Happiness in the ED -- especially a busy one

[da8s0859q]

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So, every now and again, threads pop up (like this one) talking about being happy in our specialty.

My first job out is in a pretty busy place -- one where seeing 3-4 pph, including resident/midlevel oversight, happens with some regularity. Some of the docs in my group routinely do 5-6 pph.

Maybe it's just because I'm working a lot and am too perfectionistic for my own good, or maybe it's because there are things I want to do recreation-wise that I haven't done yet but reasonably could, but I'm getting a little too short-tempered and cranky in the department.

For those of you at this point or farther down the road, what adjustments did you make as a new attending that made you happier?

 

[GeneralVeers]

So, every now and again, threads pop up (like this one) talking about being happy in our specialty.

My first job out is in a pretty busy place -- one where seeing 3-4 pph, including resident/midlevel oversight, happens with some regularity.

Maybe it's just because I'm working a lot and am too perfectionistic for my own good, or maybe it's because there are things I want to do recreation-wise that I haven't done yet but reasonably could, but I'm getting a little too short-tempered and cranky in the department.

For those of you at this point or farther down the road, what adjustments did you make as a new attending that made you happier?

3-4 pph is normal for most places. I've never worked anywhere I see less than 2pph as attending with 1-2 pph on top of it for midlevel supervision.

 

[HLxDrummer]

3-4 pph is normal for most places. I've never worked anywhere I see less than 2pph as attending with 1-2 pph on top of it for midlevel supervision.

Wow... I thought the average was 2-3pph. 4pph is 15 mins for an H&P, enter labs, write a note, review results, tell patient about results, admit/consult... That's impressive. Kinda scary considering I'm only seeing 1.5/hr (intern). Takes me 10-15 mins to do a good H&P and get orders in.

 

[GeneralVeers]

Wow... I thought the average was 2-3pph. 4pph is 15 mins for an H&P, enter labs, write a note, review results, tell patient about results, admit/consult... That's impressive. Kinda scary considering I'm only seeing 1.5/hr (intern). Takes me 10-15 mins to do a good H&P and get orders in.

You misread. OP was stating 3-4 pph INCLUDING midlevels. I typically see 2 pph on my own.

 

[HLxDrummer]

You misread. OP was stating 3-4 pph INCLUDING midlevels. I typically see 2 pph on my own.

Oh ya I'm an idiot, that seems much more reasonable.

 

[goodoldalky]

Work less

 

[emergentmd]

So, every now and again, threads pop up (like this one) talking about being happy in our specialty.

My first job out is in a pretty busy place -- one where seeing 3-4 pph, including resident/midlevel oversight, happens with some regularity. Some of the docs in my group routinely do 5-6 pph.

Maybe it's just because I'm working a lot and am too perfectionistic for my own good, or maybe it's because there are things I want to do recreation-wise that I haven't done yet but reasonably could, but I'm getting a little too short-tempered and cranky in the department.

For those of you at this point or farther down the road, what adjustments did you make as a new attending that made you happier?

I never include the ML in my calculations. They don't take much of my time. I think 2 is avg if everyone is not QC. When I do 2/hr, I feel relaxed. When I hit 3/hr, I start to dislike the day.

 

[TrumpetDoc]

It was working for a CMG out of residency that burned me out rather rapidly.
There are always things that pile on. We had to argue admits, had a terrible pay, and so on.
We had to see 3+ pph and have excellent pt sat to get paid max as both were attached to our pay. And even then people were stoked to get to the 180/hr mark.

Key is to work less, make more, and not be pushed to see more than 2 pph. Keep looking until you find the place.
Don't be married to a location!!
No matter what you love about a place, there are places that will allow a balance of work and life!
We left a city 100% owned by CMGs with 3 kids despite our family being there, and it was the right choice.

 

[The White Coat Investor]

Wow... I thought the average was 2-3pph. 4pph is 15 mins for an H&P, enter labs, write a note, review results, tell patient about results, admit/consult... That's impressive. Kinda scary considering I'm only seeing 1.5/hr (intern). Takes me 10-15 mins to do a good H&P and get orders in.

Give me a break. This is like the $500 an hour threads. Can you find a $500 an hour job? Sure. Are most jobs $500 an hour? No. Can you find somewhere that people are seeing 3-4 pph? Sure. Is that normal? Not even close.

I had a really busy shift for me today. It worked out to 2.5 pph. I never went to the bathroom and didn't eat until there were 15 minutes left in the shift. I didn't drink anything. If I was seeing that many every shift I don't think I'd like my job nearly as much as I do. Was it safe at that level? Yes, but there wasn't much surge capacity and it wasn't particularly good service for the patients.

Those of you whose shifts average more than 2.5 pph routinely are cruising for burnout. Get another doc on.

4 pph isn't impressive. It's shoddy work. You don't want to work that fast. Your patients don't want you to work that fast. You don't need that much money ($600 an hour.) That's not why you went to medical school. Guess who wants you to work that fast? The guy who's paying you $200 an hour and gets to keep everything you generate above that. His name is Dom. But don't worry. He's not actively trying to steal contracts by planting his wife on hospital boards. That was just a coincidence.

 

[shoal007]

ya agree with wci. we see between 1.5 - 2 pph, really bad shifts over 3. but usually closer to 1.5. much happier with that.

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[BJJVP]

With respect to happiness, I have to constantly remind myself to let go and not become fixated on the many problems of the ED. This helps me to keep going. Keep in mind that there has never been an aha moment where I suddenly learned to love my job/career. However, remembering to relax has made me appreciate how lucky I am. Just let go of things.

-The director/chairperson will do things you don't agree with. Don't argue, don't fight it. Just let it happen and adjust. You will not change anything anyways. If you must, state your case and move on.

-Administration will do things that show a lack of respect or understanding of the ED. Don't let it bother you. It's not personal.

-The nurses will question some of your decisions. The pts will question some of your decisions. Parents will want an x-ray, or a CT or blood work or something you didn't feel was indicated. Hospital staff will think you screwed up somewhere. Sometimes, their concern is a legitimate one. Most times, it will be a misunderstanding. Just keep going. Do your best, try to review your work objectively, but then you have to move on.

-The lab will lose some blood. It will always take forever to get a urine result back. The waiting room will eventually empty out at some point and it will blow up again at some point. It's just part of the job. Don't try to change it. You'll just stress yourself out needlessly.

-Everyone loves that one orthopedic surgeon in town but all you will ever get are stories about how bad the ER was when your neighbor went there for a non-emergent issue. Expect it. Don't get defensive. It comes with the territory.

Most of us did well academically. Therefore, we were all told we would change the world when we grew up, become the future leaders, make the rules, earn the most money, and get the best jobs. These kinds of expectations only set you up for misery. Burnout occurs when expectations exceed reality. To keep happy, I constantly have to remind myself that my job allows me to work less hours, garnishes respect from the public, makes above average pay, and gives me the opportunity to serve my community in a relatively meaningful way. My kids are far better off financially than I was growing up. My latest practice has been to reflect after every shift on something interesting or someone that was saved or helped. I even try to tell my wife about it. For many years, I would tell my wife and my friends that all I saw in the ED were drug seekers and alcoholics. If I am honest, and truly think about it after every shift, we do some amazing things in the ED (joint reductions, sedations, cardioversions, resp failure, sutures, I&Ds, LPs, central venous access, treat cardiogenic, hemorrhagic, anaphylactic, & septic shock). In the past, I did emergency medicine a disservice by not realizing this and not spreading the word.

Finally, sometimes, reading SDN makes unhappiness even worse. I am happy for all of you making $500/hr. But I have to remember that if it takes $500/hr to make me happy, or feel appreciated, then I need to adjust my point of view. Of course I don't want to be taken advantage of by anyone. But sometimes, when I get on SDN too often, I start to feel that $250/hr is being underpaid, and I know that's far from reality. Getting on SDN is kind of like going to the gym. If being around all of those healthy, in-shape people motivates you, then keep going to that gym. However, if it starts to depress you and makes you feel like an ugly slob, then it's becoming counterproductive.

 

[BJJVP]

One other thing. I think that the # of patients per hour can be a misleading figure. I currently see 2-3 pts/hr by myself (4-5 pts/hr including midlevel pts). It's not that bad compared to other ERs I've worked in because the place has decent support from radiology, the laboratory, etc.

However, I have worked in a hospital that saw approximately 1.5 to 2 pts per hr and I was completely miserable. The ancillary staff was inefficient, the nursing morale/culture was poor, the ED was a dumping ground, and the hospital was in the middle of nowhere.

 

[deleted109597]

Fantastic posts BJJVP.

 

[Venko]

I agree almost entirely with BJJVP, but would add a few things:

1. focus on the things you can control - stay on top of your emails with inbox zero, control your eating, exercise etc.
2. smile, even when you don't want to
3. EMRAP has a great segment on accepting positive feedback. Take it to heart
4. Understand that every patient takes more mental effort for the newer attending than an experienced one. That means that if people in your shop are thriving with 3 pph, that may in fact be quite exhausting for you as you are just starting out. Most folks hit a real stride about five years post residency
5. If you find that you've lost your temper, misstepped in any way, be quick to apologize
6. If there is a perfect balance between under and over testing, don't try and hit it. The goal should be that you go home without worrying about the patient even if it means over testing, consulting, or observing a patient.
7. Dont overextend yourself with administrative stuff. Most roles have minimal work upfront and pick up after about 18 months, so it can be easy to be over committed without knowing it until a ways down the road.
8. Find a good mentor and schedule regular meetings with this sage person to have coffee, a bagel etc. Be open, and be honest with them.
9. Give yourself lots of gifts - time with loved ones, travel, good food, nice clothes, shoes, video games, sneakers, whatever this is to you. (just enough to be very happy, not to put you into a new loan)

These are my thoughts and may not be right for you. Let me know what you find that works!

 

[bravotwozero]

Thread reminds me of the song happiness by the verve


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[EMDOC17]

I find people comparing PPH is like dudes sitting around talking about how big their shlong is. It is a competition. I am in residency where in a typical 8 hr shift myself as the senior, the intern (sometimes a 2nd year) and the attending can see 40 patients per 8 hour shift. Granted that is a 3 man team but the attending seeing and signing off on 40 patients per shift? No thanks. I will take the same pay and happily leave this place for a 1.5 pph; 2 pph on a busy day gig. My shlong may not be as big but I will be happier and will get paid about 25K less per year than my attendings.

 

[da8s0859q]

I agree almost entirely with BJJVP, but would add a few things:

1. focus on the things you can control - stay on top of your emails with inbox zero, control your eating, exercise etc.
2. smile, even when you don't want to
3. EMRAP has a great segment on accepting positive feedback. Take it to heart
4. Understand that every patient takes more mental effort for the newer attending than an experienced one. That means that if people in your shop are thriving with 3 pph, that may in fact be quite exhausting for you as you are just starting out. Most folks hit a real stride about five years post residency
5. If you find that you've lost your temper, misstepped in any way, be quick to apologize
6. If there is a perfect balance between under and over testing, don't try and hit it. The goal should be that you go home without worrying about the patient even if it means over testing, consulting, or observing a patient.
7. Dont overextend yourself with administrative stuff. Most roles have minimal work upfront and pick up after about 18 months, so it can be easy to be over committed without knowing it until a ways down the road.
8. Find a good mentor and schedule regular meetings with this sage person to have coffee, a bagel etc. Be open, and be honest with them.
9. Give yourself lots of gifts - time with loved ones, travel, good food, nice clothes, shoes, video games, sneakers, whatever this is to you. (just enough to be very happy, not to put you into a new loan)

These are my thoughts and may not be right for you. Let me know what you find that works!

Funny -- I do several of these things. I've always been a big fan of controlling my own little world. My inbox is meticulous (I get annoyed when I have even one message left in it) -- everything gets dealt with or filed away appropriately. Haven't heard the EMRAP thing, but sounds interesting. I think with me, I might be more meant for those 2-2.5 pph shops with a different populace, but doing everything else does help.

I always tell my residents to never go home worried about a patient / to act accordingly while in the ED to facilitate that -- for the smart ones, it seems to encourage them to think more, have better workups, and have better notes with them erring more on the side of caution.

I find people comparing PPH is like dudes sitting around talking about how big their shlong is. It is a competition. I am in residency where in a typical 8 hr shift myself as the senior, the intern (sometimes a 2nd year) and the attending can see 40 patients per 8 hour shift. Granted that is a 3 man team but the attending seeing and signing off on 40 patients per shift? No thanks. I will take the same pay and happily leave this place for a 1.5 pph; 2 pph on a busy day gig. My shlong may not be as big but I will be happier and will get paid about 25K less per year than my attendings.

It means your schlong is smarter. Point of diminishing returns with the money. Your schlong practically wears a ****in' monocle. (You're welcome.)