How to handle colleagues not pulling their weight

[emdoc799]

Advertisement - Members don't see this ad

How do others handle partners/colleagues who don’t pull their weight on shifts? I.e. letting patients get roomed and walk away to avoid signing up and “not noticing”, being selective to only low acuity patients or ones who are clearly disasters to avoid doing work/liability, playing stupid games like these?
Has anyone approached their co workers about this and how did you handle the conversation?
We’re at the point with one of ours where if you work with this person you are almost guaranteed to get out hours late because they avoid doing work at all costs. Thanks in advance for any advice.

 

[BoardingDoc]

How do others handle partners/colleagues who don’t pull their weight on shifts? I.e. letting patients get roomed and walk away to avoid signing up and “not noticing”, being selective to only low acuity patients or ones who are clearly disasters to avoid doing work/liability, playing stupid games like these?
Has anyone approached their co workers about this and how did you handle the conversation?
We’re at the point with one of ours where if you work with this person you are almost guaranteed to get out hours late because they avoid doing work at all costs. Thanks in advance for any advice.

Discuss with your chief. If not an option or not helpful because of a crappy work environment either A: get a new job, or B: simply tell lazy doc that certain patients are theirs. E.g. septic non-english speaking patient arrives from our lady of no insurance respite center. You have just picked up the social nightmare agitated patient. You tell lazy doc "hey man, they just put a patient in room 3 you should go see. I'm dealing with capt screams a lot." Obviously, fill in your own context.

Also, what people pick up should be dependent on when their shift ends. In general, I simply don't pick up complex patients in my last 90 min or so of my shift. If lazy doc is leaving soon, I would expect to have all the high acuity stuff. If lazy doc is the later doc though, literally any complex patient that rolls in during the last 1.5-2 hrs of your shift is theirs and you should simply explain that you're not picking the patient up as there's no way you can dispo them in the next 2 hours. If they push back because they "are about to go see someone else" or some BS, I just tell them that I'll eyeball the patient for them, throw in basic labs and whatnot for them and put their name on it.

 

[Fox800]

There is an art to this. Ditto about not picking up complex patients at the end of shift. Septic nursing home patients, "dizzy"/headache/HTN whatevers, lame "possible strokes", infant fever that needs a work-up, etc. Since my colleagues don't like to take sign-outs on these things, I just eyeball them, enter basic orders, and leave them as new.

 

[Tiger26]

I got sent to mediation for asking a colleague to see the same amount of patients as me. It was a real pain.

 

[Dr Mantis Toboggan]

How do others handle partners/colleagues who don’t pull their weight on shifts? I.e. letting patients get roomed and walk away to avoid signing up and “not noticing”, being selective to only low acuity patients or ones who are clearly disasters to avoid doing work/liability, playing stupid games like these?
Has anyone approached their co workers about this and how did you handle the conversation?
We’re at the point with one of ours where if you work with this person you are almost guaranteed to get out hours late because they avoid doing work at all costs. Thanks in advance for any advice.

CMG? Hospital employed? What’s the set up?

 

[HemorrhagicShock]

Since my colleagues don't like to take sign-outs on these things, I just eyeball them, enter basic orders, and leave them as new.

How is this helping though? The record shows you were the one to put in orders. In fact, I can see it generating more frustration from your partners at sign-out if you haven't actually started a note or done a little bit more of the work-up.

 

[HemorrhagicShock]

I got sent to mediation for asking a colleague to see the same amount of patients as me. It was a real pain.

You gotta tell us more than that!!

 

[BoardingDoc]

How is this helping though? The record shows you were the one to put in orders. In fact, I can see it generating more frustration from your partners at sign-out if you haven't actually started a note or done a little bit more of the work-up.

I don't understand your concern. Patient rolls in. You are going to be seeing them, not me. I walk into room, get a 1 liner history (lets say it's nonspecifically dizzy old lady), leave and order a CBC, Chem, Trop, EKG, UA. You finish doing whatever it is you're doing and go see them. Labs are now already drawn and pending. Time to dispo is now much shorter for you. I have no idea how/why this would cause frustration on your end, assuming I'm not an idiot and ordering dimers, placing consults that I expect you to follow up on, etc... which I'm not.

Edit: re the record showing that I ordered things, that doesn't really matter on my end. At my shop we have RN ordersets that get placed in triage. They go under whatever random doc is currently working so half of the patients on any given day have orders under my name that I likely never saw. I'm not terribly concerned about the medicolegal consequences of that if there is no record of me ever actually signing up for the patient.

 

[BJJVP]

How is this helping though? The record shows you were the one to put in orders. In fact, I can see it generating more frustration from your partners at sign-out if you haven't actually started a note or done a little bit more of the work-up.

It can be frustrating if you order labs that could've been avoided had you simply taken a decent history. For example, ordering a troponin in an elderly patient with chest pain that turns out to have shingles. Sometimes, it gets complicated because you have to listen and talk so much to the pt that you might as well leave a note so that the pt doesn't repeat everything all over again. However, most of the time, it keeps things moving along. There can be instances where it seems like you are just avoiding work or trying not to make a decision because you started a work-up that the oncoming physician didn't think was warranted. In short, it can help, it can hurt, and it can be frustrating. I think the varying practice patterns and risk tolerances of physicians, in addition to variations in ability to work efficiently means that signout will always suck to some extent for both parties involved.

 

[thegenius]

How do others handle partners/colleagues who don’t pull their weight on shifts? I.e. letting patients get roomed and walk away to avoid signing up and “not noticing”, being selective to only low acuity patients or ones who are clearly disasters to avoid doing work/liability, playing stupid games like these?
Has anyone approached their co workers about this and how did you handle the conversation?
We’re at the point with one of ours where if you work with this person you are almost guaranteed to get out hours late because they avoid doing work at all costs. Thanks in advance for any advice.

I find this happens only a little at all RVU shops. It does happen though and at times I’ll call them out in a nice way.

I can see this much more at an hourly place

 

[Fox800]

It can be frustrating if you order labs that could've been avoided had you simply taken a decent history. For example, ordering a troponin in an elderly patient with chest pain that turns out to have shingles. Sometimes, it gets complicated because you have to listen and talk so much to the pt that you might as well leave a note so that the pt doesn't repeat everything all over again. However, most of the time, it keeps things moving along. There can be instances where it seems like you are just avoiding work or trying not to make a decision because you started a work-up that the oncoming physician didn't think was warranted. In short, it can help, it can hurt, and it can be frustrating. I think the varying practice patterns and risk tolerances of physicians, in addition to variations in ability to work efficiently means that signout will always suck to some extent for both parties involved.

In a perfect world, we have enough docs that patients are seen instantly and they have plenty of time to see someone and take a thorough history and do the entire episode of care. In reality, I’m running a trauma activation and just intubated someone and I would rather have cookie-cutter orders going on a patient when I’m not gonna see them in the last 75 minutes of my shift…that way my partner has something to work with instead of the patient being totally ignored when they come on duty and there are 20 patients in the waiting room.

I’m sorry, I don’t have time to sit in the room for 15 minutes while meemaw tells me about how her face was numb for 48 seconds in 1972 and her third dog‘s name and that one time her and her husband went to Cancun and that’s why she may or may not have been dizzy when I’m trying to get out of work and get home on time…in the last hour of my shift. Much less if there is a language barrier.

 

[Brigade4Radiant]

Thats why i like shops with some RVUs also the doctor that signs out patients gets no rvus for that patient

 

[Kryptocoin]

I once worked with a colleague that was a lazy sob. Nurses would roll their eyes when he was on shift since they know the waiting room would be backed up. I'd often wondered how he was still employed. My CMG publishes our monthly/quarterly metrics, so I peeked into his stats and found out that he was actually more productive than me.

You see, the guy was big on workups and admissions. Every head bump gets a CT head. Every nausea gets a CT abd. Every pediatric fever got blood work and IV. His admit rate was 2x that of the group average. Most of his charts were billed at a level 5 because of the big workups. So even though I was 2x fast and doing minimal workups, our RVUs were in fact similar.

In the eyes of the CMG, he's a good worker. On the ground, I hated coming into his shifts because I know I have to clean up a packed lobby. I lasted a year at that job.

 

[Groove]

I once worked with a colleague that was a lazy sob. Nurses would roll their eyes when he was on shift since they know the waiting room would be backed up. I'd often wondered how he was still employed. My CMG publishes our monthly/quarterly metrics, so I peeked into his stats and found out that he was actually more productive than me.

You see, the guy was big on workups and admissions. Every head bump gets a CT head. Every nausea gets a CT abd. Every pediatric fever got blood work and IV. His admit rate was 2x that of the group average. Most of his charts were billed at a level 5 because of the big workups. So even though I was 2x fast and doing minimal workups, our RVUs were in fact similar.

In the eyes of the CMG, he's a good worker. On the ground, I hated coming into his shifts because I know I have to clean up a packed lobby. I lasted a year at that job.

Weird, most CMG/hospital admin will take the fast minimalist any day over the slow maximalist even if their RVU/hr is better. Usually with docs like yourself, the LWBS, Eloped are better and LOS/TATs are superior with minimal utilization of hospital resources. If they lost you over that, it's their loss.

 

[Groove]

I have the same approach as @BoardingDoc and stop picking up pt's 1.5-2 hours before the end of shift (depending on flow and confidence that work up can be completed.) I MSE everyone though and eyeball to assess stability, then drop in orders for the next doc. Occasionally, work up will get completed before next doc signs in and if so, I'll pick them up and dispo. Sure, the next doc might not appreciate all the orders and might differ on a few but probably not by much. If you've got a well seasoned crew, most will recognize this process as superior to improving overall ED metrics and reducing LOS. It's not worth just letting the pt sit there for over an hour without work up simply because you think the new doc will want to order something different. If all my notes are done, my last 30-45 mins are spent walking in all the new pt rooms and starting orders. I even dump in orders for WR patients with straightforward chief complaints and good triage notes without even seeing them just to speed things up.

 

[Brigade4Radiant]

Yeah just like being late is not good me staying late is unacceptable unless the patient is sick

 

[RustedFox]

I don’t understand this obsession with “leaving on time.” In a highly profitable SDG where you eat what you kill, you make more by working more. This quitting early and leaving on time mantra seems to be a product of hourly workers for CMG overlords that just want to collect their hourly wage and check out.

Yeah, you find me one of these mythical creatures here and I'm game.

There is literally one predatory SDG in three hours here.

 

[Groove]

I don’t understand this obsession with “leaving on time.” In a highly profitable SDG where you eat what you kill, you make more by working more. This quitting early and leaving on time mantra seems to be a product of hourly workers for CMG overlords that just want to collect their hourly wage and check out.

Emergency medicine physicians have the highest rates of burnout among all physician specialties, according to a Medscape's 2022 Physician Burnout and Depression report.

That might have something to do with it. Leaving on time is not really such an unrealistic expectation. RVU centric shops (and most CMGs) have a tendency to promulgate an internal culture that incentivizes and glamorizes habitual sacrifice at the altar of unpaid labor. I suppose an SDG would make it more tolerable, but only if you're actually getting paid for the extra hours you put in, not just the RVUs added to your scheduled hours. Still though, how long are you gonna last in your career if you're always staying 2 hours late to mop up the sh** storm from picking up too many patients at the end of your shift? Talk about a recipe for an occluded coronary...

 

[p1acebo]

I don’t understand this obsession with “leaving on time.” In a highly profitable SDG where you eat what you kill, you make more by working more. This quitting early and leaving on time mantra seems to be a product of hourly workers for CMG overlords that just want to collect their hourly wage and check out.

I don’t know about you, but after I work hard during a shift the last thing I want to do is stay later, even if I’m getting paid (which I can adjust my hours to get paid for them, not SDG but hospital employed). Sure if I was seeing 1 PPH and just sat around maybe I would be willing to stay later to lollygag, but then I feel like I would be wasting time. Extra time at work means less time at home to do whatever it is you like to do at home.

 

[Brigade4Radiant]

I go extra hard during the first 4-5 hours of my shift then I slow it down.

 

[Groove]

If you are compensated for your work, then it isn't unpaid labor. I know of several that by choice work really intense, shorter, 6-hour shifts and then stay 2-3 hours after to clean up for an effective shift length of only 8-9 hours. Some EPs that I hear about seem to work longer 12 hour shifts, but stop picking up 1.5-2 hours before the end and then leave right at 12 hours. Everyone stops picking up at some point. By saying you always stop picking up patients 1.5-2 hours prior to the end of your shift you are just shortening your shift length. It's really just arbitrary and only based upon the amount of time you spend seeing patients if you are paid based upon your productivity. Maximum productivity lasts about 10 hours. I believe a 7-8 hour shift plus 2-3 hours of cleanup results in the most bang for your buck.

Sounds miserable. How many hours are you scheduled each month (not counting the sacrificial bloodletting hours) ? I’m curious.

 

[GonnaBeADoc2222]

LOL at the tone deaf "just move to be able to work at the unicorn SDG" comment. Newsflash: life happens and not everyone has the ability to move.

At my shop (hospital employed, 100% salary, no RVU), there's a huge disparity between the top and bottom producers. We have an ungodly amount of attending and midlevel coverage, so it's pretty easy to fly under the radar with abysmal productivity. When I first joined, I worked my ass off; I wanted to be the best. When I had data proving I was in the 97th percentile of production, I approached admin and respectfully requested a raise. I was told this was not possible. Needless to say, I was pissed. In addition to this, there is this weird ponzi scheme where a handful of antiquated old timers get paid $100 / hr more than the young folk (often, these are among the least productive people), and don't have to work evenings, high acuity shifts, or shifts without a resident. It's really something else.

Therefore, I drastically reduced my productivity. Why work harder and take on more risk when I am not rewarded? I never do charts, "learning" modules, or any other admin type work outside of shift time - we are not compensated for any work outside of shifts, so why would I do unpaid work? Despite this massive reduction in effort, I am still around the 85th percentile in productivity - it's incredible.

I also do not do any committee or other non clinical activities. Again, I'm not compensated for this, so why do it?

Know thy worth. You want more product? Pay me.

 

[BoardingDoc]

I don’t understand this obsession with “leaving on time.” In a highly profitable SDG where you eat what you kill, you make more by working more. This quitting early and leaving on time mantra seems to be a product of hourly workers for CMG overlords that just want to collect their hourly wage and check out.

You describe my job. I still try to leave on time. In general we try not to sign much out. That means cleaning things up towards the end of my shift. That means not picking up patients that I can't dispo reasonably quickly. That means lower pph at the end. That means I'm getting paid less as I wind down, so I try to keep the wind down period short and sweet. Yeah, if I have the critically ill patient who I'm caring for after my shift ends, I'm getting the billing and I get paid for that time. That said, in a per hour scenario, I'm getting paid a lot more per hour for the few hours before that where I'm juggling multiple patients at the same time as I'm not winding down yet.

If volume is insane, I stay late to help and get paid well for it. If it's slow, the other doc can take the money and I'll leave early. If it's normal, I leave ~on time.

 

[turkeyjerky]

I don’t understand this obsession with “leaving on time.” In a highly profitable SDG where you eat what you kill, you make more by working more. This quitting early and leaving on time mantra seems to be a product of hourly workers for CMG overlords that just want to collect their hourly wage and check out.

There's more to life than money. Leaving on time is a quality of life issue. If I've been up all night, I like to know there's a finish line and I can get home and get to sleep. If I'm working a busy day shift, I'd like to know that I'm gonna be able to get out by 8 and meet my wife for a drink as we'd planned.

I spent most of last year working for a highly profitable SDG w/ a **** sign-out culture. It was miserable,8 hour scheduled shifts would consist of an extremely intense 7 hours, followed by 2-3 hours of sitting there refreshing epic waiting for a CT or labs to come back (on rare occasions you could signout a drunk or an MRI, but would have to suffer an inordinate amount of grumbling). Then, you do the math and suddenly your 300/hr job is actually 240/hr w/ an unpredictable schedule working alongside a bunch of burnt out and beaten down docs who have no life outside medicine.

A “unicorn” job at a SDG will more than make the choice worth the trade off. The danger is in thinking you can’t do something.

I agree w/ most of your post (and your posts in general), btw. I do think it's interesting, however, how the definition of 'unicorn job' has become expanded (ironically, as the number of such jobs has drastically decreased). I feel as though it should refer to a job that actually provides the trifecta of quality, location and pay. Whereas now it's commonly used to describe a job that provides 2, or even 1 of those. Just another example of how this field has gone downhill in just 5 years.

 

[RustedFox]

Not everyone wants to move. If you are limited geographically to a 3 hour radius then your options will be limited. I made the choice when picking EM as a speciality that I never wanted to work for a CMG. I intentionally sought out a position at a SDG located in a state that I wanted to live in. You can have 2 of the 3 (job, location, money - or 90% of all 3). If you are dead set on location, then you potentially sacrifice the job or money.

I'm not trying to be argumentative. I dig all your posts.

If SDGs were more prevalent in general, I'd jump; but you can look thru huge tracts of land and not find one.

I can seriously go up and down the gulf coast of Florida and find vanishingly few. It's all HCA and USACS. And I know those *vanishingly* few ones because I scoped them out or interviewed with them... aaand they don't fit the bill of SDG for one reason or another.

 

[WilcoWorld]

If you aren't willing to stay later and get paid for it, then why show up to get paid for any hours at all (somewhat rhetorical)?

Because your contracted hours meet your financial needs and you recognize that, beyond that, time off is worth more than money
(rhetorical answer 🤓 )

 

[thegenius]

I don’t understand this obsession with “leaving on time.” In a highly profitable SDG where you eat what you kill, you make more by working more. This quitting early and leaving on time mantra seems to be a product of hourly workers for CMG overlords that just want to collect their hourly wage and check out.

In RVU shops, docs value their time the way they want to. If they want to stop seeing patient 90 mins prior to end of shift, then that's more money for me.

You have to leave sometime. If you have an 9 hour shift and you want to see (AND DISPO) all newly picked up patients within those 9 hours, then go ahead. but don't pick up 4 patients in the last hour and sign them out. DON'T DO THAT.

Don't be critical of those who want to leave on time after being in the ER for 9 hours for a 9 hour shift. I'm totally fine with that.

 

[Groove]

I'm not trying to be argumentative. I dig all your posts.

If SDGs were more prevalent in general, I'd jump; but you can look thru huge tracts of land and not find one.

I can seriously go up and down the gulf coast of Florida and find vanishingly few. It's all HCA and USACS. And I know those *vanishingly* few ones because I scoped them out or interviewed with them... aaand they don't fit the bill of SDG for one reason or another.

 

[qwerty89]

LOL at the tone deaf "just move to be able to work at the unicorn SDG" comment. Newsflash: life happens and not everyone has the ability to move.

At my shop (hospital employed, 100% salary, no RVU), there's a huge disparity between the top and bottom producers. We have an ungodly amount of attending and midlevel coverage, so it's pretty easy to fly under the radar with abysmal productivity. When I first joined, I worked my ass off; I wanted to be the best. When I had data proving I was in the 97th percentile of production, I approached admin and respectfully requested a raise. I was told this was not possible. Needless to say, I was pissed. In addition to this, there is this weird ponzi scheme where a handful of antiquated old timers get paid $100 / hr more than the young folk (often, these are among the least productive people), and don't have to work evenings, high acuity shifts, or shifts without a resident. It's really something else.

Therefore, I drastically reduced my productivity. Why work harder and take on more risk when I am not rewarded? I never do charts, "learning" modules, or any other admin type work outside of shift time - we are not compensated for any work outside of shifts, so why would I do unpaid work? Despite this massive reduction in effort, I am still around the 85th percentile in productivity - it's incredible.

I also do not do any committee or other non clinical activities. Again, I'm not compensated for this, so why do it?

Know thy worth. You want more product? Pay me.

Sounds like someone needs to slow down.

 

[Groove]

It's just kind of silly fingering docs who leave on time as "lazy". We're talking about academic overachievers who made it through medical school and then were gunners for competitive EM residency spots and beat out other competitive candidates. Made it all the way through the gruels of residency and if we're honest with ourselves...in general, are people who have highly motivated work ethics (majority). People have to plan their frickin lives. You can't tell everyone in your life "Hey, I get off at 5pm but just wait for me at that restaurant. Have a few drinks or something. I'm usually either 2-3 hours late....OR....maybe I'm on time. I have no idea. "Honey? Wait for me to eat dinner about...say an hour or so. If I'm not back, then eat without me, tuck the kids in for me and that means I'm gonna be 3 hours late." "Boat trip? Sounds awesome, plan on me meeting you guys at 2pm, I get off at 1pm. If I'm a no show, then I got off at 3:30pm."

RVU centric shops breed this culture where you don't sign anything out and you're a TEAM PLAYER when you stay hours over your shift, as if you're on the military front lines saving downed soldiers that you're having to drag back to base through enemy fire. Nobody is going to remember you as the doc who stayed 2 hours late after every shift...FOR THE TEAM. More like the sucker who bought into the culture. There will ALWAYS be patients to pick up.

That being said, if it was a really good SDG, I might change my philosophy but the more I hear about the above SDG, the less unicorn it sounds. Sounds more like an Apollo shop. (No offense to the Apollo guys/gals.)

 

[Groove]

Actually what I do is MSE during that last 2 hours and keep/dispo the low acuity ones. 1 out of 5 of the MSE will end up having everything back and you can dispo those too, so it's not like it's 2 hours of no work and no more patients. I'll look for easy FT patient complaints in the WR that are waiting to get seen and just pull them into a corner, eval and dispo. You just don't pick up complicated patients though I'll still see them to initiate orders. It's not difficult and it's still generating RVUs while still easily getting you out on time.

 

[RustedFox]

View attachment 355527

Precisely what I was going for.

 

[GonnaBeADoc2222]

I think you kind of illustrate my point in saying know thy worth and outlying why you aren’t compensated fairly after selecting your location over a fair job. Everyone has the ability to move. It’s a choice. You chose location over the job. You don’t have control in your job in being hospital employed and it doesn’t incentivize production. That subsequently results in some physicians being lazy. The answer in some situations in to how some deal with lazy colleagues is moving with your feet to a better position. There are opportunity costs and trade offs to marrying yourself to a specific location that you “can’t” move away from. You and many others have just decided that for whatever reason you need that location over choosing a better job. I made the decision (with a supportive spouse) that the choice of job was one of the most important factors and so went with a slightly less ideal location (still semi-ideal to me in a great state). I’m looking back, I wouldn’t have done it any other way. A “unicorn” job at a SDG will more than make the choice worth the trade off. The danger is in thinking you can’t do something.

I cannot leave the state unless I don't want to see my child. That being said, despite the pyramid scheme compensation structure, I work zero night shifts and get paid 300K to see 1.5 (often times less) pph.

 

[JacobMcCandles]

In my experience, those who don't leave on time and consistently stay late (the group is part hourly/part RVU) are the more inefficient docs in the group. Sure, every once in a while, everyone will stay late 30 minutes to 1 hour but the more efficient docs get out on time. Our group also has no problem signing things out within reason because it usually all evens out in the end with receiving and taking sign outs. Typically, you're waiting on a radiology read. We also don't have a huge problem admitting patients without a complete workup if we know they're getting admitted so that also helps.

 

[turkeyjerky]

I think if I’m hearing some of you correctly the issue isn’t how long is the shift length, but more wanting a predictable end time. That’s not a always a guarantee in our 24/7/365 specialty.

I disagree. To me, given the fact that we are on the hook for working intense shifts on nights/holidays/weekends my entire career, this is exactly the reason that shift work is so important. It's a simple matter of the basic components of career satisfaction and longevity. Rob Orman had a decent podcast about signout culture w/ Mike Weinstock on his Stimulus podcast a few weeks ago.

It really shouldn’t take much more than 2 hours to disposition your final patient, so it is somewhat predictable that you should be able to leave 2 hours after your final patient even if a little more complicated. I agree with @thegenius that you shouldn’t be picking up a ton of patients right up until the end to only sign them out. That’s poor form.

This is a little confusing to me. If I had the option of walking in and seeing a board that has 5 unseen patients, vs taking a signout in which there were 5 patients who'd already been seen w/ workup in progress and had a note written, where I only need to f/u the results and dispo them and write a short addendum, I'm taking the latter. It's like a quarter of the work (and the fun part). I guess I could see it the other way if you get absolutely no compensation at all for the latter (although, personally my feeling is that I would still be okay w/ it given the fact that you'll make it up by being able to give signouts, at least if people act reasonably).

My views are likely colored by having spent the majority of my career in either single coverage or a pod system, rather than a triple coverage free for all.

Actually what I do is MSE during that last 2 hours and keep/dispo the low acuity ones. 1 out of 5 of the MSE will end up having everything back and you can dispo those too, so it's not like it's 2 hours of no work and no more patients. I'll look for easy FT patient complaints in the WR that are waiting to get seen and just pull them into a corner, eval and dispo. You just don't pick up complicated patients though I'll still see them to initiate orders. It's not difficult and it's still generating RVUs while still easily getting you out on time.

What's your coverage model? I'm just trying to picture how this would go. Obviously cherry picking simple cases in the last two hours if you're double covered makes sense, but are you also doing a brief exam on patients that someone else is going to be seeing 5 min later?

 

[turkeyjerky]

You take on the liability of patients you disposition and don’t receive any compensation for patients signed out to you.

Additionally, signing out patients carries an increased risk of errors occurring.

Compensation is group dependent. In my group, the RVUs of signed out patients goes to the oncoming doc.

I'm not completely sure that signing out patients increases liability more than the alternatives. (Certainly, every additional patient you see adds to your liability) I find that shops w/ poor sign-out culture lead to poor behaviors, such as dispoing patients early w/ incomplete workups, admitting patients early w/ incomplete workups (leading to incorrect placement, under resuscitation, delayed recognition of time-dependent conditions if the hospitalist isn't on the ball, etc), as well as untimely initial evaluation of patients, which occasionally can actually lead to harm (in addition of poor flow).

Obviously, the opposite practice of immediately dumping on the incoming doc leads to a lot of chicanery as well. I think the key is that both docs take ownership of the patient,

 

[lucid_leprechaun]

Compensation is group dependent. In my group, the RVUs of signed out patients goes to the oncoming doc.

I'm not completely sure that signing out patients increases liability more than the alternatives. (Certainly, every additional patient you see adds to your liability) I find that shops w/ poor sign-out culture lead to poor behaviors, such as dispoing patients early w/ incomplete workups, admitting patients early w/ incomplete workups (leading to incorrect placement, under resuscitation, delayed recognition of time-dependent conditions if the hospitalist isn't on the ball, etc), as well as untimely initial evaluation of patients, which occasionally can actually lead to harm (in addition of poor flow).

Obviously, the opposite practice of immediately dumping on the incoming doc leads to a lot of chicanery as well. I think the key is that both docs take ownership of the patient,

Agree. If the first doc didn’t do a good history/physical a lot of times the second doc can save them from malpractice by going behind and getting a better idea of the patient. Sometimes it’s tough seeing a new patient at the end of a shift when you aren’t as fresh. Also never hurts to have more eyes on a patient.

 

[thegenius]

You take on the liability of patients you disposition and don’t receive any compensation for patients signed out to you.

Additionally, signing out patients carries an increased risk of errors occurring.

We have a nice program where I work where pt's signed out also get credit (paid) for work done. Ultimately it makes our RVU mulitplier less because insurance isn't paying twice. So if you see a pt, order labs and a CT, and ask me to f/u on the CT, then I will and re-eval the pt. We both get paid.

It's best for patient care. They don't sit around waiting and encourages us to pick up patients.

 

[JacobMcCandles]

Fair points. I initially thought immediately after I posted that comment that I should edit it to clarify that in my group/model only the original EP seeing the patient gets the billing (other than overnight ops billing which is shared). You're both right in that it is group dependent with various models present. In an SDG productivity based environment, I'd bet though it skews more so towards a single physician receiving the entire compensation, but there are perhaps good models out there where it is split.

This seems backwards. This just encourages people to pick up patients and do a half-ass HPI, exam, workup, and plan. The next doc also has minimal incentive since they're not going to get the RVUs. If it were reversed then I think that'd be better all the way around. You could argue that the original doc still wouldn't have an incentive to pick up these patients at the end of their shift since they won't get RVUs but that just means there will be less sign outs, which we both agree are suboptimal for everyone. I would just prefer the outgoing doc to place a few basic orders to get things rolling and then I can do my own HPI and exam and go from there. I think this model is ideal since it'll minimize sign outs but also not have significant impact on throughput as long as basic orders are being put in. You'll also have a lot more people getting out on time instead of diddling their thumbs after their shift.

 

[RustedFox]

I'll pop in to say that the "half-assed sign out" is entirely avoidable.

When I take sign out, it comes in two flavors:

1. "I only put in a workup for this patient to stop the clock, see this patient."

or:

2. "Lab X and imaging study Y are pending. This is the plan in-place."

That's it. Either write no note, or a damn good one.

 

[BoardingDoc]

This seems backwards. This just encourages people to pick up patients and do a half-ass HPI, exam, workup, and plan. The next doc also has minimal incentive since they're not going to get the RVUs. If it were reversed then I think that'd be better all the way around. You could argue that the original doc still wouldn't have an incentive to pick up these patients at the end of their shift since they won't get RVUs but that just means there will be less sign outs, which we both agree are suboptimal for everyone. I would just prefer the outgoing doc to place a few basic orders to get things rolling and then I can do my own HPI and exam and go from there. I think this model is ideal since it'll minimize sign outs but also not have significant impact on throughput as long as basic orders are being put in. You'll also have a lot more people getting out on time instead of diddling their thumbs after their shift.

Meh, my group works the same as @Mount Asclepius. It works for us because it doesn't incentivize you to stay late for crap. If I have 3 lvl 5 patients all waiting on a covid swab or a UA or some crap before they can be dispoed, I don't want to stay another hour or two just so I don't lose those bills, and it isn't like doc #2 is doing any appreciable work in those cases.

Agree, that you could theoretically run into the issue where people pick crap up at the end of their shift and sign out a big workup still in progress and then you're doing the work as the doc taking signout but not getting paid. In practice, that doesn't happen (at least in our group). As I posted elsewhere, I don't pick up complex patients in my last 1.5-2 hrs of my shift. Nor does anyone else.

 

[BoardingDoc]

I'll pop in to say that the "half-assed sign out" is entirely avoidable.

When I take sign out, it comes in two flavors:

1. "I only put in a workup for this patient to stop the clock, see this patient."

or:

2. "Lab X and imaging study Y are pending. This is the plan in-place."

That's it. Either write no note, or a damn good one.

Agree. This is literally the only way signout should ever happen. Either you hand me a binary "If this then that" dispo, or I'm just going to go see the patient and make my own plan. While I just mentioned that the doc taking signout doesn't get the billing in the group, if I write a new full chart as the doc taking signout, I'm the one that takes over the billing. This almost never happens, except when something utterly unexpected and requiring some legit work happens and the 2nd doc clearly deserves the bill.

 

[JacobMcCandles]

We don’t really sign out patients in my group so it isn’t a problem. Patients in ED observation being the exception. We’ve had new hires use to a culture of signing out come in and quickly let them know that the expectation is different in our group. I’ve found that they’ve changed their practice and were satisfied with our group culture.

I guess I should also clarify that there really aren’t patients that you need to get orders going on in our setup. We have robust nursing protocol orders. So if any unseen patients are in the waiting room they usually have basic orders already placed by the triage nurse. It’s not as ideal as physician based orders, but empowering out nurses to place basic orders on patients has been effective.

In hearing responses there seems to be much more variation in practice than I imagined based on the type of ED and coverage (and I’ve worked previously in multiple different settings). I think this really depends on your group setup. I’ve just personally found my setup ideal.

I know every group is different and many new hires don't know any better but having a no sign out culture with the expectation of staying several hours late every shift sounds awful. Clearly just a personal opinion but there's no way I could go from a group where getting out on time is normal and expected to a group where there's no sign out and everyone stays several hours late.

 

[thegenius]

Fair points. I initially thought immediately after I posted that comment that I should edit it to clarify that in my group/model only the original EP seeing the patient gets the billing (other than overnight ops billing which is shared). You're both right in that it is group dependent with various models present. In an SDG productivity based environment, I'd bet though it skews more so towards a single physician receiving the entire compensation, but there are perhaps good models out there where it is split.

For real? That seems at high risk for abuse or getting bad signouts.
"Hi, I'm signing out the folliwng 4 patients who I happened to see in the past hour. Pt one might be having a stroke, please f/u on Neuro recs; pt 2 is old, frail and weak and is getting a massive workup, pt 3 has a dislocated shoulder, and pt 4 is having active chest pain"

 

[BoardingDoc]

For real? That seems at high risk for abuse or getting bad signouts.
"Hi, I'm signing out the folliwng 4 patients who I happened to see in the past hour. Pt one might be having a stroke, please f/u on Neuro recs; pt 2 is old, frail and weak and is getting a massive workup, pt 3 has a dislocated shoulder, and pt 4 is having active chest pain"

Again, all theoretically possible but something I've never seen in practice. Those 4 patients would all still be actively managed by the primary MD until the signout became: 1 had a stroke and is being admitted. 2 has a benign workup. Still hasn't peed. Needs to be admitted either way as they're old and failing at home. Click admit once UA back. 3's shoulder is back in place and they're discharged on the board. Tech is busy getting them a sling. Patient 4 is better with nitro and is being admitted.

We have enough coverage that the doc who's leaving would either 1: have decided to pick all of these up in the last hour because they know they're likely going to stay late to dispo them and will get a bunch of money, or 2: would not have picked them up and the other doc would have.

People who try to give the signout you posited would not be with our group for very long. If you wanna make a bunch of extra money, go ahead and be option 1 above. If you want to leave on time, you can do that too. I almost always pick option #2 unless the fam is out of town or something and I have literally nothing else to do except make an extra $500-$1000.

 

[BoardingDoc]

I'm bumping this thread because I'm upset that some people at several sites I work at are slow/lazy and are somehow just allowed to be slow despite metric tracking because every site I work at is short staffed despite it being a major city. It's so bad that at 2 sites, the midlevel working with us will sometimes just stop seeing patients and will have to get reminded by nurses to pickup patients. It's unbelievable. I can't in good conscience just sit in my chair watching a colleague get slammed while I just kick back.

There's a guy who trained at the same program as me. Now the chief of an ED in the southwest. He gave a talk during residency about how his shop has a system where new patients are automatically assigned to docs/pas in a round robin type system. No one signs up for anything. It's all done automatically. I don't know how it works when volume is crazy high but it apparently works well for them in terms of addressing this very issue.

I personally like the carrot approach instead of the stick which is why I really like our "eat what you kill" model. You don't want to see anyone in the last 2 hrs of your shift? Sounds good, I'll happily take an extra $1000 for the shift seeing "your" patients.

Also, the simplest option in your case is obviously to just fire this PLP. They apparently can't even get the "pretend" part right.

 

[WhatJobDoIPick]

Heavily production based compensation is the only way.

I saw admin doc saw 4 patients on their shift once.

 

[NYEMMED]

There's a guy who trained at the same program as me. Now the chief of an ED in the southwest. He gave a talk during residency about how his shop has a system where new patients are automatically assigned to docs/pas in a round robin type system. No one signs up for anything. It's all done automatically. I don't know how it works when volume is crazy high but it apparently works well for them in terms of addressing this very issue.

I personally like the carrot approach instead of the stick which is why I really like our "eat what you kill" model. You don't want to see anyone in the last 2 hrs of your shift? Sounds good, I'll happily take an extra $1000 for the shift seeing "your" patients.

Also, the simplest option in your case is obviously to just fire this PLP. They apparently can't even get the "pretend" part right.

I’ve worked for a system like this. It can be soul crushing.

Yes it makes sense on a business side.
In actuality you have shifts running from critical to critical while the other guy gets knee pains

 

[BoardingDoc]

I’ve worked for a system like this. It can be soul crushing.

Yes it makes sense on a business side.
In actuality you have shifts running from critical to critical while the other guy gets knee pains

True, but statistically you will be "the other guy" half the time that imbalance happens.

To reiterate though, this isn't my preferred solution. Keep what you kill in a busy dept is the only way to go in my mind. Turns out, if you incentivise people to work harder, they frequently do! And if you don't, they don't. Who woulda thought?

 

[xaelia]

I’ve worked for a system like this. It can be soul crushing.

Yes it makes sense on a business side.
In actuality you have shifts running from critical to critical while the other guy gets knee pains

My experience with round-robin at Kaiser was that it felt "fair" 95% of the time. It wasn't perfect, but it was alright. The greater problem was that they'd put your name on up to 3 PPH, and the rhythm of the shift was that you'd end up with 6 patients in around ~1.25 hours, followed by a steady stream of 2-3 PPH for the next 5-6 hours. AND, any triage 2 would "break" the cap on patients for whichever unlucky doc was next in the queue etc. AND they started assigning you patients before shift start so you were loaded up and ready to go from minute one.

You could exert some control over whether you remained in the round-robin if you were wrapped up with a giant mess (critically ill patient, complex lac repair, whatever) ... but then you'd have the old/slow docs abusing the "pause" status, because, you know, working is hard.

So, yeah, round-robin is not a magical answer – the devil is in the details, but it can make things more fair.