LOS... how are some so quick?

[pinipig523]

I don't get it - I'd like to think I'm doing pretty well and am significantly better than the first year I was out.... my LOS is around 120min which is maybe a little on the higher end but I'm working on it.

My medical director always says that you want to be in the bell curve but not too far on either end - not too slow and probably not too fast.

However, I recently ran into a part timer who is incredibly fast - like 55 min LOS fast. I asked him why he's so fast, he told me that "you just gotta realize that they're not that sick." He does less rule outs than I do, and more of a clinical gestalt type practice. He calls it as he sees it, whereas I look to rules and decision making criteria and labs/imaging to ensure I have thought of the majority of possible differentials and have ruled them out with a certain subjective and objective level of evidence presented.

The guy saw 28 in 7 hours without a scribe... and I ran through the list he saw, there were some decently sick ones there. The most I've seen in 7 hours was around 23 and this was with a scribe.

I know I document a lot and very well... probably slows me down. I probably spend a lot of time talking and explaining things to patients, too.

I've been trying to be more efficient and it's been working - I'm seeing significantly faster dispo's the longer I'm out.

I graduated in 2012. He graduated 15 years ago.

Just wanted to vent.

It's unfortunate that as a community attending - your worth is based on speed and not on overall quality of care. Though I'm not sure if I'm providing higher quality of care if he's 15 years out and still practicing - I'm assuming he's getting to the same end points I am.

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[WilcoWorld]

I don't get it - I'd like to think I'm doing pretty well and am significantly better than the first year I was out.... my LOS is around 120min which is maybe a little on the higher end but I'm working on it.

My medical director always says that you want to be in the bell curve but not too far on either end - not too slow and probably not too fast.

However, I recently ran into a part timer who is incredibly fast - like 55 min LOS fast. I asked him why he's so fast, he told me that "you just gotta realize that they're not that sick." He does less rule outs than I do, and more of a clinical gestalt type practice. He calls it as he sees it, whereas I look to rules and decision making criteria and labs/imaging to ensure I have thought of the majority of possible differentials and have ruled them out with a certain subjective and objective level of evidence presented.

The guy saw 28 in 7 hours without a scribe... and I ran through the list he saw, there were some decently sick ones there. The most I've seen in 7 hours was around 23 and this was with a scribe.

I know I document a lot and very well... probably slows me down. I probably spend a lot of time talking and explaining things to patients, too.

I've been trying to be more efficient and it's been working - I'm seeing significantly faster dispo's the longer I'm out.

I graduated in 2012. He graduated 15 years ago.

Just wanted to vent.

It's unfortunate that as a community attending - your worth is based on speed and not on overall quality of care. Though I'm not sure if I'm providing higher quality of care if he's 15 years out and still practicing - I'm assuming he's getting to the same end points I am.

You've got to practice in the way that you're comfortable with - perhaps discomfort is a semi-conscious safety meter that we should respect.

As for your worth, your medical director said you should aim for the middle of the pack, right? So how does it reflect negatively on you if this doc's discharging a lot of chest pains?

 

[RustedFox]

Who cares how long it takes?

"Do the right thing."

Suits would do well to remember that they're not doctors.

 

[emergentmd]

55 min is ridiculous. I am one of the fastest doc in my group and it I am at about 140 for all pts.

 

[pinipig523]

I agree man... 55 LOS, there's got to be some cutting corners. There's no way.

AMS patient who was found down (not pulseless though) at home and family did CPR preemptively... work up was neg and sent home because perhaps it was opiate toxicity but UDS showed neg opiate, she responded to narcan. I mean, no cth, no trending of trop. Meh...

He seems a lot more knowledgeable than I am... and he seems to be a great guy. I'm just really trying to figure out what he is doing that I am not doing. I thought I was decently quick until I met this dude.

I dunno... maybe I'm too conservative and residency is still engrained in my head.

 

[deleted109597]

work up was neg and sent home because perhaps it was opiate toxicity but UDS showed neg opiate, she responded to narcan. I mean, no cth, no trending of trop. Meh...
I dunno... maybe I'm too conservative and residency is still engrained in my head.

UDS only shows opiates, not opioids. If it responds to narcan, it was drug use. http://academiclifeinem.com/peeing-into-the-wind-urine-drug-screens-part-2-opiates/
And if it responds to narcan, who cares about trops or CTs? When's the last time you saw a CVA or MI that responded to narcan?

Although this makes me want to perform a study that compares narcan to tPA for CVA symptoms now. I bet it's noninferior.


He may be cutting corners, but that case isn't where he was doing it. And "do the right thing" doesn't mean "make yourself absolutely comfortable" always. We overtest a ton not for the patient's benefit, but our own.

 

[shopsteward]

I've nothing to say on the medical side, or this doctor in particular. But "he seems to be a great guy" tends to get me worried, as it has probably been said at some point about every crooked businessman and Wall Street banker there has ever been. Anyone you don't know well who presents themselves like this might or might not be a genuinely great guy. If the objective evidence says otherwise, trust the objective evidence.

 

[Arcan57]

UDS only shows opiates, not opioids. If it responds to narcan, it was drug use. http://academiclifeinem.com/peeing-into-the-wind-urine-drug-screens-part-2-opiates/
And if it responds to narcan, who cares about trops or CTs? When's the last time you saw a CVA or MI that responded to narcan?

Agree on the UDS, most chronic pain patients these days show a negative UDS or only pop positive for the Xanax their PCP is giving them.

My only concern on the "responded to narcan" is that they actually responded or had some history consistent with possible OD. If they came up screaming and puking after the narcan or went down surrounded by empty dilaudid bottles then started breathing after the narcan then I'd agree with you. I have seen EMS say a patient responded to Narcan (the homeopathic "I don't feel like having to hose out the rig" dose) and the patient's still comatose and had some entirely different etiology for their collapse.

 

[Arcan57]

It's unfortunate that as a community attending - your worth is based on speed and not on overall quality of care. Though I'm not sure if I'm providing higher quality of care if he's 15 years out and still practicing - I'm assuming he's getting to the same end points I am.

No amount of speed makes up for generating serious safety events in the eyes of ED directors and hospital admin. The docs that get in trouble are the ones at the far ends of the curve, on both sides. The slowest docs are at risk because no ones likes working when the doc doesn't see new patients for hours, is constantly adding on new diagnostic tests that require the patient to go back to radiology or get stuck again for blood, and can't make a decision about patient dispo. The fastest docs are at less risk then the slowest, but if they're light years in front of the curve then any bad outcome is going to be instinctively felt to be due to them being careless then just bad luck.

Being superfast requires having a razor sharp sense of sick vs. not sick, beyond solid relationships with the medical staff, and a willingness to be exposed to risk at a higher level then you're colleagues. Years of experience definitely hone sick/not sick and can give you time to build relationships, but your risk tolerance won't change markedly over time (except for being sued which will crater it). Focus on being good and make sure you're not falling off the LOS curve to the right and you'll be significantly happier.

 

[EM Junkie]

Being superfast requires having a razor sharp sense of sick vs. not sick, beyond solid relationships with the medical staff, and a willingness to be exposed to risk at a higher level then you're colleagues.

This is spot on. I'm also at a 60 min LOS (seen by MD to "care complete"). I'm the Medical Director, have excellent patient sat scores, and certainly don't think of myself as "unsafe".

A couple of pointers:

-admit when you find a reason to admit. Very rarely do the remainder of the labs change your management. XR and exam show SBO, admit and order CT. I could care less what the CT shows. Old, AMS, UTI? Admit before every lab comes back.

-don't even start the work up if your BS meter is going off. Chronic abd pain x 20 years, follows doc at the county hospital and pain exactly the same? Financial screen out, and bye bye. "Suicidal" homeless people that just want a warm bed for a few days? Buh bye. No labs and psych c/s needed.

-before you see a new patient, see who you can dispo first. I never go and see more than 2 at a time, and rarely see 2 at once. See one, dispo one.

We also use scribes, so that also helps tremendously. Also FWIW, almost nothing is done at triage or prior to my seeing the patients. In addition, at my shop, 120 mins is still a very respectable number.

 

[emergentmd]

Using one case proves very little.

I assume LOS is time to presentation to discharge which is what we use.

Even at the most efficient hospitals without any waiting room time, 55 minutes is impossible.

Efficient hospitals

1. Presentation to bedside traige - 5 min
2. Doc grabs chart, sees pt, put in orders - 5 min
3. Labs/Radio testing - 30 min
4. Pt recheck, pt better, write up discharge/scripts - 10 min
5. Put in discharge rack and nurses discharge pt - 5 min

There is 55 min without any hiccups, no delays. Everything has to work efficiently. Pt improved without any questions.

55 min is impossible or dangerous.

I could get to 55 min if I rarely order testing, radiological studies.

I work in a community ED with high acuity. 55 min is not possible. I would be happy if the nurses could get labs sent in 55 minutes.

If I were you, I would not look up to this guy as a role model. You should be happy being at the middle of the curve.

No one complains that you are too slow. No one complains if you have a reasonable bad outcome.

Being the fastest has its pitfalls when bad outcomes happen

 

[Apollyon]

-don't even start the work up if your BS meter is going off. Chronic abd pain x 20 years, follows doc at the county hospital and pain exactly the same? Financial screen out, and bye bye. "Suicidal" homeless people that just want a warm bed for a few days? Buh bye. No labs and psych c/s needed.

4 groups of patients have the highest chance of screwing you in the ED:
The very old
The very young
The very drunk
and the Very Crazy.

Maybe I'm just risk-averse, but, even with the drug seeker that states she drank "3 bottles of mag citrate, and nothing happened", I am going to get an abdominal XR.

 

[EM Junkie]

4 groups of patients have the highest chance of screwing you in the ED:
The very old
The very young
The very drunk
and the Very Crazy.

Maybe I'm just risk-averse, but, even with the drug seeker that states she drank "3 bottles of mag citrate, and nothing happened", I am going to get an abdominal XR.

Sure, but are you going to check labs (which entails getting every nurse a chance to hit the sclerosed veins with an U/S), get another CT, and push Dilaudid until somnolence?

Agree with a quick test like XR in specific cases.

At the end of the day, if you're going to stay up worrying about it: get the test.

 

[WilcoWorld]

If it responds to narcan, it was drug use.

I agree with your other points, but it's important to note that sepsis responds to narcan, and, moreover, a positive narcan challenge does not = safe for discharge.

 

[EM Junkie]

Using one case proves very little.

I assume LOS is time to presentation to discharge which is what we use.

Even at the most efficient hospitals without any waiting room time, 55 minutes is impossible.

Efficient hospitals

1. Presentation to bedside traige - 5 min
2. Doc grabs chart, sees pt, put in orders - 5 min
3. Labs/Radio testing - 30 min
4. Pt recheck, pt better, write up discharge/scripts - 10 min
5. Put in discharge rack and nurses discharge pt - 5 min

There is 55 min without any hiccups, no delays. Everything has to work efficiently. Pt improved without any questions.

55 min is impossible or dangerous.

I could get to 55 min if I rarely order testing, radiological studies.

I work in a community ED with high acuity. 55 min is not possible. I would be happy if the nurses could get labs sent in 55 minutes.

If I were you, I would not look up to this guy as a role model. You should be happy being at the middle of the curve.

No one complains that you are too slow. No one complains if you have a reasonable bad outcome.

Being the fastest has its pitfalls when bad outcomes happen

LOS at my shop is from the time you click that you've seen the patient (or are going in to see the patient) to "care complete", which is when you click admit/discharge/transfer/expired.

Realize this is also an average. We spend the last 3-4 hours of every shift in fast track, where I really crank them out. I don't ever do anything crazy like CTs on every abd pain from the waiting room, order CT and U/S at the same time, etc. My belly pain avg LOS is 3-4 hours. You make up that time in fast track and on other cases.

 

[Old_Mil]

There is a graph that connects length of stay, customer satisfaction, diagnostic accuracy, % of bouncebacks, and bad outcomes/lawsuits.

The shape of the graph is different for every EP, but every EP has one and as length of stay goes down at some point customer satisfaction and diagnostic accuracy also go down, percent of bouncebacks and bad outcomes/lawsuits go up. Where you live on your personal graph is up to you...

I think an average two hour length of stay is perfectly acceptable, with sick, complicated patients who need procedures taking longer, and urgent care / non sick patients being out in less than an hour, preferrably substantially less than an hour (like dispositioned out in 15-20 minutes).

One thing: order everything at once. Sometimes that's not possible, but more often than not it is. It can result in some unnecessary testing, but it helps throughput significantly.

 

[pinipig523]

Understood

UDS only shows opiates, not opioids. If it responds to narcan, it was drug use. http://academiclifeinem.com/peeing-into-the-wind-urine-drug-screens-part-2-opiates/
And if it responds to narcan, who cares about trops or CTs? When's the last time you saw a CVA or MI that responded to narcan?

Although this makes me want to perform a study that compares narcan to tPA for CVA symptoms now. I bet it's noninferior.


He may be cutting corners, but that case isn't where he was doing it. And "do the right thing" doesn't mean "make yourself absolutely comfortable" always. We overtest a ton not for the patient's benefit, but our own.

Understood... Which is why I think this guy is bad ass. I think he is doing things right and still remarkably quick. Maybe someday ill be similar to him.

 

[Old_Mil]

I agree man... 55 LOS, there's got to be some cutting corners. There's no way.

AMS patient who was found down (not pulseless though) at home and family did CPR preemptively... work up was neg and sent home because perhaps it was opiate toxicity but UDS showed neg opiate, she responded to narcan. I mean, no cth, no trending of trop. Meh...

I dunno... maybe I'm too conservative...

This sort of thing may make bean counters happy, but it will eventually make a plaintiff's malpractice lawyer very happy too...and there is 100% discordance between happy EPs and happy plaintiff's malpractice lawyers. I mean, even assume for a minute that it was an opiate overdose which responded to Narcan. There's a whole lot of methadone out there. Did he send her out on Naltrexone? If he didn't, what happens when she bounces back apenic and asystolic? Do you want to babysit this in the ED to accurately sort this out, or do you want to admit-obs for altered mental status / possible opioid overdose?

 

[The White Coat Investor]

While faster is generally better than slower, is that really what you want to be known for? If a patient doesn't absolutely need something, but it is reasonable to do, I will often offer them two options and let them choose. Then the ones who like small, inexpensive, fast work-ups get them and people who want huge work-ups and admissions get them. Patients are happy, numbers are decent, and good medical care results (because both options were reasonable.)

55 minute average LOS? I guess if you don't actually like spending time with patients or finding out what is actually going on with them then that is okay. I don't think I'd like to practice in a shop where this was expected. I actually kind of like working up sick patients. Like the guy I admitted last night with a D-dimer of 20, acute renal failure, hematuria, an acute MI, hyponatremia, hypokalemia, new onset a-flutter with RVR and no symptoms except weak and dizzy. The nurse told me as she put him in the room that he would end up in the ICU. She was right. But it took 4-5 hours to get him there with a V/Q scan and a couple of consultations from busy specialists. Is that bad medical care? I don't think so. Would it have been more efficient for me to never have seen the patient and have him go straight to the ICU from triage? Of course. At a certain point, you've got to make sure you're a "value-adding" component of the system. My nurses aren't too bad at "sick/not sick." If that's all you can do, well, perhaps you won't be needed for very long.

 

[Apollyon]

I worked with a guy that retired when I was there. He had 30 years in the can - he didn't work up anyone who didn't need it, in his medical opinion, and he (from my viewpoint) never missed. Some people just "get it" - whatever is the mix of their innate intelligence, gut feeling, and training, they "got it". Some people on SDN are just downers. They see it as a zero-sum game - they feel better by making you feel worse. Or, without even knowing the guy, talk about inadequate workups and the like. No one, in my 10+ years on SDN, has mentioned being sued yet. Either we, as a cohort, are just very fortunate, or no one is mentioning it. I have yet to be sued. However, if what some people are writing is colored by having been sued, then, I believe, to be intellectually honest, they should "fess up" and state why they are so conservative. Birdstrike wrote about a suit, but I don't know if that was real. The "Trial of a White Coat" (he of the Dr. Whitecoat's Call Room) was real. And really interesting. (And I figured out what was the case, without him stating ANYTHING but the most basic, like time.)

There is no one on the EM forum that I don't like. There are a few people to whom I would be indifferent, but, I believe, I would be cordial with most were I relieving them, or they me. And, if I needed a second set of eyes, I would ask whomever it was that was oncoming, and was fresh and ready to go.

 

[Arcan57]

Spinning off Pinipig's thread regarding an ultrafast colleague there were suggestions about how to improve your LOS (defined here as doc-to-dispo to eliminate some of the system factors outside of your control). Like any other measure of quality in EM, focusing on improving LOS in a vacuum leads to an overall decline in quality of care.

1. Don't work up people that aren't sick. This is the biggest time saver in the ED. It takes a 4 hr belly pain work-up and turns it into 20 minutes. A two and half hour peds fever work-up becomes 10 minutes of physical exam and explaining to parents conditions for which to return to the ED. This is also the most dangerous method to employ cavalierly since if something bad happens it's impossible to prove the labs wouldn't have been helpful because they were never drawn.

2. Work for (or work to implement) a system that has a culture of the admitting physician accepting responsibility for the patient on phone call from the ED. You'll never be able to replicate 40-50 min doc-to-dispo times if you have to wait for everything to come back prior to admission. This can be easily abused (see all the "ED sux" sentiment among medicine residents who work in those systems) but it's stunningly efficient to be able to look at a patient, see they need admission, make a phone call, and forget about the patient.

3. Prioritize disposition. If the metric you're aiming for is doc-to-dispo, it makes no sense to pick up bunches of new patients when you have existing patients that need to leave. This is one of the tips that has very few downsides (unless your dispo process is inordinately labor intensive such as prolonged log-in times with short time-outs on your EMR). It eliminates batching, improves flow, gives you more time when you're only thinking about one patient, etc. And for most patients, seeing you resets their clock somewhat so they're actually happier to be waiting in the room a little longer as long as once they see you things move along.

 

[EM Junkie]

I worked with a guy that retired when I was there. He had 30 years in the can - he didn't work up anyone who didn't need it, in his medical opinion, and he (from my viewpoint) never missed. Some people just "get it" - whatever is the mix of their innate intelligence, gut feeling, and training, they "got it". Some people on SDN are just downers. They see it as a zero-sum game - they feel better by making you feel worse. Or, without even knowing the guy, talk about inadequate workups and the like. No one, in my 10+ years on SDN, has mentioned being sued yet. Either we, as a cohort, are just very fortunate, or no one is mentioning it. I have yet to be sued. However, if what some people are writing is colored by having been sued, then, I believe, to be intellectually honest, they should "fess up" and state why they are so conservative. Birdstrike wrote about a suit, but I don't know if that was real. The "Trial of a White Coat" (he of the Dr. Whitecoat's Call Room) was real. And really interesting. (And I figured out what was the case, without him stating ANYTHING but the most basic, like time.)

There is no one on the EM forum that I don't like. There are a few people to whom I would be indifferent, but, I believe, I would be cordial with most were I relieving them, or they me. And, if I needed a second set of eyes, I would ask whomever it was that was oncoming, and was fresh and ready to go.

Good point re: lawsuits. I've never been sued. I think the day I am is the day everything changes. We sit around and wonder why a couple of our older doctors are so (cautious/slow/etc). Then you hear their story about the patient that came in with earache that ended up with a carotid dissection - and it all makes sense.

Hopefully I can pay off all my loans, and when I get sued one day I'll just retire!

 

[The White Coat Investor]

First, I don't think faster times are the end all be all, but that said, I agree with the above. Other suggestions:

1) Shotgun everything. You end up doing MRIs on pregnant ladies with RLQ pain that end up being UTIs, but you do get them out the door faster.
2) Make a decision. Some docs suck at doing this and opt instead to go see another patient, even though everything is back.
3) Obs admits instead of extended ED stay observations for psychs, tox stuff etc that you know if you sit on for 4-8 hours you could dispo. Just admit em
4) Do paperwork when you have time to do paperwork. For instance, I often do all the discharge paperwork before ever suturing a laceration. While the tech is irrigating, the nurse is injecting the adacel and I'm typing. As soon as I'm done, the nurse dresses it and hands them the papers while I'm seeing the next patient.
5) Count your time after the shift. Some people like to brag about the 2.5 pph they see. However, they stay 2 hours after their shift to do paperwork. Instead of seeing 20 patients at 2.5 pph, they're really seeing 20 patients at 2 pph. Not impressed.
6) Work the squirrels up once. Even squirrels get sick, so work them up once. But when you see them back again, don't work them up again and again and again. Just make sure nothing significant has changed via history and physical. Then discharge them.
7) Don't do stuff someone else can do.

 

[Arcan57]

I worked with a guy that retired when I was there. He had 30 years in the can - he didn't work up anyone who didn't need it, in his medical opinion, and he (from my viewpoint) never missed. Some people just "get it" - whatever is the mix of their innate intelligence, gut feeling, and training, they "got it".

As a profession we due everything we can to play down the value of experience. It starts in training (3 is just as good as 4) and is perpetuated once we become attendings (yeah the first year out is bumpy but once you're board certified you're the equal of anybody). It's pushed by CMGs who need a constant supply of young docs to deal with turnover and needs to avoid inconvenient questions by the hospital about drop in quality of care from pushing out the old group. It's implicit in our compensation structure (I don't know anywhere that has a seniority bonus that's not due to partnership). About half of our literature is devoted to studying and coming up with decision instruments to try and replace physician judgment (ie experience) with static variables. Most of the rules don't compare well in AUC with physician judgement.

We view old docs as a liability because of the increasing toll of random circadian shifts as we age. While no one ever says it, after 2-3 years in practice everyone (including the doc in most cases) assumes they are as good at the job as they are ever going to be. We know the algorhithms and can recite what procedures need doing. This helps us cope with the terror of being a young attending, but it's also really depressing. No wonder people talk about leaving medicine early if the other option is to stay in a job that you'll be no better at in 10 years then you are now. I'm 5 years out now and if I'm no better at clinical medicine in 2019 then I am now, I'd think of that as a failure.

So when you see the doc that's been out 15 years and is a superstar, watch how they work. But don't expect you can port what they do directly to your practice and see the same results. I've seen what happens when a good doc loses a sense of sick/not sick due to rushing and it's all sorts of ugly.

 

[Apollyon]

5) Count your time after the shift. Some people like to brag about the 2.5 pph they see. However, they stay 2 hours after their shift to do paperwork. Instead of seeing 20 patients at 2.5 pph, they're really seeing 20 patients at 2 pph. Not impressed.

That's the second time in a few days that I've seen you post this. I think that your math is disingenuous. In the time frame, more patients are affirmatively seen and discharged. They are, affirmatively, seeing 2.5/hour. Your average stretches beyond points A and B (start and end of shift, or from beginning to see patients to the end of the last patient). Your point is valid, but your denominator is incorrect. If 5 patients are disposed in 2 hours, that is 2.5. There is no denying that.

You are arguing a different point, which is doc time. On our side, your point applies. However, on the patient/hospital side, it does not.

 

[The White Coat Investor]

That's the second time in a few days that I've seen you post this. I think that your math is disingenuous. In the time frame, more patients are affirmatively seen and discharged. They are, affirmatively, seeing 2.5/hour. Your average stretches beyond points A and B (start and end of shift, or from beginning to see patients to the end of the last patient). Your point is valid, but your denominator is incorrect. If 5 patients are disposed in 2 hours, that is 2.5. There is no denying that.

You are arguing a different point, which is doc time. On our side, your point applies. However, on the patient/hospital side, it does not.

Agreed. The hospital doesn't care if you want to spend all night charting after your shift.

 

[Arcan57]

Agreed. The hospital doesn't care if you want to spend all night charting after your shift.

One of the docs that worked part time for us averaged a full pph over the group average. He didn't chart anything while on shift and would use the down time working at his free-standing to (eventually) finish the t-sheets online. He also had phenomenal people skills and could admit anything to any specialty in the hospital in almost any stage of workup.

 

[pinipig523]

So yeah... Another reason my LOS is a little longer... I spend time reducing fractures. There was a colles today that I reduced twice and took my 2h doing it. I guess I could've just had the tech splint the pt and off to ortho outpatient but I really wanted to give her a chance to avoid surgery.

Finger trapped her, hematoma blocked her, used plaster instead of ortho glass. Got it to anatomical position... She was so happy.

 

[Pinner Doc]

It's unfortunate that as a community attending - your worth is based on speed and not on overall quality of care. Though I'm not sure if I'm providing higher quality of care if he's 15 years out and still practicing - I'm assuming he's getting to the same end points I am.

Thank you for voicing this. You nailed it.

 

[EvoDevo]

As a profession we due everything we can to play down the value of experience. It starts in training (3 is just as good as 4) and is perpetuated once we become attendings (yeah the first year out is bumpy but once you're board certified you're the equal of anybody). It's pushed by CMGs who need a constant supply of young docs to deal with turnover and needs to avoid inconvenient questions by the hospital about drop in quality of care from pushing out the old group. It's implicit in our compensation structure (I don't know anywhere that has a seniority bonus that's not due to partnership). About half of our literature is devoted to studying and coming up with decision instruments to try and replace physician judgment (ie experience) with static variables. Most of the rules don't compare well in AUC with physician judgement.

We view old docs as a liability because of the increasing toll of random circadian shifts as we age. While no one ever says it, after 2-3 years in practice everyone (including the doc in most cases) assumes they are as good at the job as they are ever going to be. We know the algorhithms and can recite what procedures need doing. This helps us cope with the terror of being a young attending, but it's also really depressing. No wonder people talk about leaving medicine early if the other option is to stay in a job that you'll be no better at in 10 years then you are now. I'm 5 years out now and if I'm no better at clinical medicine in 2019 then I am now, I'd think of that as a failure.

So when you see the doc that's been out 15 years and is a superstar, watch how they work. But don't expect you can port what they do directly to your practice and see the same results. I've seen what happens when a good doc loses a sense of sick/not sick due to rushing and it's all sorts of ugly.

Thank you for voicing this.

 

[Pinner Doc]

First, I don't think faster times are the end all be all, but that said, I agree with the above. Other suggestions:

1) Shotgun everything. You end up doing MRIs on pregnant ladies with RLQ pain that end up being UTIs, but you do get them out the door faster.

I know I've posted something similar lately, but I can't believe some directors let folks get away with this. Our director is known to call providers on-shift in real time, while the director is at home watching the board: "Why did you order this test on so-and-so?" Additionally, one of our metrics is number of CT scans ordered - the director makes a bell curve of this. And finally - we get reviewed by nurses, HUCs and techs (anonymously) at our yearly review session - anything that creates more work for them ends up reflecting poorly on you ("Dr. X orders way too many tests. (S)he shotguns everything. Probably bc (s)he has no idea what's going on with the patient.")

 

[WilcoWorld]

we get reviewed by nurses, HUCs and techs (anonymously) at our yearly review session - anything that creates more work for them ends up reflecting poorly on you ("Dr. X orders way too many tests. (S)he shotguns everything. Probably bc (s)he has no idea what's going on with the patient.")

I'm struggling with this too. On the one hand, I think it's useful to get feedback from nurses, less so the clerks and techs, but maybe. On the other hand, the feedback should only be in areas that they're qualified to speak on (clarity of communication or treating team members with respect, for instance) not things like appropriateness of orders. Add on the fact that these are done anonymously and that the docs don't evaluate the nurses, and it's ripe for a complain-a-thon.

Recently a nurse was uncomfortable with an order of mine - fentanyl for pain treatment in a pregnant woman. He first asked another nurse, who said to call pharmacy. He then called pharmacy. Pharmacy then said "gee, I dunno, it's class C, but a lot of stuff is class C." Only then did he ask me about the order. Was he convinced by a discussion of what class C means, or how narcotics can be harmful in pregnancy and therefore it doesn't apply during the 1st trimester? Of course not. But when I said "OB uses it a lot" everything was hunky dory. Finally, after a 45 minute delay, the patient's pain was treated. I wouldn't be surprised if this nurse wrote me a poor evaluation, saying "Wilco writes some concerning orders - even pharmacy wasn't sure if the medicine was safe in pregnancy."

 

[Siggy]

Finally, after a 45 minute delay, the patient's pain was treated. I wouldn't be surprised if this nurse wrote me a poor evaluation, saying "Wilco writes some concerning orders - even pharmacy wasn't sure if the medicine was safe in pregnancy."

...and then Press Ganey comes along and says "Dr. Wilco didn't treat my pain in a timely manner" even through it's not Dr. Wilco's fault that the pain medication was delayed.

 

[Birdstrike]

I don't get it - I'd like to think I'm doing pretty well and am significantly better than the first year I was out.... my LOS is around 120min which is maybe a little on the higher end but I'm working on it.

My medical director always says that you want to be in the bell curve but not too far on either end - not too slow and probably not too fast.

However, I recently ran into a part timer who is incredibly fast - like 55 min LOS fast. I asked him why he's so fast, he told me that "you just gotta realize that they're not that sick." He does less rule outs than I do, and more of a clinical gestalt type practice. He calls it as he sees it, whereas I look to rules and decision making criteria and labs/imaging to ensure I have thought of the majority of possible differentials and have ruled them out with a certain subjective and objective level of evidence presented.

The guy saw 28 in 7 hours without a scribe... and I ran through the list he saw, there were some decently sick ones there. The most I've seen in 7 hours was around 23 and this was with a scribe.

I know I document a lot and very well... probably slows me down. I probably spend a lot of time talking and explaining things to patients, too.

I've been trying to be more efficient and it's been working - I'm seeing significantly faster dispo's the longer I'm out.

I graduated in 2012. He graduated 15 years ago.

Just wanted to vent.

It's unfortunate that as a community attending - your worth is based on speed and not on overall quality of care. Though I'm not sure if I'm providing higher quality of care if he's 15 years out and still practicing - I'm assuming he's getting to the same end points I am.

Sure you can get faster, more efficient and all that good stuff, and you should, but you're missing something. "That guy" knows the rules of the game and is playing to win. There's a numbers manipulation game and a "management of averages" here.

(Disclaimer: See the emergencies first, and don't compromise patient care. I'm not suggesting you do this, but with the increasing obsession with these numbers by your "keepers" here is something I've seen done by people who are determined to play the game at all costs. Do with this information as you wish.)

You work a 8 hour shift, your average LOS is 120 minutes. That's 1920 minutes for 16 patients (2 per hour in an 8 hr shift). At some point in the shift, "Mr Efficiency" snags a chest pain of the top of the list and a chief complaint: "work note" (LOS 15 min) disappears off the bottom of the list at the identical time without anyone noticing. All anyone notices is that the abdominal pain comes off the top, as it should. He picked it up, and cherry picked the "work note" simultaneously. You come along and pick up "Peds dystrophic with trach/peg, fever, sedation/LP and needs disimpaction" (LOS= eternity) like a trooper.

An hour later, "Mr Efficiency" comes along and snags a "weak and dizzy" off the top and that "29 yo chronic back pain" (LOS 15 min) halfway down the list you've been avoiding disappears off the list simultaneously, and mysteriously.

At the end of the shift, your length of stay is right at 1920 as always, for an average of 120 min or 2 hr for your 16 hard fought patients at 2.0 per hour.

"Me Efficiency" has seen 16, plus he's cherry picked 2 super quick patients. His length of stay is also 1920 for his first 16 patients, and he's added 2, at 15 minutes each. He clocks in at 1950 for 18 patients. He's done virtually no more work than you, but the average LOS drops to 108 min for him. Not only that, his PPH jumps from the group average of 2.0 to 2.25.

Since most of the group is bunched tightly around an average of LOS 120 min and 2.0 PPH,

"Mr Efficiency" moves way up the bell curve for both LOS and PPH.


How has he done it?


"Clock management."

Math.

Making the numbers look good.

Knowing the rules of the game.


Mr Efficiency also knows how important "patient sat" is to admin. He doesn't seem to treat his patients different than anyone else. But he constantly gets 3 "great job!" letters for every complaint letter you get. Also, admin has noticed that his Healthgrades.com, ucomparehealthcare.com, vitals.com and ratemds.com scores are through the roof, averaging 4.5-5/5 stars across the board with comments such as "Dr Efficiency is great! Would go back to St. General any time!" Though it doesn't directly increase his PG scores the amount of free advertising it gives to his hospital tickles admin pink. How does he do it?

He walks in to every room ready. When he has a patient say, "Thanks doc, I appreciate your help," somebody who he knows had a good experience, he whips out a pre-printed sheet of paper that says,

"Your comments and feedback are very important to Dr Efficiency and St. General Hospital. Please take the time rate Dr Efficiency and to tell us about your care at one or more of the following ratings websites:

Healthgrades.com
Ucomparehealthcare.com
Vitals.com
Ratemds.com

Also, a quick note to Joe Tool CEO sharing your thoughts would be greatly appreciated as well. Thank you!"

Only 1 in 5 follow through, but it's enough so that his averages, ratings, and stature with admin go through the roof with very little effort and at nost cost to him or the hospital. Dr Efficiency has brought positive and free internet advertising and publicity to the hand that feeds him.

 

[Arcan57]

...and then Press Ganey comes along and says "Dr. Wilco didn't treat my pain in a timely manner" even through it's not Dr. Wilco's fault that the pain medication was delayed.

It's not the docs fault, but as captain of the ship you're ultimately responsible for the care your patient receives. A mediocre doc in a good system is going to be significantly better than a good doc in a bad system.

 

[Apollyon]

Birdstrike wrote about a suit, but I don't know if that was real.

I just want to say that I don't know if Birdstrike's case was a real one, because he has a gift for writing. Also, it could have been someone else, and not him. For fiction, if the person reading thinks that it is all real, even 100% not, then you have succeeded.

However, to be clear, I am not casting aspersions at Birdstrike, in any regard. The day I get sued, I think I shall have GI distress (<-- understatement of the hour/day/week/month/year).

 

[The White Coat Investor]

I never said shotgunning is about good medicine or about controlling costs. This thread is about FASTER care, not better care. If it were my wife, I'd squeeze the urine out as we walked in the room and sure as heck wouldn't let someone order a CT/MRI until it had at least been dipped.

 

[Arcan57]

I never said shotgunning is about good medicine or about controlling costs. This thread is about FASTER care, not better care. If it were my wife, I'd squeeze the urine out as we walked in the room and sure as heck wouldn't let someone order a CT/MRI until it had at least been dipped.

Exactly. The idea is that if your director came to you and told you to prep your CV if you don't drop 20 min off your LOS then how would you do it. Most of the methods are jerky (I do love the grabbing fast track patients surreptitiously idea) but some of them are broadly applicable (prioritizing dispo).

 

[RustedFox]

Fast. Fast. fast. Fast. Faster. and faster. and faster and faster and faster.

WHAAATEVVVVERR.

Play the game all you want to. Or don't.

I don't.

I wish everybody just chose to NOT play the game.

Here's whats more important to me:

"Do the right thing."

"Do no harm."

"Treat everyone the way you would want to be treated."

That's why they hired me in the first place. To do the right thing. To practice good medicine.

Once the suits decide that they no longer want to employ people who practice good medicine.... it will get out to the community.

... and the pendulum will swing the other way. At one point or another, people are going to realize that they want doctors to care for them, not MBAs or attorneys.

Let the pointdexters who want to play their statistics game.... let them play their game.

Once that nonsense comes crashing down because the bar kept getting higher and higher and higher, what are you gonna do?

I have four rules that I practice by. I frequently say this to patients:

"I will make you four promises."

"1. I don't lie to patients or their families. That's wrong. Period."
"2. I don't fake it; if I need a specialist, I'll get one; that's why we have consultants."
"3. I will get you the best science that I can get you. There is no white magic or mysticism to what I do. That is for various houses of worship, or fortune-tellers, or whatever else you like."
"4. I will treat you with the same respect and dignity that I would want my own family to be treated with."

.. and sometimes (5). "I want you to get the best care; even if its not here with me, or at this hospital. I will transfer you if I have to."

What it comes down to is this:

"I will do the right thing for you."

How's that for "customer service", mister-administrator?

I used to get all stressed out over every metric and how its perceived.

I don't anymore. Ever.

 

[Daiphon]

Fast. Fast. fast. Fast. Faster. and faster. and faster and faster and faster.

WHAAATEVVVVERR.

Play the game all you want to. Or don't.

I don't.

I wish everybody just chose to NOT play the game.

Here's whats more important to me:

"Do the right thing."

"Do no harm."

"Treat everyone the way you would want to be treated."

That's why they hired me in the first place. To do the right thing. To practice good medicine.

Once the suits decide that they no longer want to employ people who practice good medicine.... it will get out to the community.

... and the pendulum will swing the other way. At one point or another, people are going to realize that they want doctors to care for them, not MBAs or attorneys.

Let the pointdexters who want to play their statistics game.... let them play their game.

Once that nonsense comes crashing down because the bar kept getting higher and higher and higher, what are you gonna do?

I have four rules that I practice by. I frequently say this to patients:

"I will make you four promises."

"1. I don't lie to patients or their families. That's wrong. Period."
"2. I don't fake it; if I need a specialist, I'll get one; that's why we have consultants."
"3. I will get you the best science that I can get you. There is no white magic or mysticism to what I do. That is for various houses of worship, or fortune-tellers, or whatever else you like."
"4. I will treat you with the same respect and dignity that I would want my own family to be treated with."

.. and sometimes (5). "I want you to get the best care; even if its not here with me, or at this hospital. I will transfer you if I have to."

What it comes down to is this:

"I will do the right thing for you."

How's that for "customer service", mister-administrator?

I used to get all stressed out over every metric and how its perceived.

I don't anymore. Ever.

I don't see how your 5 rules are incongruous with playing the game. I live by those 5, work nights (understaffing is hell on my throughput) and still rank in the top quartile of my group.

I agree to not stress about it, but to not understand and manipulate the metrics is, sorry buddy, naive. Kinda like knowing how to sell a flaky CP story...

We made this bed by virtue of ceding control of medicine to the suits and legislators, now we gotta lie in it until it goes kaboom... and the only survivors will be those that know how the game works.

Cheers!
-d

 

[RustedFox]

Re-read the last 2 lines of my post.

What a wonderful world we would live in if we all simply said: "G'head and fire me for not being in the top 23.334% of my group."

Its part of the lack of solidarity that we all lament on here from time to time.

Can't wait until greedy administrators are exposed in some fashion, and the torches and pitchforks assemble.

Metrics are like bikinis: they're great to look at, but they cover up what you're really trying so hard to really see.

Metrics.

Pfft.

 

[Daiphon]

Re-read the last 2 lines of my post.

What a wonderful world we would live in if we all simply said: "G'head and fire me for not being in the top 23.334% of my group."

Its part of the lack of solidarity that we all lament on here from time to time.

Can't wait until greedy administrators are exposed in some fashion, and the torches and pitchforks assemble.

Metrics are like bikinis: they're great to look at, but they cover up what you're really trying so hard to really see.

Metrics.

Pfft.

Fully agree. My point was simply that one ignores them at their own potential peril.

Remember: lies, damn lies, & statistics.

d=)

 

[Arcan57]

Re-read the last 2 lines of my post.

What a wonderful world we would live in if we all simply said: "G'head and fire me for not being in the top 23.334% of my group."

Its part of the lack of solidarity that we all lament on here from time to time.

Can't wait until greedy administrators are exposed in some fashion, and the torches and pitchforks assemble.

Metrics are like bikinis: they're great to look at, but they cover up what you're really trying so hard to really see.

Metrics.

Pfft.

There's not going to be pitchforks for the greedy admins when it all goes down. There's just going to be cratering physician compensation.

 

[RustedFox]

I'm willing to bet that a few greedy admins get run out of town.

 

[Arcan57]

I'm willing to bet that a few greedy admins get run out of town.

If by run out of town you mean get severance packages when their health system merges with a larger amoeba then sure.

 

[Venko]

There are many passionate opinions being put up here. I can say for my part, if I can do something faster with the same outcome and patient experience, why not?

Do I know if your colleague is safe or reckless? Nope, but I suspect if they have been there that long and the hospital hasn't fired them (bad press, malpractice, etc) they must be doing reasonably well.

If I were you, and I really wanted to improve my efficiency, I would take some of my own time and follow this person around. I would pay attention to see if there are tips or tricks you can incorporate into your practice that would help make your life easier. Its possible he knows how to harness the medical system to achieve similar results.

Any tricks / tips I offer would be unique to my shop and not necessarily useful to you, but this guy is facing the same struggles you are and possibly doing it better. You could even check with your medical director for the names of high efficiency, high accuracy, high satisfaction providers that you could learn from.

Keep an open mind, go see what they are doing and if you want to do it too.