Getting tired of doing primary care

[DocEspana]

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Serious question for you guys. My main site is a very busy spot. When people come in for a stupid test as long as it is an adult I’ll order this. This is in reference to the patient sent by cardiology on eliquis and with a watchman with LE pain (or whatever the symptoms were).

*without* lower extremity pain.

Which is even more so why I tried to educate her since it was just her medical anxiety talking (screaming, really). And I told her up front I will order it regardless. So there was never an argument, just an attempt to recalibrate her belief that she is a ticking timebomb of coagulopathy.

I feel 0 burn out. I enjoy my job, I am very heavily paid based on RVUs. The options in my mind are:

1) Spend a bunch of time talking the patient out of it. Leaving them unhappy and perhaps filing a complaint. Some of these energy vampires may even impact my mood depending on the interaction. Bill at a lower level than #2

2) spend 10 seconds in the room, order the US, get the negative result leave the patient feeling like I heard them and listening to their doctor ordering this dumb test. My repeat visit with them lasts another 10 seconds. No complaint, patient believing they are heard and I can potentially bill a higher code. Meanwhile I use that time and effort to see another patient and get paid for those other patients.

Outside of MRI and CTs for Peds this is my move. If people want a discussion we can have it. I am one of the lowest admitters in my group, my LOS is very low and my system cares incredibly little about patient satisfaction though my scores tend to run barely above average since I refuse to sit outside of breaking bad news. I want an honest opinion from you folks.

Arguing with a crazy patient about a test with no downside (US) seems like it would be a lose lose when dealing with a crazy person. I think this has allowed me to keep my sanity, make work enjoyable and fatten my wallet. What am I missing?

If you work in a busy ED.... #1 gets you a MUCH less busy ED and makes a lot of the pain points you think are unavoidable suddenly disappear. "why does it take 90 minutes to get a critical CT done" "why are my admission numbers so high at this site" "why is boarding time so long, and it always seems like it just gets worse each day whenever I do a run of shifts."

talk patients out of bad tests. Do it. For the whole department. But dont be stubborn. If they arent receptive or if they still want it after, you gave it your best shot and thats the time to stop the sales pitch for common sense and decency.

 

[DocEspana]

Im okay dying on the hill that everyplace I go wait times to be seen, order-to-imaging times, and inpatient boarding times/overall crowding sharply decreases cumulatively for every shift I work and then rise rapidly as soon as I am back on. True at low acuity free standings, true at quiet rural places (though less so that busier places), true at very high acuity high volume places, true with residents at the teaching hospital. Everyone notices it and tells me and seems baffled as to why its so reliably true. I'm "quick" but no where near the quickest. I consistently have among the best patient satisfaction scores and consistently have the parodox of one of the highest ICU admission rates with one of the lowest IM floor admission rates.

why? I dont order the bull****. but i tell the patients why until they either understand or can say to me that they will go home still anxious and then I give them what they want. And I document the conversation. The patients not only dont gum up the system getting those stupid tests - which is the obvious part. But also I dont find all those stupid incidentalomas that end up becoming admissions that never had to happen. Those things that we twist ourselves into a pretzel to argue must be somehow related to the uti they clearly had and do still have.... but if i didnt do that CT abdomen I wouldnt have partially visualized that lower lobe pnuemonia that has no symptoms and also, weirdly, isnt really visible on the CXR I got afterwards to confirm it - but I'm going to admit them anyway (and repeat inpatient CT showed no pna the next day and legend is patient still hasnt coughed once to this day).

edit: I get everyone else's point of path of least resistance. And I've had people tell me to my face that cant do what I do because they just don't have the energy in them to have those discussions with patient after patient. but for me its always been the only way and a less busy ED for me has always been deeply fulfilling for me and so it keeps me going.

 

[BoardingDoc]

It will make you happy that “Jenny” sent us some stupid things from UC my last shift, and our long time PA was audibly whining about it to the newest PA without naming “Jenny”.

I heard the vignette and ridiculous referral for CTA+US despite negative ddimer and clear zoster as the source of chest pain… and I said “wait is this a referral from Jenny??”

Our PA laughed and said of course, and the new PA said “do you all know Jenny?”

I started to explain the ridiculous referrals I’ve gotten for r/o dissection, PE, renal colic, epidural abscess, and septic shock on the same patient, topping it off for the ultimate referral for r/o dissection r/o ovarian torsion r/o testicular torsion (same patient!) and the other MD walked up, overheard, and said “oh that sounds like Jenny?!”

(Her name isn’t Jenny, but this is a real local UC PA that has such a ridiculous referral pattern, for the past decade, that (1) her name strikes fear in the heart of triage nurses (2) my second child’s college fund is purely from her referrals and (3) radiology may name the second CT scanner in her honor.)

I still remember the closest she got to a sane referral. She sent someone in for RUQ pain. Chart was reading reasonably. RUQ pain. Yup. Exam shows focal tenderness. Yup. Positive Murphy sign. Great. Go to local ER for CT scan to Ro appendicitis (and 13 other things....none of which were cholecystitis).

I literally stood up and yelled "God damnit 'jenny!' I was rooting for you there! God... F***ing ... Damnit!"

I got mildly more weird looks from patients than usual that shift.

 

[RustedFox]

Jenny.

 

[RustedFox]

Jenny (start the comment trend, people).

 

[thegenius]

Serious question for you guys. My main site is a very busy spot. When people come in for a stupid test as long as it is an adult I’ll order this. This is in reference to the patient sent by cardiology on eliquis and with a watchman with LE pain (or whatever the symptoms were).

I feel 0 burn out. I enjoy my job, I am very heavily paid based on RVUs. The options in my mind are:

1) Spend a bunch of time talking the patient out of it. Leaving them unhappy and perhaps filing a complaint. Some of these energy vampires may even impact my mood depending on the interaction. Bill at a lower level than #2

2) spend 10 seconds in the room, order the US, get the negative result leave the patient feeling like I heard them and listening to their doctor ordering this dumb test. My repeat visit with them lasts another 10 seconds. No complaint, patient believing they are heard and I can potentially bill a higher code. Meanwhile I use that time and effort to see another patient and get paid for those other patients.

Outside of MRI and CTs for Peds this is my move. If people want a discussion we can have it. I am one of the lowest admitters in my group, my LOS is very low and my system cares incredibly little about patient satisfaction though my scores tend to run barely above average since I refuse to sit outside of breaking bad news. I want an honest opinion from you folks.

Arguing with a crazy patient about a test with no downside (US) seems like it would be a lose lose when dealing with a crazy person. I think this has allowed me to keep my sanity, make work enjoyable and fatten my wallet. What am I missing?

You picked the one really simple straightforward case that really doesn't involve a patient talking to you on any level.

There are about 35 other kinds of complaints / expectations that suck the life out of a shift. And you know what they are.

Or are you the kind of guy that orders the 14th CTH over the past 2 years for a headache? Or the clearly non-indicated MRI of "name that non-central nervous system body part"

 

[thegenius]

Bottom line is, it is still a Job. A very high paying job. You/I will never change the system. If my mindset was to do what is always medically correct, I would be hated by specialists/patients/admin. If I do what makes pts happy (to an extent), then my life is better. TBH, doing test reassures pts and this alone helps them mentally.

this "it's just a job, keep 'em happy" vibe is a copout that trades the right, good work for shortcuts. You're not helping patients by tossing tests to ease their worries—you're slowly hurting them with extra risks, bills, and fake scares, all while feeding the same bloated system everyone's complaining about. This is not directed necessarily at you (well it kind of is but not really) it's at the MD-populace-at-large.

 

[thegenius]

I agree w this. I spend very little time in the room as well and tend to "just order the test" outside of peds stuff. It's the people who are still dissatisfied after negative unnecessary testing that grind my gears. My system cares very much about patient satisfaction, although I care very little.

that's it, and it's like almost all of them

 

[thegenius]

People with low IQ are unable to recognize people w expertise.

If my fan belt needs replacing, I don't criticize my mechanic for the method of replacing. I pay my money, say thank you, and are on my way.

I got even ripped off then too...my son's mazda needed a new engine harness and it cost $2300. Ridiculous and highway robbery

 

[WhatJobDoIPick]

I got even ripped off then too...my son's mazda needed a new engine harness and it cost $2300. Ridiculous and highway robbery

How old are you? Can you semi retire?

 

[bravotwozero]

In California? fat chance lol

 

[ERMudPhud]

Serious question for you guys. My main site is a very busy spot. When people come in for a stupid test as long as it is an adult I’ll order this. This is in reference to the patient sent by cardiology on eliquis and with a watchman with LE pain (or whatever the symptoms were).

I feel 0 burn out. I enjoy my job, I am very heavily paid based on RVUs. The options in my mind are:

Pretty much agree with you. I just undersell and overdeliver on the LOS. I tell them. Sure I can get you an ultrasound. I think it will be negative for the following reasons but I can get you one. Then I say, "Ultrasound is pretty backed up right now, there is a real shortage of sonagraphers and we are down to our last one. You will probably be here minimum 5 hours but happy to get you one" Then I stick them in obs status so it doesn't affect my length of stay and park them in a corner and ignore them. When they get their study in 90 minutes they think I did them a favor.

I can see 6 more patients while they are waiting for the ultrasound they don't need

Same for MRI except I tell them "There is only one MRI machine for the entire hospital and strokes and paralyzed people get priority so expect a length of stay of 8 hours. " Same deal

Only exception is ionizing radiation. Then I say " I can get you that head CT but here is why I don't think you need it and what you should do instead. There is a 1/500 chance that CT will give you brain cancer later in life but if you want it I"m happy to order it. Oh, yeah expect a length of stay of 4 hours"

Bottom line though, I don't give a **** about patient satisfaction. I do my best to be polite, act like my mom raised me right, sit when I can, etc... But until my patient satisfaction scores cost me a job I just don't care. I'm still getting texts and emails literally daily offering me locums jobs and none of them have ever asked for a copy of my PG scores. When they let me go its because they found someone cheaper, not nicer.

 

[VA Hopeful Dr]

this "it's just a job, keep 'em happy" vibe is a copout that trades the right, good work for shortcuts. You're not helping patients by tossing tests to ease their worries—you're slowly hurting them with extra risks, bills, and fake scares, all while feeding the same bloated system everyone's complaining about. This is not directed necessarily at you (well it kind of is but not really) it's at the MD-populace-at-large.

Sure, and you can blame lawsuits and satisfaction scores for it.

I do lots of things to cover my ass and/or keep patients from bitching to admin about me that I wouldn't do otherwise. And I'm just an FP, y'all have both of those things worse than we do.

 

[bky3c]

People with low IQ are unable to recognize people w expertise.

If my fan belt needs replacing, I don't criticize my mechanic for the method of replacing. I pay my money, say thank you, and are on my way.

Completely agree. Apparently a lot of it has to do with the idea that experts acknowledge when something is uncertain, whereas non-experts (whether fake or just uninformed) speak in absolutes. Very few absolutes in medicine, especially in the the ED with the vast majority of patients, who fall somewhere between "hangnail" and "decapitation." So when we start talking about probabilities, reasons a test or treatment isn't perfect, etc., all they hear is "I don't know because I'm a bad doctor and/or I don't care about you." Add the TikTokification of society's attention span, and you have the mess we're in now.

 

[WhatJobDoIPick]

Completely agree. Apparently a lot of it has to do with the idea that experts acknowledge when something is uncertain, whereas non-experts (whether fake or just uninformed) speak in absolutes. Very few absolutes in medicine, especially in the the ED with the vast majority of patients, who fall somewhere between "hangnail" and "decapitation." So when we start talking about probabilities, reasons a test or treatment isn't perfect, etc., all they hear is "I don't know because I'm a bad doctor and/or I don't care about you." Add the TikTokification of society's attention span, and you have the mess we're in now.

That's a great point.

I would add to it by saying you don't need to be an expert to appreciate uncertainty and probability, just intelligent. Patients who are engineers and scientists are able to follow my lines of reasoning because they have a brain. The people referred to upthread have maybe two non synapsing neurons remaining after their years of THC and cooler ranch dorito abuse, so cannot process concepts like pre test probability.

 

[emergentmd]

this "it's just a job, keep 'em happy" vibe is a copout that trades the right, good work for shortcuts. You're not helping patients by tossing tests to ease their worries—you're slowly hurting them with extra risks, bills, and fake scares, all while feeding the same bloated system everyone's complaining about. This is not directed necessarily at you (well it kind of is but not really) it's at the MD-populace-at-large.

TBH, I completely agreed with you. We all were taught to be minimalist in Residency and this is how I started. But eventually you have to choose between continuing to fight or giving them psychological happiness. There is a balance and I would not advocate doing unnecessary test where the potential side effects are worse like an LP for clearly not meningitis.

But if a 40 yr old likely non cardiac called his PCP for CP, told to come to the ER for evaluation, then I am doing to do a quick cardiac workup.

I have always backed docs who practice medicine their way. Some are minimalist, some order everything. There is no right or wrong. Do whatever helps you sleep at night.

 

[sloh]

That's a great point.

I would add to it by saying you don't need to be an expert to appreciate uncertainty and probability, just intelligent. Patients who are engineers and scientists are able to follow my lines of reasoning because they have a brain. The people referred to upthread have maybe two non synapsing neurons remaining after their years of THC and cooler ranch dorito abuse, so cannot process concepts like pre test probability.

Sometimes you can’t fix stupid

 

[thegenius]

How old are you? Can you semi retire?

51. surprisingly I still like going to work. every year that goes by it gets a little more tiresome though. can't semi retire yet and I'll probably work until I'm 70 anyway unless 10M somehow appears in my account.

 

[thegenius]

Pretty much agree with you. I just undersell and overdeliver on the LOS. I tell them. Sure I can get you an ultrasound. I think it will be negative for the following reasons but I can get you one. Then I say, "Ultrasound is pretty backed up right now, there is a real shortage of sonagraphers and we are down to our last one. You will probably be here minimum 5 hours but happy to get you one" (1) Then I stick them in obs status so it doesn't affect my length of stay and park them in a corner and ignore them. When they get their study in 90 minutes they think I did them a favor.

I can see 6 more patients while they are waiting for the ultrasound they don't need

Same for MRI except I tell them "There is only one MRI machine for the entire hospital and strokes and paralyzed people get priority so expect a length of stay of 8 hours. " Same deal

Only exception is ionizing radiation. Then I say " I can get you that head CT but here is why I don't think you need it and what you should do instead. There is a 1/500 chance that CT will give you brain cancer later in life but if you want it I"m happy to order it. Oh, yeah expect a length of stay of 4 hours"

(2) Bottom line though, I don't give a **** about patient satisfaction. I do my best to be polite, act like my mom raised me right, sit when I can, etc... But until my patient satisfaction scores cost me a job I just don't care. I'm still getting texts and emails literally daily offering me locums jobs and none of them have ever asked for a copy of my PG scores. When they let me go its because they found someone cheaper, not nicer.

(1) that is a neat trick. need to look into this more. putting ER patients in Obs I need to look into this more.

(2) me too. I'm nice to people but ultimately it's pretty hard to satisfy everyone who comes to the ER for obvious reasons that have been repeated on this board 23,910 times over the past 5 years.

 

[thegenius]

Completely agree. Apparently a lot of it has to do with the idea that experts acknowledge when something is uncertain, whereas non-experts (whether fake or just uninformed) speak in absolutes. Very few absolutes in medicine, especially in the the ED with the vast majority of patients, who fall somewhere between "hangnail" and "decapitation." So when we start talking about probabilities, reasons a test or treatment isn't perfect, etc., all they hear is "I don't know because I'm a bad doctor and/or I don't care about you." Add the TikTokification of society's attention span, and you have the mess we're in now.

So I've been doing this a lot more recently over the past 5 years and it befuddles about 90% of patients. Most just don't get the concept.
Every diagnosis should come with a probability.

I have often though that maybe I should just tell people what they want to hear. it's completely against the way I think doctors should work.

 

[WhatJobDoIPick]

51. surprisingly I still like going to work. every year that goes by it gets a little more tiresome though. can't semi retire yet and I'll probably work until I'm 70 anyway unless 10M somehow appears in my account.

Do you though? I ask this sincerely.

The ER is a toxic place. We bring the toxicity home. It's unavoidable. I've noticed I've become less patient, more defensive with the people I love. My attention span is decreased. This is a direct result of EM. Is it a dramatic change? No. But I notice it creeping in, and I can't have that in my life, especially as my children get older.

My friend recently fled the ER for pharma. It was a position open to her because of her MPH and research background. She describes the work as "intellectually challenging, I work hard but I love what I'm working on and everybody that I work with is smart, everything and everyone within the company has a purpose." That's exactly the opposite of EM, and medicine broadly. I think it's what the majority of us thought we were getting into, but we're surprised once we got here. She gets paid the same as an average EM community job, although admittedly more hours worked now. No nights weekends swings holidays.

Life is too short to do this long term.. I have about 5 years left in this field and I'm counting the days.

 

[HemorrhagicShock]

Do you though? I ask this sincerely.

The ER is a toxic place. We bring the toxicity home. It's unavoidable. I've noticed I've become less patient, more defensive with the people I love. My attention span is decreased. This is a direct result of EM. Is it a dramatic change? No. But I notice it creeping in, and I can't have that in my life, especially as my children get older.

My friend recently fled the ER for pharma. It was a position open to her because of her MPH and research background. She describes the work as "intellectually challenging, I work hard but I love what I'm working on and everybody that I work with is smart, everything and everyone within the company has a purpose." That's exactly the opposite of EM, and medicine broadly. I think it's what the majority of us thought we were getting into, but we're surprised once we got here. She gets paid the same as an average EM community job, although admittedly more hours worked now. No nights weekends swings holidays.

Life is too short to do this long term.. I have about 5 years left in this field and I'm counting the days.

It took almost 2 years after leaving the ED for me to return to the "normal" human being my friends and family knew prior to starting residency.

And this isn't by my own observation, this is from them directly telling me "you were different while working in the ED, but now you're back to who you were"

It's subtle too. I didn't think I was THAT different. Yes, I was more short, had less patience, easier to frustrate and anger. But I didn't realize how bad it had gotten.

You give up so much of your spiritual, physical, and emotional energy to work in the ED. It was cool for a few years, and I've posted about the massive lay person social benefits you get from it, but eventually the trade off was no longer worth it for me.

Kudos to anybody who can do it long term, IMHO ER docs are wildly underpaid.

 

[WhatJobDoIPick]

It took almost 2 years after leaving the ED for me to return to the "normal" human being my friends and family knew prior to starting residency.

And this isn't by my own observation, this is from them directly telling me "you were different while working in the ED, but now you're back to who you were"

It's subtle too. I didn't think I was THAT different. Yes, I was more short, had less patience, easier to frustrate and anger. But I didn't realize how bad it had gotten.

You give up so much of your spiritual, physical, and emotional energy to work in the ED. It was cool for a few years, and I've posted about the massive lay person social benefits you get from it, but eventually the trade off was no longer worth it for me.

Kudos to anybody who can do it long term, IMHO ER docs are wildly underpaid.

Do you think your recovery would still be achievable if you went to 1 shift a week or did it need to be a clean break?

 

[HemorrhagicShock]

Do you think your recovery would still be achievable if you went to 1 shift a week or did it need to be a clean break?

Great question. I believe 1 shift a week would have improved things remarkably.. probably to the point where I could have continued. But as you can see it took me on the order of years to get back normalcy, so it's had to know retrospectively if I would have stuck it out for more than a year doing 1 shift a week.

Either way it wasn't an option for me. Based on my location there were no jobs that would allow that kind of schedule unless you agreed to a nocturnist 1 shift a week hell, and I'm not doing that. Unfortunately I live in a VHCOL desirable area, one where the ER doc spouse is usually the lower earner between the two. As such it's impossible to get a princess job like that since every shift is coveted. I wasn't willing to travel either for a locums type gig because it would be a minimum of 1.5-2 hours to drive somewhere that would allow me to keep a 1 shift per week schedule, and even that is questionable.

It made the most sense to just stop working and see if I could leverage my MD for other things. I found out the hard way that I have little to offer beyond what a subscription-based-MD-supervised PA/NP can do in a very very very competitive and crowded market for aesthetics, weight loss, peptides, and all the other BS you see burned out docs dive into.

I failed at starting a DPC/concierge gig, mostly because I realized it was far more of a marketing and sales role than a physician role, and it's not really a thing I wanted to do either. More of an "a/b testing" of the model in my local area to see if anybody would bite.

 

[Apollyon]

I used to tell pts "a lot of things look similar - bad and not bad live next door. Also, if 5-6 is classical presentation of disease, those are easy to diagnose, but, also, half of those people are dying or dead. Now, we see disease at a 1-2 level, and plants mostly look the same when they're just a bud."

But, I would also quote the lyrical George Michael and say, "There's things that you guess, and things that you know".

 

[DocEspana]

You picked the one really simple straightforward case that really doesn't involve a patient talking to you on any level.

There are about 35 other kinds of complaints / expectations that suck the life out of a shift. And you know what they are.

Or are you the kind of guy that orders the 14th CTH over the past 2 years for a headache? Or the clearly non-indicated MRI of "name that non-central nervous system body part"

I think we just became best friends

 

[DocEspana]

Do you though? I ask this sincerely.

The ER is a toxic place. We bring the toxicity home. It's unavoidable. I've noticed I've become less patient, more defensive with the people I love. My attention span is decreased. This is a direct result of EM. Is it a dramatic change? No. But I notice it creeping in, and I can't have that in my life, especially as my children get older.

My friend recently fled the ER for pharma. It was a position open to her because of her MPH and research background. She describes the work as "intellectually challenging, I work hard but I love what I'm working on and everybody that I work with is smart, everything and everyone within the company has a purpose." That's exactly the opposite of EM, and medicine broadly. I think it's what the majority of us thought we were getting into, but we're surprised once we got here. She gets paid the same as an average EM community job, although admittedly more hours worked now. No nights weekends swings holidays.

Life is too short to do this long term.. I have about 5 years left in this field and I'm counting the days.

It took almost 2 years after leaving the ED for me to return to the "normal" human being my friends and family knew prior to starting residency.

And this isn't by my own observation, this is from them directly telling me "you were different while working in the ED, but now you're back to who you were"

It's subtle too. I didn't think I was THAT different. Yes, I was more short, had less patience, easier to frustrate and anger. But I didn't realize how bad it had gotten.

You give up so much of your spiritual, physical, and emotional energy to work in the ED. It was cool for a few years, and I've posted about the massive lay person social benefits you get from it, but eventually the trade off was no longer worth it for me.

Kudos to anybody who can do it long term, IMHO ER docs are wildly underpaid.

I'm over here at PGY-13 and... like... i still love this every day. Going to work thrills me. What I will say is that I did experience a personality shift but it was sort of the opposite of what I think most experience. I had been working at high acuity, high volume (and high pay) sites since essentially the moment I graduated residency. Really including residency too. Had been hearing about all of these easy jobs from you guys and other sites forever so I jumped ship to a slower and lower acuity place that offered me leadership. The leadership deal was real but it was not quite what they promised and now I was stranded at a 1.5 pph (or less) site with acuity mostly of the "person from a nursing home who is a chronic horizontal" shows up every 2-3 hours and otherwise everyone else was easy nonsense. And my wife and parents noticed I became increasingly more frustrated, short with them, and generally stressed out despite this being a nominally easier job by a wide margin. But it did pay less. and we thought maybe the grumpiness was due to pay or due to not getting the leadership quite the way I was promised it.

So I switched jobs to an even easier job at a FSED where they let me be a director of that FSED (part of a larger group that manages many FSEDs for a mega-hospital). Loved the director work.... but now I had moderate volume and almost no acuity. And somehow the pay largely didnt change because the hourly was so low that the stipend just brought me to more than the last job but still notably less than the first few jobs out of residency that all paid the same and were high acuity. And I continued to be grumpy. And I continued to be short. And I just felt like the job satisfaction wasn't there. This job was so easy. I joked I could do it with my eye closed.... but I was suddenly stressed out about work despite it being so friggen easy. I would get annoyed at work when previously I had the best time ever every shift. So I stepped back from leadership, kept doing work there as a worker bee, and took a part time job back at the stupidly high acuity and volume place.... AND I WAS HAPPY. God... so happy. Those shifts gave me life and it was clear the easy shifts drained me of life. also it paid great, which I mention because annoyance at the pay was a part of the grumpiness at home.

So now I'm back to working fulltime at a high volume very high acuity place. and the pay is, finally, good again. Waiting room is never empty for long (and if other people are working besides me, its just never empty at all), there is always more people to see, everyone is a ticking time bomb for me to diffuse, the drunks and the druggies are back to regale me with their lives on the street, and I'm tossing central lines and intubating on the regular again. And I couldnt be happier. and my wife has commented that she got her husband back because suddenly I have the energy to be present for my family and child and want to do lots of stuff after work because I leave work energized and excited rather than stress and drained..... despite going to a place where I am nominally working so much harder.

I was not having burnout, I was having rustout. The takeaway obviously isnt that everyone needs to ramp their **** back up. Its that you need to understand maybe the place you view as 'your home' isnt actually the right setting for you. and I would never have thought that the easier jobs were stressing me out much more than the harder jobs, but its true.

 

[AlmostAnMD]

It took almost 2 years after leaving the ED for me to return to the "normal" human being my friends and family knew prior to starting residency.

And this isn't by my own observation, this is from them directly telling me "you were different while working in the ED, but now you're back to who you were"

It's subtle too. I didn't think I was THAT different. Yes, I was more short, had less patience, easier to frustrate and anger. But I didn't realize how bad it had gotten.

You give up so much of your spiritual, physical, and emotional energy to work in the ED. It was cool for a few years, and I've posted about the massive lay person social benefits you get from it, but eventually the trade off was no longer worth it for me.

Kudos to anybody who can do it long term, IMHO ER docs are wildly underpaid.

Same dude. Everyone--family, friends all commented on it. Even if they didn't comment on my disposition they commented on my significant weight loss and overall better health. Regular sleeping/eating schedule alone changed my life. Never going back. Also my new life is deeply personally and professionally rewarding. I don't want to for time reasons, but I could do this current job till I'm 90. Ain't no EM doc doing that.

I'm over here at PGY-13 and... like... i still love this every day. Going to work thrills me. What I will say is that I did experience a personality shift but it was sort of the opposite of what I think most experience. I had been working at high acuity, high volume (and high pay) sites since essentially the moment I graduated residency. Really including residency too. Had been hearing about all of these easy jobs from you guys and other sites forever so I jumped ship to a slower and lower acuity place that offered me leadership. The leadership deal was real but it was not quite what they promised and now I was stranded at a 1.5 pph (or less) site with acuity mostly of the "person from a nursing home who is a chronic horizontal" shows up every 2-3 hours and otherwise everyone else was easy nonsense. And my wife and parents noticed I became increasingly more frustrated, short with them, and generally stressed out despite this being a nominally easier job by a wide margin. But it did pay less. and we thought maybe the grumpiness was due to pay or due to not getting the leadership quite the way I was promised it.

So I switched jobs to an even easier job at a FSED where they let me be a director of that FSED (part of a larger group that manages many FSEDs for a mega-hospital). Loved the director work.... but now I had moderate volume and almost no acuity. And somehow the pay largely didnt change because the hourly was so low that the stipend just brought me to more than the last job but still notably less than the first few jobs out of residency that all paid the same and were high acuity. And I continued to be grumpy. And I continued to be short. And I just felt like the job satisfaction wasn't there. This job was so easy. I joked I could do it with my eye closed.... but I was suddenly stressed out about work despite it being so friggen easy. I would get annoyed at work when previously I had the best time ever every shift. So I stepped back from leadership, kept doing work there as a worker bee, and took a part time job back at the stupidly high acuity and volume place.... AND I WAS HAPPY. God... so happy. Those shifts gave me life and it was clear the easy shifts drained me of life. also it paid great, which I mention because annoyance at the pay was a part of the grumpiness at home.

So now I'm back to working fulltime at a high volume very high acuity place. and the pay is, finally, good again. Waiting room is never empty for long (and if other people are working besides me, its just never empty at all), there is always more people to see, everyone is a ticking time bomb for me to diffuse, the drunks and the druggies are back to regale me with their lives on the street, and I'm tossing central lines and intubating on the regular again. And I couldnt be happier. and my wife has commented that she got her husband back because suddenly I have the energy to be present for my family and child and want to do lots of stuff after work because I leave work energized and excited rather than stress and drained..... despite going to a place where I am nominally working so much harder.

I was not having burnout, I was having rustout. The takeaway obviously isnt that everyone needs to ramp their **** back up. Its that you need to understand maybe the place you view as 'your home' isnt actually the right setting for you. and I would never have thought that the easier jobs were stressing me out much more than the harder jobs, but its true.

I wouldn't necessarily brag about thriving in high volume, high acuity places....you're working high volume, high acuity and not complaining, which means the masters that be will see this and just dump on you like the commodity you are. Gratitude for your work extends about as far as the revenue you generate.

It's the broken concept of "resilience" taken to an extreme. As someone that flamed out hard in one of those environments reading that post gives me shivers. Congrats....I guess? Just remember the more you tolerate, the more the standard moves, and one day when docs are forced to see 8 pph they'll look back at the time 4 pph seemed great.

 

[DocEspana]

Same dude. Everyone--family, friends all commented on it. Even if they didn't comment on my disposition they commented on my significant weight loss and overall better health. Regular sleeping/eating schedule alone changed my life. Never going back. Also my new life is deeply personally and professionally rewarding. I don't want to for time reasons, but I could do this current job till I'm 90. Ain't no EM doc doing that.






I wouldn't necessarily brag about thriving in high volume, high acuity places....you're working high volume, high acuity and not complaining, which means the masters that be will see this and just dump on you like the commodity you are. Gratitude for your work extends about as far as the revenue you generate.

It's the broken concept of "resilience" taken to an extreme. As someone that flamed out hard in one of those environments reading that post gives me shivers. Congrats....I guess? Just remember the more you tolerate, the more the standard moves, and one day when docs are forced to see 8 pph they'll look back at the time 4 pph seemed great.

Seeing 1.25-1.5 pph of low to moderate acuity was killing me. I was getting so bored of cross word puzzles and reading the same newspaper articles between patients. 2+pph very high acuity with another 2+ from the mid-level and resident (combined. Not each) feels good and fulfilling and the day flies by.

Maybe I'm weird. The bigger thing is just make sure you find what makes you happy because I really thought easier would mean happier but it felt like dying professionally. And people kept pushing me to consider even easier jobs and it would have just made me feel more like I was suffocating professionally.

 

[TooMuchResearch]

Serious question for you guys. My main site is a very busy spot. When people come in for a stupid test as long as it is an adult I’ll order this. This is in reference to the patient sent by cardiology on eliquis and with a watchman with LE pain (or whatever the symptoms were).

I feel 0 burn out. I enjoy my job, I am very heavily paid based on RVUs. The options in my mind are:

1) Spend a bunch of time talking the patient out of it. Leaving them unhappy and perhaps filing a complaint. Some of these energy vampires may even impact my mood depending on the interaction. Bill at a lower level than #2

2) spend 10 seconds in the room, order the US, get the negative result leave the patient feeling like I heard them and listening to their doctor ordering this dumb test. My repeat visit with them lasts another 10 seconds. No complaint, patient believing they are heard and I can potentially bill a higher code. Meanwhile I use that time and effort to see another patient and get paid for those other patients.

Outside of MRI and CTs for Peds this is my move. If people want a discussion we can have it. I am one of the lowest admitters in my group, my LOS is very low and my system cares incredibly little about patient satisfaction though my scores tend to run barely above average since I refuse to sit outside of breaking bad news. I want an honest opinion from you folks.

Arguing with a crazy patient about a test with no downside (US) seems like it would be a lose lose when dealing with a crazy person. I think this has allowed me to keep my sanity, make work enjoyable and fatten my wallet. What am I missing?

You're not missing. I tell them I think the test will look okay but if they're (patient, outpatient doctor, whoever) concerned, I'm happy to order it. Often they want it done, I get it done. Occasionally they are happy that I'm not worried and don't want the test. Unless it's a non-indicated CT in a kid etc

 

[FrustratedFamDoc]

The well known dichotomy between the patient encounter when they see me vs when they see y’all is at best, irritating.

My theory is this: they feel the need to oversell their symptoms in every possible way and dramatize their physical exam findings so they can get the work-up that they’ve already googled. It really paints me in to a corner. ‘Worst headache of my life, doc! Came on suddenly and woke me up last night. Half my face is numb.’ Of course their subjective exam findings will be pure BS and over the top. If they would have just come out and said, ‘hey doc, this headache makes me nervous, can I get an MRI?’ I would rejoice… but hell no. Now I’m on the liability hook. Do I send that home? Can’t. So off to y’all they go. They really just wanted an MRI but couldn’t just say so. I would have happily obliged… But now they’re in the ED fearing that if they continue the rouse, they’ll get admitted... so now it’s ‘I really feel fine, not sure why doc sent me here.’ FML.

Cardiac better have a high pre test probability and/or some really goofy badness for me to send. Abdomen paints me into to a corner at times but these patients *usually, at least to me, are more open to reason.

An under appreciated steer job for the ED is the call center. My system got gobbled up by a big fish a few years ago. All calls to the clinic are now routed to a central call center staffed by ‘RNs.’ They’re great. Superb. Why would a call center RN not be awesome at everything?

I get after the fact messages about BS they’ve sent y’all. Feels fantastic to see my very nice and trusting patients get financially screwed over like they have been. Some sends are ticky tacky, others are egregious. Ex. Patient recently titrated off Effexor 2 weeks ago. She’s 25. Feels shaky and nervous. They told her to go to the ER. Thank God she didn’t go.

 

[Janders]

Seeing 1.25-1.5 pph of low to moderate acuity was killing me. I was getting so bored of cross word puzzles and reading the same newspaper articles between patients. 2+pph very high acuity with another 2+ from the mid-level and resident (combined. Not each) feels good and fulfilling and the day flies by.

Maybe I'm weird. The bigger thing is just make sure you find what makes you happy because I really thought easier would mean happier but it felt like dying professionally. And people kept pushing me to consider even easier jobs and it would have just made me feel more like I was suffocating professionally.

I'd rather see 2+ personally and another 1-2 PA patients / hour with some decent acuity here and there, than see 1.3/hr solo of low acuity...

IF the first job pays more! Which it clearly should. Much like you, I like the sick ones, I like undifferentiated badness, I improve w/ volume-stress. My provider starling curve is still pretty robust! But being roughly 15yr out... if you paid me the same, I'd see 1-1.5/hr of mostly UC patients and get some excellent reading and Civ 7 and music listening done between patients 🙂

 

[thegenius]

Do you though? I ask this sincerely.

The ER is a toxic place. We bring the toxicity home. It's unavoidable. I've noticed I've become less patient, more defensive with the people I love. My attention span is decreased. This is a direct result of EM. Is it a dramatic change? No. But I notice it creeping in, and I can't have that in my life, especially as my children get older.

My friend recently fled the ER for pharma. It was a position open to her because of her MPH and research background. She describes the work as "intellectually challenging, I work hard but I love what I'm working on and everybody that I work with is smart, everything and everyone within the company has a purpose." That's exactly the opposite of EM, and medicine broadly. I think it's what the majority of us thought we were getting into, but we're surprised once we got here. She gets paid the same as an average EM community job, although admittedly more hours worked now. No nights weekends swings holidays.

Life is too short to do this long term.. I have about 5 years left in this field and I'm counting the days.

Yes, and I'm being sincere. And it is true that every year that goes by I get a little bit more unhappy.
But it's really dependent on shifts though. Each month, out of the 13 shifts that I work, I really enjoy a handful of them, most are neutral, and a few just suck. That's par for the course for any job that anyone does.
When it comes to the day where I dread going to work, or I have no good shifts over a few months, then I'm in trouble.

The other issue with me is this is already my second career. I was a software engineer for 7 years. So I'm not about go to changing jobs again.

It's hard to have a fulfilling job in any career for 2-3 decades. There will be ups and downs. I wonder how I'll feel 5 years from now.