New attending woes

[hopefulERdoc251]

Hey ya'll, had a question for everybody.

1 month out of being a new attending and definitely struggling. I feel like I'm overtesting (esp CT scans - d-dimers, CTAs for dissection etc) compared to my colleagues. Residency at a high volume/high acuity place so the sick patients are easier but for the fringe patients, I find myself more fearful than I was in residency of missing something and therefore have been overtesting (getting that extra CT, getting that d-dimer that invariably pidgeon holes me for a patient who's mildly tachcyardic and having intermittent CP). Most of those tests have been negative (had a few catches here and there) but I've been thinking of each patient as a potential lawsuit and I am not practicing great EBM. Have been afraid that I'm stepping on a landmine for some of these patients and therefore have been much more conservative.

Also trying to juggle volume at a current high acutiy place. Many of my colleagues are seeing 2+ pph with PA patients and I'm averaging 1.5pph atm with a few PA patients here and there. When my list gets to 8-9 patients I start to feel overwhelmed and need to tone back picking up patients because I feel uncomfy and feel like I'll miss something.

Any tips/tricks/advice that you guys have for combating this or is this just normal adjustment after starting residency?

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[southerndoc]

Most people who order less have been doing this for longer than you. Eventually you'll get your comfort zone.

 

[Tenk]

EBM doesn’t save you from a lawsuit.

Having patients like you actually saves you from a lawsuit more than anything. It’s the reason family doctors are rarely sued. Sadly, people like tests over not tests so ordering tests makes people like you more.

I order a ****ton of CTs. Definitely more than most. I am not slow. Some of the reasons have nothing to do with what I order but how I order. The second the patient comes back I’m in the room. Right after I see them I put in all my orders and everything I would even consider ordering. This means I’m not tagging on additional labs/imaging. X->Y->Z is far slower than XYZ. As soon as I get all my stuff back I dispo the patient. I don’t sit on anyone.

So if not ordering a ct will keep you up at night just order it and don’t fret it. Just figure out other ways to speed up your practice. Trust me, they exist.

 

[TooMuchResearch]

EBM doesn’t save you from a lawsuit.

Having patients like you actually saves you from a lawsuit more than anything. It’s the reason family doctors are rarely sued. Sadly, people like tests over not tests so ordering tests makes people like you more.

I order a ****ton of CTs. Definitely more than most. I am not slow. Some of the reasons have nothing to do with what I order but how I order. The second the patient comes back I’m in the room. Right after I see them I put in all my orders and everything I would even consider ordering. This means I’m not tagging on additional labs/imaging. X->Y->Z is far slower than XYZ. As soon as I get all my stuff back I dispo the patient. I don’t sit on anyone.

So if not ordering a ct will keep you up at night just order it and don’t fret it. Just figure out other ways to speed up your practice. Trust me, they exist.

What about patients that need a few hours of treatment with a fair probability of discharge home? Do you sit on those or just admit them?

 

[Tenk]

What about patients that need a few hours of treatment with a fair probability of discharge home? Do you sit on those or just admit them?

My main shop is a 21 bed ED in a critical access hospital (yes my ED has almost as many beds as my hospital) in a state with a critical bed shortage for four years running. I routinely correct DKA and convert to sliding scale, treat NSTEMIs for 48 hours on heparin and do all sorts of other crazy hospitalist **** I never got trained to do. I would definitely treat and discharge that patient because I need beds for sicker people that don’t exist anyways.

 

[cyanide12345678]

It will take you 6 months to find your groove as an attending. The first month is hard especially if you didn’t moonlight.

It’s okay to order more, life goes on. You might hone things in over time, but don’t worry if you order an extra dimer or two. Doesn’t matter.

 

[EctopicFetus]

I have hired a ton of young docs. It takes time to hit your groove. Honesltly, my experience is the people who train at high acuity big name programs are often woefully prepared to practice community EM. They never felt the pressure to dispo patients, they have near no ability to quickly dispo simple stuff cause they are looking for some needle in the haystack diagnosis that isn't there.

It took me some time to get my feet under me.. OP you will be fine.. Frankly it is a good sign you recognize this in yourself. It is also why I encourage my residents to moonlight at low volume places to get used to dispositioning people as the acuity is lower in general. Discharging a belly pain with no CT early in your career all alone can be nerve wracking.

You will catch up.. if you show up on day 1 and are amongst the fastest people wherever you work there is a problem.

I would say unlike others on here, don't order useless tests early on sure.. order some extra stuff to make you feel good but eventually be an actual doctor and not a robot ordering tests "just because". 1) doing that makes the nurses hate you 2) doing that is terrible patient care 3) if in a high volume place your colleagues will hate you 4) its very very bad patient care.

Again, sometimes you have to order a stupid test for any number of reasons but it shouldn't a regular thing.

One of the questions I ask my residents is why are you ordering this test? What are you looking for?

If you don't know radiology has a major shortage of docs. Much of it is from the testing boom post covid. I think part of this is the docs who trained then have no idea how to practice EM. The students also had no experience but I'm not sure that matters as much as they could pick up much of this in their training.

 

[Porfirio]

Worry less about over ordering. Worry more about not ordering enough. You are young and most likely to make a mistake right now. You were hired knowing you are new. Always do what you think is right for the patient, so you can sleep well at night.

 

[odyssey2]

I’m in radiology, you should definitely order less 🙂

We know the ER docs who over-order and we dread the shifts with them.

 

[HemeOncHopeful19]

I find myself more fearful than I was in residency of missing something

 

[Apollyon]

No, nurses hate you if you add to their work. So, order everything all at once. Do NOT "nickel and dime" along, adding this, then that, then this. That will mark you as "ugh, it's him".

 

[gruemd]

Order what you feel in your bones and ignore haters for the first 3-6 months. Do what lets you sleep at night without feeling like you missed something. Agree with the "no nickel and diming", though sometimes it just happens, oh well. Don't worry about being the fastest or moving the meat your first 3-6 months, worry about good workups and becoming efficient, then the speed will come.

Also, I CT people probably more than I should if we're talking about just the EBM part (though not nearly as much as some of my colleagues). But I'll stop doing it when the legal environment in the US is different, and when patient satisfaction metrics are uncoupled from pay and the likelihood of my group contract being renewed.

Lastly, FWIW, I have yet to meet a radiologist who will come evaluate a patient in person to tell me why they think an order isn't justified, though it's an open invitation 🙃

 

[BoardingDoc]

Lastly, FWIW, I have yet to meet a radiologist who will come evaluate a patient in person to tell me why they think an order isn't justified, though it's an open invitation 🙃

There was one during residency that would come see patients at times based on the indication for the study and then suggest different imaging studies. She was great. Absolute unicorn.

 

[thegenius]

Hey ya'll, had a question for everybody.

1 month out of being a new attending and definitely struggling. I feel like I'm overtesting (esp CT scans - d-dimers, CTAs for dissection etc) compared to my colleagues. Residency at a high volume/high acuity place so the sick patients are easier but for the fringe patients, I find myself more fearful than I was in residency of missing something and therefore have been overtesting (getting that extra CT, getting that d-dimer that invariably pidgeon holes me for a patient who's mildly tachcyardic and having intermittent CP). Most of those tests have been negative (had a few catches here and there) but I've been thinking of each patient as a potential lawsuit and I am not practicing great EBM. Have been afraid that I'm stepping on a landmine for some of these patients and therefore have been much more conservative.

Also trying to juggle volume at a current high acutiy place. Many of my colleagues are seeing 2+ pph with PA patients and I'm averaging 1.5pph atm with a few PA patients here and there. When my list gets to 8-9 patients I start to feel overwhelmed and need to tone back picking up patients because I feel uncomfy and feel like I'll miss something.

Any tips/tricks/advice that you guys have for combating this or is this just normal adjustment after starting residency?

I would not change a single aspect of what you do to "modify your statistics". That would be disastrous.

Over time you will (probably) become more comfortable and order less.

Or perhaps I'm wrong and you'll scan everybody for ever. And you know what???

NGAF what you do. Make pts happy and you'll have as easy as a life one can have in EM.

 

[thegenius]

EBM doesn’t save you from a lawsuit.

Having patients like you actually saves you from a lawsuit more than anything. It’s the reason family doctors are rarely sued. Sadly, people like tests over not tests so ordering tests makes people like you more.

+1

 

[thegenius]

My main shop is a 21 bed ED in a critical access hospital (yes my ED has almost as many beds as my hospital) in a state with a critical bed shortage for four years running. I routinely correct DKA and convert to sliding scale, treat NSTEMIs for 48 hours on heparin and do all sorts of other crazy hospitalist **** I never got trained to do. I would definitely treat and discharge that patient because I need beds for sicker people that don’t exist anyways.

Well, there you go. So much for ordering XYZ-ABC-123 all off the bat if you are managing an NSTEMI in the ED for 48 hours. What a f'ed up hospital system you work in.

 

[thegenius]

Lastly, FWIW, I have yet to meet a radiologist who will come evaluate a patient in person to tell me why they think an order isn't justified, though it's an open invitation 🙃

Ding Ding!!!

 

[TooMuchResearch]

I’m in radiology, you should definitely order less 🙂

We know the ER docs who over-order and we dread the shifts with them.

Our radiologists are a private group and don't seem to mind.

Our patients expect imaging, the people that send them in expect imaging, the nurses expect imaging, and I'm getting sick of getting patient complaints for practicing appropriate medicine.

I think sometimes it's okay to find the unlikely diagnosis on a second visit, but people who like committees more than me feel differently.

 

[TooMuchResearch]

Order what you feel in your bones and ignore haters for the first 3-6 months. Do what lets you sleep at night without feeling like you missed something. Agree with the "no nickel and diming", though sometimes it just happens, oh well. Don't worry about being the fastest or moving the meat your first 3-6 months, worry about good workups and becoming efficient, then the speed will come.

Also, I CT people probably more than I should if we're talking about just the EBM part (though not nearly as much as some of my colleagues). But I'll stop doing it when the legal environment in the US is different, and when patient satisfaction metrics are uncoupled from pay and the likelihood of my group contract being renewed.

Lastly, FWIW, I have yet to meet a radiologist who will come evaluate a patient in person to tell me why they think an order isn't justified, though it's an open invitation

Every time I want to stop ordering so many damn CTs, I find something weird and surgical that I wasn't expecting, and then I forget about my plan about ordering less CTs.

 

[Tenk]

Well, there you go. So much for ordering XYZ-ABC-123 all off the bat if you are managing an NSTEMI in the ED for 48 hours. What a f'ed up hospital system you work in.

Tell me about it. Technically that patient was going to be admitted anyways so overall it doesn’t change anything they just became a border.

Oregon as a state has become a dumpster fire post Covid and I'm going to be moving back to watch movies after getting drunk at Red Robin with @AlmostAnMD soon.

 

[cyanide12345678]

I CT 27 ish percent of people between 18 and 65 year olds that are discharged and not involved in a trauma. I’m at the 70th percentile for my 200-300 doc system. The goal for this metric sits at 20 percent i believe (or was it 25? I don’t remember)

Here’s how my quarterly check ins go with my med director:

‘You’re doing great. Keep it up. Oh yeah they’re monitoring the number of CTs we order but don’t worry about it. You do what you think needs to be done’

You’ll 100% get in trouble for missing a big diagnosis, never For being extra careful. Granted I was named in a lawsuit as a pgy2 for literally responding to a code blue, so i like to protect myself first before anything else.

 

[Groove]

The fact that you're concerned about your performance and unsure of yourself is actually very reassuring insomuch that you are not a half cocked Dunning-Kruger grad who gets shell shocked back to reality with a bad outcome or lawsuit. All that being said, everyone is different in their practice style and as many have already stated in this thread...getting into a comfortable rhythm with some practice confidence can take some time as well as experience. I was probably very much like you in my early years and over tested but my style has most definitely evolved to the point that I'm probably the groups biggest minimalist these days. Then again, I probably have 100K+ patient experiences under my belt to draw upon whereas you won't have that luxury this early and that's perfectly ok. Better to be cautious than cavalier when you're starting out IMO.

 

[TooMuchResearch]

I CT 27 ish percent of people between 18 and 65 year olds that are discharged and not involved in a trauma. I’m at the 70th percentile for my 200-300 doc system. The goal for this metric sits at 20 percent i believe (or was it 25? I don’t remember)

Here’s how my quarterly check ins go with my med director:

‘You’re doing great. Keep it up. Oh yeah they’re monitoring the number of CTs we order but don’t worry about it. You do what you think needs to be done’

You’ll 100% get in trouble for missing a big diagnosis, never For being extra careful. Granted I was named in a lawsuit as a pgy2 for literally responding to a code blue, so i like to protect myself first before anything else.

They tried showing us metrics like this about 5+ years ago (imaging utilization, admission rates, door to doc, doc to dispo, etc) but overall we weren't interested and that's the last I heard of it.

 

[EctopicFetus]

They tried showing us metrics like this about 5+ years ago (imaging utilization, admission rates, door to doc, doc to dispo, etc) but overall we weren't interested and that's the last I heard of it.

The amount of wasted effort by systems on this is amazing. Where I work this is where we are with pt satisfaction. They show us scores every now and then.. tell us it’s important and then nothing. Our ascores arent bad but they are not amazing. We remind them that their behavior / staffing/ throughput have more of an impact on our scores than anything we do. I never sit when i see patients unless im breaking bad news. It is fascinating to me. Report scores.. do nothing with them. IMO the issue is addressing the outliers. We have docs where if you are seen by them you are about 2x as likely to be admitted. Thats a problem. I have also seen a doc who is 3+SD above the mean in CT utilization. We can all sit around and make excuses but there is a problem there. I think if you are with 1 SD of other docs at your site controlled for shift time (after 6-12 months post residency) then you are fine, this is true for almost any metric.

 

[deleted1140701]

I CT pretty much every non-pregnant abdominal pain. Too much to lose with a miss. Patients are way happier too. I've noticed a lot of bouncebacks in patient's not CTed the first time. Just last night I had two cases of cholecystitis with normal labs and vitals with "epigastric pain radiating to chest for 2 months" in otherwise health early 20s females. Per the metrics, I'm still around the mean. Even if I weren't I wouldn't really care.

 

[WhatJobDoIPick]

I'm a very high CT utilizer, but my LOS is below the mean. It's because I pull the trigger on CT very early.

 

[Kryptocoin]

It's certainly okay to still have some hesitancy six months out of residency. We've all been there. I'd be more worried if you still practice like this two years out. I dread taking sign-outs from docs who order everything and then leave you a messy sign-out. I also hate working shifts with them because they tie up the waiting room doing big workups.

At some point, we have to differentiate ourselves from mid-levels because they just shotgun everything and hope for the best.

 

[WhatJobDoIPick]

They tried showing us metrics like this about 5+ years ago (imaging utilization, admission rates, door to doc, doc to dispo, etc) but overall we weren't interested and that's the last I heard of it.

I disagree about the take on metrics here.

LOS type metrics like doc to dispo are a reflection of the health of the department. Being really slow is not good for patients or your colleagues. It's also not good business if you're an SDG. We need to turn over those rooms. I aim for 3-4 hours for discharged patients and to be moderately better than average. Being too fast is not good either.

I also aim to be mild to moderately better than average in pts/hr, RVUs/pt...and their product, RVUs/hr. Don't be an outlier either way.

Patient satisfaction, sometimes a PITA, is actually important too. We know that happier patients sue less and adhere more to our advice. It makes hospital admin happy.That doesn't mean you need to sling narcs and MRIs around. Sitting actually helps, and is a nice break sometimes. I try my best to shake everyone's hand in the room. Patients eat it up and it takes seconds. I still have time to see 2pph and have all my charts done when I go home.

 

[bky3c]

I disagree about the take on metrics here.

LOS type metrics like doc to dispo are a reflection of the health of the department. Being really slow is not good for patients or your colleagues. It's also not good business if you're an SDG. We need to turn over those rooms. I aim for 3-4 hours for discharged patients and to be moderately better than average. Being too fast is not good either.

I also aim to be mild to moderately better than average in pts/hr, RVUs/pt...and their product, RVUs/hr. Don't be an outlier either way.

Patient satisfaction, sometimes a PITA, is actually important too. We know that happier patients sue less and adhere more to our advice. It makes hospital admin happy.That doesn't mean you need to sling narcs and MRIs around. Sitting actually helps, and is a nice break sometimes. I try my best to shake everyone's hand in the room. Patients eat it up and it takes seconds. I still have time to see 2pph and have all my charts done when I go home.

I agree with you... but IME, the trash can (or biohazard bin) lid ends up being the default "doctor's chair." Hospitals need to do better (and society... patients' visitors putting their feet or personal items on the available chairs).

Also agree with everyone above. Ordering what allows you to sleep at night is fine when you're new. Better to err in that direction than to start your career with a big miss and the guilt and/or lawsuit that come with it.

 

[TooMuchResearch]

Hey you know what OP?
I cycle between trying to use my brain and just shot gunning anything and everything.
After a recent patient complaint I'm cycling back to open season for testing, brain need not come with me to work.

 

[WhatJobDoIPick]

Hey you know what OP?
I cycle between trying to use my brain and just shot gunning anything and everything.
After a recent patient complaint I'm cycling back to open season for testing, brain need not come with me to work.

I lean towards testing heavy for this reason.

Most patients are unintelligent. They don't want to hear your reasoning. They want tests. If you deny tests, you get complaints.

There's a subset, maybe 10% of patients or so, that you can engage with intellectually. These encounters are very fulfilling for me

 

[thegenius]

I lean towards testing heavy for this reason.

Most patients are unintelligent. They don't want to hear your reasoning. They want tests. If you deny tests, you get complaints.

There's a subset, maybe 10% of patients or so, that you can engage with intellectually. These encounters are very fulfilling for me

I find that your percentages are off. For me it's more like 66% engage vs 33% not engage.

I get way more in the not engage group. This group also includes those with language barriers, even if using a certified translator.

 

[Arcan57]

I lean towards testing heavy for this reason.

Most patients are unintelligent. They don't want to hear your reasoning. They want tests. If you deny tests, you get complaints.

There's a subset, maybe 10% of patients or so, that you can engage with intellectually. These encounters are very fulfilling for me

That sounds like a path to burning out quickly. If your patients aren't meth'ed out, somewhere around 3/4 to 4/5 of them should be engageable. If you're only clicking with 10%, have you looked into modifying your approach or else seeking a practice environment that's more simpatico?

FWIW, patients don't want to hear your reasoning if they don't feel like you care about them or take them seriously. Once you've connected emotionally, you can give your reasoning but mostly they want to know that someone competent is looking out for them. For most visits, the patient is still going to leave 1) feeling unwell and 2) not having a definitive 100% guaranteed diagnosis. Getting comfortable with discussing that with a patient is a useful skill, regardless of whether a CT was ordered. Unless you're missing stuff left and right, most of your CT ABD/PEL are going to be either negative or have incidental pathology, so you're still dealing with convincing a patient that feels sick to go home.

 

[Angry Birds]

Hey you know what OP?
I cycle between trying to use my brain and just shot gunning anything and everything.
After a recent patient complaint I'm cycling back to open season for testing, brain need not come with me to work.

Ok I think you all are onto something but let me develop it further.

Patients want something. It is a transactional encounter. They spend their time (and sometimes copays) and want to get something worthwhile out of it. Your words alone are not worth much to them.

So, you either need to test a lot and show them the negative results. OR you need to treat their symptoms aggressively.

Oftentimes the latter approach can save tons of time. I give high doses of meds in my first volley of treating pain, nausea, anxiety, whatever.

If I go the second route, I’ll often say something like, “Look, I got good news and bad news. The bad news is that I am not confident we can figure this out today, as this requires follow up with (insert specialist). But the good news is that I can aggressively treat (insert symptom) and make you feel a ton better today. Sound good? Any questions?”

I routinely see other ER docs under- treating and over-testing. That leads to prolonged throughput times. I give 1 walloping dose of whatever and tell them to call their ride.

For the ones getting heavy testing, I make sure everything is done in parallel and call/annoy the radiology tech every time, and peskily keep asking the nurse, “is he in CT yet?”

 

[Angry Birds]

That sounds like a path to burning out quickly. If your patients aren't meth'ed out, somewhere around 3/4 to 4/5 of them should be engageable. If you're only clicking with 10%, have you looked into modifying your approach or else seeking a practice environment that's more simpatico?

FWIW, patients don't want to hear your reasoning if they don't feel like you care about them or take them seriously. Once you've connected emotionally, you can give your reasoning but mostly they want to know that someone competent is looking out for them. For most visits, the patient is still going to leave 1) feeling unwell and 2) not having a definitive 100% guaranteed diagnosis. Getting comfortable with discussing that with a patient is a useful skill, regardless of whether a CT was ordered. Unless you're missing stuff left and right, most of your CT ABD/PEL are going to be either negative or have incidental pathology, so you're still dealing with convincing a patient that feels sick to go home.

I am in the camp that thinks talking to patients a lot is a huge waste of time. Test or treat is my philosophy. Talking is torture.

 

[Angry Birds]

I lean towards testing heavy for this reason.

Most patients are unintelligent. They don't want to hear your reasoning. They want tests. If you deny tests, you get complaints.

There's a subset, maybe 10% of patients or so, that you can engage with intellectually. These encounters are very fulfilling for me

Denying tests is if they specifically ask for it. In that case, I think you’re right. Unless it’s totally unreasonable, I do let patient preference play a significant role for imaging in many cases.
However, I actually don’t think they all want testing. They want something. Sometimes treatment can be that something. But words alone mean nothing to them. You gotta give them something tangible.

 

[Angry Birds]

Hey ya'll, had a question for everybody.

1 month out of being a new attending and definitely struggling. I feel like I'm overtesting (esp CT scans - d-dimers, CTAs for dissection etc) compared to my colleagues. Residency at a high volume/high acuity place so the sick patients are easier but for the fringe patients, I find myself more fearful than I was in residency of missing something and therefore have been overtesting (getting that extra CT, getting that d-dimer that invariably pidgeon holes me for a patient who's mildly tachcyardic and having intermittent CP). Most of those tests have been negative (had a few catches here and there) but I've been thinking of each patient as a potential lawsuit and I am not practicing great EBM. Have been afraid that I'm stepping on a landmine for some of these patients and therefore have been much more conservative.

Also trying to juggle volume at a current high acutiy place. Many of my colleagues are seeing 2+ pph with PA patients and I'm averaging 1.5pph atm with a few PA patients here and there. When my list gets to 8-9 patients I start to feel overwhelmed and need to tone back picking up patients because I feel uncomfy and feel like I'll miss something.

Any tips/tricks/advice that you guys have for combating this or is this just normal adjustment after starting residency?

It’s fine to start out this way. But please don’t let it persist. Don’t be that guy.

 

[DOswag]

Hey ya'll, had a question for everybody.

1 month out of being a new attending and definitely struggling. I feel like I'm overtesting (esp CT scans - d-dimers, CTAs for dissection etc) compared to my colleagues. Residency at a high volume/high acuity place so the sick patients are easier but for the fringe patients, I find myself more fearful than I was in residency of missing something and therefore have been overtesting (getting that extra CT, getting that d-dimer that invariably pidgeon holes me for a patient who's mildly tachcyardic and having intermittent CP). Most of those tests have been negative (had a few catches here and there) but I've been thinking of each patient as a potential lawsuit and I am not practicing great EBM. Have been afraid that I'm stepping on a landmine for some of these patients and therefore have been much more conservative.

Also trying to juggle volume at a current high acutiy place. Many of my colleagues are seeing 2+ pph with PA patients and I'm averaging 1.5pph atm with a few PA patients here and there. When my list gets to 8-9 patients I start to feel overwhelmed and need to tone back picking up patients because I feel uncomfy and feel like I'll miss something.

Any tips/tricks/advice that you guys have for combating this or is this just normal adjustment after starting residency?

Hell hopefulERdoc251, I felt that way for a little bit out of psych residency. I think it's pretty normal for most if not all docs to feel this to some sense out of residency. I remember the first patient I saw starting them on zoloft and thought "I don't have to run this by anyone? What if they develop serotonin syndrome? Do I need to order X, Y, Z labs on a 25 year very healthy individual who's only complaint is anxiety due to work stress? What if they have a manic episode? What if, what if, what if...?" It'll pass as you get more comfortable. I was also in the military and had to learn how to think "how does me starting X medication impact their military career? How do I put them on a profile? What if this leads them down the path of getting medically discharged from the military?" Yeah that part of milmed was a pain in the a$$ for sure...

You'll be fine

 

[Arcan57]

I am in the camp that thinks talking to patients a lot is a huge waste of time. Test or treat is my philosophy. Talking is torture.

I will whole heartedly agree that if you think talking to patients is a huge waste of time, then it will be a huge waste of time. Having spent a decent amount of my career cleaning up after docs that don't talk to their patients, I agree with you that overtesting is pretty useless. The number of complaints I've dealt with involving docs that "did nothing for me" when they got a CBC, CMP, trop, EKG, lipase, UA, RUQ U/S, and CT ABD/PEL w/ IV contrast is unfathomably high. The "hitting them hard initially" treatment pathway is very much a double edged sword: 1) You have to be correct that what's causing their symptoms is self-limited and benign and 2) You are hosing every doc that comes after you that doesn't snow the patient with you favorite cocktail. If you're really accurate with the first and don't care about the second, it's a great way to be top tier in terms of throughput metrics and it means all those messy interactions get foisted onto someone else (either next doc or medical director).

 

[Angry Birds]

I will whole heartedly agree that if you think talking to patients is a huge waste of time, then it will be a huge waste of time. Having spent a decent amount of my career cleaning up after docs that don't talk to their patients, I agree with you that overtesting is pretty useless. The number of complaints I've dealt with involving docs that "did nothing for me" when they got a CBC, CMP, trop, EKG, lipase, UA, RUQ U/S, and CT ABD/PEL w/ IV contrast is unfathomably high. The "hitting them hard initially" treatment pathway is very much a double edged sword: 1) You have to be correct that what's causing their symptoms is self-limited and benign and 2) You are hosing every doc that comes after you that doesn't snow the patient with you favorite cocktail. If you're really accurate with the first and don't care about the second, it's a great way to be top tier in terms of throughput metrics and it means all those messy interactions get foisted onto someone else (either next doc or medical director).

As long as I don’t have to talk to them