drip system vs q4 call system

[cbrons]

Our medicine program moved from a q4 call system to a drip system. We have 4 medicine teams of 1 senior, 2 interns. Do any of you have experience going from a system where one team takes all admissions from morning to evening every 4 days to a system where everyone gets 2-3 admissions everyday?

I find the drip system to be pretty bad. It seems that the benefit is you spread the work out more. But the fact is, we've gotten to the point where we're all in the hospital then everyday till past 3 or 4. Whereas on the old system, yes you had your bad day where you could be there till 8 or 9, but then you had pre-call days where you'd finish at noon.

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[Jolie South]

Could be worse. You could be a surgeon and get 10 consults every day 5 days a week on the call service, have to see all, and operate on some all while being manned with one senior and one intern only.

 

[FutureInternist]

Could be worse. You could be a surgeon and get 10 consults every day 5 days a week on the call service, have to see all, and operate on some all while being manned with one senior and one intern only.

But then write a 3 line note on each , since surgeons get paid for the procedure and not the notes.

 

[Raryn]

But then write a 3 line note on each , since surgeons get paid for the procedure and not the notes.

AF/VSS
AAOX3, NAD
RRR, CTAB, NWOB
S/NT/ND/NABS
LLE dsg C/D/I, DP 2+
34 yo M s/p L THA POD1
WBAT LLE
DVT ppx
PT/OT
D/W HMS
D/C SAR vs. HHPT

http://gomerblog.com/2014/12/soap-note/

 

[akwho]

AF/VSS
AAOX3, NAD
RRR, CTAB, NWOB
S/NT/ND/NABS
LLE dsg C/D/I, DP 2+
34 yo M s/p L THA POD1
WBAT LLE
DVT ppx
PT/OT
D/W HMS
D/C SAR vs. HHPT

http://gomerblog.com/2014/12/soap-note/

Too long.

S: NAEON
O: NAD, LLE DRSG C/D/I, +EHL/FHL/TA/GS, SILT M/L/D/P/FDWS, 2+ DP
A/P: 31M POD1 L THA. WBAT, lovenox 40 qday, PT to D/C

 

[deleted245139]

Gotta shorten that to LVX. Amature. Haha jk

 

[LucidSplash]

But then write a 3 line note on each , since surgeons get paid for the procedure and not the notes.

Actually surgeons get E&M charges too for notes. It’s just that we’re not trying to manage exclusively medical conditions.

 

[Smurfette]

Actually surgeons get E&M charges too for notes. It’s just that we’re not trying to manage exclusively medical conditions.

Only pre-op notes; no charge for 90 days post op including d/c summaries.

 

[LucidSplash]

Only pre-op notes; no charge for 90 days post op including d/c summaries.

True, I should have clarified. But surgeons do nonop mgmt of some problems too. This is especially true in trauma and ACS.

 

[BigRedBeta]

Our medicine program moved from a q4 call system to a drip system. We have 4 medicine teams of 1 senior, 2 interns. Do any of you have experience going from a system where one team takes all admissions from morning to evening every 4 days to a system where everyone gets 2-3 admissions everyday?

I find the drip system to be pretty bad. It seems that the benefit is you spread the work out more. But the fact is, we've gotten to the point where we're all in the hospital then everyday till past 3 or 4. Whereas on the old system, yes you had your bad day where you could be there till 8 or 9, but then you had pre-call days where you'd finish at noon.

Lots of different ways to divvy up work. Where I did my training (both for residency and fellowship) at peds programs, there were multiple inpatient teams that spread out the general pediatric patients but also had a subspecialty flavor so you'd end up rounding with two sets of attendings (or sometimes more if the subspecialties were small services). No other way to divide gen peds patients fairly but your so-called "drip" method.

My guess is that there may have been educational or patient safety reasons for the switch -

• Ensure everyone is covering enough admissions (we all have friends who are at the extremes of the black cloud/white cloud spectrum...as a notorious white cloud, my black cloud friends are better doctors than I am, I know this, because they got more practice)
• To limit the amount of time residents are cross covering (an educational and patient safety related concern)
• Or it could be that the attendings decided they wanted a more consistent day to day work week, and figured this was a better set up.
• Another consideration might have been that in the q4 system, invariably one team becomes a rock garden and can't empty their list by the time the next call day comes around, and rather quickly they're covering 3 times as many patients as everyone else, still piling up admits - and there can be a lack of enthusiasm from the other teams to help them out when they either just got hammered with admissions the day before or are on the docket to get swamped the next day.

 

[Jolie South]

AF/VSS
AAOX3, NAD
RRR, CTAB, NWOB
S/NT/ND/NABS
LLE dsg C/D/I, DP 2+
34 yo M s/p L THA POD1
WBAT LLE
DVT ppx
PT/OT
D/W HMS
D/C SAR vs. HHPT

http://gomerblog.com/2014/12/soap-note/

The note is not the work. Any monkey can auto populate a note in the EMR. We have to decide operate vs medical management. The decision making is not always easy which is what we’re getting paid for. Not a note about how we’re going to increase the lantus from 10 to 15 units daily and maybe we should bump the amlodipine up to 10 mg. I know when you’re not doing the surgery it seems like pushing a button that has no physiologic ramifications, but that could not be further from the truth.

 

[calvnandhobbs68]

The note is not the work. Any monkey can auto populate a note in the EMR. We have to decide operate vs medical management. The decision making is not always easy which is what we’re getting paid for. Not a note about how we’re going to increase the lantus from 10 to 15 units daily and maybe we should bump the amlodipine up to 10 mg. I know when you’re not doing the surgery it seems like pushing a button that has no physiologic ramifications, but that could not be further from the truth.

Someone can't take a joke.

 

[theacks1]

We are q4 for medicine and drip for pediatrics. For medicine, Mon-Fri short admits to 5:30 and long to 6:30 alternating based on census, with short taking two on weekends and long doing 28s Fri-Sun. Overall, admitting days can get a little rough and non admitting days a little slow, but overall I find the work very reasonable. For pediatrics, we are also mixed with general peds and a subspecialty for each team, and every day is a slog. I consider it a minor miracle to leave the hospital before 6pm, feel like we cross cover more, and frequently admit patients to other teams. I'm sure there are good ways to do it and we are trying to change things to split the subspecialties to their own teams and reduce admitting to other teams, but overall pretty minor changes.

 

[URHere]

I'm also in a system where we have q4 for medicine and drip for pediatrics...but the q4 call tends to be more of a bear.

On medicine, you alternate between call, post-call, short-call, and pre-call. On short-call days, you admit until one of the following happens: (1) it's 4pm on weekdays or 2pm on weekends, (2) your team is 1 admit away from capping, or (3) you've taken 2 patients. Long-call teams start admitting when the short-call teams stop (see above), and you continue until 7:30. Ideally, you don't get so many patients that you super-cap, but that happens sometimes. In that case, you give away some of your admits to other teams the next day. Most long-call days are brutal. Teams are 1 intern-1 senior. On long-call, you are cross-covering 4-6 teams at the same time and can generally expect to spend several hours after sign-out wrapping up admissions. Regardless of call day, no one is allowed to sign out before 4pm.

On peds, it's a modified drip in the sense that it's really the interns instead of entire teams who are on call. Each team is made up of 3 interns and 1-2 seniors and each color team is "paired" with another color team. Each day, interns will be assigned to short-call, long-call, or no call. Long-call alternates so that an intern from color team A will be on one day, and color team B will be on the next day. (This helps make sure that admissions are pretty evenly distributed between teams). Seniors are not assigned to long-call (they flip between days and nights) - whichever senior is currently in house will supervise whichever intern is on long-call and an on-call attending will see and staff patients before night float arrives. All teams get admits until about 4pm, then only the long-call intern takes admissions. Confusing to learn, but it works pretty well in practice and interns almost always leave within 30-45 minutes of their shifts ending. It also helps that each on call intern is only cross-covering one team in addition to their own. Interns are generally on long-call once a week. Non-call interns can leave at noon, short-call interns leave at 4.

 

[hmockingbird]

Peds - Ours is based on census (whoever has less patients gets the admission). It can get kind of confusing keeping track between teams and you can get screwed over easily (by bad luck lol). I’d definitely prefer either a straight drip OR short/long call lol! I think medicine here does short and long call.

 

[Psai]

Peds - Ours is based on census (whoever has less patients gets the admission). It can get kind of confusing keeping track between teams and you can get screwed over easily (by bad luck lol). I’d definitely prefer either a straight drip OR short/long call lol! I think medicine here does short and long call.

Short long is way better.

 

[dpmd]

Only pre-op notes; no charge for 90 days post op including d/c summaries.

Unless you can find a problem unrelated to the surgery you are addressing and then you can bill for it with a modifier (whether you get pain for it is different)