How bad is bureaucracy / paperwork in EM compared to other fields?

[neoevolution]

Are things like patient satisfaction surveys just an annoying aspect of care that's becoming more common for all fields (especially compared to hospitalists for example), or does EM specifically have it worse? Is this something that's a significant contributor to burnout?

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[Dr Mantis Toboggan]

Probably better than most specialties. One thing that's nice is at least for now we can pretty much order any testing (CT, MRI etc) we deem emergent. It seems insurance pre-authorization is becoming more of a pain for outpatient specialities.

 

[neoevolution]

Probably better than most specialties. One thing that's nice is at least for now we can pretty much order any testing (CT, MRI etc) we deem emergent. It seems insurance pre-authorization is becoming more of a pain for outpatient specialities.

So would you say that it's the stress/pace and day/night shifts that are causing the burnout? I guess what I'm wondering is why EM has such high burnout stats in some surveys

 

[namethatsmell]

So would you say that it's the stress/pace and day/night shifts that are causing the burnout? I guess what I'm wondering is why EM has such high burnout stats in some surveys

Search this forum and read the many, many threads on burnout. Read any thread involving lifestyle, medmal, and pt satisfaction and there'll be good pertinent info there, too.


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[Dr Mantis Toboggan]

Different for everyone. For me:

1) challenging patient population: mental illness, substance abuse, opioid seekers, chronic disease burden. You will see patients again and again who use the ED more in one year than your entire immediate family has in their combined lifetimes. It gets frustrating. And inevitably bad things happen to them, and you feel responsible. At times you feel like you are not really helping anyone. It's not true, but you feel that way.

2) haunted by bad/unexpected outcomes. I expect myself to help everyone/nail every intubation/central line/LP/make every diagnosis/sniff out all the zebras. It's not possible. And over time the misses/bad outcomes seem to hurt me more than my saves help me, if that makes sense.

3) pressure. You have to make incredibly difficult decisions (tPA for stroke, etc) in a limited time with incomplete information with at times other very sick patients who need you as well. At times Monday morning quarterbacking from admin, docs upstairs after the fact can kick you while you are down.

4) family/friends. Number of hours worked is not bad but you work a lot when your wife/kids are at home. Monday I missed my kids band concert because I had to stabilize what it is in all likelihood a terminal patient. Got out > 2 hours past the end of my shift. I know it was the right thing to do but still felt bad I wasn't there for my kid.

I wouldn't say I'm burned out, but I can easily see why it happens to people.

 

[da8s0859q]

Different for everyone. For me:

1) challenging patient population: mental illness, substance abuse, opioid seekers, chronic disease burden. You will see patients again and again who use the ED more in one year than your entire immediate family has in their combined lifetimes. It gets frustrating. And inevitably bad things happen to them, and you feel responsible. At times you feel like you are not really helping anyone. It's not true, but you feel that way.

2) haunted by bad/unexpected outcomes. I expect myself to help everyone/nail every intubation/central line/LP/make every diagnosis/sniff out all the zebras. It's not possible. And over time the misses/bad outcomes seem to hurt me more than my saves help me, if that makes sense.

Two of my issues as well. As a smaller thing but because I feel like ranting, I'd add to this my annoyance when something in the chart comes across as if the ED attending is treated as a sub-par disposable commodity to a patient's medical course. "The ER said", "the ER doctor apparently didn't think that __" -- yeah, no. Go read my MDM. Seems to be an EM-specific thing.

But this all comes with good parts, too. I want a CT/ultrasound/MRI? I order it, and it magically happens. I can have any labs I want drawn on the spot. I have the luxury of a full call panel. We all will have the occasional patient complaint, but I don't have nearly the kind of paperwork and correspondence headaches that I imagine the PMDs do. I don't have a pager. I work fewer (if more intense, a la @Birdstrike's 1:1.5 rule) hours than many.

Every single specialty has its pros and cons. You just have to pick the one that's more in line with what you want in the "pros" column and lets you have the kind of life you want.

 

[Venko]

I think bureaucracy and non patient care work burdens will vary by location. They are also different than other specialties.

Politics / bureaucracy can exist as you will need the support of the hospital for admissions, you will be held to standards of disease care (i.e. Sepsis, stemi, pna, stroke) and yet you may not have a strong voice in designing care models depending on the place you work. You may find battles over sedation medications, nerve blocks, care of psychiatric patients, sick but not icu level patients etc depending upon your shop.

You may have to manage paperwork for transfers, holds, patient complaints etc at higher rates than other specialties depending on the specific place you choose.

As for burnout, I think it comes down to the number of high intensity decisions per unit of time. A question from a nurse that is non critical about a patient you've known for 24 hours or more is not as difficult as one from a nurse about a patient you just met twenty minutes ago and may in fact be of critical importance to the patients outcome. Many physician workloads for the day (not all) will cap or reach capacity at 16; whereas some EM attendings I know staff 45-60 on a busy but not extraordinary day. Also the patient volumes in outpatient and inpatient environments have a smaller range than do EM shifts. The majority of EM work happens in second shift whereas most other specialties batch work in first shift....the list of factors contributing to burnout continues on and on.

Don't get me wrong, I love my job, and I'm only listing some of the stressors without an equal amount of attention to the rewards of an EM practice.


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[HooliganSnail]

Are things like patient satisfaction surveys just an annoying aspect of care that's becoming more common for all fields (especially compared to hospitalists for example), or does EM specifically have it worse? Is this something that's a significant contributor to burnout?

Administrators irritate me like no other. I have a full proof strategy for them, I have developed over the past two years.

- Disease specific metrics - highly irritating. I'm talking stroke (hate stroke), MI, Sepsis (thanks CMS), that stuff. Highly metric'd, watched like a hawk. It seems every case you have with one of these will involve at least one conversation with the **** coordinator. Our stroke lady comes down and times you at bedside, literally drives me nuts.

- In general, they like to dictate from the C-suite lots of policies that clearly do not take into account what actually goes on the ER. They kinda just lord over you and talk to you like your a simpleton. They always have smiles on their faces though, kinda like Goodfellas. "they come as your friends"

- My strategy for dealing with them( Very effective, no problems so far): ALWAYS agree. Just agree and smile back. And then just continue doing whatever you were going to do anyway. NEVER argue with them, it will get you nowhere. They can not understand the medicine, they are never going to understand what it's actually like in the pit, so just AGREE with everything they say, and then ignore their request. They can't actually do anything to you. They can't actually make me admit more people. They can't actually make me see 3pph. Sure eventually they could find a different doctor, but I'm far from the worst at these metrics, and new doctors are expensive, and there is no reason they would, because I always smile and shake their hands, and laugh with them. The physician who gets fired is always the loud, disruptive one, who argues with administration. Don't argue, just smile, nod and IGNORE. Works like a charm.

 

[HooliganSnail]

Two of my issues as well. As a smaller thing but because I feel like ranting, I'd add to this my annoyance when something in the chart comes across as if the ED attending is treated as a sub-par disposable commodity to a patient's medical course. "The ER said", "the ER doctor apparently didn't think that __" -- yeah, no. Go read my MDM. Seems to be an EM-specific thing.

But this all comes with good parts, too. I want a CT/ultrasound/MRI? I order it, and it magically happens. I can have any labs I want drawn on the spot. I have the luxury of a full call panel. We all will have the occasional patient complaint, but I don't have nearly the kind of paperwork and correspondence headaches that I imagine the PMDs do. I don't have a pager. I work fewer (if more intense, a la @Birdstrike's 1:1.5 rule) hours than many.

Every single specialty has its pros and cons. You just have to pick the one that's more in line with what you want in the "pros" column and lets you have the kind of life you want.

Agree with the "ER did this" thing. Very frustrating to never get respect from your colleagues. We deliver excellent, high quality medicine on a daily basis. It seems like I can do 20 things right, but all anyone wants to talk about is the 1 thing I did wrong. And mostly, it's not like I did it wrong, I just didn't do it how they like it.

 

[shoal007]

Agree with the "ER did this" thing. Very frustrating to never get respect from your colleagues. We deliver excellent, high quality medicine on a daily basis. It seems like I can do 20 things right, but all anyone wants to talk about is the 1 thing I did wrong. And mostly, it's not like I did it wrong, I just didn't do it how they like it.

right on. i admitted a 70yo M with dizziness with dysmetria the other day knowing full well it was a posterior stroke. My note clearly states as such. Admitting doctor.. this is peripheral vertigo. doc in the morning states might be stroke so orders the MRI. Neuro consult note. thank you doctor inpatient for catching this subtle stroke. WTF???? The inpatient doc just did what i said. Im the one who caught it. Its frustrating. I know if i didnt catch it, my ass would be grass.

anyways move along.

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