Does anyone just like....hate this?

[turkeyjerky]

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I honestly don't see it as fudging the chart.

You can get a patient to say yes to any symptom if you question them enough and in the right way. If it isn't why they're presenting, and they're not making a big deal of it, chances are it's probably more right to call it negative than positive.

Exactly. I look at the HPI as my interpretation of the patient's provided history. Everything in there is still subjective, but digested into a logical format. Also, I have no qualms about 'interpreting' a patient's 10/10 pain as 'moderate severity'.

But that's not really "malingering", as that is "feigning illness". "Unspecified psychosocial problem" is Z modifier (and will downcode your chart, even if level 5), along with "hunger" as a dx. "Homeless status" is another you can tack on.

Really--where do you find this stuff?

As if you're actually going to collect on this patient's bill...

Even if you don't collect, most groups (hopefully) base pay on billings rather than collections. It might not change the size of the pie, but could affect the size of your slice.

 

[turkeyjerky]

If I mention "PE" then miss one, a lawyer will zero in on it. Better to not give them help. Also, write the chart so the history/exam don't make it look like a possible PE.

I think opinions on this just differ and there isn't any definitive answer. I'm on the side that it's better to consider and reject a diagnosis than to not consider it at all. I'd rather have a chart that makes it look like I took the patient seriously and considered all possible emergent conditions rather than just dismissed them.

 

[WilcoWorld]

If you thought about a diagnosis and missed it, how does that help?

If I mention "PE" then miss one, a lawyer will zero in on it. Better to not give them help. Also, write the chart so the history/exam don't make it look like a possible PE.

I'm not a lawyer, so this is just opinion.

I'd rather defend a missed diagnosis when I have good charting to explain why I thought the test wasn't indicated. For example, a missed cord impingement case. Patient presents with acute on chronic low back pain and right leg paresthesias. Which chart would you rather defend?

Assessment & Plan:

#1 - Acute on chronic lumbrosacral back pain with sciatica. Analgesia provided with good effect, patient will follow up with PCP within the week to consider outpatient MRI if symptoms don't resolve.

#2 - Acute on chronic lumbrosacral back pain with sciatica. Cauda equina syndrome considered, but in the absence of incontinence/retention and in the presence of intact and symmetric achilles/patellar reflexes and normal perineal sensation emergent MRI is not indicted. Analgesia provided with good effect, patient will follow up with PCP within the week to consider outpatient MRI if symptoms don't resolve, will return to ED for prompt reassessment if new or concerning symptoms develop.

It's not a novel, takes me maybe an extra 12 seconds and gives me warm fuzzies if I have to read my chart after a bounce back.

 

[Birdstrike]

Don't think you've found the hack to the formula, or that any amount of righteous indignation, or outright being right, will alter the formula. The wording doesn't matter much. Because the people making the decisions don't understand the wording, like you and I do. They only understand the equation. Any uncertainty is followed with, "Uh....Sounds good, but you still missed it and he's still ___dead/paralyzed/maimed (insert bad outcome du jour)____." So, yes, do whatever gives you the warm and fuzzies, because that's the main value of it.

Tests help, though. Order mountains of them, without remorse. "Negative CT" beats "He died but I wrote some stuff," every time.

Words are paper. Tests are gold.

 

[WilcoWorld]

"Your name" + "bad outcome" = settlement.

Don't think you've found the hack to the formula, or that any amount of righteous indignation, or outright being right, will alter the formula. The wording doesn't matter much. Because the people making the decisions don't understand the wording, like you and I do. They only understand the equation. Any uncertainty is followed with, "Uh....Sounds good, but you still missed it and he's still ___dead/paralyzed/maimed (insert bad outcome du jour)____." So, yes, do whatever gives you the warm and fuzzies, because that's the main value of it.

Tests help, though. Order mountains of them, without remorse. "Negative CT" beats "He died but I wrote some stuff," every time.

Words are paper. Tests are gold.

I don't claim to have a hack, just a practice that allows me to continue to practice EM in the way I think is best for the patient & my mental well-being.

You go your way & I'll go mine.

 

[Birdstrike]

I don't claim to have a hack, just a practice that allows me to continue to practice EM in the way I think is best for the patient & my mental well-being.

You go your way & I'll go mine.

My post wasn't meant to offend. Sorry if it did. From everything I've read from you on this forum over 10 years, I'm sure you're doing as good or better job than I ever did (or do) at any of this stuff. I was just trying to give my general feelings on the subject, as there are newbies on this forum, and in a colorful way. Sorry, if my general disillusionment on the subject, offended you specifically. I value your opinion.

 

[Angry Birds]

If I mention "PE" then miss one, a lawyer will zero in on it. Better to not give them help. Also, write the chart so the history/exam don't make it look like a possible PE.

I will tell you that this exact thing happened to me. It was a residency case: my attending got sued because I wrote all over the chart, time-stamped just a few minutes after I evaluated the patient, "STRONGLY SUSPECT PE."
We diagnosed it and the patient died anyways, but the point is, they used the fact that I wrote those words to say, "Why didn't you do XYZ at that point in time if you already knew the diagnosis...?"
This made me realize that they will try to use whatever you write to screw you.
(Thankfully, the case was dismissed before it ever went to trial though.)

I also think that you can just say in your deposition, "I always consider XYZ when patients come with ABC..."
Also, by listing some d/d in the actual chart itself, what if it turns out to be something NOT in that list?
My approach is not to list d/d and then I can just rattle off the standard d/d if deposed: "Of course I thought of..."

To be clear, however, this is all theoretical and I might be way off/wrong here.
Again, I just feel that the more you write, the more you hang. And I agree with the idea that negative tests are your actual best defense, as well as strongly worded disposition instructions about returning to the ER, etc. I often write, "All diagnoses are tentative in the ER and require close follow up and further reevaluation by your PCP," along with strict return instructions.

 

[southerndoc]

I'm not a lawyer, so this is just opinion.

I'd rather defend a missed diagnosis when I have good charting to explain why I thought the test wasn't indicated. For example, a missed cord impingement case. Patient presents with acute on chronic low back pain and right leg paresthesias. Which chart would you rather defend?

Assessment & Plan:

#1 - Acute on chronic lumbrosacral back pain with sciatica. Analgesia provided with good effect, patient will follow up with PCP within the week to consider outpatient MRI if symptoms don't resolve.

#2 - Acute on chronic lumbrosacral back pain with sciatica. Cauda equina syndrome considered, but in the absence of incontinence/retention and in the presence of intact and symmetric achilles/patellar reflexes and normal perineal sensation emergent MRI is not indicted. Analgesia provided with good effect, patient will follow up with PCP within the week to consider outpatient MRI if symptoms don't resolve, will return to ED for prompt reassessment if new or concerning symptoms develop.

It's not a novel, takes me maybe an extra 12 seconds and gives me warm fuzzies if I have to read my chart after a bounce back.

According to a very well respected medical malpractice defense attorney (who I've used in the past and currently using for a meritless case), if you document your reasoning to exclude something, it makes it much, much easier to defend your care. In fact, he said a lot of litigation is averted because the expert witness understands your reasoning and won't certify a case.

 

[RustedFox]

According to a very well respected medical malpractice defense attorney (who I've used in the past and currently using for a meritless case), if you document your reasoning to exclude something, it makes it much, much easier to defend your care. In fact, he said a lot of litigation is averted because the expert witness understands your reasoning and won't certify a case.

It is better to win the war before the battle ever begins. That is the acme of skill.

- Sun Tzu.

 

[emergentmd]

When someone gets discharged, my charts are vanilla. you prob see all my discharged chest pain pts and think they are the same person.

Pt you know is non cardiac comes in with Chest pressure, radiating to the arm, short of breath with exertion.

My chart = pt with sharp chest pain, non radiating, reproducible, same as his other Chest pain he has all the time.

Call me a chart liar but 80% of pts with CP have cardiac qualities and I am not putting it in the chart if they go home. Last thing I want is for them to have an MI weeks later and the expert witness asks why you sent them home with chest pressure that is a classic angina complaint. Much easier for me to defend a clean chart.

 

[GeneralVeers]

When someone gets discharged, my charts are vanilla. you prob see all my discharged chest pain pts and think they are the same person.

Pt you know is non cardiac comes in with Chest pressure, radiating to the arm, short of breath with exertion.

My chart = pt with sharp chest pain, non radiating, reproducible, same as his other Chest pain he has all the time.

Call me a chart liar but 80% of pts with CP have cardiac qualities and I am not putting it in the chart if they go home. Last thing I want is for them to have an MI weeks later and the expert witness asks why you sent them home with chest pressure that is a classic angina complaint. Much easier for me to defend a clean chart.

Exactly this. My young, healthy, anxious patients with "crushing, substernal pain" get charted by me as reproducible chest wall tenderness.

 

[southerndoc]

When someone gets discharged, my charts are vanilla. you prob see all my discharged chest pain pts and think they are the same person.

Pt you know is non cardiac comes in with Chest pressure, radiating to the arm, short of breath with exertion.

My chart = pt with sharp chest pain, non radiating, reproducible, same as his other Chest pain he has all the time.

Call me a chart liar but 80% of pts with CP have cardiac qualities and I am not putting it in the chart if they go home. Last thing I want is for them to have an MI weeks later and the expert witness asks why you sent them home with chest pressure that is a classic angina complaint. Much easier for me to defend a clean chart.

It helps that we have a system-wide protocol that relies on the HEART score. I tell patient's they're not having a heart attack, but that doesn't rule out a blockage. Per xxx system protocol, the patient will be discharged with cardiology referral.

 

[GeneralVeers]

It helps that we have a system-wide protocol that relies on the HEART score. I tell patient's they're not having a heart attack, but that doesn't rule out a blockage. Per xxx system protocol, the patient will be discharged with cardiology referral.

I've found HEART score to be incredibly useful. Also I can manipulate most people to be "slightly suspicious" to get them a lower score and defend my discharge.

 

[Apollyon]

Exactly this. My young, healthy, anxious patients with "crushing, substernal pain" get charted by me as reproducible chest wall tenderness.

Reported 10-15% of MIs have reproducible chest wall tenderness. Are you sending home 25 y/o MIs? No, you are not. However, it's not completely black and white. But, what would you think if you had a 1 in 10 chance of ending up without a chair when the music stops?

I don't know the numbers for PEs with reproducible CP.

 

[GeneralVeers]

Reported 10-15% of MIs have reproducible chest wall tenderness. Are you sending home 25 y/o MIs? No, you are not. However, it's not completely black and white. But, what would you think if you had a 1 in 10 chance of ending up without a chair when the music stops?

I don't know the numbers for PEs with reproducible CP.

Well we all know that nothing rules out anything. The point is to direct the narrative so that IF something bad happens, you haven't destroyed yourself by documenting symptoms of MI.

 

[RustedFox]

Well we all know that nothing rules out anything. The point is to direct the narrative so that IF something bad happens, you haven't destroyed yourself by documenting symptoms of MI.

Yep.

It's a shame we have to do things like this, because if we actually practiced the way that medical school teaches us to practice; nothing would ever get done. Again; the number-one cause of burnout is - the patient - .

 

[WilcoWorld]

When someone gets discharged, my charts are vanilla. you prob see all my discharged chest pain pts and think they are the same person.

Pt you know is non cardiac comes in with Chest pressure, radiating to the arm, short of breath with exertion.

My chart = pt with sharp chest pain, non radiating, reproducible, same as his other Chest pain he has all the time.

Call me a chart liar but 80% of pts with CP have cardiac qualities and I am not putting it in the chart if they go home. Last thing I want is for them to have an MI weeks later and the expert witness asks why you sent them home with chest pressure that is a classic angina complaint. Much easier for me to defend a clean chart.

Exactly this. My young, healthy, anxious patients with "crushing, substernal pain" get charted by me as reproducible chest wall tenderness.

I don't lie. I teach my residents not to lie. But that doesn't mean I have to transcribe the patient's exact words into the chart like they're the Dali Lama or Aristotle giving a teaching.

"Your charting should reflect your disposition" is what I teach residents. If you want to chart "lethargic" then you'd better LP that kiddo. If you want to chart "pain out of proportion to exam" then you'd better work up mesenteric ischemia.

If you don't want to check compartment pressures because they aren't indicated, then chart why! Don't chart "pain with passive stretch" just because the patient is a wimp and EVERY SINGLE THING hurts. Chart "compartments are soft and patient displays full ROM of flexion and extension without difficulty".

Just my practice

 

[RustedFox]

I don't lie. I teach my residents not to lie. But that doesn't mean I have to transcribe the patient's exact words into the chart like they're the Dali Lama or Aristotle giving a teaching.

"Your charting should reflect your disposition" is what I teach residents. If you want to chart "lethargic" then you'd better LP that kiddo. If you want to chart "pain out of proportion to exam" then you'd better work up mesenteric ischemia.

If you don't want to check compartment pressures because they aren't indicated, then chart why! Don't chart "pain with passive stretch" just because the patient is a wimp and EVERY SINGLE THING hurts. Chart "compartments are soft and patient displays full ROM of flexion and extension without difficulty".

Just my practice

It's because 100% of the way we're taught to do things in medical school assumes that the patient is honest and reasonable; but 99% of patients are dishonest and unreasonable.

 

[GeneralVeers]

It's because 100% of the way we're taught to do things in medical school assumes that the patient is honest and reasonable; but 99% of patients are dishonest and unreasonable.

Exactly. Patients want more testing, more treatments, and admission to the hospital. Most people in America are hypochondriacs with a degree of Munchausen's.

 

[RustedFox]

Exactly. Patients want more testing, more treatments, and admission to the hospital. Most people in America are hypochondriacs with a degree of Munchausen's.

Oof.

It hurts so much because it's true.

 

[thegenius]

If you thought about a diagnosis and missed it, how does that help?

Suppose a patient goes to an ER and is diagnosed with PE and has a very poor outcome.

Then suppose that same patient was seen at your ER 24 hours ago and one of two things happened there
- Doc A: pt presents with chest pain, labs, enzymes, EKG, CXR are all normal, no ddimer sent, pt discharged.
- Doc B: pt presents with chest pain, labs, enzymes, EKG, CXR are all normal, PERC and WELLS are 8/8 and 0/8 so per guidelines will not send a ddimer, pt discharged

Doc A will be in a lot of trouble...never talked about PE, never considered it...he basically missed a PE.
Doc B has a much higher amount of protection and maybe won't even lose a lawsuit. He applied standard of care principles and considered PE and didn't work it up.

We don't know how Doc A thought...and Doc A can say whatever he wants on the witness stand but Doc A cannot prove anything because he didn't document anything. Doc A cannot claim that he used clinical decision rules because he didn't document it.

 

[thegenius]

I don't claim to have a hack, just a practice that allows me to continue to practice EM in the way I think is best for the patient & my mental well-being.

You go your way & I'll go mine.

Yes I tend to think that opinions on how to write a legally protective chart differ. We have all had this conversation many times over the past 3 years or so and we never come to a consensus. Why can't we get a prosecuting and defense malpractice attorney on this forum to help us answer this question?

 

[thegenius]

I will tell you that this exact thing happened to me. It was a residency case: my attending got sued because I wrote all over the chart, time-stamped just a few minutes after I evaluated the patient, "STRONGLY SUSPECT PE."
We diagnosed it and the patient died anyways, but the point is, they used the fact that I wrote those words to say, "Why didn't you do XYZ at that point in time if you already knew the diagnosis...?"
This made me realize that they will try to use whatever you write to screw you.
(Thankfully, the case was dismissed before it ever went to trial though.)

I also think that you can just say in your deposition, "I always consider XYZ when patients come with ABC..."
Also, by listing some d/d in the actual chart itself, what if it turns out to be something NOT in that list?
My approach is not to list d/d and then I can just rattle off the standard d/d if deposed: "Of course I thought of..."

To be clear, however, this is all theoretical and I might be way off/wrong here.
Again, I just feel that the more you write, the more you hang. And I agree with the idea that negative tests are your actual best defense, as well as strongly worded disposition instructions about returning to the ER, etc. I often write, "All diagnoses are tentative in the ER and require close follow up and further reevaluation by your PCP," along with strict return instructions.

Funny I almost never tell people to come back to the ER. Maybe 9 times out of 10 I don't.

Again...maybe I should change that practice. I see patients that come back 4 hours later for their abdominal pain because "the doctor told them to." They were literally just there with normal labs and imaging. These cases almost never produce a real emergency.

 

[xaelia]

Suppose a patient goes to an ER and is diagnosed with PE and has a very poor outcome.

Then suppose that same patient was seen at your ER 24 hours ago and one of two things happened there
- Doc A: pt presents with chest pain, labs, enzymes, EKG, CXR are all normal, no ddimer sent, pt discharged.
- Doc B: pt presents with chest pain, labs, enzymes, EKG, CXR are all normal, PERC and WELLS are 8/8 and 0/8 so per guidelines will not send a ddimer, pt discharged

Doc A will be in a lot of trouble...never talked about PE, never considered it...he basically missed a PE.
Doc B has a much higher amount of protection and maybe won't even lose a lawsuit. He applied standard of care principles and considered PE and didn't work it up.

We don't know how Doc A thought...and Doc A can say whatever he wants on the witness stand but Doc A cannot prove anything because he didn't document anything. Doc A cannot claim that he used clinical decision rules because he didn't document it.

Re: Doc A – it depends. They can pull other charts and see if they're all the same documentation standard, or whether this specific chart is particularly sparse. If all Doc A's charts are bland, then he can stand up on the witness thing and say – I consider the same differential dx on every chest pain patient, my documentation is a pale chimera of my complex medical decision-making because my job is to be at the bedside providing care, not at a computer writing dense CYA.

If Doc A typically puts a DDx into the chart that sometimes does and sometimes does not, then it's easier to make the case Doc A screwed up here and didn't actually think it through.

TBH, we've basically brought this medicolegal quagmire on ourselves by endlessly circling back reviewing how better documentation might have avoided a legal case ... thus raising the floor for acceptable documentation ... etc. to the point where the post above is describing citing decision instruments and guidelines ....

 

[southerndoc]

I will trust a well respected malpractice attorney who has defended hundreds of docs (the majority successfully) instead of the opinions of other ER docs when it comes to the ways to document to prevent or defend litigation.

Nobody said that you can't be sued if you document everything. It's less likely you'll be sued according to him, and it's more likely that you successfully defend your case.

I will always document what I consider, why I didn't think it was likely, etc. As @thegenius pointed out, doc B documented his rationale behind things and follows within accepted protocols/guidelines/standards of care. Doc A could be presented as being careless or incompetent because he never considered PE. I've been told it's easier to defend something that you considered and documented why it wasn't likely than it is to defend something you didn't mention, which the plaintiff will skew that you didn't even consider it and will point out that it's a standard consideration in emergency medicine but you're too incompetent to consider it.

Pardon the rambling. Coffee hasn't kicked in.

 

[GonnaBeADoc2222]

I will trust a well respected malpractice attorney who has defended hundreds of docs (the majority successfully) instead of the opinions of other ER docs when it comes to the ways to document to prevent or defend litigation.

Nobody said that you can't be sued if you document everything. It's less likely you'll be sued according to him, and it's more likely that you successfully defend your case.

I will always document what I consider, why I didn't think it was likely, etc. As @thegenius pointed out, doc B documented his rationale behind things and follows within accepted protocols/guidelines/standards of care. Doc A could be presented as being careless or incompetent because he never considered PE. I've been told it's easier to defend something that you considered and documented why it wasn't likely than it is to defend something you didn't mention, which the plaintiff will skew that you didn't even consider it and will point out that it's a standard consideration in emergency medicine but you're too incompetent to consider it.

Pardon the rambling. Coffee hasn't kicked in.

This. My standard low risk chest pain that I am discharging MDM looks like this:

"Very likely benign musculoskeletal chest pain. I have considered but do not suspect ACS (low risk by HEART score, negative troponin, normal EKG, atypical symptoms), PE (low risk by wells score, negative PERC), aortic dissection, myo/pericarditis. Will discharge with close PCP follow up, return precautions"

 

[Arcan57]

Funny I almost never tell people to come back to the ER. Maybe 9/10 I don't.

Again...maybe I should change that practice. I see patients that come back 4 hours later for their abdominal pain because "the doctor told them to." They were literally just there with normal labs and imaging. These cases almost never produce a real emergency.

I always write "Return for worsening symptoms", then verbally give much more directed return precautions. Return for recheck was really common in old school EM before we just scanned everybody out in triage. That being said, I've seen people die of perf'ed appendicitis at home after an initial neg workup, and it's important that they understand while it's unlikely this could be an early miss.

 

[thegenius]

I always write "Return for worsening symptoms", then verbally give much more directed return precautions. Return for recheck was really common in old school EM before we just scanned everybody out in triage. That being said, I've seen people die of perf'ed appendicitis at home after an initial neg workup, and it's important that they understand while it's unlikely this could be an early miss.

Yea I probably say something different than what I write. Sometimes. It really depends on what the complaint is. What I honestly tell most patients after a thorough workup is "you can come back, but if you have similar symptoms to what you have now I don't know what else we would do."

- and I tell them I'm not trained to workup most things;
- this is why 95% of all doctors work out in the community, they want your business, they want to help;
- I believe your symptoms, but it's not a life-death scenario
- the ER is not the place to get all health care and you'll never be satisfied with the ER if it's used as such

Sometimes they come back sometimes they don't.

 

[GeneralVeers]

I tell them come back in (my shift end time + 2 hours) hours if you feel worse, or something changes.

 

[thegenius]

I'm sure your fellow docs love you too for that

 

[RuralEDDoc]

- the ER is not the place to get all health care and you'll never be satisfied with the ER if it's used as such

Sometimes the come back sometimes they don't.

Respect.

 

[bravotwozero]

Yea I probably say something different than what I write. Sometimes. It really depends on what the complaint is. What I honestly tell most patients after a thorough workup is "you can come back, but if you have similar symptoms to what you have now I don't know what else we would do."

- and I tell them I'm not trained to workup most things;
- this is why 95% of all doctors work out in the community, they want your business, they want to help;
- I believe your symptoms, but it's not a life-death scenario
- the ER is not the place to get all health care and you'll never be satisfied with the ER if it's used as such

Sometimes the come back sometimes they don't.

But do they then call up the patient care rep and complain about you?

 

[thegenius]

But do they then call up the patient care rep and complain about you?

LOL
I actually get good marks. Maybe it's my charisma when I say "sorry there is nothing else I can offer you."

LOLZ

 

[Birdstrike]

LOL
I actually get good marks. Maybe it's my charisma when I say "sorry there is nothing else I can offer you."

LOLZ

"But here's a CD. It's 8/13/75. Listening to this might help."

 

[thegenius]

"But here's a CD. It's 8/17/75. Listening to this might help."

That’s not a bad idea!

 

[turkeyjerky]

I always write "Return for worsening symptoms", then verbally give much more directed return precautions. Return for recheck was really common in old school EM before we just scanned everybody out in triage. That being said, I've seen people die of perf'ed appendicitis at home after an initial neg workup, and it's important that they understand while it's unlikely this could be an early miss.

Sometimes I'll see a patient who was told to come back for a routine recheck and it's always a puzzle as to why, b/c most docs who are conservative enough to do this also seem to scan the patient at the initial visit (also bugs me that triage always seems to document this like it's an unexpected return visit). At my old shop there were a few docs who would always tell r/o ectopics to come back in xx hours for repeat labs (this drove me nuts--we were a vag bleeding center of excellence and obgyns would get these patients in for followup w/o issue).

I will occasionally do this for peds whom I don't want to scan though. I do think there's value in that. Mainly an issue when the parents bring the kid in for like an hour of pain and I tell them that it's just to early to tell anything.

 

[AlmostAnMD]

I’m not confident the novel will help. More you write the more they can hang you on.
but I admit this is just a theory I have.

100% believer in this. I've seen some of my colleagues write goddam books in their MDM.

In addition to wasting time, you cannot possibly tell me, in those MULTIPLE LONG PARAGRAPHS, there isn't a single piece of contradictory information that can tear that doc apart.

I write bare minimum to what I think is appropriate after a long discussion with an MD/JD. I always have the nursing triage note in a separate window on my other monitor. I need 100% of provided information to mesh perfectly without any discrepancy ("Doctor, the nurse said 1 day of chest pain, you said 4?") I am crafting a goddam story that I am sticking to, and it is 100% consistent internally and externally and generally brief.

 

[emergentmd]

Which state/city you work is more imp that what you write.
Write what you want or how much you want but your story better fit your disposition.
I always tell them to follow up with PCP 2 dys
I always tell them to return if worse.

If they go home and have an MI in a week, then its not my fault they didn't follow up which I can stand on.

I have been sued once in 20+ yrs doing my vanilla charting when I KNOW they have nothing. My ONE suit was from a floor patient on pressures that crashed. Yeah, I take fault for coming in at the end of a cluster Show.

If I am concerned, I will work them up. But I will NOT write down that a healthy anxiety person has heaviness, shortness of breath regardless of what some algorithm tells me.

Any doc who will write down what the pts tells them all the time is lying to themselves

 

[emergentmd]

Sometimes I'll see a patient who was told to come back for a routine recheck and it's always a puzzle as to why, b/c most docs who are conservative enough to do this also seem to scan the patient at the initial visit (also bugs me that triage always seems to document this like it's an unexpected return visit). At my old shop there were a few docs who would always tell r/o ectopics to come back in xx hours for repeat labs (this drove me nuts--we were a vag bleeding center of excellence and obgyns would get these patients in for followup w/o issue).

I will occasionally do this for peds whom I don't want to scan though. I do think there's value in that. Mainly an issue when the parents bring the kid in for like an hour of pain and I tell them that it's just to early to tell anything.

I have never told a pt to return to the ER for a recheck. If they need to come back so quickly, admit them or call their PCP/OB.

If not, then they need to find someone to follow them up. We are not an outpt center.

 

[GeneralVeers]

I have never told a pt to return to the ER for a recheck. If they need to come back so quickly, admit them or call their PCP/OB.

If not, then they need to find someone to follow them up. We are not an outpt center.

The only exception for this is the positive HCG, negative US women who I tell to come back in 48 hours for repeat HCG. The mere fact that most of these women are in the ER indicates that they are unable/unwilling to get an OB/GYN and lack the cognitive ability to arrange their own follow-up.

 

[zurned]

To the OP: You are where I was 5 years ago.

I was able to get a few more years out of the specialty by not worrying about any of that stuff. The rectal exam patient for example. Just put on the tracking board "MD will see patient when in a room and undressed" and punt it back to nursing. Just remember you are a cog in a widget factory. Try to move the widgets through so you get paid. Don't worry about the stuff that's not yours to worry about.

Clock in, move the widgets, sign your charts, and go home on time. Don't stay late to "go the extra mile" as you aren't paid for that, and no one will give you any recognition.

Always understand that you will only ever get grief and demotivation from talking to your medical directors. They never pull you aside to say "Job well done" or "I'm giving you a raise for great work". No conversation with them is the best conversation.

This is the best mindset. If you view our job as just a job. A cog in the machine. A part of an assembly line. Getting a patient a turkey sandwich is easy. Waiters get paid 1/10th of what we get paid for getting ppl sandwiches. Just go in clock your hours, and get paid handsomely (relatively).

I am still in awe that I get paid over $2000 a day listening to people complain about things, and telling them they are fine.

 

[Mr. Vandemar]

I have nothing meaningful to contribute that hasn't already been said, but...reading these types of threads are like therapy for me. This is my first job out of residency and I spend every day off dreading the next day I have to work.

 

[GeneralVeers]

This is the best mindset. If you view our job as just a job. A cog in the machine. A part of an assembly line. Getting a patient a turkey sandwich is easy. Waiters get paid 1/10th of what we get paid for getting ppl sandwiches. Just go in clock your hours, and get paid handsomely (relatively).

I am still in awe that I get paid over $2000 a day listening to people complain about things, and telling them they are fine.

Why get the patient a turkey sandwich? I don't get a tip, and don't get extra money. My time is better spent seeing another patient and racking up more RVUs. If the hospital allows me to accept cash tips, or pays me to do other people's jobs too then I have no problem.

 

[bravotwozero]

Agree with the above. I feel like this job trains you to hate people

The busier and more understaffed your ED, the more likely this is to be true.

 

[Dr Mantis Toboggan]

I have nothing meaningful to contribute that hasn't already been said, but...reading these types of threads are like therapy for me. This is my first job out of residency and I spend every day off dreading the next day I have to work.

 

[Birdstrike]

Why get the patient a turkey sandwich? I don't get a tip, and don't get extra money. My time is better spent seeing another patient and racking up more RVUs. If the hospital allows me to accept cash tips, or pays me to do other people's jobs too then I have no problem.

Agree with the above. I feel like this job trains you to hate people

The busier and more understaffed your ED, the more likely this is to be true.

I'll never forget during my intern year when we had an outrageously rude, obnoxious and verbally abusive patient screaming and just generally being a jerk. He had nothing remotely resembling an "emergency." At one point, he starts screaming and demanding a coffee, "Get me a coffee NOW, or else!"

On my shift as an intern, I'm naively thinking I'm there to learn how to save lives, restart hearts and breath for people that needed air to live. Bwahahaha! My attending then promptly orders me to leave the ED, walk to the cafeteria and deliver a coffee to this jackhole, "Because admin." I should have walked off shift right there, quit EM and never come back.

Like a dummy, I stayed. It took me another 10 years to muster up the cajones to act on the instinct I felt that day.

 

[dadaddadaBATMAN]

I'll never forget during my intern year when we had an outrageously rude, obnoxious and verbally abusive patient screaming and just generally being a jerk. He had nothing remotely resembling an "emergency." At one point, he starts screaming and demanding a coffee, "Get me a coffee NOW, or else!"

On my shift as an intern, I'm naively thinking I'm there to learn how to save lives, restart hearts and breath for people that needed air to live. Bwahahaha! My attending then promptly orders me to leave the ED, walk to the cafeteria and deliver a coffee to this jackhole, "Because admin." I should have walked off shift right there, quit EM and never come back.

Like a dummy, I stayed. It took me another 10 years to muster up the cajones to act on the instinct I felt that day.

Bizarre move by the attending. My response would have been ama paperwork. I would also have probably put in his quotes verbatim in the chart

 

[Birdstrike]

Bizarre move by the attending.

He would do...I mean make the intern do, anything for the Press Ganies.

 

[dadaddadaBATMAN]

I assume you probably mean just discharge. I’ve seen some physicians make rude or disruptive patients without emergencies leave AMA, which never made sense to me. It isn’t your advice for them to stay, and making them leave AMA doesn’t really ‘punish’ them or even protect you if not truly indicated. If you make them leave AMA, then that implies you wanted them to stay, which you don’t. AMA paperwork by itself also doesn’t offer a ton of legal protection vs. the actual conversation and charting in your MDM. If I don’t think a rude or disruptive patient has an emergency, then I discharge them and have security escort them out if they won’t leave peacefully. Luckily I’m not as beholden to patient satisfaction at my job like some others, so I don’t have to bend over backwards for clearly obnoxious patients. I also chart quotes. I try to keep the charting as objective and non-judgmental as I can. On the rare off chance I was wrong and it comes back to bite me, then I don’t want it to easily look like my care was clouded by being judgmental.

If they are saying “or else” I am presuming they are declining some sort of workup. If they are refusing a workup, they can leave ama. I treat them like any other discharge and tell them to come back if they change their mind. I will let people choose not to be npo after documenting it, but I’m not getting them coffee or a tray.

if no workup was indicated, then I was already writing the dc order anyway. If they’re a jerk they get security.

quotes aren’t adversarial. Quotes are quotes. I don’t interpret them, I just write pt informed me he was refusing workup and demanded coffee. Pt then left.

 

[dadaddadaBATMAN]

It’s almost impossible to work as an EP over a long period of time without developing a dislike for people. These are the changes that I think are key to restoring physician satisfaction as an EP:

1) In an EMTALA bound environment, autonomy has to be increased to dictate patients’ ED course, care and disposition. We can’t select or fire our patients. They just show up 24/7/365. Therefore, we need to have more control over those that we do see. If it isn’t an emergency, then we shouldn’t be obligated to continue to provide care for them unless we want to and there is a clear financial benefit to doing so that both the patient and physician mutually agree upon. Patient satisfaction for ED patients doesn’t correlate with improved care. Our work shouldn’t be tied to patient satisfaction metrics. Even if you wanted to use patient satisfaction, the metric should be applied to patients with emergencies that you stabilized and not the worried well without emergencies that you discharged home.

2) Improved medicolegal protection. A high percentage of testing we do in the ED is for medicolegal protection, and also a large percentage for patient satisfaction. We often don’t feel testing is indicated or want to order, but pretty much have to a lot of the time for the above reasons. We can’t practice medicine if the lawyers and patients are doing it for us.

3) Decrease the level of charting required. Most charting is medicolegal protection. The second biggest reason is billing. Very little is actually done for future patient care.

4) Payment for services provided needs to primarily go to those providing the services. I’m lucky to work in an environment where this is the case, but many aren’t who are employed by CMGs. Also, billing shouldn’t be so tedious. A certain number of ROS elements shouldn’t dictate how much we are paid. No one honestly goes through and documents an entire ROS for every level 5 encounter.

5) Decrease circadian rhythm disruption. Most presentations to the ED aren’t emergencies. If it’s not an emergency, it can wait until the morning. No one pays a plumber or an electrician to come to their house in the middle of the night because a toilet won’t flush or their TV stops working. Many things can wait until the morning. If EDs can significantly decrease overnight staffing, then it will dramatically improve the quality of life of EPs. We can be on call with a quick response time like other physicians. It’s not perfect, but seems like a satisfactory compromise.

None of these are easy to address, hence why the odds of EPs continuing to dislike people and burnout is high. The solution is potentially there though.

I have daydreams too. Mostly that I can shoot energy beams with my hands or that I could magically blast Ken/Karen to a third world country for two weeks with no resources.