iaskdumbquestions

2+ Year Member
Jul 1, 2016
16
1
Just looking for an "on average." Shift length and patient acuity certainly play a role. I'm just looking for a relative perspective.

For example, I am an intern and usually see 0.75-1.25 patients per hour. Sometimes I see less than 1 patient per hour if some of my patients are really sick and need lots of attention. Sometimes I go into a trauma trolling for tubes or lines and see less. And then sometimes it's slow at night and I see 1/hr.

Just curious where your numbers are. often I start out strong, seeing maybe up to 2/hr, and then one patient really takes me by surprise and I drop significantly (whether the patient is sick or just a 'challenging personality'). I dunno, I feel like it really takes the air out of my tires and ruins my motivation sometimes. I need to see people to learn, but I struggle sometimes with people who just should not be in the ED. And then I stop caring for a bit.

Like the patient I saw the other night, who had a bad dream and thought they were dying, and while I was convincing them they didn't need a CT head to rule out impending death, a septic patient came in and I missed a tube and good patient management because I was convincing someone they weren't dying because they dreamed they were.

at the heart of things, I'm just paranoid that at the end of these 4 years I'm not going to know enough. So i guess I'm just on par with my paranoid sleep death-er :(
 

thedoctor8706

10+ Year Member
Dec 12, 2008
749
44
Ohio
Status
Attending Physician
We work 9 hours shifts, and numbers depend on the time of day, I usually see 16-18 or so. I'm 2 months into my second year. It comes with time and experience, I know I have much room to improve with efficiency and what not, but I've definitely improved from the start. I remember in my first month, I was pushing myself to really see a lot and felt like I never set down or took a break, but was maybe seeing only 9 or 10 in a 9 hour shift. But the other day it was a slow overnight shift, and I was 5 hours from finishing and had seen 10 and I felt like I was moving at a snail's pace.

As an intern they tell us to focus on learning good EM, seeing at least 1 an hour, but now I'm trying to push myself to be uncomfortable so that I start getting used to moving the department. Keep pushing yourself and you will be surprised how many you will start to see!


Sent from my iPhone using SDN mobile
 

Cinclus

Es un pájaro.
Moderator Emeritus
7+ Year Member
Feb 2, 2011
3,592
384
Behind the waterfall
Status
Attending Physician
How should we factor patients we received during sign-out into our number seen per hour? Sometimes I am signed out quite a few patients that require active management, so those eat up my time without allowing me to see as many new patients.
 

Zebra Hunter

5+ Year Member
Sep 17, 2014
530
724
Status
Attending Physician
It really depends on how your ER is set up. One person's numbers are not going to be comparable to another's at a different program. One of the sites that we work at I probably only see ~1.4pph, but every single patient is either sick as ****, a trauma activation, or has an extensive PMHx. That is because most of the BS is siphoned off by either fast track or a lower acuity pod (although I've intubated someone in that lower acuity pod before). Another site that we work at, I'm usually hovering around 2.3pph, but there is much less pts being siphoned off.

Another thing to keep in mind when thinking about your numbers in residency and how they will compare to the real world is that you don't truly grasp how much having an attending slows you down. Waiting for them to get back from a room to bounce an idea off them, waiting on them to approve on a patient being d/c'd, talking about pts with them, having them drop some knowledge pearls all adds up.
 

Zebra Hunter

5+ Year Member
Sep 17, 2014
530
724
Status
Attending Physician
How should we factor patients we received during sign-out into our number seen per hour? Sometimes I am signed out quite a few patients that require active management, so those eat up my time without allowing me to see as many new patients.
Anyone who is signed out to you counts towards your numbers; however, the opposite holds true, too. Anyone you sign out to someone else does not count towards your numbers. Also, it's pretty poor form for someone to be handing off "quite a few patients", unless your residency program has absolutely no shift overlap.
 

exsanguination

2+ Year Member
Apr 30, 2014
167
174
Status
Resident [Any Field]
While I am not calling "BS" on some of these numbers (keep in mind this is SDN so the kind of posters you see here represent a biased sampling), I think a lot of what is being posted here is either inflated or you're talking to the upper echelon of 1% of residents.

A quick google search yields some evidence:
http://aaemrsa.blogspot.com/2016/07/how-do-i-know-if-i-go-too-slow.html

"Across all included studies, interns (PGY1) averaged from 0.73 to 1.06 pts/hr; PGY2 residents ranged from 0.85 to 1.33; and senior (PGY3) residents ranged from 1.05 to 1.41."

Any time I hear or read of an intern trying to see "two patients per hour" or even a PGY3 who sees that much with all the charting burden, learning burden, and inherent slowed paced due to needing an attending's approval, I am usually suspect.

I am a PGY2 at a well-regarded four year academic program and I am really at best seeing 1.25 an hour.

The proof is in the objective data!
 
Last edited:

Tenk

10+ Year Member
Jan 5, 2007
2,115
6,921
Status
Attending Physician
Patients per hour is a very poor goal for residents to track. The reason is that patients vary in acuity. If all I had to do is see greens I could probably see 6+ patients an hour. Add one patient who needs multiple procedures and that number would plummet.

A better goal and what I tell my residents is to look at how many patients you can manage at one time. For a new intern I expect you to always have two patients at all time. By the end of your first year you want to be able to handle 3. Early second year 4, middle 5, late 6. Third year you should be able to handle over 6 and work on your speed and efficiency.

The reason this system I feel is better is because it matches an actual flow of the emergency department with juggling multiple things at once. These numbers are the minimum imo. If you can do more. Kudos.

Overall, you should always feel uncomfortable as a resident. Always. If you are thinking this is easy, it's time to sign up for another patient! Better to push yourself when it's not your malpractice on the line.
 

WildcatS11

10+ Year Member
Jul 17, 2009
111
121
Status
Resident [Any Field]
While I am not calling "BS" on some of these numbers (keep in mind this is SDN so the kind of posters you see here represent a biased sampling), I think a lot of what is being posted here is either inflated or you're talking to the upper echelon of 1% of residents.

Evidence:
http://aaemrsa.blogspot.com/2016/07/how-do-i-know-if-i-go-too-slow.html

"Across all included studies, interns (PGY1) averaged from 0.73 to 1.06 pts/hr; PGY2 residents ranged from 0.85 to 1.33; and senior (PGY3) residents ranged from 1.05 to 1.41."

Any time I hear or read of an intern trying to see "two patients per hour" or even a PGY3 who sees that much with all the charting burden, learning burden, and inherent slowed paced due to needing an attending's approval, I am usually suspect.

I am a PGY2 at a well-regarded four year academic program and I am really at best seeing 1.25 an hour.

The proof is in the objective data!
Huh. Then maybe I'm the top 1% like you said. As a 2nd year, were expected to carry the burden of moving the room. I rarely saw less than 20 pt's on 10 hour shifts, had 31 on my busiest. Sure I stayed an extra 45 minutes charting. But if you're not seeing 2 PPH or more throughout all of residency, I can't imagine you're prepared to work a busy community job.
 

thedoctor8706

10+ Year Member
Dec 12, 2008
749
44
Ohio
Status
Attending Physician
While I am not calling "BS" on some of these numbers (keep in mind this is SDN so the kind of posters you see here represent a biased sampling), I think a lot of what is being posted here is either inflated or you're talking to the upper echelon of 1% of residents.

Evidence:
http://aaemrsa.blogspot.com/2016/07/how-do-i-know-if-i-go-too-slow.html

"Across all included studies, interns (PGY1) averaged from 0.73 to 1.06 pts/hr; PGY2 residents ranged from 0.85 to 1.33; and senior (PGY3) residents ranged from 1.05 to 1.41."

Any time I hear or read of an intern trying to see "two patients per hour" or even a PGY3 who sees that much with all the charting burden, learning burden, and inherent slowed paced due to needing an attending's approval, I am usually suspect.

I am a PGY2 at a well-regarded four year academic program and I am really at best seeing 1.25 an hour.

The proof is in the objective data!
I have a hard time arguing objective data like that, but those numbers, especially for PGY-3, seem awfully low. If I get caught seeing less that 1.5 an hour at minimum as a PGY-2, I really hear it from my attendings. I rotate through three different, very busy community EDs, and numbers are not hard to come by, if you really push yourself to manage many patients at once. I try to pick up a good mix of sick and not sick, so I can see a good variety, plus I don't want to hog all the good stuff from the other resident that is on at the same time. My attendings can easily see 40+ in a 9 hour shift (with midlevels of course), so I'm not sure where this 1.72/hour for an attending rate is coming from! Just my experience.


Sent from my iPad using SDN mobile
 
  • Like
Reactions: Cinematographer

exsanguination

2+ Year Member
Apr 30, 2014
167
174
Status
Resident [Any Field]
I have a hard time arguing objective data like that, but those numbers, especially for PGY-3, seem awfully low. If I get caught seeing less that 1.5 an hour at minimum as a PGY-2, I really hear it from my attendings. I rotate through three different, very busy community EDs, and numbers are not hard to come by, if you really push yourself to manage many patients at once. I try to pick up a good mix of sick and not sick, so I can see a good variety, plus I don't want to hog all the good stuff from the other resident that is on at the same time. My attendings can easily see 40+ in a 9 hour shift (with midlevels of course), so I'm not sure where this 1.72/hour for an attending rate is coming from! Just my experience.


Sent from my iPad using SDN mobile
What EMR do you guys use and I'm interested in your charting workflow - do you guys stay late?
 

brk81144

Attending
Apr 10, 2014
68
50
First year we were expected to see 1pph. First day of second year they really pushed us to pick up the pace. By third year it was a nice shift if we saw less than 2.5pph and they were sick. We had a fast track that siphoned off level 3-5 patients. That's what prepared me for the community
 

shoal

Oinker!
10+ Year Member
Apr 24, 2005
502
127
Status
im currently a second yr attending and we see 1.6 to 2.1 pph with midlevels taking off the top.

In this day and age of patient satisfication, my colleuges and i are very busy during our shifts.

Sent from my VS986 using Tapatalk
 

medic4lyfe

2+ Year Member
Sep 25, 2015
111
70
Status
Resident [Any Field]
As an intern I'm averaging 8-10 in an 8 hour shift. Like above, I get through 4 charts relatively "quickly", but then all their stuff comes back around the same time and I'm trying to call consults/admit/dispo 4 people at once and my productivity greatly decreases. Most I've done in 8 hours was 12 or 13 thanks to a hefty dose of fast track patients.

Sent from my SM-G930V using Tapatalk
 

filhodeinferno

10+ Year Member
Mar 22, 2009
379
187
Status
Resident [Any Field]
Just looking for an "on average." Shift length and patient acuity certainly play a role. I'm just looking for a relative perspective.

For example, I am an intern and usually see 0.75-1.25 patients per hour. Sometimes I see less than 1 patient per hour if some of my patients are really sick and need lots of attention. Sometimes I go into a trauma trolling for tubes or lines and see less. And then sometimes it's slow at night and I see 1/hr.

Just curious where your numbers are. often I start out strong, seeing maybe up to 2/hr, and then one patient really takes me by surprise and I drop significantly (whether the patient is sick or just a 'challenging personality'). I dunno, I feel like it really takes the air out of my tires and ruins my motivation sometimes. I need to see people to learn, but I struggle sometimes with people who just should not be in the ED. And then I stop caring for a bit.

Like the patient I saw the other night, who had a bad dream and thought they were dying, and while I was convincing them they didn't need a CT head to rule out impending death, a septic patient came in and I missed a tube and good patient management because I was convincing someone they weren't dying because they dreamed they were.

at the heart of things, I'm just paranoid that at the end of these 4 years I'm not going to know enough. So i guess I'm just on par with my paranoid sleep death-er :(
PGY-3 here. Our dept is divided by acuity.

In highest acuity, usually see about 1 pph, or 8 in an 8 hour shift.
In medium acuity, usually see about 2 pph, or about 16-18 in an 8 hour shift.
In lowest acuity, can easily see 3+ mph, or about 25-30 in an 8 hour shift.

I imagine that if the acuity was mixed I'd average around 2 pph or so, with the ability to kick it up to 2.5-3 if I worked in a more efficient ED without an attending slowing me down.
 

dav86

10+ Year Member
Jun 18, 2007
221
60
IN
Status
Attending Physician
I agree that PPH is a stupid metric to measure. It varies upon acuity, whether or not you have scribes, whether you include PA charts that you sign or only the PA pts you see.

If you are going to measure it, then it is more beneficial to make the denominator how many hours you are spending on documenting and patient care. Meaning if you see 20 pts in a 10 hour shift but you are staying 1-2 hours late to chart or chart at home then it is 20 pts in 12 hours. It is nice to have inflated numbers as a resident and say yeah I saw 3 PPH but if you are staying super late or doing a lot of work at home you are not really being that efficient. I think it is way more impressive to see 18 pts in 10 hours and leave five min late. Once you become an attending minimizing time spent charting really helps with work-life balance and it will increase your enjoyment with your job.

I remember in residency we should have competitions over how "fast" we were and how many patients we could see. Looking back I'd much rather see 20 pts in a 9 hour shift and walkout on time then see 23 and leave 1.5 hours late.

As long as you can see the ACEP recommended avg (2-2.2 pph?) you will be fine. This becomes much much easier when you don't have to staff pts with an attending and become more comfortable making decisions on the 45 yr old chest pains and 60 yr old abd pains. The sick ones are easy and the FT pts are easy. It is the pts that don't have a diagnosis and you are worried about that become ones that can take some time to dispo as a resident or new attending.
 

thedoctor8706

10+ Year Member
Dec 12, 2008
749
44
Ohio
Status
Attending Physician
What EMR do you guys use and I'm interested in your charting workflow - do you guys stay late?
We use Epic, and charting is something I am trying to get faster at doing. We have Dragon Dictation, but I still find myself staying over 45 minutes to an hour to wrap up my notes and what not. So I guess if you take my quoted 16-18 per hour and divide it over 10 hours instead of 9, it's about 1.6-1.8 an hour. We have a built in hour of overlap too, so I usually only get 1, maybe 2 sign-outs, so that doesn't eat into time too much.
 

Alvarez13

PGEEE2 mediates FEEEVER
10+ Year Member
May 29, 2007
1,252
257
Status
Attending Physician
Huh. Then maybe I'm the top 1% like you said. As a 2nd year, were expected to carry the burden of moving the room. I rarely saw less than 20 pt's on 10 hour shifts, had 31 on my busiest. Sure I stayed an extra 45 minutes charting. But if you're not seeing 2 PPH or more throughout all of residency, I can't imagine you're prepared to work a busy community job.
You obviously don't work at a tertiary care center.

I echo what everyone is saying about pt population and setting. If all your patients have to be admitted and have complex medical histories with long differentials, you're not seeing 2 pph most days. Someone else mentioned this is SDN which means everyone on here scored 260+ on their usmles and sees 3-4 pph. You'd be better comparing yourself to other people in your program and talking to those ahead of you as they work in the same setting.

As an intern, focus purely on learning. If you see 8 pts in an 8 hr shift, that's fine. Talk about it with your fellow interns.
As a 2nd yr, you get better at efficiency and multitasking.
As a 3rd yr, you should be nearing your attending's level knowing you'll be under as you're doing the pelvic/line/orders and then trying to find them.
As a 4th yr, question yourself daily why you took a $250,000 pay cut because your too scared to be on your own.
 

WildcatS11

10+ Year Member
Jul 17, 2009
111
121
Status
Resident [Any Field]
You obviously don't work at a tertiary care center.

I echo what everyone is saying about pt population and setting. If all your patients have to be admitted and have complex medical histories with long differentials, you're not seeing 2 pph most days. Someone else mentioned this is SDN which means everyone on here scored 260+ on their usmles and sees 3-4 pph. You'd be better comparing yourself to other people in your program and talking to those ahead of you as they work in the same setting.

As an intern, focus purely on learning. If you see 8 pts in an 8 hr shift, that's fine. Talk about it with your fellow interns.
As a 2nd yr, you get better at efficiency and multitasking.
As a 3rd yr, you should be nearing your attending's level knowing you'll be under as you're doing the pelvic/line/orders and then trying to find them.
As a 4th yr, question yourself daily why you took a $250,000 pay cut because your too scared to be on your own.
I work at the ivoriest of ivory towers, actually. (not in a bragging way, I'd rather work at our poor-access community site long term)
 

emergentmd

10+ Year Member
Jul 6, 2008
1,473
1,612
Status
Attending Physician
You obviously don't work at a tertiary care center.

I echo what everyone is saying about pt population and setting. If all your patients have to be admitted and have complex medical histories with long differentials, you're not seeing 2 pph most days. Someone else mentioned this is SDN which means everyone on here scored 260+ on their usmles and sees 3-4 pph. You'd be better comparing yourself to other people in your program and talking to those ahead of you as they work in the same setting.

As an intern, focus purely on learning. If you see 8 pts in an 8 hr shift, that's fine. Talk about it with your fellow interns.
As a 2nd yr, you get better at efficiency and multitasking.
As a 3rd yr, you should be nearing your attending's level knowing you'll be under as you're doing the pelvic/line/orders and then trying to find them.
As a 4th yr, question yourself daily why you took a $250,000 pay cut because your too scared to be on your own.
Year four made me laugh b/c its so true. Never understand a 4th yr other than to allow an extra year of servitude for the hospital or allows them to hire less attending coverage.
 
  • Like
Reactions: theseeker4

carbonizedeyesockets

5+ Year Member
Oct 27, 2013
207
198
East Coast
Status
Attending Physician
PPH is a sort of pissing match we(?) seem to get into, but we're all using different metrics, as if all EDs (or residencies) are set-up the same.

Is PPH the number of new patients you see or the number new plus the sign outs? Or is it the number of signs outs plus new minus patients you sign out?

Which is it?

NO WAY you getting near 2pph when having to manage airways in the trauma bay, placing central lines on septic shock patient, teaching interns different procedures (from splinting to reductions to CVCs to a-lines to I&Ds, and so on), coding patients, etc. Even as a third year resident, you could see your numbers plummet to near 1pph if you're seeing mostly level 2 patients who need admission.

And again, things will depend on the patient population. Patients with good out-pt follow-up or PCPs who admit makes things much easier (a resident gets more work, but an attending gets more pay for admission, so who do think is actually easier to deal with). Patients with little to no follow-up or who are unreliable can make things much more difficult.

Now, go some place where you get to see a lot of "low" acuity patients, sure you can burn through many patients and still see a sick patient here and there.

Me and my co-residents track pph loosely. I know that in out high acuity zone, a goal for interns is 1 pph by end of year and to up things as a second year, but usually 1.25 to 1.5 and 3 rd years tend to stay near 1.5 (especially since they're now tasked to responding to ALL traumas and stay until secondary survery is complete since we're at the head). In our medium acuity zone, we hit 2-2.5 and some of us (not me) will bang out 3+ pph, but obviously interns will be around 1.5. No traumas, no codes, rarely ever ICU patients in that area; 85% are D/C'd to home. Of course, we do community rotations and everyones numbers in terms of PPH goes up because those EDs aren't broken up by acuity aside from having a fast track staffed w/ PAs. I would see around 1.8-2 pph, but I would be the only resident and could cherry-pick patients and had first dibs at airways and lines.

My point is that you can have low PPH but still have great training. Based on what literature exists on the subject, "low" pph (~1.5) is the norm for residency. Those hitting 2+ pph are out-liers. But, nonetheless the pph is going to depend on how the ED is set-up and that varies immensely.
 
  • Like
Reactions: TooMuchResearch

gamerEMdoc

Associate PD; EM Clerkship Director
Gold Donor
2+ Year Member
Feb 10, 2016
2,167
4,050
Status
Attending Physician
General rule of thumb:

1 patient/hr for R1's
1.5 patient/hr by middle of R2 year
2.0 patient/hr by mid/end of R3 year

Those are both realistic and attainable numbers. You'll see faster residents than this, some slower, but in general, if you are consistantly hitting those numbers, you're going to be fine.
 
  • Like
Reactions: Cinclus

gamerEMdoc

Associate PD; EM Clerkship Director
Gold Donor
2+ Year Member
Feb 10, 2016
2,167
4,050
Status
Attending Physician
PPH is like bench press. Everyone mentions their max, but in reality, you don't usually do max. Just as long as you have double plates (two 45's) on each side, you're golden.

People report PPH like height. 5'10.5" is basically 6'.
Yep. PPH is generally overestimated. Noone considers that when they have a slow day where noone is there in the ED and they see 10 patients, that they need to see 30 some shift to keep up their 2 PPH pace. Most people think about their best shifts and consider that their PPH. In reality, that's more their PPH potential.
 
  • Like
Reactions: Makati2008

n2b8me

10+ Year Member
May 27, 2008
101
35
Status
Attending Physician
1.27. Its not how many you see, but how many you dispo (ie see them leave the er). total annual volume/total physician hours.
 

Arcan57

Junior Member
15+ Year Member
Nov 21, 2003
2,860
1,301
Visit site
Status
Attending Physician
Agree with pph being wildly inflated by almost everyone . The poster that was talking about simultaneously active patients is getting closer to a meaningful number. The only problem with that is that once you get above 6 or so it's almost always at the cost of delaying discharge for patients that are ready to go. The ideal metric would be something approaching a combo of LOS, D2D time, and pph. It would also require some standardization based on turn-around times for lab and radiology results as well as hold hours. Surely some of the more sabermetric docs could gin up the EM version of VORP.
 
  • Like
Reactions: BoardingDoc

Dr.McNinja

Nobel War Prize Winner
Moderator
10+ Year Member
Aug 2, 2006
10,291
6,967
Texas
Status
Attending Physician
Agree with pph being wildly inflated by almost everyone . The poster that was talking about simultaneously active patients is getting closer to a meaningful number. The only problem with that is that once you get above 6 or so it's almost always at the cost of delaying discharge for patients that are ready to go. The ideal metric would be something approaching a combo of LOS, D2D time, and pph. It would also require some standardization based on turn-around times for lab and radiology results as well as hold hours. Surely some of the more sabermetric docs could gin up the EM version of VORP.
I'm sure they could. Like baseball. But while some stats might be modified by the parks, eg: Coors Field vs AT&T Park, none of them require the batter to bat with the opposite hand, or only hit when the outfield bleachers have capacity, or any number of useless things you can think of.

Yes, I'm sure you could find an ideal dispos/hr metric, but it would be dependent on nurses/pt, lab techs/lab, order enter to time completed, and more.
 

OccupyTheED

Attending Physician
7+ Year Member
Feb 8, 2012
122
70
NY --> ATL --> Nashville --> NY --> ATL
Status
Attending Physician
I think its pretty difficult to gauge as a resident. A lot of variables in play. In my fairly dysfunctional county shop I would dispo somewhere in the neighborhood of 1.2-1.3 per hour. In my very functional community shop as a new attending I'm seeing/dispositioning 1.8/hr so far while working at a very comfortable pace. I don't think I've changed that much as a doc in the last two months, its all the other things around me.
 

shookwell

10+ Year Member
Apr 9, 2008
205
114
Status
Attending Physician
You should compare yourself with residents at your own program, and with the expectations of your program directors. It's not possible to compare with anonymous people online because of how different practice environments are. Even as an attending, at one of my jobs I average 2-3pph, and another one in the same town probably less than 1.5pph because of how different it is to work at different hospitals.
 
  • Like
Reactions: Makati2008

Cinclus

Es un pájaro.
Moderator Emeritus
7+ Year Member
Feb 2, 2011
3,592
384
Behind the waterfall
Status
Attending Physician
I am a few months into intern year, and I had what I though was a fairly efficient day today (for my level, at least). I saw 0.75 PPH, not counting several sign-outs for whom I did pretty much nothing before they got admitted, and counting my single sign-out for whom I did pretty much everything; tied that patient up with a bow. All documentation and other essential tasks complete before the end of the shift. Yesterday, on the other hand.....haha. It varies a lot, but today was probably an average sort of day for me. I rarely see more patients per hour than this in a shift.
 

gamerEMdoc

Associate PD; EM Clerkship Director
Gold Donor
2+ Year Member
Feb 10, 2016
2,167
4,050
Status
Attending Physician
I am a few months into intern year, and I had what I though was a fairly efficient day today (for my level, at least). I saw 0.75 PPH, not counting several sign-outs for whom I did pretty much nothing before they got admitted, and counting my single sign-out for whom I did pretty much everything; tied that patient up with a bow. All documentation and other essential tasks complete before the end of the shift. Yesterday, on the other hand.....haha. It varies a lot, but today was probably an average sort of day for me. I rarely see more patients per hour than this in a shift.
Well, you just started intern year. By mid/end of this year, you'll be at 1.0 patients/hr easy.
 

TooMuchResearch

i'm goin' to Kathmandu...
Lifetime Donor
10+ Year Member
Oct 21, 2008
5,372
1,596
Townsville, USA
Status
Attending Physician
I'm above the reported median for my class and within the range of expectation for residents in my program. As many others have said, the specific number is irrelevant.
 

Aesculapius

Junior Member
10+ Year Member
Dec 30, 2004
228
2
Status
Resident [Any Field]
The expectation for my prior residency was by the end of the first year, 1 patient per hour, second year, 2 per hour, and third year, 2.5 per hour. There was a separate Fast Track area that siphoned off some of the more simple stuff/procedural stuff, and there was a Critical Care area that siphoned off the highest acuity stuff (grossly unstable, trauma codes, etc.), so the main ED generally had "medium" acuity. But we were in a rather inefficient system that relied on residents to basically make all of the phone calls, get all the supplies for procedures, do pretty much all the procedures that weren't blatantly nursing-type stuff (IV, foley), and we also did the bulk of the charting and orders, which was on paper for the first two and a half years. Currently as an attending in a pretty high acuity ED for my main location, I tend to be between 1.8-3 patients per hour, depending on the time of the shift, how busy the department is, and the general acuity of the patients (which actually tends to be less of a factor), but since we have great ancillary and nursing staff, scribes, and very helpful unit secretaries, it tends to be much more manageable, even if basically almost all of the patients that I see are more complicated (as a lot of cases, even things that aren't necessarily "Fast Track" per se, such as pregnant vaginal bleeders, abdominal pain, some low risk chest pain, a lot of pediatric stuff are sent to our midlevel side).
 

Tiger26

Senior Member
15+ Year Member
Mar 14, 2004
1,446
107
Visit site
Status
Attending Physician
1) PPH is always like telling a fish story, much higher afterwards than it really is. Moreover, being "involved" in care does not equal seeing a patient primary and doing all the work. Though a senior resident may "see" the patient, they often aren't writing a supervisory note and doing all the work. In the community, you have to do it all, from orders to procedures to charting and discharge instructions.

2) I went from a very academic place with lots of high acuity patients to a fellowship with a more under-served population to my current job in a midwest middle-class college town. The community job is easily my hardest, though I still work academic shifts.

3) It's not how many you can see per hour, but how many you can see in one hour. Unlike a clinic, there is tremendous variability in most community EDs. We're single coverage at night and I often have 8-12 people register in an hour yet other times I'll go quite a few hours without seeing anybody. In all but a code situation, I can see a patient and write orders about every 5 minutes, though I then obviously have quite a bit of documentation time. I've found that the extreme variability has been the hardest thing to wrap my head around, especially as single coverage.
 

Spectre of Ockham

2+ Year Member
Jun 17, 2016
188
155
Status
Medical Student
PPH stats sound more like PPC (Pay-Per-Click) and it's as terrible of an idea as is click-bait. A more accurate measure of the workload is the number of patients per shift however the 12 hour night shift usually has the same amount of patients as an 6 hour day shift.

Over here the medium emergencies unit sees about 100 to 200 patients per shift with Monday morning being even more crowded. Critical patients tough are between 5 to 20 per shift so as a resident you will treat between one to 10 patients depending on staff levels in that day.
 

link2swim06

10+ Year Member
Dec 14, 2007
3,278
792
Status
Attending Physician
How about we talk about RVUs per hour. That is more meaningful to compare.

I am PGY-3 and see maybe an average of 10-15 in a 8 hour shift...which is hitting 6-7 RVUs per hour.
 

HooliganSnail

7+ Year Member
Mar 13, 2012
641
644
Status
Attending Physician
While I am not calling "BS" on some of these numbers (keep in mind this is SDN so the kind of posters you see here represent a biased sampling), I think a lot of what is being posted here is either inflated or you're talking to the upper echelon of 1% of residents.

A quick google search yields some evidence:
http://aaemrsa.blogspot.com/2016/07/how-do-i-know-if-i-go-too-slow.html

"Across all included studies, interns (PGY1) averaged from 0.73 to 1.06 pts/hr; PGY2 residents ranged from 0.85 to 1.33; and senior (PGY3) residents ranged from 1.05 to 1.41."

Any time I hear or read of an intern trying to see "two patients per hour" or even a PGY3 who sees that much with all the charting burden, learning burden, and inherent slowed paced due to needing an attending's approval, I am usually suspect.

I am a PGY2 at a well-regarded four year academic program and I am really at best seeing 1.25 an hour.

The proof is in the objective data!
1 to 1.4 an hour for a senior!!!!

What the hell are you doing? If its a quickie, do the paperwork and d/c them, if it's a work up, then start the line, get the labs/scan, and move onto the next patient while that is cooking. Seeing 1 patient per hour is just plain LAZY.

We have ALL had those patients that total septic messes, and you are in there logging some critical care time, but those comprise like 2-3% of your patients.

Seriously blows my mind.....
 

e30ftw

peace
7+ Year Member
Feb 23, 2012
485
383
Status
Attending Physician
around average for my program:

pgy1 first 6mo: 12-18 per 12 hr shift
pgy1 last 6mo: 18-24 per 12 hr shift

pgy2/3: 18-24 per 10 hr shift.

Some faster some slower, a couple much slower.

One way to describe those who saw 1.1-1.5pph as upper levels: residents who did not get job offers in our metropolitan area.

crappiest shift I remember from residency: super slow attending, off service intern, upper level mid-shift unfilled, worked 7-5 day shift, saw 35 patients just trying to keep the place from imploding. Admitted ~12 (lots of those transfers so easy) put in 2 central lines and tubed a guy. Still left a few minutes after 5. Definitely had shifts where I did more procedures but that one took the cake in terms of trying to keep everyone alive long enough to make it upstairs..
 

link2swim06

10+ Year Member
Dec 14, 2007
3,278
792
Status
Attending Physician
1 to 1.4 an hour for a senior!!!!

What the hell are you doing? If its a quickie, do the paperwork and d/c them, if it's a work up, then start the line, get the labs/scan, and move onto the next patient while that is cooking. Seeing 1 patient per hour is just plain LAZY.

We have ALL had those patients that total septic messes, and you are in there logging some critical care time, but those comprise like 2-3% of your patients.

Seriously blows my mind.....
Lots of factors make it impossible to compare:

Acuity is highly variable from one shop to another.
Charting.
Nursing.
Lab and imaging turn around time.
Boarding in ER.
 

winkleweizen

7+ Year Member
Apr 10, 2011
801
45
Status
Attending Physician
1 to 1.4 an hour for a senior!!!!

What the hell are you doing? If its a quickie, do the paperwork and d/c them, if it's a work up, then start the line, get the labs/scan, and move onto the next patient while that is cooking. Seeing 1 patient per hour is just plain LAZY.

We have ALL had those patients that total septic messes, and you are in there logging some critical care time, but those comprise like 2-3% of your patients.

Seriously blows my mind.....
Our program the r3s prob averaged 1.2 to 1.3. I was the "fast" one at 1.5. Imagine every inefficiency possible multiply that times by 2 and that was our program. Our average attending who oversees 2 and sometimes 3 residents was 1.7/ hour. Needless to say, I started to hate residency
 

hundreddaysoff

5+ Year Member
Jan 2, 2013
198
114
TX
Status
Attending Physician
around average for my program:

pgy1 first 6mo: 12-18 per 12 hr shift
pgy1 last 6mo: 18-24 per 12 hr shift

pgy2/3: 18-24 per 10 hr shift.

Some faster some slower, a couple much slower.

One way to describe those who saw 1.1-1.5pph as upper levels: residents who did not get job offers in our metropolitan area.

crappiest shift I remember from residency: super slow attending, off service intern, upper level mid-shift unfilled, worked 7-5 day shift, saw 35 patients just trying to keep the place from imploding. Admitted ~12 (lots of those transfers so easy) put in 2 central lines and tubed a guy. Still left a few minutes after 5. Definitely had shifts where I did more procedures but that one took the cake in terms of trying to keep everyone alive long enough to make it upstairs..
Just curious... were all your notes done when you left a few minutes after 5? If so, how?
 

Arcan57

Junior Member
15+ Year Member
Nov 21, 2003
2,860
1,301
Visit site
Status
Attending Physician
Just curious... were all your notes done when you left a few minutes after 5? If so, how?
Chart in real time and create a defensible note without a lot of extra detail. If you're waiting till the rush dies down to chart or if you have to create the perfect chart that will live on as a shining example of the perfect unabridged description of the patient then budget a couple of hours after your shift.

Or do what most people do and try to document a complete history on your early admitted patients then get tired and confused and halfass a bunch of iffy notes at the end of your shift on all the belly pain and dizzy pts you sent home.
 

HooliganSnail

7+ Year Member
Mar 13, 2012
641
644
Status
Attending Physician
Lots of factors make it impossible to compare:

Acuity is highly variable from one shop to another.
Charting.
Nursing.
Lab and imaging turn around time.
Boarding in ER.

I suppose that's true. My shop has a TON of urgent care type stuff, we have no fast track. We still get the bad trauma's and the super sick people too just like any ED, but there is always the quick ones to do as well, so that brings my total patient numbers up a bit.
 

e30ftw

peace
7+ Year Member
Feb 23, 2012
485
383
Status
Attending Physician
Just curious... were all your notes done when you left a few minutes after 5? If so, how?
On my phone at a labor day party so short version:

Seeing a patient takes 5 minutes. Writing a note takes 2-5 minutes.

3-4 pph = ~35 min documentation and initial encounter time.

If you can keep that up and spend ~25 min per hour dispoing (discussing w consultants, writing rx, having closing discussion w patients) and doing procedures, not too difficult to manage but does make for a draining and hopefully very atypical shift.
 

brk81144

Attending
Apr 10, 2014
68
50
I always chart in real time. See a patient, write an hpi, templates for ros and exam then see the next patient. When I dispo someone I complete their mdm and sign their chart. Started this as a second year resident and it hasn't let me down. once it becomes a habit it is much more efficient since your not having to go back and figure out your train of thought.
 

Jlaw

10+ Year Member
7+ Year Member
Apr 15, 2009
814
271
Status
Resident [Any Field]
I always chart in real time. See a patient, write an hpi, templates for ros and exam then see the next patient. When I dispo someone I complete their mdm and sign their chart. Started this as a second year resident and it hasn't let me down. once it becomes a habit it is much more efficient since your not having to go back and figure out your train of thought.
I do this as an intern. I see a lot of co-residents stuck behind an hour or two after shift ends doing notes and it makes no sense. It might take 1 min to document an accurate PE you just did, its going to take 3 or 4 if you have to go through notes or rack your brain 6 hours later. Or you end up just making **** up and that may come back to bite you down the line.