How not to become a crappy ER Doc

[Matia03]

---

Members don't see this ad.

Current 3rd year EM resident.

Will be working my first attending job at a small community hospital (around 25,000 visits).

It has been my limited experience and opinion that some ER docs are more prone to losing their skill sets (specifically in procedures) and medical knowledge very quickly in these settings.

Looking for advice on how to avoid this.

 

[two guys]

The fact that you're asking this makes it unlikely.

I disagree that there is ANY correlation between practice size and "crappy EM docs". Perhaps only because some rural sites can't recruit BC EM docs or the best and the brightest but still I think you've come up with an inaccurate generalization. You'll meet great and bad docs in every setting. Of course, people with somewhat coveted jobs (ie big cities, certain academic centers) are going to be pretty good - there's a long line waiting to fill their shoes. That being said, we can all remember clinically questionable attendings from residency. I know plenty of guys in places with EM residents and specialty coverage who don't do hardly any procedures and aren't the ones making the dept move. That's not a knock on them, they have a very special skill set. I'm just saying that volume doesn't always mean experience.

It's never been easier to stay up on the national cutting edge of medicine. Get EMRAP and listen to it religiously, go to conferences. If you do just expend all of your time working shifts and don't fill your bank of knowledge back up then it will erode.

One thing I did every month my first year out and still occasionally (should be doing it every month) is basically go through the "game tape" of one shift a month. I sit down the next day and read every chart from the day before and go through how I documented, what I ordered and didn't, how I interacted with the patients/family, and my discharge plan. Some days I don't make it through the first 5 patients before I get sucked in to reading on a particular topic (oral anticoagulation, steroids for bells, etc). Other days I spend more time trying to figure out how to explain a topic better and interact with the patient better. It's hard to get excited to do this on your day off but I have learned something every time I've done this.

Lastly, get involved at your hospital with something. Try to make it a better place for the guys you'll be recruiting the next year. It will make you feel much better about your partners and the hospital admin.

 

[Birdstrike]

Current 3rd year EM resident.

Will be working my first attending job at a small community hospital (around 25,000 visits).

It has been my limited experience and opinion that some ER docs are more prone to losing their skill sets (specifically in procedures) and medical knowledge very quickly in these settings.

Looking for advice on how to avoid this.

Does this place accept ambulances? Because if so, you'll still get lots of sick people. I've worked at places like this, and while you don't necessarily get as much high acuity, you still get some, ie, drop-off ODs, the occasional unexpected arrest and the "indigestion" that turns out to be a STEMI. Then, when the fit hits the shan in this setting, your skills are actually tested more than at Consultomania General, absent outrageous levels of support. But honestly, I wouldn't worry about it that much. It's your first job. You can always get credentialed at some other bigger place for a few shifts here or there, or if the acuity isn't high enough after one year, you can move on. Having worked at everything from non-trauma, Level III, II, I and up, I would say your skills maybe get tested the most in the middle of that spectrum. For example, at a place big enough to get acuity, but not so big that even a hangnail gets shipped stat to the awaiting Peds middle-toe only-on-the-left-foot podiatry-team.

Either way, if you're good, you're good, and you'll be able to adapt to each setting with a brief initial warm up period. Good doctors are good doctors. And let's face it, once you've learned these "skills" they kind of become ingrained in you forever.

 

[emergentmd]

Current 3rd year EM resident.

Will be working my first attending job at a small community hospital (around 25,000 visits).

It has been my limited experience and opinion that some ER docs are more prone to losing their skill sets (specifically in procedures) and medical knowledge very quickly in these settings.

Looking for advice on how to avoid this.

I would say that you do lose some skill set when you have not done it often/lately. My greatest advice to all medical students is train at an inner city/trauma center. Like Riding a bike. I trained at one of the biggest trauma center and was able to do and see everything. I will always be comfortable dealing with sick patients as I have seen the sickest of sick.

I have 4th yr med students who shadow me that goes to a community based hospital. Some have never put in a central line or intubate a pt. So go to a place that will allow you to do everything. Its a more difficult 3 yrs but it is invaluable

 

[Arcan57]

Does this place accept ambulances? Because if so, you'll still get lots of sick people. I've worked at places like this, and while you don't necessarily get as much high acuity, you still get some, ie, drop-off ODs, the occasional unexpected arrest and the "indigestion" that turns out to be a STEMI. Then, when the fit hits the shan in this setting, your skills are actually tested more than at Consultomania General, absent outrageous levels of support. But honestly, I wouldn't worry about it that much. It's your first job. You can always get credentialed at some other bigger place for a few shifts here or there, or if the acuity isn't high enough after one year, you can move on. Having worked at everything from non-trauma, Level III, II, I and up, I would say your skills maybe get tested the most in the middle of that spectrum. For example, at a place big enough to get acuity, but not so big that even a hangnail gets shipped stat to the awaiting Peds middle-toe only-on-the-left-foot podiatry-team.

Either way, if you're good, you're good, and you'll be able to adapt to each setting with a brief initial warm up period. Good doctors are good doctors. And let's face it, once you've learned these "skills" they kind of become ingrained in you forever.

Disagree about the ingrained forever comment. I've seen multiple skilled docs that left for jobs where you basically worked as a rubber stamp for admissions or as a pseudo-resident for the private docs and not be able to transition back into an actual ED due to some miscalibration of "sick/not-sick" due to the limitations of the prior environment.

I would also point out that volume has only a moderate influence on acuity. If you're the only hospital in 75 miles, a 25k shop may have some wicked acuity due to it being too far to drive to the tertiary care center. If there are 4-5 hospitals within 10 miles of you, a 25k shop may see little acuity depending on ambulance transport patterns (are you bypassed for STEMI, trauma, CVA?) and the general healthiness of affluent suburbs compared to inner cities (citation needed).

 

[Birdstrike]

I've seen multiple skilled docs that left for jobs where you basically worked as a rubber stamp for admissions or as a pseudo-resident for the private docs...

What the the heck kind of job would that be?

 

[fancymylotus]

What the the heck kind of job would that be?

 

[Birdstrike]

Introducing everyone to....

Fancymylotous. In real life, she looks exactly like Jasmine from Aladdin. (Seriously). She's here specifically to help beat back all the trolls on this forum.








(And fix teeth for an exorbitant cash-only price).

 

[mestielest]

Current 3rd year EM resident.

Will be working my first attending job at a small community hospital (around 25,000 visits).

It has been my limited experience and opinion that some ER docs are more prone to losing their skill sets (specifically in procedures) and medical knowledge very quickly in these settings.

Looking for advice on how to avoid this.

I'm not an ER resident but I worked as a primary care practitioner (outpatient+emergency+administrative+forensic 7/24 - but I gave up outpatient after two collegues have started to run a family medicine clinic) in a small town. Daily administration was about 70-80 people for outpatient and 30-40 for emergency(most of them were not real emergencies of course). 20 km.s (mountain road) far away from nearest hospital and 120 km.s far away from tertiary center. I didnot observed loose in my invasive or examination skills but I remember that two other doctor who were in charge before me (and they had worked 5+ years in that town) were very irrevelant from clinical approach. They were just filling their time 🙂 . I think it was because of their lack of attention but maybe the situation led them to that. I'm not sure. Anyway I think one may keep his/her knowledge up-to-date and a skill you mastered is always in your armenterium you can call it anytime you want. Maybe you may loose you practical movements but you will not forget the exact skill anytime.

And I want to remember that I'm living with "keeping my whole medical skills up and performing the best" idea since I started residency and now I'm diagnosed with obsessive compulsive disorder 🙂 Dont make that mistake, dont take this things so hard and take care 🙂

 

[The White Coat Investor]

I would say that you do lose some skill set when you have not done it often/lately. My greatest advice to all medical students is train at an inner city/trauma center. Like Riding a bike. I trained at one of the biggest trauma center and was able to do and see everything. I will always be comfortable dealing with sick patients as I have seen the sickest of sick.

I have 4th yr med students who shadow me that goes to a community based hospital. Some have never put in a central line or intubate a pt. So go to a place that will allow you to do everything. Its a more difficult 3 yrs but it is invaluable

While I trained at an inner city trauma center, I have observed something in hiring folks for our suburban ED that people who train in an inner city trauma center DON'T get. That's the ability to relate to "normal" suburban folks in an appropriate manner. Their customer service skills and ability to relate to consultants and EMS are often absolutely terrible. They think EM is all about seeing 4 patients an hour, discharging anybody who isn't going to die in the next 24 hours as soon as possible, taking care of trauma, and resuscitating folks circling the drain. The "softer" skills required for a happy career with plenty of longevity are taught much less often in an institution where you are continually bombarbed by "an inner city population" who doesn't take care of themselves.

Now, most EM docs are smart enough that they can pick many of these up in their first 6 months in a suburban ED, but they certainly don't come out of residency with them. Now, what are some of these skills and how important they are can be debated, but I assure you they are important to the people hiring you.

Things like:

Knowing when to get an MRI in a hospital that encourages you to order as many as you like
Knowing how to say no to a drug-seeker while making that drug-seeker and the facilitator with them think you care about their health
Documenting in a manner such that you are rarely downcoded
Documenting in a manner that will keep you out of the court room
Defusing upset patients, especially when they're upset about stupid stuff
Selling a patient to a consultant such that they don't "block" admissions
Working well with a set of consultants who will generally give orders by phone, NOT come in to the ED to see the patient- everything that needs to be done tonight will need to be done by you
Knowing when and how to transfer a patient despite the fact that your hospital is supposed to be able to do what the patient needs, but you wouldn't let them do it to your mother or child
Defending your contract from a CMG
Encouraging EMS to bring you MORE patients, not less (why nurses and recent EM grads do this is beyond me)
Figuring out how to keep administrators happy so you can keep your job
Getting a consultant to do the right thing while preserving a long-term relationship
Dealing with toxic personalities in consultants or partners or administrators
Finding help for uninsured patients in your community
Getting nurses to respect you (particularly tricky for female docs straight out of residency)
Doing appropriate work-ups in patients with psychosomatic issues- when 3/4 of your ED is full of patients having them, while convincing said patients to not only consider anxiety as a possible cause of the symptoms, but also to seek care for it.
Knowing which patients go to medicine, which go to surgery, which go to cardiology etc (different in every institution)
Knowing when to do your own US, and when to let the radiology department do it
Understanding the concept of a "Medical Screen Out" and when and how to use it
How to effectively use your state's CSD
How to maintain skills on procedures you do rarely
How to restrain patients and their family members when your only security guard weighs a buck twenty and you only have three nurses and a clerk, all female.

I could go on but you get the picture. An inner city trauma center is different from most EM jobs, and so can't provide complete preparation for most EM jobs.

That said, some things you also must learn are very difficult to learn outside that setting.

 

[Arcan57]

What the the heck kind of job would that be?

One where the main deciding factor in admissions is in-network insurance and the hospital exists to funnel patients to specialists that perform all their procedures in house. I hadn't encountered this type prior to moving, so I'm hoping they are rare.

 

[KarlPilkington]

You just described my first job out of residency.
Ended up working at a lower acuity shop, through a series of odd non-medical twists along the way.
Best first job I could have hoped for, lower volume, lower acuity, and it gave me plenty of time to figure out how the "Real world" works and focus on passing boards.
I shifted from that job to a high acuity, super high volume inner city academic shop with no issues.
Take a job that gives you the time to take good care of folks.

 

[TeddyBoomBoom]

While I trained at an inner city trauma center, I have observed something in hiring folks for our suburban ED that people who train in an inner city trauma center DON'T get. That's the ability to relate to "normal" suburban folks in an appropriate manner. Their customer service skills and ability to relate to consultants and EMS are often absolutely terrible. They think EM is all about seeing 4 patients an hour, discharging anybody who isn't going to die in the next 24 hours as soon as possible, taking care of trauma, and resuscitating folks circling the drain. The "softer" skills required for a happy career with plenty of longevity are taught much less often in an institution where you are continually bombarbed by "an inner city population" who doesn't take care of themselves.

Now, most EM docs are smart enough that they can pick many of these up in their first 6 months in a suburban ED, but they certainly don't come out of residency with them. Now, what are some of these skills and how important they are can be debated, but I assure you they are important to the people hiring you.

Things like:

Knowing when to get an MRI in a hospital that encourages you to order as many as you like
Knowing how to say no to a drug-seeker while making that drug-seeker and the facilitator with them think you care about their health
Documenting in a manner such that you are rarely downcoded
Documenting in a manner that will keep you out of the court room
Defusing upset patients, especially when they're upset about stupid stuff
Selling a patient to a consultant such that they don't "block" admissions
Working well with a set of consultants who will generally give orders by phone, NOT come in to the ED to see the patient- everything that needs to be done tonight will need to be done by you
Knowing when and how to transfer a patient despite the fact that your hospital is supposed to be able to do what the patient needs, but you wouldn't let them do it to your mother or child
Defending your contract from a CMG
Encouraging EMS to bring you MORE patients, not less (why nurses and recent EM grads do this is beyond me)
Figuring out how to keep administrators happy so you can keep your job
Getting a consultant to do the right thing while preserving a long-term relationship
Dealing with toxic personalities in consultants or partners or administrators
Finding help for uninsured patients in your community
Getting nurses to respect you (particularly tricky for female docs straight out of residency)
Doing appropriate work-ups in patients with psychosomatic issues- when 3/4 of your ED is full of patients having them, while convincing said patients to not only consider anxiety as a possible cause of the symptoms, but also to seek care for it.
Knowing which patients go to medicine, which go to surgery, which go to cardiology etc (different in every institution)
Knowing when to do your own US, and when to let the radiology department do it
Understanding the concept of a "Medical Screen Out" and when and how to use it
How to effectively use your state's CSD
How to maintain skills on procedures you do rarely
How to restrain patients and their family members when your only security guard weighs a buck twenty and you only have three nurses and a clerk, all female.

I could go on but you get the picture. An inner city trauma center is different from most EM jobs, and so can't provide complete preparation for most EM jobs.

That said, some things you also must learn are very difficult to learn outside that setting.

First year med student strongly going for EM here. I'm going to print this out and not forget it.

Srs

 

[iish]

.

 

[iish]

First year med student strongly going for EM here. I'm going to print this out and not forget it.

Srs

Post it on your wall and read it daily young one. Keep another under your pillow so you can absorb the contents of the advice in your sleep.

 

[Birdstrike]

Post it on your wall and read it daily young one. Keep another under your pillow so you can absorb the contents of the advice in your sleep.

All kidding aside, his list is a pretty good one, and pretty much is EM in a nutshell.

 

[EMbeastmode]

Excellent thread.

 

[Mighty Mouse]

JUST ABOUT THE BEST POST EVER PUT ON THIS SITE

While I trained at an inner city trauma center, I have observed something in hiring folks for our suburban ED that people who train in an inner city trauma center DON'T get. That's the ability to relate to "normal" suburban folks in an appropriate manner. Their customer service skills and ability to relate to consultants and EMS are often absolutely terrible. They think EM is all about seeing 4 patients an hour, discharging anybody who isn't going to die in the next 24 hours as soon as possible, taking care of trauma, and resuscitating folks circling the drain. The "softer" skills required for a happy career with plenty of longevity are taught much less often in an institution where you are continually bombarbed by "an inner city population" who doesn't take care of themselves.

Now, most EM docs are smart enough that they can pick many of these up in their first 6 months in a suburban ED, but they certainly don't come out of residency with them. Now, what are some of these skills and how important they are can be debated, but I assure you they are important to the people hiring you.

Things like:

Knowing when to get an MRI in a hospital that encourages you to order as many as you like
Knowing how to say no to a drug-seeker while making that drug-seeker and the facilitator with them think you care about their health
Documenting in a manner such that you are rarely downcoded
Documenting in a manner that will keep you out of the court room
Defusing upset patients, especially when they're upset about stupid stuff
Selling a patient to a consultant such that they don't "block" admissions
Working well with a set of consultants who will generally give orders by phone, NOT come in to the ED to see the patient- everything that needs to be done tonight will need to be done by you
Knowing when and how to transfer a patient despite the fact that your hospital is supposed to be able to do what the patient needs, but you wouldn't let them do it to your mother or child
Defending your contract from a CMG
Encouraging EMS to bring you MORE patients, not less (why nurses and recent EM grads do this is beyond me)
Figuring out how to keep administrators happy so you can keep your job
Getting a consultant to do the right thing while preserving a long-term relationship
Dealing with toxic personalities in consultants or partners or administrators
Finding help for uninsured patients in your community
Getting nurses to respect you (particularly tricky for female docs straight out of residency)
Doing appropriate work-ups in patients with psychosomatic issues- when 3/4 of your ED is full of patients having them, while convincing said patients to not only consider anxiety as a possible cause of the symptoms, but also to seek care for it.
Knowing which patients go to medicine, which go to surgery, which go to cardiology etc (different in every institution)
Knowing when to do your own US, and when to let the radiology department do it
Understanding the concept of a "Medical Screen Out" and when and how to use it
How to effectively use your state's CSD
How to maintain skills on procedures you do rarely
How to restrain patients and their family members when your only security guard weighs a buck twenty and you only have three nurses and a clerk, all female.

I could go on but you get the picture. An inner city trauma center is different from most EM jobs, and so can't provide complete preparation for most EM jobs.

That said, some things you also must learn are very difficult to learn outside that setting.

 

[Matia03]

You just described my first job out of residency.
Ended up working at a lower acuity shop, through a series of odd non-medical twists along the way.
Best first job I could have hoped for, lower volume, lower acuity, and it gave me plenty of time to figure out how the "Real world" works and focus on passing boards.
I shifted from that job to a high acuity, super high volume inner city academic shop with no issues.
Take a job that gives you the time to take good care of folks.

Out of curiosity, why did you leave your first job?

 

[Birdstrike]

Since this is a thread on how not to become a crappy ER doctor, do we need a twin thread on "How to become a crappy ER doc"?

It could be pretty entertaining.

Do I have a second?

 

[EMIM2011]

Second!

 

[WilcoWorld]

Frankly, I'm surprised that we haven't heard from a bunch of non-EM docs on this already.

 

[gman33]

In the post above by WCI, he mentioned learned to diffuse upset patients.

This is something I have had issues with at times.
Not the agitated drug seeker, more the somewhat normal person who is found to have no acute pathology but refuses to leave without "an answer".
I have had this situation arise at times with an exploding ED.
After taking what I thought was an appropriate amount of time explaining the testing and follow up needed, I have patients refusing to leave.
When there are multiple patients dying in the other rooms, it's hard to take the time to address all of their concerns.

What are some ideas for defusing these patients? and doing so in a timely fashion.
In the current environment of patient satisfaction, this is an important skill.
As was alluded to above, this is not a skill that is learned in an urban environment.

 

[The White Coat Investor]

In the post above by WCI, he mentioned learned to diffuse upset patients.

This is something I have had issues with at times.
Not the agitated drug seeker, more the somewhat normal person who is found to have no acute pathology but refuses to leave without "an answer".
I have had this situation arise at times with an exploding ED.
After taking what I thought was an appropriate amount of time explaining the testing and follow up needed, I have patients refusing to leave.
When there are multiple patients dying in the other rooms, it's hard to take the time to address all of their concerns.

What are some ideas for defusing these patients? and doing so in a timely fashion.
In the current environment of patient satisfaction, this is an important skill.
As was alluded to above, this is not a skill that is learned in an urban environment.

I've run into this many times.

1) Set expectations early on. You usually know by the time you're done with the H&P whether this person has something you're going to diagnose today or not. If the answer is not, set those expectations really low. "I'm just an emergency doc. I'll make sure you don't have an emergency today. That means something you need to be put in the hospital for, need antibiotics for, or need surgery for. If I can't find anything, I'll refer you to a specialist who is smarter than me for further evaluation."

2) Validate their symptoms. "I understand you have this terrible pain/bizarre paresthesias/weird sensation of a gopher in your throat." I'm concerned about it too. Unfortunately, I am not able to diagnose it due to the fact that certain tests are not available to me in the ED/I haven't had sufficient experience in this area. However, I'm going to refer you to the right specialist who can order any further tests that are indicated.

3) Ask them "what are you worried you have?" Is it cancer? Is it MS? Is it a stroke? Once you know what they're really worried about, you can rule it out or explain why you don't need any more testing to rule it out.

4) Occasionally, they are so bent out of shape and I'm so frustrated, I ask them, "What would you like me to do?" If it is even remotely reasonable, I do it- MRI, US, CT, special send-out lab, discuss the case with a consultant (although I don't drag a consultant in unless I think it's indicated and it almost never is in these situations) etc. More often, this is usually where they defuse and express that they're just frustrated not to have an answer. I sympathize and validate their symptoms and they go on their merry way.

5) Open the door for a psychiatric cause of their symptoms. "I can't say this is caused by anxiety, but I can't rule that out. I wish I had an "anxiety blood test" where I could draw your blood, see that your anxiety level is 47, and definitively rule that in. However, I don't have it. It's a diagnosis of exclusion, meaning we need to rule everything else out. But I've seen anxiety cause chest pain, belly pain, headaches, shortness of breath, even paralysis of an arm. The mind and body are intimately connected, and the body can cause psychiatric symptoms, and the mind can cause physical symptoms." Then, after they see the specialists and all those tests are negative too (which they probably will be) it will be easier for them to accept that they're just nuts. You'll be doing your consultants a huge favor. You might even suggest they "reduce their stress" and see a therapist while continuing their medical work-up.

6) Make sure your ED is staffed adequately so you can take the time to talk to these patients. If you're routinely getting pulled away because multiple patients are actually dying in other rooms, you're staffed too thinly. We're seeing <1.5 pph and making plenty of money. There's no reason you need to be seeing 3 per hour. Yes, occasionally it gets really busy. You can offer to let them wait until it's less busy and you have more time to talk or you can just refer them to the specialist.

7) Whatever you do, don't blow them off. Even squirrels get sick. While you don't want poor customer service scores, and you certainly don't want to be sued, most importantly, you don't want to miss something bad just because you don't know what's going on. I refer almost all of the patients I see with chest pain for at least an outpatient stress test, even the squirrelly ones. I've had several come back (for whom I had a very low suspicion) and thank me later for that stress test since they have since been stented.

It's one of those stupid things that those old fart doctors tried to ram down your throat as a first year med stud- "They don't care how much you know until they know how much you care." Darn it, they were right. Try not to project a "god complex" and put yourself on their team. It's you and the patient against the system/disease/symptom/squirrels.

 

[Birdstrike]

I've run into this many times.

1) Set expectations early on. You usually know by the time you're done with the H&P whether this person has something you're going to diagnose today or not. If the answer is not, set those expectations really low. "I'm just an emergency doc. I'll make sure you don't have an emergency today. That means something you need to be put in the hospital for, need antibiotics for, or need surgery for. If I can't find anything, I'll refer you to a specialist who is smarter than me for further evaluation."

2) Validate their symptoms. "I understand you have this terrible pain/bizarre paresthesias/weird sensation of a gopher in your throat." I'm concerned about it too. Unfortunately, I am not able to diagnose it due to the fact that certain tests are not available to me in the ED/I haven't had sufficient experience in this area. However, I'm going to refer you to the right specialist who can order any further tests that are indicated.

3) Ask them "what are you worried you have?" Is it cancer? Is it MS? Is it a stroke? Once you know what they're really worried about, you can rule it out or explain why you don't need any more testing to rule it out.

4) Occasionally, they are so bent out of shape and I'm so frustrated, I ask them, "What would you like me to do?" If it is even remotely reasonable, I do it- MRI, US, CT, special send-out lab, discuss the case with a consultant (although I don't drag a consultant in unless I think it's indicated and it almost never is in these situations) etc. More often, this is usually where they defuse and express that they're just frustrated not to have an answer. I sympathize and validate their symptoms and they go on their merry way.

5) Open the door for a psychiatric cause of their symptoms. "I can't say this is caused by anxiety, but I can't rule that out. I wish I had an "anxiety blood test" where I could draw your blood, see that your anxiety level is 47, and definitively rule that in. However, I don't have it. It's a diagnosis of exclusion, meaning we need to rule everything else out. But I've seen anxiety cause chest pain, belly pain, headaches, shortness of breath, even paralysis of an arm. The mind and body are intimately connected, and the body can cause psychiatric symptoms, and the mind can cause physical symptoms." Then, after they see the specialists and all those tests are negative too (which they probably will be) it will be easier for them to accept that they're just nuts. You'll be doing your consultants a huge favor. You might even suggest they "reduce their stress" and see a therapist while continuing their medical work-up.

6) Make sure your ED is staffed adequately so you can take the time to talk to these patients. If you're routinely getting pulled away because multiple patients are actually dying in other rooms, you're staffed too thinly. We're seeing <1.5 pph and making plenty of money. There's no reason you need to be seeing 3 per hour. Yes, occasionally it gets really busy. You can offer to let them wait until it's less busy and you have more time to talk or you can just refer them to the specialist.

7) Whatever you do, don't blow them off. Even squirrels get sick. While you don't want poor customer service scores, and you certainly don't want to be sued, most importantly, you don't want to miss something bad just because you don't know what's going on. I refer almost all of the patients I see with chest pain for at least an outpatient stress test, even the squirrelly ones. I've had several come back (for whom I had a very low suspicion) and thank me later for that stress test since they have since been stented.

It's one of those stupid things that those old fart doctors tried to ram down your throat as a first year med stud- "They don't care how much you know until they know how much you care." Darn it, they were right. Try not to project a "god complex" and put yourself on their team. It's you and the patient against the system/disease/symptom/squirrels.

This is a very good answer and I can't add much to it except one thing. In addition to validating a patient's symptoms and giving them reassurance you've ruled out life and limb threats, sometimes it helps to explain that often times admitting someone to the hospital to get a certain complaint or problem worked up will not always speed up the process. Sometimes it can actually be slower, to try and get certain things worked up in-patient, that are more appropriately and more efficiently processed in the outpatient setting.

"Sir, I assure you we can help you arrange outpatient (insert: allergy-testing/ chemotherapy/ rheumatology-infusion/ PET-scan/pain-injection/ in-office-eye-procedure) for this important problem as admitting you will only delay that process, since this problem is most efficiently addressed in the outpatient setting."

 

[VA Hopeful Dr]

Frankly, I'm surprised that we haven't heard from a bunch of non-EM docs on this already.

Well, since you asked...

Keep in mind that as an EP, you are the master of acute care medicine. Don't berate another doctor for sending something that was "easy" for you to fix. Easy for you doesn't mean easy for everyone.

Admittedly, this is a very rare occurence, but I have had a few EPs call me up after I send them something (usually a dislocation I can't reduce or a complex lac that I'm just not comfortable with) and lecture at me for wasting their time with something I apparently should've been able to handle.

 

[Apollyon]

Well, since you asked...

Keep in mind that as an EP, you are the master of acute care medicine. Don't berate another doctor for sending something that was "easy" for you to fix. Easy for you doesn't mean easy for everyone.

Admittedly, this is a very rare occurence, but I have had a few EPs call me up after I send them something (usually a dislocation I can't reduce or a complex lac that I'm just not comfortable with) and lecture at me for wasting their time with something I apparently should've been able to handle.

I'll apologize for those guys. As you may recall, that is not unique to EM docs - I can't recall how many surgeons were dicks about "you should be able to do this". I don't remember who said it or who told me, but I just think of, "Someone needs help from you. It is more than they can handle. Help them out." The trick is not to be paternalistic or condescending about it.

 

[WilcoWorld]

Well, since you asked...

Keep in mind that as an EP, you are the master of acute care medicine. Don't berate another doctor for sending something that was "easy" for you to fix. Easy for you doesn't mean easy for everyone.

Admittedly, this is a very rare occurence, but I have had a few EPs call me up after I send them something (usually a dislocation I can't reduce or a complex lac that I'm just not comfortable with) and lecture at me for wasting their time with something I apparently should've been able to handle.

I agree with you and with Apollyon's response - when someone asks for your help, assume they need it. This applies to all medical specialties.

 

[Birdstrike]

Well, since you asked...

Keep in mind that as an EP, you are the master of acute care medicine. Don't berate another doctor for sending something that was "easy" for you to fix. Easy for you doesn't mean easy for everyone.

Admittedly, this is a very rare occurence, but I have had a few EPs call me up after I send them something (usually a dislocation I can't reduce or a complex lac that I'm just not comfortable with) and lecture at me for wasting their time with something I apparently should've been able to handle.

I agree. They should blame EMTALA, not wage a futile war to override it one patient at a time by berating outpatient docs. It's just a sign someone is frustrated. Why be a jerk about sending something easy, to begin with? You mean you want a total disaster/train-wreck next time, so your shift really goes to hell?

I understand the frustration, but Federal law authorizes anyone, to send anything to the ED, any time of day. It sucks, but it is what it is. That's not the referring docs fault.

"You farted too loud at 4am on Christmas night-shift?

Okay, go to the ED."

I hate to say it, but if you don't like getting paid to see that very easy patient no matter how ridiculous or non-emergent seeming, then you chose the wrong specialty. I know codes are coming in at the same time, and the CEO wants them all impossibly seen in <15 min, as I've been there, but that's "emergency" medicine. It's not the fault of the outpatient doc that's not about to meet a patient at his office at 3am, and they don't deserve to be berated.

 

[deleted547339]

Well, since you asked...

Keep in mind that as an EP, you are the master of acute care medicine. Don't berate another doctor for sending something that was "easy" for you to fix. Easy for you doesn't mean easy for everyone.

Admittedly, this is a very rare occurence, but I have had a few EPs call me up after I send them something (usually a dislocation I can't reduce or a complex lac that I'm just not comfortable with) and lecture at me for wasting their time with something I apparently should've been able to handle.

That's wild. As an intern, I did this once or twice and my attending pulled me aside. I would see well-appearing trauma patients, Peds with URIs or asymptomatic patients with 220-160 transferred in and say something pejorative. My attending made it clear that these are physicians that for whatever reason are asking for help - maybe the aren't well trained in trauma, maybe it's an internist who doesn't know kids, maybe they haven't sewed a lac in 20 years and would look better if you did it, whatever. It doesn't matter. They are asking for help. Give them crap and their going to think twice about shipping that borderline trauma patient or the septic neonate. I've even heard the same thing from out nastiest trauma surgeons, which caught me off guard.

I just can't believe someone would take time out of their busy day to call someone up and tell them that they suck.

Sorry. We'll take whatever you got. I don't mind the 530PM runny noses. The only thing that bugs me is when someone goes from the clinic to the ER "to be admitted" back to the same doctor. That always confused me.

Thanks for doing what you do.

 

[Birdstrike]

The only thing that bugs me is when someone goes from the clinic to the ER "to be admitted" back to the same doctor. That always confused me.

Typically that's going to be a doc that's tied up in clinic or a procedure day and wants the patient admitted, and they just can't (or don't want to) cancel their clinic/procedure to run to the floor, do an H&P for a direct admit and all that. If you cancel a bunch of procedures or clinic patients, it's a loss of serious dinero, not to mention having to reschedule everyone. You're helping them out by buying them some time, getting some labs/X-rays/whatever started and helping plug the patient in whereas they can pick up the baton more easily later.

"Hey Joe, so what do you and on this guy?"

"Uh..some labs, chest X-ray, and have the nurse call me for admit order when that stuff's back."

"Okay, cool. Bye."

Who cares. Easy RVUs. Easy level 5 billable admit.

Now that being said, if this is a guy that's a total ****troll every time you need some help then...

 

[VA Hopeful Dr]

Who cares. Easy RVUs. Easy level 5 billable admit.

Now that being said, if this is a guy that's a total ****troll every time you need some help then...

Exactly. My experience at my current gig (was never an issue anywhere else) has really made it clear just how valuable it is for y'all to be paid, at least in part, on productivity.

 

[deleted547339]

Typically that's going to be a doc that's tied up in clinic or a procedure day and wants the patient admitted, and they just can't (or don't want to) cancel their clinic/procedure to run to the floor, do an H&P for a direct admit and all that. If you cancel a bunch of procedures or clinic patients, it's a loss of serious dinero, not to mention having to reschedule everyone. You're helping them out by buying them some time, getting some labs/X-rays/whatever started and helping plug the patient in whereas they can pick up the baton more easily later.

"Hey Joe, so what do you and on this guy?"

"Uh..some labs, chest X-ray, and have the nurse call me for admit order when that stuff's back."

"Okay, cool. Bye."

Who cares. Easy RVUs. Easy level 5 billable admit.

Now that being said, if this is a guy that's a total ****troll every time you need some help then...

It just doesn't makes sense where I work. Clinic and the ED/hospital have the same EMR. Most services have skeleton order sets that can buy several hours. H&Ps can be done later in the day. Seems like laziness. In the private world, I totally get it.

Basically all transfers come through the ED. That I get, too. Sometimes ortho will get a transfer "oh, yea, just a tib/fib, otherwise stable..." that comes in hypotensive from a belly full of blood or "needs to be evaluated by x/y/x subspecialty we don't have" and comes in overtly septic. I want those to come to us so they don't sit on a floor for hours before ortho/neurosurgery/ENT/vascular/whoever gets out of the OR and sees them.

 

[The White Coat Investor]

Typically that's going to be a doc that's tied up in clinic or a procedure day and wants the patient admitted, and they just can't (or don't want to) cancel their clinic/procedure to run to the floor, do an H&P for a direct admit and all that. If you cancel a bunch of procedures or clinic patients, it's a loss of serious dinero, not to mention having to reschedule everyone. You're helping them out by buying them some time, getting some labs/X-rays/whatever started and helping plug the patient in whereas they can pick up the baton more easily later.

"Hey Joe, so what do you and on this guy?"

"Uh..some labs, chest X-ray, and have the nurse call me for admit order when that stuff's back."

"Okay, cool. Bye."

Who cares. Easy RVUs. Easy level 5 billable admit.

Now that being said, if this is a guy that's a total ****troll every time you need some help then...

I agree it's very convenient for the doc, but it does give the patient an ED bill he wouldn't have otherwise had. In this day of HDHPs, that can be pretty painful for the patient. Although if they're being admitted, they'll probably hit their max out of pocket and you're only hurting them for $1-500. Not as bad as a full ED bill, but still a bit mean when the doc could have simply called in some admission orders to the floor and sent the patient over for a direct admission. Unstable patient, different story. As I'm sure you're aware, I don't turn these patients down and finish my phone conversation with "Thank you for letting me participate in the care of this patient" but I think we have a duty to the patient's pocketbook also, not just their health.

 

[The White Coat Investor]

That's wild. As an intern, I did this once or twice and my attending pulled me aside. I would see well-appearing trauma patients, Peds with URIs or asymptomatic patients with 220-160 transferred in and say something pejorative. My attending made it clear that these are physicians that for whatever reason are asking for help - maybe the aren't well trained in trauma, maybe it's an internist who doesn't know kids, maybe they haven't sewed a lac in 20 years and would look better if you did it, whatever. It doesn't matter. They are asking for help. Give them crap and their going to think twice about shipping that borderline trauma patient or the septic neonate. I've even heard the same thing from out nastiest trauma surgeons, which caught me off guard..

When I take a transfer from someone who sounds incompetent to me (and its usually a mid level working solo in an urgent care) I just view it as rescuing the patient and am happy to do it. Sometimes if its really silly I'll offer an alternative plan, always prefacing it with, "I'll be happy to accept the transfer. It might be cheaper if you just write a script for oral Vitamin K for that INR of 7 with no bleeding" or Would you like to just directly admit the patient to the hospitalist, I can give you his number?" But if they're uncomfortable in any way, I just tell them to send the patient on over and I would be very happy to take care of him. Thank you for the referral.

Also, keep in mind they might not only be hesitant to send a sick patient to any ED (and thereby hurt the patient) but they might also quit sending patients to your ED because you're a jerk. Fewer patients = smaller paychecks when you own the business, and eventually even if you don't own the business.

 

[Old_Mil]

Current 3rd year EM resident.

Will be working my first attending job at a small community hospital (around 25,000 visits).

Do not assume that 25,000 visits a year in a community hospital will be less challenging than working at a tertiary care hospital. That's almost 70 patients a day, or averaging out to 3 triages an hour. Also, everything will be coming to your door undiagnosed unlike a tertiary care facility where the helicopter will be flying in a known head bleed, possibly already intubated from a facility like yours where someone else diagnosed it. With that visit volume you should have plenty of pathology. You can go to Ron Walls' course every few years to maintain your airway knowledge if you wish (just treat it like an ACLS renewal).

 

[dav86]

Agree. It is not about total volume. It is about PPH of the providers, especially the physicians and the acuity (admission rate, etc.).

 

[Doctor Bob]

Keep in mind that as an EP, you are the master of acute care medicine.

That just made my day.
I hear "EM knows a little about a lot and isn't the master of anything" all the time.
Master of acute care medicine... I'll have to remember that the next time I get called a glorified triage nurse.

Sorry. We'll take whatever you got.

When I get a phone call from a doc's office or smaller hospital, I usually have the monologue in my head about how this patient has no need to be in the ED/ICU, then say out loud "ok thanks, send them on over".

 

[VA Hopeful Dr]

That just made my day.
I hear "EM knows a little about a lot and isn't the master of anything" all the time.
Master of acute care medicine... I'll have to remember that the next time I get called a glorified triage nurse.

Can't remember where I heard that, but essentially someone in a discussion about EM and FM was saying that y'all are expert at all ages acute care medicine while us FPs are expert at all ages chronic care medicine (with obviously a good bit of overlap between the two).

 

[Apollyon]

Can't remember where I heard that, but essentially someone in a discussion about EM and FM was saying that y'all are expert at all ages acute care medicine while us FPs are expert at all ages chronic care medicine (with obviously a good bit of overlap between the two).

It was in this thread in the FM forum, post #7:
EM - acute generalists
FM - chronic generalists

 

[deleted547339]

It was in this thread in the FM forum, post #7:
EM - acute generalists
FM - chronic generalists

I've heard that "EM is FP on speed." One of my good buddies (a radiologist) says "But what if FMs are just EMs smoking weed?"

Think about it.....

 

[Birdstrike]

I've heard that "EM is FP on speed." One of my good buddies (a radiologist) says "But what if FMs are just EMs smoking weed?"

Think about it.....

Here's my version:

Anesthesiology = 99% boredom + 1% panic.

EM = 99% sprint + 1% panic.

FP = 99% walk + 1% calling 911