ER Provider Efficiency

[valianteffort]

As of late I have noticed my efficiency has started to trend down in multiple ways. Same job, same needy patients, same area but I leave the shift with more and more notes than I used to have years ago. Yesterday, I left shift and nurse mentioned, 'well today wasn't too bad was it?' I reluctantly agreed but I got my *ss handed to me with multiple sick patients in a row requiring procedures and true emergent attention. I have noticed a decline in my PPH than right out of residency as compared to my current workflow. This made me postulate if this is general trend with the more years of ER medicine you take on. Did I spend too much time theorizing something that may be completely untrue and an individual issue? Most definitely, but would love to hear thoughts to those more veteran.

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[JacobMcCandles]

I find it hard to believe that peak efficiency is basically right out of/ at the end of residency.

 

[carbonizedeyesockets]

So much goes in to PPH beyond the physician. In my experience docs generally seem to over estimate their average PPH. In the end we're not nearly as good at multitasking as we think we are. Our collective desire to 'see more' patients only helps admin and compensates for the inability of others to do their jobs and puts us more at risk (i.e. misses). Unless you're an owner, I don't see the point of killing ones self to see every BS complaint that comes through the door. 2/hr is plenty if you're in a high acuity shop and something like 1.8 is probably ideal. And for what it's worth, most of the old heads I work with can keep pace, and some of the 'most efficient' are the ones who've been doing this 30+ years.

 

[EctopicFetus]

Agreed.. its complicated.. The ED you work at matters. In my groups busiest site 4 of the top 5 PPH docs are 15-25 years out.

At one of our other sites the single fastest guys is almost 30 years out.. the slowest is about 10 years out.. I don't agree with the curve and I do think for the first 20-25 years (excluding the first year or 2), I think it depends on the individual, burn out, etc.

 

[JacobMcCandles]

I think it just depends on too many factors. Overall department efficiency, compensation model, owner vs. employed model, staffing, who the other providers are that you’re on with, burn out, personal motivation, etc. I think physicians who are efficient 1-2 years out of residency stay efficient and those who aren’t generally stay non-efficient.

 

[hoot504]

People absolutely overestimate their PPH. We actually get daily report cards at our main site. No one's name is hidden, everyone can see everyone else's PPH, acuity level, dispo time, etc. I love it.

There's basically two cohorts. The folks that see 1.4 or less every, single, shift. These people are generally lazy and/or not particular competent. Then there's the docs who without fail see 1.8+ every shift. Personally I try to thread the needle right at 1.7 - 1.9. We get bonuses based on RVU but 90% of our pay just winds up being our straight hourly rate, hence I try to see just enough to avoid being the turd in the punchbowl without taking on unnecessary legal risk.

 

[BoardingDoc]

As of late I have noticed my efficiency has started to trend down in multiple ways. Same job, same needy patients, same area but I leave the shift with more and more notes than I used to have years ago. Yesterday, I left shift and nurse mentioned, 'well today wasn't too bad was it?' I reluctantly agreed but I got my *ss handed to me with multiple sick patients in a row requiring procedures and true emergent attention. I have noticed a decline in my PPH than right out of residency as compared to my current workflow. This made me postulate if this is general trend with the more years of ER medicine you take on. Did I spend too much time theorizing something that may be completely untrue and an individual issue? Most definitely, but would love to hear thoughts to those more veteran. View attachment 395130

My shop has grown steadily busier over time. My personal PPH has also risen steadily over time. This isn't just gestalt. I get quarterly reports about how many PPH I am seeing solo and how many PPH I am seeing as me + midlevel. Both numbers have steadily risen over time.

I only have data going back 2 years in front of me as the other stuff is on a different computer but this time in 2022:
Personal PPH: 2.11. Group avg: 1.90.
Personal + PA: 2.85. Group avg: 2.66

Last quarter:
Personal PPH: 2.77. Group avg: 2.37
Personal + PA: 3.43. Group avg: 2.98

 

[CoolDoc1729]

I feel like I steadily became more efficient the first ten years - sharpest in the first 2-3 years but still improved. I’m 12 out now and I’ve been working single coverage nights forever.. so I kind of have to see most everyone who comes in during my single coverage time unless the volume is truly overwhelming then I don’t see the nonsense. I typically see 2.7/h or so. At my site nights are fairly low acuity, a lot of homeless phony medical or psych issues, so doesn’t feel excessive.

Over time I have learned to prepare the obvious dispos so I don’t necessarily have to go back (“if everything is normal then you’ll go home with x and y” or “you’re super high risk so plan on staying overnight” getting the overbearing family to go home once they have provided their vital collateral information). I have scripts for explaining what the gallbladder is, what TNK is, why we’re not throwing narcotics at headaches or undifferentiated abdominal pain at discharge, etc etc. I think of new dotphrases that would make documenting quicker.

Im not sure why efficiency would decrease with experience until the point where the doc is physically not able to go from room to room as quickly.

 

[hoot504]

My shop has grown steadily busier over time. My personal PPH has also risen steadily over time. This isn't just gestalt. I get quarterly reports about how many PPH I am seeing solo and how many PPH I am seeing as me + midlevel. Both numbers have steadily risen over time.

I only have data going back 2 years in front of me as the other stuff is on a different computer but this time in 2022:
Personal PPH: 2.11. Group avg: 1.90.
Personal + PA: 2.85. Group avg: 2.66

Last quarter:
Personal PPH: 2.77. Group avg: 2.37
Personal + PA: 3.43. Group avg: 2.98

Are you staying/charting after your shift ends?

 

[JacobMcCandles]

My shop has grown steadily busier over time. My personal PPH has also risen steadily over time. This isn't just gestalt. I get quarterly reports about how many PPH I am seeing solo and how many PPH I am seeing as me + midlevel. Both numbers have steadily risen over time.

I only have data going back 2 years in front of me as the other stuff is on a different computer but this time in 2022:
Personal PPH: 2.11. Group avg: 1.90.
Personal + PA: 2.85. Group avg: 2.66

Last quarter:
Personal PPH: 2.77. Group avg: 2.37
Personal + PA: 3.43. Group avg: 2.98

Do you see all the PA patients? If so, your PAs are terrible/slow.

 

[Mount Asclepius]

Off topic, but I hate the thread title. We work in the ED. We’re physicians, not providers.

 

[JacobMcCandles]

Im not sure why efficiency would decrease with experience until the point where the doc is physically not able to go from room to room as quickly.

It’s much more likely that they don’t care about the metrics, what admin says, or clearing the waiting room.

 

[Mount Asclepius]

Years 1-3: Learning curve as new attending with increasing efficiency.

Years 3-10: Maximum average efficiency with ability peaking around 5. Ability doesn’t always correlate with efficiency.

Years 10-20: More variable efficiency with job environments and burnout playing a role for some.

Years 20+: Decreased efficiency on average, although not universally true.

 

[BoardingDoc]

Are you staying/charting after your shift ends?

No. My charts are all done in real time and signed when I leave on time. I have a LOT of macros which require minimal edits that I've written over the past decade.

 

[BoardingDoc]

Do you see all the PA patients? If so, your PAs are terrible/slow.

The PAs present every patient to us as would a resident. I don't see all the PA patients, as most are relatively straightforward. We also have the benefit of hiring and firing our own PAs, and as such, we don't have any with crappy medical judgement or who are too stubborn/dumb to ask me to see someone when they aren't sure about their interpretation of what's going on.

I don't have a PA for my entire shift. The way our shifts overlap, I will generally have a PA for ~4-5 hours out of an 8 or 9 hour shift. That explains the relatively minor contribution to my PPH as we don't parse out hours of PA assigned time vs hours I worked. It's just total patients I saw with them divided by my total hours. The PAs will generally see approx 1.5-2pph.

 

[Janders]

I’m closer to 15yr out.

I was probably peak physical speed at the 5yr out mark.

But I’m more efficient now. I’m just so much better with macros and charting tricks and ways to explain things and knowing immediately which rooms I need to spend time in and which I can cut loose quickly.

Now the physical toil and burnout and general ennui of multiple shifts in a row of code disaster crazy volume do add up.

A bigger thing for me is as the admin work has become a larger part of my portfolio I am CONSTANTLY interrupted by texts emails
Calls meetings and impromptu “hey I wanted to ask you about XYz” admin things while I’m working. I counted over 20 today while on shift. This puts a dent in the old moving the meat…


… I didn’t realize how much this drug me down, until I realized I leave Saturday / Sunday shifts on time all the time… minkmal
Admin conversations 😂

 

[RustedFox]

OP:

1. Sweet graph; but where'd you get the data from?
2. "Doc fatigue" needs to be considered. After 4-5 years out, I remember my attitude changing to include a degree of "THIS patient can WAIT. Scream at me for all I care; I'm sick of this circus." The "enthusiasm of youth" will only get you so far.
3. Hard to give a true-blue feeling if your waiting room isn't consistently feeding you patients like a pitching machine. Right now, I couldn't give you an honest "one-rep-max PPH" because I just don't have the traffic like I used to.
4. Solid topic. We need more stuff like this on here.

 

[valianteffort]

OP:

1. Sweet graph; but where'd you get the data from?
2. "Doc fatigue" needs to be considered. After 4-5 years out, I remember my attitude changing to include a degree of "THIS patient can WAIT. Scream at me for all I care; I'm sick of this circus." The "enthusiasm of youth" will only get you so far.
3. Hard to give a true-blue feeling if your waiting room isn't consistently feeding you patients like a pitching machine. Right now, I couldn't give you an honest "one-rep-max PPH" because I just don't have the traffic like I used to.
4. Solid topic. We need more stuff like this on here.

A colleague of mine did a survey regarding this for his second year residency project. Unfortunately, the data on this graph has an N that was less than 80 but it seems to have some truth to it. Of course, some older docs can be out outliers and younger docs as well.

The shop you work at certainly matters. I was hoping to see if this data was questioned as ‘what capacity do you believe you could operate at at your current stage in your career’ as opposed to ‘what capacity do you operate at’. I only have the power point which didn’t include the question itself in the slides.

 

[WhatJobDoIPick]

Shop most certainly matters.

I seem to be mildly above average in a group that is already very productive.

We are sent monthly stats with everyone's name, and I enjoy the competition aspect of it.

I don't go back into rooms of patients I know I am admitting unless I'm forced to. I go back into all the rooms of discharged as those get surveys.

 

[Groove]

I don't agree with that graph at all. I was much slower right out of residency because I didn't have the experience and confidence. I most definitely over ordered. Nowadays, I'm a fairly severe minimalist. I was probably middle of the bell curve in PPH and LOS as a new grad and currently have the shortest LOS and probably top 5% PPH in our current group. There's no way I could have been that productive or efficient in my early career. That being said, I have met some docs who are super fast right out of residency but that definitely wasn't me. I had to get there over time. I can't really say it's an age thing either because two of the fastest docs I've worked with over the years were in their 60s. Agree with Fox about burnout though as that's probably a huge factor and lots of mid career or late career docs are crispy by then with eyes focused on the exit and are just trying to tread water while not inducing a heart attack.

 

[thegenius]

I find it hard to believe that peak efficiency is basically right out of/ at the end of residency.

I can see it being years 3-8 for peak efficiency. That's true in most cases.

 

[Old_Mil]

The other thing to consider is PPH. When I was working 12 hour shifts, my highest PPH were probably the first 1/3rd of the shift, the next 1/3rd was slower, and by the last 1/3rd, I was more than ready to go home. I never tracked it, but it wouldn't have surprised me if my PPH dropped by 50% from the start of the shift to the end of it.

 

[GatorCHOMPions]

The other thing to consider is PPH. When I was working 12 hour shifts, my highest PPH were probably the first 1/3rd of the shift, the next 1/3rd was slower, and by the last 1/3rd, I was more than ready to go home. I never tracked it, but it wouldn't have surprised me if my PPH dropped by 50% from the start of the shift to the end of it.

Definitely true for me. In my current job when I work 8 hour shifts I can see and dispo around 14-16 patients. When I work 12 hour shifts I end up around 20-22 most of the time.

 

[WhatJobDoIPick]

Definitely true for me. In my current job when I work 8 hour shifts I can see and dispo around 14-16 patients. When I work 12 hour shifts I end up around 20-22 most of the time.

Agree w this. 8 hours in a busy setting is my sweet spot.

 

[Arcan57]

I feel like depending on age of doc you're going to see some temporal trends that have more to do with EMR and nursing than your own personal efficiency.

I graduated into paper T-sheets, a referral hospital where the average RN had been in the ED there for 10 years, and we didn't have boarding problems. The only substantive delays I ever faced were getting official reads back on body CTs and having consultants come in from home. Year 4 I moved to a shop that used electronic T-sheets, the average nurse had been there for 2 years, and we boarded 3000 hrs/month. I knew more and could juggle more active patients but my pph were pretty stagnant despite being a better doc. 7 years out started working in a smaller satellite hospital and despite same system bumped up my pph by 0.3-0.5 depending on the month. 10 years out I'm back at a quaternary care center but this time it's with Epic, a mix of brand new and burned out old nurses, entire shifts spent in the waiting room and I'm down almost a full pph from my peak.

I think to get anywhere approaching clean data you'd need to control for a fair number of variables as well as the fact that everyone adds 0.5-1.0 pph unless you're making them read off of their official metrics.

 

[DocEspana]

The other thing to consider is PPH. When I was working 12 hour shifts, my highest PPH were probably the first 1/3rd of the shift, the next 1/3rd was slower, and by the last 1/3rd, I was more than ready to go home. I never tracked it, but it wouldn't have surprised me if my PPH dropped by 50% from the start of the shift to the end of it.

Definitely true for me. In my current job when I work 8 hour shifts I can see and dispo around 14-16 patients. When I work 12 hour shifts I end up around 20-22 most of the time.

See I just end up doing >>>2.0 pph steadily for whatever length of time the shift is, but i pull the "im done" cord at a point where I think I need to just chart to finish on time and mathematically end up still >2.0. In most places I've worked this ends up being me picking up as many patients as my partners dont physically beat me to and ends up with me being one of the most productive people around even though I always get to leave on time unless one of the last patients is a medical nightmare that I dont want to sign out. If the day is busy enough that ends up being like 25/26ish patients in 8.5 hours and then tidying up everyone for half an hour, and then an hour of documenting essentially exclusively unless - i wasnt able to clean up someone during the last paid hour.

I had a 12 hour shift job that sort of hijacked my desire to work hard by making the workflow be that you will take turns with the other doc on staff seeing 100% of everyone who walked in the front door every other hour, and take 100% of every ambulance that arrived on the hours you're not on the front door. You did have a PA to hand stuff off to, but it was all you or your PA during your 'hours' up front. BUT there was a built in two hours at the end of the shift for just documenting, because your PA was offset from you by 2 hours (so if you start at 6am, they started at 8am) and they did your job alone for those last two hours and the boss knew this and was okay with it barring someone needing CPR or a critical procedure.

anyway that job eventually burned me out and made me seek more reasonable work flows, but because it was a busy site. I'd be seeing 30 (just me, not me + PA) patients in the first 10 hours most days, and not infrequently could you get into the mid 30s and rarely into the low and mid 40s. And you didn't get there by doing 3 pph steadily, it would be 4, 1, 7, 2, 5, 0, 6, 2, 4, 1 sort of deal on not busy day - followed by two hours to just clean up. But when the expectation is to see everyone... those first 10 hours can become a grueling gauntlet and 2 hours of paid documenting time may not be enough. BUT it did train me that I can see >>>2.0 patients per hour steadily and for multiple consecutive hours and it makes me be near the top of pph everywhere else that I work because I do a similar phenomenon of hoovering up everyone I can comfortably handle and pull the rip cord when I have too many charts left to see new people.