Metric BS

[sylvanthus]

How in gods name did this keeping track of metric BS start? As a resident I was largely shielded from the absolute nonsense that is doc to door time, LOS, press ganey, etc etc etc. But now as an attending for the past year Im getting hammered with it. We just recently had an email telling us to get our arses out in the waiting room and draw blood if needed to get our LOS and doc to door times down or theyd take away a PA. How did this begin? Federal requirement? Tied to reimbursement? Some asshat in hospital management started it and it spread? Ive gotten to the point where every patient is given a "goodie bag" diclofenac, flexeril, nasal spray, eye drops, tessalon, etc etc just to boost ridiculous patient satisfaction scores.

The more pessimistic side of me thinks this will get a lot worse, especially with the incoming job crunch, The slower docs or those with bad press ganey scores run the risk of losing their employment in favor of those that have better metric scores.

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[sylvanthus]

Can a mod move this to the EM forum, totally wrong forum, my bad.

 

[Tangerine123]

I thought this was going to be a thread complaining about the metric system vs imperial in the US.

Disappointed.

 

[group_theory]

Can a mod move this to the EM forum, totally wrong forum, my bad.

Moving. Depends on your "boss" (and your boss's boss") and how much they respect physicians (unfortunately, most don't)

 

[Angry Birds]

How in gods name did this keeping track of metric BS start? As a resident I was largely shielded from the absolute nonsense that is doc to door time, LOS, press ganey, etc etc etc. But now as an attending for the past year Im getting hammered with it. We just recently had an email telling us to get our arses out in the waiting room and draw blood if needed to get our LOS and doc to door times down or theyd take away a PA. How did this begin? Federal requirement? Tied to reimbursement? Some asshat in hospital management started it and it spread? Ive gotten to the point where every patient is given a "goodie bag" diclofenac, flexeril, nasal spray, eye drops, tessalon, etc etc just to boost ridiculous patient satisfaction scores.

The more pessimistic side of me thinks this will get a lot worse, especially with the incoming job crunch, The slower docs or those with bad press ganey scores run the risk of losing their employment in favor of those that have better metric scores.

This has been going for a long, long, long time. But yeah, it's BS -- people just game the system, as your boss instructed you to do.
However, I *do* think the metric of "total time to discharge" is relevant, so as to penalize those docs who hold on to their patients forever and ever. Of course, in order to make this a useful metric, you have to make sure people are not gaming the system, such as by clicking discharge but not printing discharge paperwork, etc.

But, I suppose the metrics are not for actual patient care anyways, but rather like those standardized tests that even the high school teachers want their students to cheat and get good scores on...

 

[Birdstrike]

How in gods name did this keeping track of metric BS start? As a resident I was largely shielded from the absolute nonsense that is doc to door time, LOS, press ganey, etc etc etc. But now as an attending for the past year Im getting hammered with it. We just recently had an email telling us to get our arses out in the waiting room and draw blood if needed to get our LOS and doc to door times down or theyd take away a PA. How did this begin? Federal requirement? Tied to reimbursement? Some asshat in hospital management started it and it spread? Ive gotten to the point where every patient is given a "goodie bag" diclofenac, flexeril, nasal spray, eye drops, tessalon, etc etc just to boost ridiculous patient satisfaction scores.

The more pessimistic side of me thinks this will get a lot worse, especially with the incoming job crunch, The slower docs or those with bad press ganey scores run the risk of losing their employment in favor of those that have better metric scores.

Hospital administrators started this at least as far back as 20 years ago when I was starting residency (probably earlier) as a means to make more money. If they can make 20% more widgets per day, and sell 20% more widgets to "satisfied" customers, they can make 20% more money. It's all about money, nothing else. Like almost everything else in life, if you follow the money, you'll find your answer more often than not.

EM leadership and teaching attendings try to isolate the medical students and residents from this reality. It's one of the key pillars of recruiting lies they've been telling for decades, that I've mentioned ad nauseam on this forum, over the years. "It's all about the Medicine...focus on the Medicine...see the sick ones first....no one else is dying, the walking-well can wait..." Wrong! That's a lie. It's about going as fast as possible and satisfying as many customers as possible as quick as possible, to fatten the wallets of people that don't take care of patients. Administrators don't differentiate between "sick" and "not sick." All paying customers are equal to them; "green is green," as they say, and it's your job to make it for them.

They try to shelter you from this reality, because if you knew about this insanity back when choosing a career, we never wouldn't chosen EM. EM recruiting wouldn't be hot like it usually is, it would be a wasteland. That can't happen. Because that would mean there's no doctors to crank widgets through their money-making machine.

 

[namethatsmell]

Awwwwww, c'mon. Aren't you a team player?

Without the metrics how will our admin "partners" be able to justify holding 34 meetings about the door to doc time going up 3 seconds on a Thursday? Without metrics to spawn "efficiency initiatives," how will they justify hiring more underlings to do their work for them? Without metrics, how will admin be able to justify promotions and bonuses for themselves when they get those 3 seconds back on the d2d time?

Have you no vision? Have you no heart?

Oh btw, we're going to need you to work more overnights or find another job as we're cutting doctor hours and adding more midlevels to pay for the awesome value the genious administrators bring to the table.

 

[WilcoWorld]

I pay attention to metrics to the degree required to practice good medicine within and/or in spite of them. Once you know the metrics, they're like The Matrix. You can take good care of patients while Metricians thank you for reporting your data quarterly.

 

[RustedFox]

However, I *do* think the metric of "total time to discharge" is relevant, so as to penalize those docs who hold on to their patients forever and ever. Of course, in order to make this a useful metric, you have to make sure people are not gaming the system, such as by clicking discharge but not printing discharge paperwork, etc.

I agree in general; but there's an unseen problem with this.
I actually said this one day during a telephone meeting with all our docs.

"Wait; on one hand you want us to dispo them as quickly as possible - but on the other hand, you want us to take the time to explain everything to the patient, answer all their questions to satisfaction, and talk to their family member/other person in room. Those are diametrically opposing goals. Every minute that you take to do one thing, steals from the other."

As expected, I got a mealy-mouthed answer from the Regional Vice D!ckhead hosting the call, who is not a physician.

 

[southerndoc]

Do it better and do it faster, but don't mess up and you can't have any additional resources. Ready, set, go!

 

[RustedFox]

Without metrics to spawn "efficiency initiatives," how will they justify hiring more underlings to do their work for them? Without metrics, how will admin be able to justify promotions and bonuses for themselves when they get those 3 seconds back on the d2d time?

This wins the thread.

If you think that these metrics are anything else than a means for the admins to parlay themselves into more bonuses for them and their cronies, then you're dead wrong.

 

[RustedFox]

They try to shelter you from this reality, because if you knew about this insanity back when choosing a career, we never wouldn't chosen EM.

I've thought about this a lot as of late.
I fully expect the millennial set to not tolerate this at all, and we will see serious upheaval during my career as a result.
Time will only tell if the millennials succeed in taking back the specialty, or find roads out as soon as they find a road in.

 

[RustedFox]

My responses are in italics:


How in gods name did this keeping track of metric BS start? As a resident I was largely shielded from the absolute nonsense that is doc to door time, LOS, press ganey, etc etc etc. But now as an attending for the past year Im getting hammered with it.

Yep. Welcome to the real world, Neo. Your eyes hurt because you've never used them before. Residents and med students; read this twice. Three times is better.


We just recently had an email telling us to get our arses out in the waiting room and draw blood if needed to get our LOS and doc to door times down or theyd take away a PA.

Yep. But... you don't see an admin getting out there are doing lab draws, do you? Its remarkable that they want this to be done; or they'll "take away a PA", thus making achieving their own goal that much more impossible. That's admins to a "T". They like to make rules; as long as it doesn't get in the way of their catered lunches and make them get their asses out of their expensive leather chairs.


How did this begin? Federal requirement? Tied to reimbursement? Some asshat in hospital management started it and it spread?

Simple. Asshats and money. Greedy admins are greedy.


Ive gotten to the point where every patient is given a "goodie bag" diclofenac, flexeril, nasal spray, eye drops, tessalon, etc etc just to boost ridiculous patient satisfaction scores.

Wait until one of those things causes a lawsuit because its unindicated. Betcha it won't fall back on the admins; just in the lap of the doc that stepped on that landmine.


The more pessimistic side of me thinks this will get a lot worse, especially with the incoming job crunch, The slower docs or those with bad press ganey scores run the risk of losing their employment in favor of those that have better metric scores.

It's already happened. It started awhile ago.

 

[GeneralVeers]

It's going to get worse too. Government won't shield us from this. Government looks to try and claw back as much reimbursement as possible. They are already penalizing us for "quality metrics" to the order of 1-2% of reimbursement. Expect the punishment to increase as deficits increase in the future.

 

[Zebra Hunter]

My work around for this is to find every single possible loophole for each ridiculous metric.

- Can’t have a sepsis fallout if you convince the hospitalist to just call it pneumonia rather than pneumonia and sepsis. Or sepsis rather than “severe sepsis”.

- Every patient immediately gets an NPO order to meet the door to order time.

- Every ESI level 4 or 5 that is supposed to be discharged in 80 min or less suddenly is switched to a ESI level 3 by nursing staff at my request when they go over that time.

- ridiculous patients that I know are going to give a bad press ganey are dx’d with “anxiety regarding health” as their primary dx in order to prevent them from getting a survey. Same with “drug seeker” diagnosis.

These work arounds keep me sane enough to continue practicing good medicine without caving to stupid metrics pressuring me to practice **** medicine.

 

[southerndoc]

@Zebra Hunter The hospital misses out on increased revenue by not calling it sepsis. Simply put the time you order cultures/lactate/antibiotics with a note stating "treated for severe sepsis at this time; infection not previously suspected." That starts the clock then.

 

[Zebra Hunter]

@Zebra Hunter The hospital misses out on increased revenue by not calling it sepsis. Simply put the time you order cultures/lactate/antibiotics with a note stating "treated for severe sepsis at this time; infection not previously suspected." That starts the clock then.

Per our sepsis coordinator docs, this does not work at restarting the clock. If a hospitalist after the fact states that sepsis was present at admission, it will still count as a fallout.

 

[southerndoc]

Per our sepsis coordinator docs, this does not work at restarting the clock. If a hospitalist after the fact states that sepsis was present at admission, it will still count as a fallout.

That's the problem. You should tell your hospitalists not to document that. There is no reason for it to be documented as such. Do they also document "MI present at admission, acute pancreatitis present at admission," etc or do they just document it as a diagnosis?

 

[Birdstrike]

Time will only tell if the millennials succeed in taking back the specialty

I put the chances of this happening at less than 1%. Not because of anything having to do with millennials. My generation (X) hasn't done any better. But there's no real incentive for anyone to change on either side. Admins make too much money with the current system. And more importantly, EM physicians also make too much money in the current system. They'll say they don't make enough money, but when compared to the alternative, which is going on strike and making nothing for prolonged, indefinite periods of time, they cave in a nanosecond in favor of lifestyle. Not to mention the fact that 98% of doctors are rule followers, rarely rebels, and hate being viewed as "the bad guy" much more than burnout, especially since they're conditioned from day #1 in pre-med/medical school/residency, to tolerate hating their chosen field because "even though is miserable now, someday it'll get better." When >50% of doctors are pissed off enough to quit, not get paid for 6 months, and deal with the social shaming that goes with walking off the job, then and only then will I move the likelihood of improvement from it's current <1%.

 

[RustedFox]

@Zebra Hunter

Sounds like an HCA shop. Been there.
At my one job site; they nixed NPO as an order that qualifies to meet that metric.

 

[Birdstrike]

A. The likelihood of doctors "changing the system": <1%
B. The likelihood of you changing your own situation: This number is set by you. Pick a number between 0 and 100%

The easy choice is waiting and hoping for "A." The effective but more difficult choice, is "B."

 

[Arcan57]

Metrics are all about identifying the rate limiting step, then trying to enforce change on everything that's not the rate limiting step. Not enough nursing resources (which these days is completely different from not enough nurses) causing prolonged length of stays? Push on the docs to see the patient early (collect that cash) and measure them on patient seen to disposition decision. Nevermind, that the RNs perceiving themselves to be even more overworked by this sped up system will respond by getting into the habit of just not doing certain discharge critical tasks on patients that they don't deem acutely ill. Migrainer just needs a pregnancy test and meds? That urine isn't getting sent for hours. Belly pain that needs a CT? Sorry, pt's a difficult stick and we're waiting for Rip vanWinkle to wake up since he's good at US IVs.

Figured out exactly the right ratio of nurses to rooms to optimize efficiency? Awesome. Now give that optimized work force 8hrs of on-line training every 2-4 weeks, don't give them admin/education days, and don't let them draw overtime. Great, now the nurse doesn't notice the tech never sent the blood because they're 30 screens deep into a mandated 2hr course, because of the latest JC visit, on the evils of leaving foleys in post-surgical patients. And what's that? You've now normalized doing on-line courses while you're supposed to be working clinically? Watch productivity grind to a halt as your staff crowd-sources the answer to how blood moves through the body for the DNP/MBA/CRNA/WTF exam they're taking.

 

[GeneralVeers]

Arcan, don't forget the famous: "Doctor, we just simply can't get an IV on this patient! Can you do it?"

 

[Vandalia]

I put the chances of this happening at less than 1%. Not because of anything having to do with millennials. My generation (X) hasn't done any better. But there's no real incentive for anyone to change on either side. Admins make too much money with the current system. And more importantly, EM physicians also make too much money in the current system. They'll say they don't make enough money, but when compared to the alternative, which is going on strike and making nothing for prolonged, indefinite periods of time, they cave in a nanosecond in favor of lifestyle. Not to mention the fact that 98% of doctors are rule followers, rarely rebels, and hate being viewed as "the bad guy" much more than burnout, especially since they're conditioned from day #1 in pre-med/medical school/residency, to tolerate hating their chosen field because "even though is miserable now, someday it'll get better." When >50% of doctors are pissed off enough to quit, not get paid for 6 months, and deal with the social shaming that goes with walking off the job, then and only then will I move the likelihood of improvement from it's current <1%.

I got a fund-raising letter from my local med school touting the fact that they had 12 applicants who met qualifications for every medical school slot. This was not Harvard, or even Michigan. Now lets say things get bad enough that they are down to six qualified applicants for every med school slot. How will things change?

Medicine is still a great gig compared with all the others. The "prestige" factor of the profession will keep people applying. Heck, even in the Soviet Union, when physicians were paid the same as factory workers, people were lining up to go to med school. There are elite graduates at elite medical school who are perfectly happy to do six years additional training to snare a tenure-track adolescent medicine position at $120K/year.

The supply will always be there no matter the salary or the workload.

 

[EM Junkie]

Arcan, don't forget the famous: "Doctor, we just simply can't get an IV on this patient! Can you do it?"

“That sounds like a nursing issue, come to me when you have a physician issue.”

 

[Birdstrike]

I got a fund-raising letter from my local med school touting the fact that they had 12 applicants who met qualifications for every medical school slot. This was not Harvard, or even Michigan. Now lets say things get bad enough that they are down to six qualified applicants for every med school slot. How will things change?

Medicine is still a great gig compared with all the others. The "prestige" factor of the profession will keep people applying. Heck, even in the Soviet Union, when physicians were paid the same as factory workers, people were lining up to go to med school. There are elite graduates at elite medical school who are perfectly happy to do six years additional training to snare a tenure-track adolescent medicine position at $120K/year.

The supply will always be there no matter the salary or the workload.

You're right. It's the perfect recipe for those in power to keep doing what they're doing.

 

[southerndoc]

I believe this is incorrect. I serve on our hospital’s sepsis committee. CMS identifies time zero when an infection is identified by a nurse, physician or pharmacist (don’t have a clue why they include pharmacist) and 2/4 SIRS criteria are present. If you state the time sepsis is suspected or identified, then that can be used. If a hospitalist later on states sepsis present on admission, that just indicates that sepsis was present upon the patient’s admission to the hospital and doesn’t include the entirety of the ED course. If you identified sepsis, then that predates the hospitalist’s note and identification.

Unfortunately, CMS views "present on admission" as present upon entering the hospital (i.e., the ER). "Admitted to the ER" -- another great CMS rule.

Glad they finally stopped counting prehospital vital signs for hypotension.

 

[nexus73]

Perhaps some of these metrics could be useful for tracking and improving certain goals of patient care. But the problem is when they’re implemented in an irrational way, or manipulative or abusive way, then people abandon working toward the patient care goal, and the focus shifts so that hitting the metric becomes the goal. And this generates all kinds of creative workarounds that don’t accomplish the patient care goal the metric is supposedly in place to track. This is a classic problem and is a sign that metrics are failing.

 

[RustedFox]

Perhaps some of these metrics could be useful for tracking and improving certain goals of patient care. But the problem is when they’re implemented in an irrational way, or manipulative or abusive way, then people abandon working toward the patient care goal, and the focus shifts so that hitting the metric becomes the goal. And this generates all kinds of creative workarounds that don’t accomplish the patient care goal the metric is supposedly in place to track. This is a classic problem and is a sign that metrics are failing.

You don't say?

 

[deleted547339]

That's the problem. You should tell your hospitalists not to document that. There is no reason for it to be documented as such. Do they also document "MI present at admission, acute pancreatitis present at admission," etc or do they just document it as a diagnosis?

I do both EM and ICU. Yes, we document everything as POA that is. This is what the all important O:E ratio is based on. Funding is based on O:E. If an intern writes ?sepsis in a note on a patient with 72 hours of admission I will get an email from some compliance something or other asking to document whether or not it is POA or not POA and whether or not it is confirmed, suspected, etc.

 

[southerndoc]

I believe this is also incorrect. If ‘sepsis present on admission’ is charted by an inpatient physician, but not by an EP, then the time of the inpatient physician’s note or the hospital admit order is used for the time of onset of sepsis, whichever is earliest. If ‘sepsis present on arrival’ is charted, then it is when the patient arrived to the ED.

I'm the sepsis police for my hospital and heavily involved in SEP-1 for our health system, and this is not how CMS has interpreted it with our retrospective cases (which we have challenged previously).

 

[Arcan57]

Pro-tip: CMS regulations always have significant gray areas. Think of it like A holy text. It’s there, it’s really really important to some people, running afoul of it invokes penalties that are feared by some and scoffed at by others, and there is an entire profession devoted to explaining how these cryptic, archaic texts actually apply to our present day actions.
It’s likely that even the relevant government agencies have variability in enforcement. Since the penalties are often threatened to end a hospital’s viability, numerous overly conservative rituals have developed in an attempt to keep Poseidon from summoning his waves to flatten the offending hospital.

Also, as painful and soul crushing as it is to interact with your hospital’s compliance officer, there is no logical argument or sick burn that’s going to make them stop. What enticement or threat can you make that outweighs the fear of having to go back to wiping up patients in gen pop after having been a warden?

 

[southerndoc]

Pro-tip: CMS regulations always have significant gray areas. Think of it like A holy text. It’s there, it’s really really important to some people, running afoul of it invokes penalties that are feared by some and scoffed at by others, and there is an entire profession devoted to explaining how these cryptic, archaic texts actually apply to our present day actions.
It’s likely that even the relevant government agencies have variability in enforcement. Since the penalties are often threatened to end a hospital’s viability, numerous overly conservative rituals have developed in an attempt to keep Poseidon from summoning his waves to flatten the offending hospital.

Also, as painful and soul crushing as it is to interact with your hospital’s compliance officer, there is no logical argument or sick burn that’s going to make them stop. What enticement or threat can you make that outweighs the fear of having to go back to wiping up patients in gen pop after having been a warden?

There are variabilities in enforcement from region to region. I knew of one region that didn't count prehospital hypotension before it was officially allowed to discredit it July 1 of this year.

Luckily my health system doesn't fire people over sepsis metrics (well, I'm sure if you failed consistently you would be fired). Nonetheless, I do believe it creates over treatment and over utilization of broad spectrum antibiotics. People are getting cultures and lactates where they normally wouldn't.

 

[turkeyjerky]

I'm the sepsis police for my hospital and heavily involved in SEP-1 for our health system, and this is not how CMS has interpreted it with our retrospective cases (which we have challenged previously).

Yeah, I think a lot of the issues here are with certain systems enforcing overly rigid interpretations of CMS metrics in order to ensure 100% adherence. Same thing happens with cva’s. They always present this as “we want to ensure even Higher Quality care”, ignoring the fact that BS antibiotics, lactates and fluid boluses have never been purported to have benefit in strep throat or the flu.

 

[goodoldalky]

This, my friends, is the law of unintended consequences.

CMG: "We need contracts. Our company has value only to the degree we take cash off the top. More sites, more contracts, more docs, more cash off the top. Let's talk to Best Hospital System."
Best Hospital System: "I suppose we are interested in you staffing our hospitals, but our reimbursement is affected by metrics such as HCAHPs scores, and if the ED provides a bad experience, our reimbursement goes down. You can staff our hospitals, but you need to meet Super Fast Door-to-Doc time metric, and Super Duper Press Ganey threshold. If you don't, we dock your group's pay by 15%."
CMG: "That sounds good to us. We can always ratchet down pay where needed, and we have tons of docs across the country that we can plug in here. We are in, and will deliver your Super Duper LOS and Press Ganey scores!"
CMG to Docs: "Listen up, people. I don't care if the patients leave without getting their workup complete. You need to click the button on the chart within 10 minutes. If they leave without being seen after that, they won't get a PG survey, and your LOS goal will be met. The excellent news is that if you meet these metrics, your pay will not receive a 15% penalty that it will receive if you miss. And if you miss, we will cut the PA in triage to make up for the cost, so that we can continue to drive profit to shareholders!"
Quality Frontline Attending Physician: "How in gods name did this keeping track of metric BS start? As a resident I was largely shielded from the absolute nonsense that is doc to door time, LOS, press ganey, etc etc etc. But now as an attending for the past year Im getting hammered with it. We just recently had an email telling us to get our arses out in the waiting room and draw blood if needed to get our LOS and doc to door times down or theyd take away a PA. How did this begin?"

This may seem bad, but it gets even worse...

Gullible Civilian: "Healthcare is too expensive, and I read a mom blog post referencing an obscure non-peer reviewed journal that said quality of healthcare in this country is not only expensive, it's also bad. Fix it!"
CMS: "Well then, we should start to pay for quality, and not just fee-for-service! It's too expensive, and it rewards things like... well, cardiologists doing all sorts of heart catheterizations for no good reason, to just rack up a bill."
Gullible civilian: "Fix it! Fix it!"
CMS: "Simple. We will review all of their heart catheterizations, and pay them based on quality. In this case, it's pretty easy, we can pay them based on their mortality rate! If people die, they get paid less. Live, paid more. What do you think?"
Gullible civilian: "It's perfect!"

Fast forward 2 years:

ER doctor: "Good morning, cardiologist. I have a patient here, Gullible Civilian, in the ED with a massive AMI s/p ROSC after a VF cardiac arrest."
Cardiologist: "Well, we aren't taking Gullible Civilian to the cath lab. They're too sick right now. Far too unstable. Treat them medically, and we will cath them in a couple of days, if they are still alive."

Fortunately, Cardiologist's PCI statistics are pristine, and the mortality rate is extremely low, making this facility a center of excellence, paid out in full for the highest quality.

(This is not an indictment of cardiologists, you can plug and play speciality and situation of your choice here. Most physicians I know across the board are wonderful professionals with the best of intentions and are suffering in a broken system with the rest of us.)

 

[Vandalia]

You're right. It's the perfect recipe for those in power to keep doing what they're doing.

We, excuse me, "you", I am still not use to that... still have some power.

When relatively few West Virginia specialists went on "strike" years ago delaying some elective cases, it was enough to force through some dramatic malpractice reforms in a state that has always been very pro-trial lawyer.

If physicians are willing to stick together and willing to sacrifice some income, and are smart enough to frame things correctly, e.g,, "it is not about income" then they do have some political power.

The problem of course is that those are incredibly large "if's." Right along the lines of IF everyone in America stopped drinking soft drinks and exercised for a half-hour a day we could solve Medicare insolvency....

But the idea that if things don't change "no one will want to do medicine" is absurdly false.

It is important to identify the correct source of power, even if the chances of it ever being used are nil.

 

[Birdstrike]

We, excuse me, "you", I am still not use to that... still have some power.

When relatively few West Virginia specialists went on "strike" years ago delaying some elective cases, it was enough to force through some dramatic malpractice reforms in a state that has always been very pro-trial lawyer.

If physicians are willing to stick together and willing to sacrifice some income, and are smart enough to frame things correctly, e.g,, "it is not about income" then they do have some political power.

The problem of course is that those are incredibly large "if's." Right along the lines of IF everyone in America stopped drinking soft drinks and exercised for a half-hour a day we could solve Medicare insolvency....

But the idea that if things don't change "no one will want to do medicine" is absurdly false.

It is important to identify the correct source of power, even if the chances of it ever being used are nil.

Of course, we as doctors have power. We have tremendous power. But I don't think doctors, as a group, have the guts to use their power, certainly not for any principles we're discussing. Most have sold out principle and sacrifice, for salary and lifestyle. (The exceptions to this rule may be a few specialists, usually surgeons and proceduralists, who traditionally are much more aggressive in defending themselves and their interests, without apology.) By and large, most doctors cave the minute they're accused of acting in their own self interest, or even faster if standing for principle requires a stoppage of income. It's not a matter of "if." It's a matter of "will."

Politicians and administrators aren't stupid. They know that if they ensure a >95 percentile income, they can get them to put up with anything.

 

[emergentmd]

I am so glad I have not had to deal with any metrics for 2 years. What a complete bunch of BS. There are no other fields that are held to the same standard.

 

[emergentmd]

What kind of power do EM docs really have. Lets pretend that we can get 1/2 of the EM docs to strike and take no pay for 2 wks.

The hospital and ER will stay open. They will bring in IM, FM docs to cover the holes. They will money whip the EM docs to working more hours. The ERs will get covered.

Sure there will be some media hoopla and the hospitals will get bad press. This will quickly die down.

In 1 month, the striking docs will have no jobs and likely black balled for the foreseeable future. What are you going to do to pay off your loan, house payments, 2nd wife?

The EM docs will blink much quicker than the hospitals would. Don't get me wrong. This applies to any field. Noone is inexpendible.

 

[bravotwozero]

Wouldn't say 'no one'. EM docs are absolutely replaceable. No one, not so much. Not that easy to replace a pediatric neurosurgeon or a CT Surgeon. Some places have like 6 peds neurosurgeons in the entire state. In fact, a hospital in houston went so far as to try and malign a CT Surgeon's character to prevent him from moving his practice to a competitor hospital. He sued them for defamation of character and was awarded $5 million.

 

[WilcoWorld]

In 1 month, the striking docs will have no jobs and likely black balled for the foreseeable future. What are you going to do to pay off your loan, house payments, 2nd wife?

This is a good argument for paying off your loans before you start living like an attending, keeping at least 6 mo of expenses in liquid savings, and preserving your 1st marriage.

Of course, you know all that without my telling you

 

[southerndoc]

Here is some more information for anyone that is curious.

"If the note states an infection was present on arrival, use the earliest documented arrival date and time. If the note states an infection was present on admission, use the earliest documented hospital observation/inpatient admission date and time."

https://www.sepsiscoordinatornetwork.org/wp-content/uploads/2018/05/Sepsis-Alliance-SEP-1-Core-Measure.pdf

I know this doesn't specifically address though if ED patients are considered 'admitted.' From what I understand regarding CMS and private insurance reimbursement, ED patients are not usually considered under inpatient status. If someone has specific information disputing this I would be curious to see it.

No they are not inpatient status in the ED. However, many places incorrectly use the term "admitted to the ER" with CMS being one of the ones who has used it in the past.

Like anything, it's always changing and subject to interpretation. What one region interprets as a SEP-1 fallout another region may not. Just like EMTALA violations.

 

[deleted820760]

- ridiculous patients that I know are going to give a bad press ganey are dx’d with “anxiety regarding health” as their primary dx in order to prevent them from getting a survey. Same with “drug seeker” diagnosis.

Interesting. I didn’t know certain patients don’t get a survey based on their diagnosis. Doesn’t their diagnosis show on their discharge papers? Those patients would have a fit if they saw they were labeled as drug seeker or having psych issues, even if it’s true.

Your NPO order idea made me chuckle, but so many patients in the ED request food shortly after arrival. Especially the homeless.

 

[Arcan57]

Interesting. I didn’t know certain patients don’t get a survey based on their diagnosis. Doesn’t their diagnosis show on their discharge papers? Those patients would have a fit if they saw they were labeled as drug seeker or having psych issues, even if it’s true.

Your NPO order idea made me chuckle, but so many patients in the ED request food shortly after arrival. Especially the homeless.

Some systems do filter their survey pool, some don't. Depending on your billing and coding departments, taking the time to filter out malingerers (and/or primary psych) may cause the survey to drop after the patient receives their bill. Since essentially everyone's view of their time in the ED is tarnished by the eye watering cost, from a system's view it's better to take the hit on a few patients with agendas than have many people respond due to sticker shock. Of course if you're the doc that has at least some part of their pay dependent on PG and of all the patients you saw that month, 1 of the 4 that got the survey happened to be a drug-seeker with a vendetta, it doesn't feel like the better choice.

Depending on EMR, the diagnosis and instructions on the discharge forms are selected by the provider. While certain EMRs pull up a list of suggested instructions based on the ICD-10 code, you're free to go off script. Now once our notes become available in real-time to the patient, ""labeling" is going to be an issue.

 

[RoyBasch]

"Wait; on one hand you want us to dispo them as quickly as possible - but on the other hand, you want us to take the time to explain everything to the patient, answer all their questions to satisfaction, and talk to their family member/other person in room. Those are diametrically opposing goals. Every minute that you take to do one thing, steals from the other."

I had this same conversation with an administrator once, the mental gymnastics that ensued afterwards were impressive.