitalist compensation, including tendencies for reimbursement cuts from Medicare every year, potential to use more midlevels as extenders (without technically replacing attendings), and the fact that the job market is already getting saturated in the big cities, and that hospitalist medicine has a relatively low entry barrier compared to other specialties. Any IM or FM grad can do it and these are the 2 largest and least competitive specialties to match into. It's become popular that even a good amount of FM grads are getting into it (and traditionally FM residency has emphasized more outpatient medicine while IM residency tends to be more inpatient focused), and even some fellowship trained sub-specialisits like Nephro and ID are doing it since in the the recent market it has paid more per hour than the lower paying IM subspecialities.

Minimizing consults doesn't really save the hospital money. Consults are additional E/M that the other specialties can bill for, and many places they want the business (especially if there's 2 or more groups in the same specialty competing for business at the same hospital).

 

[Siggy]

Minimizing consults doesn't really save the hospital money. Consults are additional E/M that the other specialties can bill for, and many places they want the business (especially if there's 2 or more groups in the same specialty competing for business at the same hospital).

High consultant utilization is associated with increased length of stay without mortality benefit. Longer lengths of stay does increase the hospital's cost.

Association of Variation in Consultant Use Among Hospitalists With Outcomes Among Medicare Beneficiaries

This cohort study examines whether higher rates of specialty consultation are associated with outcomes of hospitalized US Medicare beneficiaries.

jamanetwork.com

 

[VA Hopeful Dr]

If this worked every hospital system would be doing this. If anything, hospitalist salaries are going up not down.

Yep, and I suspect hospitals have started to realize that it's cheaper to pay more for existing doctors than pay to recruit new ones and arrange locums coverage while waiting for new people to start.

Starting next year my hospital is starting a new retirement plan for us. It's 100% hospital funded and slowly vests over 15 years. They've done the math and figured out that doing this will increase retention rates and end up being a net positive to their bottom line.

 

[end stage fibro]

Hospitalist salaries have definitely gone up in the past decade. According to this report (Key trends in hospitalist compensation from the 2020 SoHM Report) it went from median of $215k in 2010 to $307k in 2020. Even after adjusted for inflation, that's about a 21% increase in pay over a 10 year period. If this trend continued you would expect the median hospitalist compensation to be around $370k in 2030 (in 2020 dollars).

Not sure if that trend will continue for the next decade though. There are a few things going against further large increases in hospitalist compensation, including tendencies for reimbursement cuts from Medicare every year, potential to use more midlevels as extenders (without technically replacing attendings), and the fact that the job market is already getting saturated in the big cities, and that hospitalist medicine has a relatively low entry barrier compared to other specialties. Any IM or FM grad can do it and these are the 2 largest and least competitive specialties to match into. It's become popular that even a good amount of FM grads are getting into it (and traditionally FM residency has emphasized more outpatient medicine while IM residency tends to be more inpatient focused), and even some fellowship trained sub-specialisits like Nephro and ID are doing it since in the the recent market it has paid more per hour than the lower paying IM subspecialities.

Minimizing consults doesn't really save the hospital money. Consults are additional E/M that the other specialties can bill for, and many places they want the business (especially if there's 2 or more groups in the same specialty competing for business at the same hospital).

1. 370k seems a bit high but i can see another 10 to 20k coming down the pipe. Just a gut feeling

2. I think it takes someone that can put up with a little masochism to be a prolific career hospitalist. I do not think mid levels are huge threat in hospital medicine as they are not much cheaper and there's a push for specialization with them too. My last two jobs- one in a massive health system with employed hospitalists and one in in a small trying to grow to a medium health system with contracted hospitalistist groups - both eschewed midlevels except in observation units as extenders. This May reflect an east v. west bias ( i practice west of quoddy head,Maine).

3. Lol good one. I get trying to keep the consultants fed. See siggy's link above regarding LOS. Internal data from some of the largest systems in the country are all consistent in an extra 1 to 1.5 day hit in LOS per consultant. Disregarding that -the context of my last post was if your health system has its own insurance company attached. They are then paying money and attention to "Consults...that the other specialties can bill for."

 

[efle]

2. I think it takes someone that can put up with a little masochism to be a prolific career hospitalist. I do not think mid levels are huge threat in hospital medicine as they are not much cheaper and there's a push for specialization with them too. My last two jobs- one in a massive health system with employed hospitalists and one in in a small trying to grow to a medium health system with contracted hospitalistist groups - both eschewed midlevels except in observation units as extenders. This May reflect an east v. west bias ( i practice west of quoddy head,Maine).

My hospital has a whole bunch of residents and then a bunch of PAs on top of that who also function as residents on the wards teams, some services are even a mix where the team is attending + one intern + one PA.

Considering how much work/money a resident generates, I'm surprised it's not popular to hire PAs for the role too pretty much everywhere

 

[end stage fibro]

My hospital has a whole bunch of residents and then a bunch of PAs on top of that who also function as residents on the wards teams, some services are even a mix where the team is attending + one intern + one PA.

Considering how much work/money a resident generates, I'm surprised it's not popular to hire PAs for the role too pretty much everywhere

academics is a whole 'nother hellscape. Attending Production is a more nebulous term and many ivory towers are at the forefront of destroying the profession, as @blue.jay has written on. I'm not sure if academics is the future or some walled off abscess that won't spread

 

[Redpancreas]

At my current hospital site all the residents are explicitly forbidden from any kind of pushback against ED admits. This leads to some pretty absurd stuff - for example I recently admitted a patient in the ED who was already improved to baseline s/p IVF, just to be told to write their discharge about an hour later when the attending saw them at the floor. Another example would be a LOL in NAD denied at their usual hospital because they "dont accept admits for placement"...admitted here. Multiple admits for ACS ruleout this week with negative trops, normal EKG and no cardiac history but still having their "weird chest feeling" after GERD treatment.

At the other hospitals I've rotated through theres usually some ability for residents to push back on this kind of thing to stop the unwarranted admission in the first place - what's your experience been like? Anyone else out there with a strict policy to accept any and all admits?

Each place has it's own system. One place I worked at afforded the senior residents the chance to have a discussion with the ED attending, but ultimately the ED attending had the final say unless the resident escalated to the attending in which case the two attendings duked it out. It hardly ever came to that because it's much easier for a hospitalist to accept the patient graciously than risk the working relationship with a colleague and earn brownie points from the resident even if it did mean charging the patient for an expensive observation/short term stay. In other places, there's an admitting/triaging hospitalist(s) who take calls from ED residents/attendings, jots down a few notes, and they just assign them to academic/non-academic teams and they teams find out via pager. In those cases, it can be a challenge to ultimately follow the paper trail and figure out why the patient was really admitted.

 

[neoexile]

At my current hospital site all the residents are explicitly forbidden from any kind of pushback against ED admits. This leads to some pretty absurd stuff - for example I recently admitted a patient in the ED who was already improved to baseline s/p IVF, just to be told to write their discharge about an hour later when the attending saw them at the floor. Another example would be a LOL in NAD denied at their usual hospital because they "dont accept admits for placement"...admitted here. Multiple admits for ACS ruleout this week with negative trops, normal EKG and no cardiac history but still having their "weird chest feeling" after GERD treatment.

At the other hospitals I've rotated through theres usually some ability for residents to push back on this kind of thing to stop the unwarranted admission in the first place - what's your experience been like? Anyone else out there with a strict policy to accept any and all admits?

Dude just admit the patient and discharge them the same day rofl;

 

[efle]

Dude just admit the patient and discharge them the same day rofl;

I mean, I did. Would've been cooler if I could tell the ED she's feeling better and can go home though. And think about how awful it would be for her to get a fat bill inflated with all extra costs for no reason

 

[Redpancreas]

I mean, I did. Would've been cooler if I could tell the ED she's feeling better and can go home though. And think about how awful it would be for her to get a fat bill inflated with all extra costs for no reason

I get the feeling. One point to note which I'm not sure about is whether the patient actually gets charged a significant amount of their actual hospital price tag if they get admitted. We have this thing called Utilization management (I suspect it's pretty universal) that goes around and reviews MARs/Vitals with a checklist for whether the med and vitals warrant inpatient status to see if the patient can be downgraded to observation. If it's Observation, I think the hospital gets to charge the patient directly and there's a big rush to discharge the patient (at least seems like the patient's want to leave). I suspect it's communicated somehow to the patient that bills is on them. The reason I mention this is because if patient meets inpatient criteria (or slips by Utilization Management which I see all the time) then I think they legit get a lot of their admission costs covered by insurance (Medicare A, etc.) or the hospital eats the fee. Not sure which...if patient's were routinely billed even a fraction of their hospital costs, many wouldn't show up as often as they do.

 

[efle]

Bumping this thread again after another doozy of an admission.

Reason for admission: Electrolyte abnormalities.

On reviewing labs, all electrolytes (and other CMP components like AST/ALT, albumin, protein) are down except for two. You guessed it, Na and Cl. Prior labs are completely normal and they have no history except HTN they take an ACEi for.

Page the ED this looks like blood diluted with saline. ED response - not possible, patient did not get IVF, do the admission. Unwilling to hold onto them at ED for a repeat draw.

Admitted patient, lo and behold repeat labs on transfer are normal, someone in the lab must have made a mistake.

I really wish as an MS4 I had made one of my interview questions "what's the policy on telling the ED no"?

 

[NewYorkDoctors]

Bumping this thread again after another doozy of an admission.

Reason for admission: Electrolyte abnormalities.

On reviewing labs, all electrolytes (and other CMP components like AST/ALT, albumin, protein) are down except for two. You guessed it, Na and Cl. Prior labs are completely normal and they have no history except HTN they take an ACEi for.

Page the ED this looks like blood diluted with saline. ED response - not possible, patient did not get IVF, do the admission. Unwilling to hold onto them at ED for a repeat draw.

Admitted patient, lo and behold repeat labs on transfer are normal, someone in the lab must have made a mistake.

I really wish as an MS4 I had made one of my interview questions "what's the policy on telling the ED no"?

Usually the ED initial labs are drawn off an IV insert which really should eliminate the error of drawing off an IV locked with saline . Still you never know .

Usually the ED gives a bolus of saline if not in chf and then repeats the labs before deciding on admission . At my institution, nephrology would have been called before IM to assist ED with triage and management .

Now you do a valid point about unnecessary admissions . But don’t be “that resident.” Just talk to your hospitalist attending to figure it out amicably and professionally . Professionalism is one of the ACGME pillars and you don’t want to be seen as an unprofessional resident as that will affect the PD LoR for fellowship or future jobs .

Make the point known to the hospitalist to take care of things . Vent on here . Then move on and become chief resident Pgy 4 to deal with these issues .

 

[efle]

Usually the ED initial labs are drawn off an IV insert which really should eliminate the error of drawing off an IV locked with saline . Still you never know .

Usually the ED gives a bolus of saline if not in chf and then repeats the labs before deciding on admission . At my institution, nephrology would have been called before IM to assist ED with triage and management .

Now you do a valid point about unnecessary admissions . But don’t be “that resident.” Just talk to your hospitalist attending to figure it out amicably and professionally . Professionalism is one of the ACGME pillars and you don’t want to be seen as an unprofessional resident as that will affect the PD LoR for fellowship or future jobs .

Make the point known to the hospitalist to take care of things . Vent on here . Then move on and become chief resident Pgy 4 to deal with these issues .

Unfortunately was an after-hours admit, so nobody to turn to after the ED attending told me and the PGY-2 to shut up and take the admission.

Luckily I'm going into radiology and will only have to deal with reading studies that weren't indicated! No more unnecessary H&Ps for me.

But man, what an eye opening experience intern year was. Such perverse incentives. So many "ACS ruleout" admissions with negative troponins x2 and resolved pain who get discharged for outpatient workup the next morning. Because if you're the ED doc, why not? Why take that liability when you can just generate extra work for someone else and take all personal risk away?

 

[VA Hopeful Dr]

Unfortunately was an after-hours admit, so nobody to turn to after the ED attending told me and the PGY-2 to shut up and take the admission.

Luckily I'm going into radiology and will only have to deal with reading studies that weren't indicated! No more unnecessary H&Ps for me.

But man, what an eye opening experience intern year was. Such perverse incentives. So many "ACS ruleout" admissions with negative troponins x2 and resolved pain who get discharged for outpatient workup the next morning. Because if you're the ED doc, why not? Why take that liability when you can just generate extra work for someone else and take all personal risk away?

Why would I (hypothetical EM doctor) take on extra liability when I can have someone else prevent that by doing what is literally their job?

I get that it sucks having to do this as an intern, but for regular hospitalists chest pain rule outs are the easiest admissions in the world.

Besides, if you truly feel that admission is not warranted you have the ability to discharge them from the ER.

 

[efle]

Why would I (hypothetical EM doctor) take on extra liability when I can have someone else prevent that by doing what is literally their job?

I get that it sucks having to do this as an intern, but for regular hospitalists chest pain rule outs are the easiest admissions in the world.

Besides, if you truly feel that admission is not warranted you have the ability to discharge them from the ER.

Now that's an interesting point. At many programs it's considered part of the residents job to accept the triage, no? Supposed to be able to say no, that person needs ICU or no, they don't need admission. "Do whatever makes the ED comfortable, no questions allowed" isn't the job.

But you're right there is also no reason for pushback from hospitalist. They get to attest "agree with below" and bill. It's all crap rolling down hill to the poor chump stuck doing all the med recs, chart reviews, notes and orders.

 

[VA Hopeful Dr]

Now that's an interesting point. At many programs it's considered part of the residents job to accept the triage, no? Supposed to be able to say no, that person needs ICU or no, they don't need admission. "Do whatever makes the ED comfortable, no questions allowed" isn't the job.

But you're right there is also no reason for pushback from hospitalist. They get to attest "agree with below" and bill. It's all crap rolling down hill to the poor chump stuck doing all the med recs, chart reviews, notes and orders.

What are you talking about? Who do you think does all of that in non-academic hospitals? Hint: the hospitalist.

And again, if you don't think someone needs to be admitted you can discharge them from the ED. The ED calls you with an admission, you go see the patient, decide they don't need admission, and put in the discharge orders yourself. Its quite straightforward.

 

[efle]

What are you talking about? Who do you think does all of that in non-academic hospitals? Hint: the hospitalist.

And again, if you don't think someone needs to be admitted you can discharge them from the ED. The ED calls you with an admission, you go see the patient, decide they don't need admission, and put in the discharge orders yourself. Its quite straightforward.

Oh we're talking about outside of training program structure? In that case my gripes would evaporate because the BS admit becomes easy money earned.

Same with other services dumping work on medicine, like an arm abscess I was told to admit so surg could I&D the next day. Young, no home meds or significant hx besides the heroin use. Surg says admit to medicine because they're on one IV antibiotic, I guess that's too medically complex for them.

Attending surg wants to do that to attending hospitalist? Fine, easy money. Surg resident tells ED to dump the work on medicine resident? Not fine, but I'm powerless to push back on it, gotta do what ED tells me.

I'm sure you can see the difference

 

[VA Hopeful Dr]

Oh we're talking about outside of training program structure? In that case my gripes would evaporate because the BS admit becomes easy money earned.

Same with other services dumping work on medicine, like an arm abscess I was told to admit so surg could I&D the next day. Young, no home meds or significant hx besides the heroin use. Surg says admit to medicine because they're on one IV antibiotic, I guess that's too medically complex for them.

Attending surg wants to do that to attending hospitalist? Fine, easy money. Surg resident tells ED to dump the work on medicine resident? Not fine, but I'm powerless to push back on it, gotta do what ED tells me.

I'm sure you can see the difference

Yeah my main point (which was my second paragraph in my initial reply) was that this sort of stuff sucks as an intern but is no big deal as a regular hospitalist.

 

[aafisahar]

That's like 15 minutes of work for a year end intern. Easy obs admit, dc in am. Easiest 5 RVUs you can make.

 

[sunshinefl]

That's like 15 minutes of work for a year end intern. Easy obs admit, dc in am. Easiest 5 RVUs you can make.

We don’t get RVUs bro. Plus there is no way it would only take 15 minutes even if it wasn’t a multi step process being on a teaching service.

 

[efle]

That's like 15 minutes of work for a year end intern. Easy obs admit, dc in am. Easiest 5 RVUs you can make.

I wish I could do 15 minute admissions but they usually have about 50 recently dispensed meds, 20 admissions in the last 6 months, and we aren't allowed to chart at the level of the "efficient" docs

Which reminds me I saw one of my favorite ever H&Ps this week. The GI direct admitting had an H&P that just said

"HPI: jaundice

[autofilled dotphrases]

assessment/plan: ERCP"

We of course had to have an intern go write an actual H&P note.

 

[VA Hopeful Dr]

I wish I could do 15 minute admissions but they usually have about 50 recently dispensed meds, 20 admissions in the last 6 months, and we aren't allowed to chart at the level of the "efficient" docs

Which reminds me I saw one of my favorite ever H&Ps this week. The GI direct admitting had an H&P that just said

"HPI: jaundice

[autofilled dotphrases]

assessment/plan: ERCP"

We of course had to have an intern go write an actual H&P note.

Yeah, that's one of the burdens of being in training. Like almost everything else, it gets way better once you're out.

 

[Kaustikos]

Yeah, that's one of the burdens of being in training. Like almost everything else, it gets way better once you're out.

That's true. And it happens in specialty services too. How many unnecessary consults I rolled my eyes at in training but then realizing it's easy money when you're an Attending. And also why I realize some notes from specialists are very basic. Because the alternative is being condescendingly sarcastic

 

[NewYorkDoctors]

I wish I could do 15 minute admissions but they usually have about 50 recently dispensed meds, 20 admissions in the last 6 months, and we aren't allowed to chart at the level of the "efficient" docs

Which reminds me I saw one of my favorite ever H&Ps this week. The GI direct admitting had an H&P that just said

"HPI: jaundice

[autofilled dotphrases]

assessment/plan: ERCP"

We of course had to have an intern go write an actual H&P note.

Honestly the reason for this is becuase attending have found out you get paid the same for the icd10 and the cpt codes and not for the note . You don’t need to write anything to get paid just the codes. The note is for patient care and also to serve as a legal document in case you get sued and the discovery team is trying to find dirt or insurance wants an audit to see if you wrote the note or not to confirm payment .

This happens in private practice all the time . Usually it’s becuase the attendings are older and computer illiterate .

Then again the younger generation likes to note bloat and copy forward everything

As for me I do copy forward but I make sure things are updated , accurate , and concise . It’s not hard at all for Gen Y onward who are good at computers

Mercifully those dinosaurs are going extinct (retiring bye bye boomers )

 

[efle]

Honestly the reason for this is becuase attending have found out you get paid the same for the icd10 and the cpt codes and not for the note . You don’t need to write anything to get paid just the codes. The note is for patient care and also to serve as a legal document in case you get sued and the discovery team is trying to find dirt or insurance wants an audit to see if you wrote the note or not to confirm payment .

This happens in private practice all the time . Usually it’s becuase the attendings are older and computer illiterate .

Then again the younger generation likes to note bloat and copy forward everything

As for me I do copy forward but I make sure things are updated , accurate , and concise . It’s not hard at all for Gen Y onward who are good at computers

Mercifully those dinosaurs are going extinct (retiring bye bye boomers )

Our EMR has a button you can toggle that reveals how much of a note is newly entered, puts all the autofill and copy forward into faint text. Funny in a sad way to see a three page document with 1% changed per day. Why can't a progress note just have what I want it to - just a few bullet point updates on most days for most patients.

 

[NewYorkDoctors]

Our EMR has a button you can toggle that reveals how much of a note is newly entered, puts all the autofill and copy forward into faint text. Funny in a sad way to see a three page document with 1% changed per day. Why can't a progress note just have what I want it to - just a few bullet point updates on most days for most patients.

Yeah A&P should be in a box in top that’s concise .

Like a conclusions in the radiology report . Can always jump onto the main report and open up the PACS to look at things more carefully as needed

 

[VA Hopeful Dr]

Our EMR has a button you can toggle that reveals how much of a note is newly entered, puts all the autofill and copy forward into faint text. Funny in a sad way to see a three page document with 1% changed per day. Why can't a progress note just have what I want it to - just a few bullet point updates on most days for most patients.

Give it time. Outpatient coding is that way now, I can't think inpatient is far behind.

 

[NewYorkDoctors]

The biggest thing that “gets better” after training is not needing to present to the attending anymore . Not that a resident can function without an attending . Once you are independent and completed training , the day just zips by faster

 

[end stage fibro]

Honestly the reason for this is becuase attending have found out you get paid the same for the icd10 and the cpt codes and not for the note . You don’t need to write anything to get paid just the codes.

This may be true in theory (although I doubt that as well) but untrue in practice. You need justification to bill your 99233 or 99223. It is a rarity for your payor or health system to give you RVU credit independent of your documentation. CMS will absolutely clawback money from your system if they feel the notes do not support the billing. For private payors, you may get some leeway depending on the wording of your contract

Our EMR has a button you can toggle that reveals how much of a note is newly entered, puts all the autofill and copy forward into faint text. Funny in a sad way to see a three page document with 1% changed per day. Why can't a progress note just have what I want it to - just a few bullet point updates on most days for most patients.

The majority of what you encounter in progress notes is not suitable to wipe my dog's rear end. A few bullet point updates actually can be sufficient. I am not joking when I say part of my job is to help physician's remove a ton of garbage from the notes now that patient's can see them. Soon, they will be able to see inbasket messages as well (see USCDI v2 for more info). As @VA Hopeful Dr mentioned above, outpt documentation is already more streamlined. SHM is working to change inpt documentation/billing. Was supposed to be by 2023- I am not holding my breath.

 

[rokshana]

What are you talking about? Who do you think does all of that in non-academic hospitals? Hint: the hospitalist.

And again, if you don't think someone needs to be admitted you can discharge them from the ED. The ED calls you with an admission, you go see the patient, decide they don't need admission, and put in the discharge orders yourself. Its quite straightforward.

And the many an ED doc finds that to be a personal affront…the better way ( for the hospitalist anyway) is to go see the pt on the ED as a consult and let the pt know that an admission isn’t necessary ( if it really isn’t) and they can let the ED doc know that they don’t want to be admitted…IM bills for a consult and pt doesn’t have to undergo am unnecessary admission…if the pt want to admit… then admit.

 

[rokshana]

Honestly the reason for this is becuase attending have found out you get paid the same for the icd10 and the cpt codes and not for the note . You don’t need to write anything to get paid just the codes. The note is for patient care and also to serve as a legal document in case you get sued and the discovery team is trying to find dirt or insurance wants an audit to see if you wrote the note or not to confirm payment .

This happens in private practice all the time . Usually it’s becuase the attendings are older and computer illiterate .

Then again the younger generation likes to note bloat and copy forward everything

As for me I do copy forward but I make sure things are updated , accurate , and concise . It’s not hard at all for Gen Y onward who are good at computers

Mercifully those dinosaurs are going extinct (retiring bye bye boomers )

This is not true for inpt notes.

 

[NewYorkDoctors]

This is not true for inpt notes.

Correct. I was referring to outpatient notes .

 

[rokshana]

Correct. I was referring to outpatient notes .

Sorry, the thread was about residents and ED admission so thought you were referring to inpt.

 

[Siggy]

Unfortunately was an after-hours admit, so nobody to turn to after the ED attending told me and the PGY-2 to shut up and take the admission.

Luckily I'm going into radiology and will only have to deal with reading studies that weren't indicated! No more unnecessary H&Ps for me.

But man, what an eye opening experience intern year was. Such perverse incentives. So many "ACS ruleout" admissions with negative troponins x2 and resolved pain who get discharged for outpatient workup the next morning. Because if you're the ED doc, why not? Why take that liability when you can just generate extra work for someone else and take all personal risk away?

As you get more experienced in medicine you start to take these with a grain of salt.

I've seen people who should have been screened out pop positive for an NSTEMI. Literally no medical history construction worker (an actual ditch digger) who developed very short, sharp transient chest pain and light headedness 8 hours prior to coming to the ED. First trop negative... I had agreement to do an evening discharge if the second trop was negative. It was mildly positive... ok... load lovenox. Third trop was over 10. Full ACS protocol.

I've also admitted the "likely lab error as otherwise lab was inconsistent with life" patient as a resident. Easy admit, repeat labs several times and discharged later that day.

As an ICU attending, I constantly hear my NPs whine about HTN emergency admissions ("why didn't they just give the symptomatic patient more hydralazine?") and mild DKA/HHNK admissions (seriously, just start the insulin drip and call it a day).

Fudge... I'll just do them sometimes and finish everything including the note and med rec in less than 10 minutes. It gets easier with both experience and, as an attending, less oversight.

 

[Siggy]

Oh we're talking about outside of training program structure? In that case my gripes would evaporate because the BS admit becomes easy money earned.

Same with other services dumping work on medicine, like an arm abscess I was told to admit so surg could I&D the next day. Young, no home meds or significant hx besides the heroin use. Surg says admit to medicine because they're on one IV antibiotic, I guess that's too medically complex for them.

Attending surg wants to do that to attending hospitalist? Fine, easy money. Surg resident tells ED to dump the work on medicine resident? Not fine, but I'm powerless to push back on it, gotta do what ED tells me.

I'm sure you can see the difference

It took me a little over a year to relax and enjoy admitting the drunks. See, the problem with where I trained was that the police put the drunks on psych holds... because they were alcoholics... and because they were alcoholics they were a danger to themselves. This is despite the psych hold statute explicitly excluding substance abuse disorders. So all the Baker acted drunks got admitted to medicine for clearance.

Most of them were sleeping it off, plus or minus some assistance from Vitamin H.

Easiest admission ever. Poke the patient, whisper in their ear. "Patient admitted for alcohol intoxication. Patient minimally responsive but protecting his airway and unable to participate in exam." HPI, SxHx, PMH, Soc Hx, Family Hx, ROS all "unable to obtain" A/P. Toxic encephalopathy, IV hydration, thiamine, monitor airway."

If you really wanted to be a baller, you could do a Maddreys score... but why in most cases?

Next day? If they didn't go to the NP... have psych clear and discharge home. There are more important hills to die on.

 

[Siggy]

The majority of what you encounter in progress notes is not suitable to wipe my dog's rear end. A few bullet point updates actually can be sufficient. I am not joking when I say part of my job is to help physician's remove a ton of garbage from the notes now that patient's can see them. Soon, they will be able to see inbasket messages as well (see USCDI v2 for more info). As @VA Hopeful Dr mentioned above, outpt documentation is already more streamlined. SHM is working to change inpt documentation/billing. Was supposed to be by 2023- I am not holding my breath.

Just make everything time based. Best part of critical care is that there's no complex matrix for 91s and 92s. It's "can you add 2 digit, occasionally 3 digit numbers" and "how many 30s can I subtract after subtracting 75 before the number of minutes goes negative."

Besides that, just having a decent template should at least net a -22 or -32. Ironically enough, the system I've spent the most time in didn't have a chief complain box or ROS in the base EMR progress note... which is causing issues with our non-critical care notes being decreased to -31s.

 

[end stage fibro]

Just make everything time based. Best part of critical care is that there's no complex matrix for 91s and 92s. It's "can you add 2 digit, occasionally 3 digit numbers" and "how many 30s can I subtract after subtracting 75 before the number of minutes goes negative."

Besides that, just having a decent template should at least net a -22 or -32. Ironically enough, the system I've spent the most time in didn't have a chief complain box or ROS in the base EMR progress note... which is causing issues with our non-critical care notes being decreased to -31s.

Definitely agree. Hospitalists in general should be billing 99233 by complexity frequently and snagging a few extra with time. The problem is when a cardiologist comes and sees 30 odd pts and bills >35 min F2F for each then goes to the clinic in the afternoon. adding those 2 digit numbers doesn’t sum up.

 

[Siggy]

Definitely agree. Hospitalists in general should be billing 99233 by complexity frequently and snagging a few extra with time. The problem is when a cardiologist comes and sees 30 odd pts and bills >35 min F2F for each then goes to the clinic in the afternoon. adding those 2 digit numbers doesn’t sum up.

You think it adds up for critical care time?

 

[NonNocere]

Having worked on both sides, emergency and the admitting team .... it should be a discussion, I think.