Possible to work all day shifts?

[LiamNeesons]

Is it possible to work all day shifts, or are you constantly switching between days/nights at most places? I'm interested in rural EM.

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[Doctor Bob]

Is it possible to work all day shifts, or are you constantly switching between days/nights at most places? I'm interested in rural EM.

Anything is possible. It depends on the arrangement you make with the group you join.

 

[Makati2008]

Yes it is. I worked at my old job 8-5 M-F but worked a weekend of night call per month as my choice. I had that job as a PA but God willing I will be an EP there in the future

 

[Birdstrike]

Is it possible to work all day shifts, or are you constantly switching between days/nights at most places? I'm interested in rural EM.

This would be exceedingly difficult to find. There would almost certainly be swing shifts required, late shifts that aren't "nights" but really are nights (6pm-2am, for example) or some sort of "deal with the devil" for getting rid of all nights and swing shifts, like doing all weekends, or holidays. Sure anything is possible, like being a General Surgeon who sleeps in until 9am, doesn't ever go to the OR before 10 am and never takes call. There's also Big Foot, matching all five numbers in the MegaMillions lottery plus the Megaplier, friendly space creatures that let you take their spaceship for a spin around the Milky Way, and the Chupacabra, too. Sure, its possible, just don't count on ever seeing it in this lifetime.

 

[jendc08]

Possible but unlikely unless you are doing urgent care. If you are doing all the day shifts who does the nights? Sometimes the overnights are covered by nocturnists...but shifts like a 4p-2a still need to be covered by the rest of the group.

 

[jendc08]

Possible but unlikely unless you are doing urgent care. If you are doing all the day shifts who does the nights? Sometimes the overnights are covered by nocturnists...but shifts like a 4p-2a still need to be covered by the rest of the group.

 

[jendc08]

No idea why it posted twice

 

[GeneralVeers]

It is possible. My current (soon to be former) group has 6 docs who do all nights. As a result, I never do do night shifts. You can find groups like that, but be advised it can change at any time. If one of the "night docs" quits, then you may get stuck with a few night shifts.

 

[The White Coat Investor]

We have 5 eight-hour shifts (6, 11, 2, 7, 10.) Most of the group very rarely works 10s, and works few of the 7s. Several docs work only 6s and 11s. One only works 11s. They pay the rest of us to work their nights. It's not a deal with the devil, but we make more money and they get a better lifestyle. It's fair. And when it isn't, we adjust the shift differentials.

 

[Birdstrike]

Is it possible to work all day shifts, or are you constantly switching between days/nights at most places? I'm interested in rural EM.

Take very close note of all these replies. None of them actually answered the question you asked.

Yes it is. I worked at my old job 8-5 M-F but worked a weekend of night call per month as my choice. I had that job as a PA but God willing I will be an EP there in the future

Question asked: "Is it possible to work all day shifts?"
Question Makati2008 actually answered: "Is it possible for an EM PA to have a... s w e e t ...8am-5pm M-F schedule?"

A PA schedule does not equal a doctor schedule. Extenders are typically put on day- and swing-shifts for added coverage during peak times and rarely overnight shifts to begin with, unlike doctor schedules. Makati2008 will never see that schedule again; not as an EP getting an EP salary. 8am-5pm M-F only, as an EP? No way. Show me this and I'll show you blind leprechaun with a side gig as a radiologist.

Possible but unlikely unless you are doing urgent care. If you are doing all the day shifts who does the nights? Sometimes the overnights are covered by nocturnists...but shifts like a 4p-2a still need to be covered by the rest of the group.

Question asked: "Is it possible to work all day shifts?"
Question jendc08 answered: "Is it possible to work all day shifts in urgent care?"

Typically urgent care shifts are 7am-7pm or something close to that. One does not have to even do an EM residency to work in urgent care. Anything that is an actual "emergency" is sent directly to an ED. Since, "urgent care" is not emergency medicine, by definition, this exception actually proves the rule.

It is possible. My current (soon to be former) group has 6 docs who do all nights. As a result, I never do do night shifts. You can find groups like that, but be advised it can change at any time. If one of the "night docs" quits, then you may get stuck with a few night shifts.

Question asked: "Is it possible to work all day shifts?"
Question GeneralVeers answered: "Is it possible to not have to do the most extreme late shift, yet still get stuck with a few when the "night doc" quits?"

Getting "stuck with a few nights" does not equal "working all day shifts." Most man hours in the typical Emergency Department are between late morning to very late evening (10-11am until 11pm-12am). Getting out of the most extreme late shift (ie, 11pm-7am or 9pm-7am) in no way guarantees getting out of swing shifts (noon-midnight, 3pm-11pm, or 6pm-4am, for example). In fact, it likely means more of those shifts. Swing (afternoon) shifts are not day shifts. This is another "exception" that actually proves the rule.

Day shift (6am-2pm, 9am-5pm, or something very close to this) = starting shift rested; having dinner with kids/spouse/significant other; see kids/significant other after school/work that day.
Swing/afternoon shift (3pm-11pm, noon - midnight) = starting shift generally rested, but inhaling pop-tart from doctors lounge between patients circa 7pm at work, not having dinner with kids/spouse/significant other; not seeing kids/spouse/sig.other that day after school/work.

We have 5 eight-hour shifts (6, 11, 2, 7, 10.) Most of the group very rarely works 10s, and works few of the 7s. Several docs work only 6s and 11s. One only works 11s. They pay the rest of us to work their nights. It's not a deal with the devil, but we make more money and they get a better lifestyle. It's fair. And when it isn't, we adjust the shift differentials.

(I'm assuming he is referring to the following 8 hour shifts: 6am-2pm, 11am-7pm, 2pm-10pm, 7pm-3am and 10pm-6am)

Question asked: "Is it possible to work all day shifts?"
Question The White Coat Investor answered: "Is it possible, that by agreeing to a pay cut, I may be able to avoid having to work any 10pm to 6am shifts, have to work some, but less 7pm-3am shifts, and as a result get more "day" shifts such as 6am-2pm shifts, and also have to work more swing shifts such as 11am-7pm, and 2pm-10pm?"

Again, working some 6am-2pm "day" shifts, but also lots of 2pm-10pm shifts and some, but not many 7pm-3am shifts, does not equal "working all day shifts." This exception also proves the rule.




Rule: It is (almost) impossible to work "all day shifts" as an Emergency Physician. (That is to the extent that you define "days shift" like the rest of the non-EM world does, ie, starting a shift after 6am and being home to see your family/signficant other after school/work or for dinner, at a traditional time). The only legitimate exceptions I can think of, thinking outside the box very hard, would be if you were at a single job for 20 years, ruled the place, were director and made your own schedule. This could work but would not be available to many and would irritate anyone else in the group, and might not last for that reason. At that point, as a director 20 years in, you likely wouldn't be working many shifts at all to begin with, so it's a moot point. Another, would be to not have a single job, but to be credentialed at multiple desperate locums sites an only cherry pick one or two day shifts per month at each place. Again, this wouldn't likely last, as those shifts would be first to fill with the local docs and wouldn't last long once they realized their locums fill-in guy only wanted to cherry pick their favorite day shifts.

 

[Brigade4Radiant]

Is it possible to work all day shifts, or are you constantly switching between days/nights at most places? I'm interested in rural EM.

Yes in the South and being board certified you can work what shifts you want.

 

[NERDY]

It is possible. My current (soon to be former) group has 6 docs who do all nights. As a result, I never do do night shifts. You can find groups like that, but be advised it can change at any time. If one of the "night docs" quits, then you may get stuck with a few night shifts.

Are you leaving vegas?

 

[deleted6669]

there are docs in my group who work all cush 8-9 hr day shifts. they trade their assigned nights away to the younger guys and pay them a bit extra in the mix for the favor. one of our senior guys has done this for over a decade. he only works 11a-7p shifts.
some groups pay more for nights so folks looking to pay back loans faster, make more money, etc can opt for all nights. if you are single and under 40 it's not a bad deal. I'm not a doc but I work all nights at my primary EM PA job (8p-7a). I actually prefer this over rotating shifts. much easier on the circadian rhythm.

 

[Apollyon]

8am-5pm M-F only, as an EP? No way. Show me this and I'll show you blind leprechaun with a side gig as a radiologist.

You better break out your Lucky Charms, then. I work with a guy that does Weds, Thurs, Fri day every week - no overnights, and no weekends. I do weekends only, and there is a guy that works 22-23 nights per month. We get EM pay (not great, but not the worst - about 45th percentile).

So, to affirmatively, black-letter, full-stop say that it doesn't happen is just not true, even if mine is the only anecdote.

edit: However, it IS 8a-8p. I guess that gives you an out.

 

[GeneralVeers]

Are you leaving vegas?

Not physically though I will be doing locums out of state.

Our hospital unceremoniously cancelled our contract after being caught in a conflict of interest and possibly committing EMTALA violations. They scapegoated the doctors and cancelled our contract in an effort to try and shift the blame. Read about it here:

http://www.lasvegassun.com/news/201...ngly-sending-patients-umc-stat/#axzz2YDrLwuqD

and here:

http://www.lasvegassun.com/news/2013/apr/18/st-rose-hospitals-drop-er-doctors-group/#axzz2YDrLwuqD

The hospital then hired a new group, owned by one guy (who has crooked ties to administration). The new group offered to keep us on with $10 more per hour, but minimum 20 hours more per month, 30% cut in our 401K, 5 vacation days less per month, no ownership in the new group, and health insurance not contracted at our own hospital (with more out-of-pocket expenses). The hospital was never a great place to work anyway and had burned most of us out, what with the holding 35 patients in our 30 ED bed every day. 20 of 30 doctors promptly said no thank-you to the offer and are seeking other employment.

 

[KinesiologyNerd]

As birdstrike points out, this doesn't really answer your question. With that said, the EM group I scribed for (and wouldn't mind returning to as an attending) does 4 months of days, 2 months of nights. So you aren't switching week of days/week of night or even switching around within your week. I could live with the 4/2 arrangement. Then again I'm young and night shifts are my favorite.

 

[Birdstrike]

there are docs in my group who work all cush 8-9 hr day shifts. they trade their assigned nights away to the younger guys and pay them a bit extra in the mix for the favor. one of our senior guys has done this for over a decade. he only works 11a-7p shifts.
some groups pay more for nights so folks looking to pay back loans faster, make more money, etc can opt for all nights. if you are single and under 40 it's not a bad deal. I'm not a doc but I work all nights at my primary EM PA job (8p-7a). I actually prefer this over rotating shifts. much easier on the circadian rhythm.

Why does that doc "pay them a bit extra" to work their nights? Because he's done plenty of them before and doesn't like them. That's one EM doc that worked plenty of nights that got him to the point that he's paying someone else to take the nights on his schedule. That is not someone who "worked only days" for his career. Why don't Derm MDs not have to pay their partners "extra in the mix" to cover their night shifts? 'Cause Derm truly does work "only day shifts." Ask a Dermatologist how many nights and swing shifts he's one post residency and the answer will be "zero" every time. Ask any EP the same question, and it will never be "zero." Another exception that proves the rule.

You better break out your Lucky Charms, then. I work with a guy that does Weds, Thurs, Fri day every week - no overnights, and no weekends. I do weekends only, and there is a guy that works 22-23 nights per month. We get EM pay (not great, but not the worst - about 45th percentile).

So, to affirmatively, black-letter, full-stop say that it doesn't happen is just not true, even if mine is the only anecdote.

edit: However, it IS 8a-8p. I guess that gives you an out.

Don't count your "luck" charms, yet. 8am-8pm is a "day" shift, alright. It's a day shift, and a HALF of a swing shift: a "shift and a half." 8am-8pm is as much a "day shift" as is 4am-4pm. Both guys work the "day shift" from 8am-4pm. One stays for an extra half afternoon shift from 4pm-8pm and his butt isn't on his couch until 9pm. The other tacks a half night shift on prior to his "day shift" and works from 4am-8am before finishing out the other 8 hours. How many times did your 8-8 guy work shifts past 8pm or straight up nights in his career? Never? I bet: plenty. How long will his 8-8 arrangement last? There's no guarantee. Another exception that proves the rule.


Go ahead. Tell pre-meds and med students they can go into EM and "work all days." Have them waltz right into their first job interview asking to work "all days." See them get laughed right off the interview trail. See if you are doing them a favor. SDN should be better than this.

 

[Doctor Bob]

There is a possibility which might allow you to work lots of days fresh out of residency.

You mentioned being interested in rural EM. If you're a residency-trained EM person and you want to go work at a rural EM that's currently staffed by FM-trained or IM-trained docs, you might have some leverage. But even that's not a guarantee.

Expect to take your scheduling lumps coming out of residency, and then if you luck out and find the perfect gig, you'll be pleasantly surprised.

 

[suckstobeme]

1) If you are dead set against night shifts or really hate them, maybe EM is not the specialty for you.
2) If you are thinking about rural EM, you should be thinking 24hr shifts- which are suprisingly totally awesome (in the right places)

 

[Xerxes1729]

Going into EM with a plan to find a place where you can work only 9a-5p is like signing up for the basketball team in high school with a plan to play in the NBA. It's not necessarily impossible, but counting on it is not a wise choice.

 

[NERDY]

At a place I interviewed for residency, the hospital has a core group of doctors who do only nights (the only night docs get some sort of differential for working only nights). The rest of the night shifts are covered by core faculty. Thus, the non-core faculty doctors only have to work an occasional over night since the majority are covered. I think this arrangement is the exception more than the norm.

 

[dchristismi]

I've been pondering this, and it dawned on me that I have a partner who only works 9-5 shifts.

And he's a wheelchair-bound paraplegic after a horrific MVC a couple of years after he finished residency. We don't let him work single coverage because he can't put hips in or get to floor codes, and his home helpers are limited in their hours. He does just about everything else, but has had enough medical issues that we keep him on days. He's also been with the group for nearly 15 years, and was the medical director for many of those before stepping down due to various medical complications

But I don't know that you want to go that route.

 

[Brigade4Radiant]

EM is not derm or dentistry lifestyle and never will be but compared to most medical specialties it's a good deal.

 

[Angry Birds]

The worst shift is the evening, not the overnight...at least where I do my residency.

If I could do just mornings and overnights post-residency, I'd be happy.

 

[Arcan57]

The worst shift is the evening, not the overnight...at least where I do my residency.

If I could do just mornings and overnights post-residency, I'd be happy.

That is definitely doable. Our director worked exclusively the 6a or the 8p shift prior to taking on the directorship. The main issue with that is you are going to have brutal circadian swings because there aren't going to be swings to buffer the transitions.

 

[SoCuteMD]

At a place I interviewed for residency, the hospital has a core group of doctors who do only nights (the only night docs get some sort of differential for working only nights). The rest of the night shifts are covered by core faculty. Thus, the non-core faculty doctors only have to work an occasional over night since the majority are covered. I think this arrangement is the exception more than the norm.

Well, that depends. Do the attendings work 12s or shorter shifts? If they work shorter shifts then they won't have night shifts, but they'll still work evenings. If you look at ED volume and time of day, the morning starts out slowly and volume builds from about 10 AM until 10 PM or so and then tapers off overnight. Thus, an efficiently-staffed department will actually have more people on evening shifts than on day shifts. Even with dedicated nocturnists you may still work a lot of off hours shifts.

 

[Arcan57]

Well, that depends. Do the attendings work 12s or shorter shifts? If they work shorter shifts then they won't have night shifts, but they'll still work evenings. If you look at ED volume and time of day, the morning starts out slowly and volume builds from about 10 AM until 10 PM or so and then tapers off overnight. Thus, an efficiently-staffed department will actually have more people on evening shifts than on day shifts. Even with dedicated nocturnists you may still work a lot of off hours shifts.

+1

Staffing based on patient arrivals generates all kinds of doc unfriendly hours. Abdominations like 4p-2a or 6p-4a are the direct result of staring at arrival by hour grafts and willing yourself to ignore how disruptive to home life it's going to be.

 

[Birdstrike]

http://www.lasvegassun.com/news/2013/apr/18/st-rose-hospitals-drop-er-doctors-group/#axzz2YDrLwuqD

The hospital then hired a new group, owned by one guy (who has crooked ties to administration)....

"The two doctors, Dr. David Watson and Dr. M. Mark Ferdowsian...allege that when they refused to transfer patients, they were fired, which triggered their lawsuits alleging wrongful termination. St. Rose spokeswoman Kate Grey said the move to drop Emergency Medicine Physicians as the ER contractor was a 'business decision' on the part of hospital and that it is "no reflection" on the company's physicians"

If anyone doubts that dirty dealings, conflicts of interest, corporate interests and the Almightly Dollar are rotting the profession of Medicine, including Emergency Medicine to its core like a cancer, read General Veers' post and the link in his quote. Does it say anywhere that they were dropped because:

A. They were bad doctors,

B. Weren't saving enough lives,

C. Weren't properly diagnosing and stabilizing patients with emergencies, or

D. They weren't doing their jobs?



"...it is 'no reflection' on the company's physicians"?


What?!


You're doing a GREAT job, but oh....I forgot. You're fired. Oh, yeah, don't take it personally,


IT'S JUST BUSINESS


It flashes me back to a quote from one of my own posts from a few weeks ago,:

"Don't dare question, that which you see. Don't rock the boat. Get in line ‘little soldier'. Don't get in the way of our immensely profitable status quo."


Could that quote be anymore apropo?

 

[Birdstrike]

+1

Staffing based on patient arrivals generates all kinds of doc unfriendly hours. Abdominations like 4p-2a or 6p-4a are the direct result of staring at arrival by hour grafts and willing yourself to ignore how disruptive to home life it's going to be.

Yes, and this model absolutely is the industry standard, isn't it? Looking at last week, last month, last year, seeing how many patients were seen per hour, plotting it on a graph, adding X% for projected growth, dividing by 2, 2.5, 3 patients per physician per hour (pick a number) to get your physician man hours needed?

Note that the physician hours need are based on TOTAL patient arrivals per hour, and not with a focus on urgent or emergent patients per hour. The physician hours are also not based on how many (or how few) hours the groups' doctors want to work.

Why?

To those in power, patients = money. Period.


Take note:

When that staffing formula is used to calculate physician man hours needed (and as a result how many EP doc will work, whether they like it or not) when TOTAL patient arrivals are used, there is a huge national EP shortage.

This creates a false "crisis" in coverage. Follow the logic:

Non-urgent patients "waiting without being seen" in your "emergency room" is a crisis. If those same non-urgent patients walk into a primary care doctor's office without appointments, "leave without being seen" and don't get treated, no one considers it a crisis. If they walk around walmart with a blood pressure of 150/89, and "don't get seen" by a doctor, it's not a crisis. Yet if they stroll into your ED while you're overwhelmed and leave, it's a crisis. Why?

Someone elses money.

If a patient strolls into Joe Schmoe MD's office, he's booked, they have a stuffy nose, the doctor refuses to work them in, it's no "crisis." The minute they walk into your slammed ED, it's a "left without being seen" crisis.

It's all about "other people's money," EPs have no control and it makes me sick thinking about it. I don't know what possesses me to care at this point, but I do.

Burnout is Emergency Medicine is not new:

2013 - http://www.kevinmd.com/blog/2013/05/emergency-physicians-burning.html

1997 - http://onlinelibrary.wiley.com/doi/10.1111/j.1553-2712.1997.tb03543.x/abstract

It's been a problem way before that.

If the needed man hours were calculated based on urgent and emergent patient arrivals, you would have an OVER SUPPLY of EPs. But no. There's a "crisis." It's a crock of....well, you know.

So which wins?

A) The EP group pit docs desire to work X number of hours (such that fits in with his family life) seeing X patients per hour (such that jives with his own peace of mind/burnout avoidance plan) while focusing on the sick people he didicated his life to helping, or

B) "Staffing based on patient arrivals" as Arcan57 says, and the desire of those at the top of the pyramid to use the false "crisis" to motivate the pit docs to crank through as many (mostly) not-sick patients, plus the sick patients (which are merely a distraction away from the dollar generating quicky level 3's) as fast as possible, at burnout pace, under the false assumption that the world will end if a patient with a "needs doctors note" chief complaint waits more that 15 minutes in the waiting room while you take a breather after a Peds code or death notification, so that max profits can be raked in by the guys at the top of the pyramid and top of the hospital food chain.

Which wins? A or B.

 

[deleted547339]

So which wins?

A) The EP group pit docs desire to work X number of hours (such that fits in with his family life) seeing X patients per hour (such that jives with his own peace of mind/burnout avoidance plan) while focusing on the sick people he didicated his life to helping, or

B) "Staffing based on patient arrivals" as Arcan57 says, and the desire of those at the top of the pyramid to use the false "crisis" to motivate the pit docs to crank through as many (mostly) not-sick patients, plus the sick patients (which are merely a distraction away from the dollar generating quicky level 3's) as fast as possible, at burnout pace, under the false assumption that the world will end if a patient with a "needs doctors note" chief complaint waits more that 15 minutes in the waiting room while you take a breather after a Peds code or death notification, so that max profits can be raked in by the guys at the top of the pyramid and top of the hospital food chain.

Which wins? A or B.

Oooh, ooh. Pick me. I know this one! lol

 

[Arcan57]

Yes, and this model absolutely is the industry standard, isn't it? Looking at last week, last month, last year, seeing how many patients were seen per hour, plotting it on a graph, adding X% for projected growth, dividing by 2, 2.5, 3 patients per physician per hour (pick a number) to get your physician man hours needed?

Note that the physician hours need are based on TOTAL patient arrivals per hour, and not with a focus on urgent or emergent patients per hour. The physician hours are also not based on how many (or how few) hours the groups' doctors want to work.

Why?

To those in power, patients = money. Period.


Take note:

When that staffing formula is used to calculate physician man hours needed (and as a result how many EP doc will work, whether they like it or not) when TOTAL patient arrivals are used, there is a huge national EP shortage.

This creates a false "crisis" in coverage. Follow the logic:

Non-urgent patients "waiting without being seen" in your "emergency room" is a crisis. If those same non-urgent patients walk into a primary care doctor's office without appointments, "leave without being seen" and don't get treated, no one considers it a crisis. If they walk around walmart with a blood pressure of 150/89, and "don't get seen" by a doctor, it's not a crisis. Yet if they stroll into your ED while you're overwhelmed and leave, it's a crisis. Why?

Someone elses money.

If a patient strolls into Joe Schmoe MD's office, he's booked, they have a stuffy nose, the doctor refuses to work them in, it's no "crisis." The minute they walk into your slammed ED, it's a "left without being seen" crisis.

It's all about "other people's money," EPs have no control and it makes me sick thinking about it. I don't know what possesses me to care at this point, but I do.

Burnout is Emergency Medicine is not new:

2013 - http://www.kevinmd.com/blog/2013/05/emergency-physicians-burning.html

1997 - http://onlinelibrary.wiley.com/doi/10.1111/j.1553-2712.1997.tb03543.x/abstract

It's been a problem way before that.

If the needed man hours were calculated based on urgent and emergent patient arrivals, you would have an OVER SUPPLY of EPs. But no. There's a "crisis." It's a crock of....well, you know.

So which wins?

A) The EP group pit docs desire to work X number of hours (such that fits in with his family life) seeing X patients per hour (such that jives with his own peace of mind/burnout avoidance plan) while focusing on the sick people he didicated his life to helping, or

B) "Staffing based on patient arrivals" as Arcan57 says, and the desire of those at the top of the pyramid to use the false "crisis" to motivate the pit docs to crank through as many (mostly) not-sick patients, plus the sick patients (which are merely a distraction away from the dollar generating quicky level 3's) as fast as possible, at burnout pace, under the false assumption that the world will end if a patient with a "needs doctors note" chief complaint waits more that 15 minutes in the waiting room while you take a breather after a Peds code or death notification, so that max profits can be raked in by the guys at the top of the pyramid and top of the hospital food chain.

Which wins? A or B.

Couple of points:

1) There's no useful way to calculate how many physician man hours are needed to weed through the not sick level 3s to find the mistriaged level 2s. If triage nurses were perfect then I'd agree with a &@&! the non urgent patients but they're not. That uncertainty defines and validates our profession but leaves us vulnerable to the less pure of heart.

2) Never, ever forget that your job is to find the sick and start the resuscitation. No one will forgive you for screwing up on the sick because you were seeing 3.5 pts/hr. It's far better to get fired for being to slow (usually from a place that sucks to work in already) then it is to go through peer review and get sued because you didn't do the right thing.

 

[Birdstrike]

Couple of points:

1) There's no useful way to calculate how many physician man hours are needed to weed through the not sick level 3s to find the mistriaged level 2s. If triage nurses were perfect then I'd agree with a &@&! the non urgent patients but they're not. That uncertainty defines and validates our profession but leaves us vulnerable to the less pure of heart.

2) Never, ever forget that your job is to find the sick and start the resuscitation. No one will forgive you for screwing up on the sick because you were seeing 3.5 pts/hr. It's far better to get fired for being to slow (usually from a place that sucks to work in already) then it is to go through peer review and get sued because you didn't do the right thing.

1-Absolutely yes there is. Past patients per hour broken down by admitted vs discharged. Past patients per hour stratified by billing levels:

99201+99202+99203 = non-urgent/non-emergent

99204+99205+99291 and greater = urgent/emergent

Any one shift or moment in time is unpredictable, but trends over time are absolutely predictable. It absolutely is doable. Easily doable.

2-Agree.

 

[NinerNiner999]

To answer the OP's original question of whether it is possible to work all days in an ER....

No. (note the period).

 

[Arcan57]

1-Absolutely yes there is. Past patients per hour broken down by admitted vs discharged. Past patients per hour stratified by billing levels:

99201+99202+99203 = non-urgent/non-emergent

99204+99205+99291 and greater = urgent/emergent

Any one shift or moment in time is unpredictable, but trends over time are absolutely predictable. It absolutely is doable. Easily doable.

2-Agree.

There are plenty of non-urgent admits (sent in by PCP for in-patient services like transfusion for chronic anemia or to have line/port/tube placed) and urgent/emergent discharges (displaced fractures with potential for vascular compromise, head trauma on Coumadin).

Billing levels would be insensitive to pt urgency since most ESI level 3 patients will still code out as a level 5 despite wide variations in actual severity of illness.

Both formulas assume that no non-urgent patient makes it to the back before any urgent patients which was my original point. I don't see any way to factor in that fudge factor of getting stuck seeing a patient that made it back as a ESI level 3 or 4 right before a bunch of level 2s check into an at-capacity ED.

 

[Birdstrike]

There are plenty of non-urgent admits (sent in by PCP for in-patient services like transfusion for chronic anemia or to have line/port/tube placed) and urgent/emergent discharges (displaced fractures with potential for vascular compromise, head trauma on Coumadin).

Billing levels would be insensitive to pt urgency since most ESI level 3 patients will still code out as a level 5 despite wide variations in actual severity of illness.

Both formulas assume that no non-urgent patient makes it to the back before any urgent patients which was my original point. I don't see any way to factor in that fudge factor of getting stuck seeing a patient that made it back as a ESI level 3 or 4 right before a bunch of level 2s check into an at-capacity ED.

This is like two guys that agree on something arguing over whether the sun rises in the East or sets in the West. My whole point is that I agree with your point below:

Staffing based on patient arrivals generates all kinds of doc unfriendly hours. Abdominations like 4p-2a or 6p-4a are the direct result of staring at arrival by hour grafts and willing yourself to ignore how disruptive to home life it's going to be.

Staffing based on patient arrivals, like you said, metered to a set "door to doctor time" goal (pick 15 min, for example) will "generate all kinds of doc unfriendly hours" and "abominations like 4p-2a or 6p-4a" shifts. You are 100% right. Basing it on patient arrivals only, where a "need work note" equals an "acute MI" equals a "uri" equals "child hit by car" will necessarily mean that no matter how many acute MIs and kids-hit-by-car you have, you'll still be expected to somehow manage to see the "work note" and "uri" with enough urgency to bend that "door to doctor time" average back to 15 min.

That is the way that it is. It will never change in my lifetime, and I'm not even saying it should change, but know that that aggressive stance has a consequence. One consequence is job security. The other consequence is that frequently the pot doc will be expected to do the impossible.

At 3am, why is there a panicked urgency to rush out and see the "need doctors note and Tylenol written on Rx so Medicaid will pay for it" chief complaint when you've been waiting 6 hours to take a ----?

Let Greg Henry tell you. From his article this month on epmonthly.com:

"We cry ED overcrowding, forgetting that we are a volume-driven business. Most hospital EDs in the country could not live on major emergencies. You need the “small potatoes” to pay the bills... Most of us will need to live on small potatoes. If we do it right, we can make rather tasty meals out of those small potatoes."

 

[EM_Rebuilder]

As many pointed out, the true answer is NO...

However, there are many jobs out there with limited to no nights. Night time rate incentives help tremendously as there are usually a few people willing to transition to all nights to make more money. If the day guys are willing to make a bit less for less night/day transitioning, then it can happen.

I am surprised at this point and time we do not see MORE disconnects between most staffing positions day/night rates.

Your other option is to work yourself into admin roles which may or may not help, and sometimes takes years to accomplish...

 

[Apollyon]

The group I joined in Hawai'i had just formed the year before. Prior, they were managed by Schumacher, and, before that, EmCare.

The group president only worked the 6a-2p shift, 14 shifts a month, her choosing (she would give the scheduler a list of the days she could "only" work, and that was IT - no more, no less).

She did not have any more cachet than any of the other 7 partners. As the scheduler (who was a partner) said, "I have to deal with 7 prima donnas every month".

I had forgotten about that, and I don't see in any way how this "proves the rule". To say it is "zero" is just wrong.

Hell, I think I still have the old schedules. I'll PM/email them to anyone interested.

 

[gman33]

The group I joined in Hawai'i had just formed the year before. Prior, they were managed by Schumacher, and, before that, EmCare.

The group president only worked the 6a-2p shift, 14 shifts a month, her choosing (she would give the scheduler a list of the days she could "only" work, and that was IT - no more, no less).

She did not have any more cachet than any of the other 7 partners. As the scheduler (who was a partner) said, "I have to deal with 7 prima donnas every month".

I had forgotten about that, and I don't see in any way how this "proves the rule". To say it is "zero" is just wrong.

Hell, I think I still have the old schedules. I'll PM/email them to anyone interested.

Probably a good reason to try look at the schedule before you sign up for a job.
If you see somebody who takes all the "good" shifts and doesn't work any "bad" shifts, run away from that job.

Somebody, "you" might get stuck with all the garbage.

 

[docB]

First let me try to answer the OP’s question or at least throw in my experience. In my group you can not work all days. Only the site directors can really cherry pick their schedules and they pretty much work Mon - Thurs 6-3s. The rationale behind allowing them to do this is that they need to be available to admin who also work banker’s hours. They work some token nights every year to keep up with what those shifts are like but... you know.

We have some dedicated night guys because the nights pay a lot more. But several got burnt out and bailed on nights. We decided not to increase the night differential and to just work the nights. For me it’s financially worth it to suck it up and do 3 nights a month.

Even back when we had more night docs you still couldn’t just work days. You had to work afternoon and evening shifts too.

Couple of points:

1) There's no useful way to calculate how many physician man hours are needed to weed through the not sick level 3s to find the mistriaged level 2s. If triage nurses were perfect then I'd agree with a &@&! the non urgent patients but they're not. That uncertainty defines and validates our profession but leaves us vulnerable to the less pure of heart.

Very true. As a for example many nurses look at bouncebacks as an instant nothing. We have to look at bouncebacks as a second chance.

Let Greg Henry tell you. From his article this month on epmonthly.com:

"We cry ED overcrowding, forgetting that we are a volume-driven business. Most hospital EDs in the country could not live on major emergencies. You need the “small potatoes” to pay the bills... Most of us will need to live on small potatoes. If we do it right, we can make rather tasty meals out of those small potatoes."

He’s right, of course, but this is a reason that the current ascendency of EM and EDs is bad for society. We do indeed make our living off the worried well. And we shouldn’t. Society is hurt by us charging and collecting what we do for the sore throats and ankle sprains. We (as in we the people, not we the EPs) would do better to triage these patients away to more appropriate levels of care.

We, the EPs trained in ferreting out the emergent pathology and resuscitating the critically ill should not be sitting in 80 bed ERs with fast tracks staying solvent on the levels 4s to be available for the level 1s and 2s. We should be in 6 bed EDs that only serve Level 1s and 2s.

We (and by we I mean ACEP) should not be fighting the FM guys over their medical home model. Let them see the primary care stuff, that’s what they do. Keep it out of my ER and I’ll see the emergencies.

The real danger here is that we are positioning ourselves to do more urgent and primary care so we can feast on the small potatoes. This lets us grow the EDs and the specialty and expand our power. But we are likely to see a situation where all the paying worried well are skimmed off and we are left doing this purely as EMTALA mandated charity. Once it’s apparent the strategy left us holding that responsibility it will be too late to change it.

 

[Hercules]

How much of a night differential do you guys pay? My group pays an extra $50/hr waiting for one of us to bite, but so far no one is willing to pick up extra nights. That's probably the hazard of having a group predominantly made up of married docs with children.

 

[NERDY]

We (and by we I mean ACEP) should not be fighting the FM guys over their medical home model. Let them see the primary care stuff, that’s what they do. Keep it out of my ER and I’ll see the emergencies.

Hi, Why is ACEP against the medical home model?

 

[Birdstrike]

.I had forgotten about that, and I don't see in any way how this "proves the rule". To say it is "zero" is just wrong.

The OP wasn't really asking "Is it possible to work all days in EM?"

He was really asking "Is it possible, if I go into EM, can I work just all day shifts?"

The answer to that question is a categorical and absolute,

NO.

Now, if he does go into EM under the deluded premise he can avoid working ANY afternoon shifts and night shifts, if after 10 years and 1000+ various afternoon and night shifts he ascends to the oft-dreamed about "pot-of-gold at the end of the completely-unbroken-circular-rainbow" schedule of 7-3, Mon-Thurs, it will prove the rule by the sheer fact it took him 10 years and countless non-day shifts to attain the status of working "only day shifts."


It is not possible LiamNeesons. Don't even dream it's possible.

 

[The White Coat Investor]

How much of a night differential do you guys pay? My group pays an extra $50/hr waiting for one of us to bite, but so far no one is willing to pick up extra nights. That's probably the hazard of having a group predominantly made up of married docs with children.

Our shift differentials are as follows:

6a 0.83
11a 0.83
2p 0.98
7p 1.07
10p 1.26

I might be a little off, but you can see the night shift pays almost 50% more than a day shift. So if the monthly hourly rate were $250, the night shift would pay $320 an hour and the day shift would pay $207.50. That's $112.50 an hour. No wonder no one will bite at a mere $50 an hour. Even if the hourly that month were only $200 an hour, the difference between staying up until midnight (the 2 p shift) and being up until dawn (the 10p shift) would be $56.

You guys just need to offer more money. (Said as a guy in a group that mostly has children at home.) I bet you'd start getting takers at $75-100.

 

[The White Coat Investor]

We, the EPs trained in ferreting out the emergent pathology and resuscitating the critically ill should not be sitting in 80 bed ERs with fast tracks staying solvent on the levels 4s to be available for the level 1s and 2s. We should be in 6 bed EDs that only serve Level 1s and 2s.

We (and by we I mean ACEP) should not be fighting the FM guys over their medical home model. Let them see the primary care stuff, that's what they do. Keep it out of my ER and I'll see the emergencies.
.

In some small way I agree with you. That would be a fun practice. In a very large way, I just want to say good luck getting a job in Portland (or Denver, or Salt Lake or anywhere else it's tough to get a job as an EP) if all the EPs do there is take care of level 1s and 2s. There would be one ED staffed by 6 docs.

In fact, good luck getting into an EM residency, since we'd only need 1/10th of them. Plus the job would be so great (and pay so well with all those procedures and critical care codes) that it would be more competitive than derm.

Think it through. It just doesn't work. EM will always be what it is, with or without EMTALA. Our for-profit hospital is begging us to MSO people, but there just aren't that many without insurance that don't have an emergency. 5% maybe. Even if you add in the insured patients I can determine don't have an emergency after just an H&P we're only talking about 25% or so. If they need a STAT test to determine if they have an emergency or not, they have an emergent reason to come in. Heck, if they need an exam to determine they don't have an emergency they had a valid reason to come in.

You can't say that Susie with the belly pain doesn't have an emergency after doing a pelvic, an HCG, and a CT. It just doesn't work that way. You have to be willing to say she doesn't have an emergency BEFORE seeing her. It turns out that's really hard and really risky to do.

The level 3s and 4s keep the doors open and the equipment paid for so we can care for the 1s and 2s. That's just the way it is. The intensivists and hospitalists complain about similar stuff. "Why do I have to babysit all these overdoses on ventilators and telling families to let grandpa go? I should be saving septic 30 year olds!" But if all they had to take care of were septic 30 year olds there would only be one 6 bed ICU and 3 intensivists in town.

Sure, having one 6 bed ED and one 6 bed ICU in town would save a lot of money, but so would just shooting everyone when they turn 65.

 

[Mwalk7]

In a big city, what is typically the average number of shifts a private guy works? 2 to 3?

 

[Arcan57]

In a big city, what is typically the average number of shifts a private guy works? 2 to 3?

Most big city(?) shops are going to have between 33% and 40% of the shifts be nights (usual configurations will be day/swing/night or early am/late am/swing/evening/night excluding separate doc for fast-track staffing etc). So if you're working 12-15 shifts per month that's 4-6 overnights per month.

Nocturnists change the numbers somewhat:

A nocturnist in a 3 shift system working 12 shifts per month drops the percentage of nights from 33% to (30 nights-12)/90 shifts= 20%. So you're looking at 2-3 night shifts/month.

In a 5 shift system, the same nocturnist drops you from 40% to (60 nights-12)/150 shifts = 32%. So you're looking at 4-5 shifts/month. Having 2 nocturnists drops you to 24% so you're at 3-4 shifts/month.

 

[Mwalk7]

Good info.


I actually meant to ask 'weekend shifts' ha. I would assume 2-3 12 hr weekend shifts per month in the ER is common but I am not sure.

 

[NinerNiner999]

A fair group, fully staffed, lighter schedule on the weekends, will usually schedule everyone to work 1/2 of the weekends every month - days, evenings, and nights included.

Some groups will pay a premium to docs who prefer to work only weekend shifts (every week fri, sat, sun) - similar to night differential. I have heard of groups that pay a "double differential" (weekend rate PLUS night rate) for these providers, but it varies.

 

[The White Coat Investor]

We don't do a weekend differential, but they're tracked and kept even by the scheduler. I work 15 shifts a month. There are 30 days a month. Therefore I work half the weekend days. If you count the night shifts on Friday night and Sunday night, I work even more. Same with holidays. That might be working both weekend days twice a month or one weekend day on all 4 weekends. More typically, I'll work one full weekend and one day on two others. To be honest, weekends have never really existed for me. I never planned on having "weekends off" when I chose to go into EM and you shouldn't either.

Nights, weekends, holidays, drug-seekers, EMTALA care.....that's the price you pay to be a doctor, make a great salary, and only work 120 hours a month.

 

[Arcan57]

Good info.


I actually meant to ask 'weekend shifts' ha. I would assume 2-3 12 hr weekend shifts per month in the ER is common but I am not sure.

Again, doing the math, 2/7 shifts are weekend (or 2.5/7 counting Friday overnight which I would for a 12hr shift). Which leads to ~4 weekend shifts/month for a pretty standard 12 12hr shifts. 2 weekends per month is pretty standard as a work expectation, 2.5 lead to grumbling, and 3 weekends per month causes hurt feelings if it happens more than once a year. In a reverse of the night shift situation, nocturnists tend to make you work more weekends since weekend nights for no weekends is a pretty standard swap.

Showing the work for your 12 hr shift hypothetical with single coverage (which is actually uncommon in urban settings unless you're in academics or working a free-standing with low volume):

2.5 weekend shifts/ 7 shifts x 12shifts/month = 4.28 weekend shifts/month (go-go dimensional analysis)

Assuming 11 weekend days/month you are looking at 22/60 or 37% weekend shifts counting Friday overnights. Now if a nocturnist is taking 12 weekday overnights a month (assuming they don't work Friday nights which is also common) you're now looking at distributing 22 weekend shifts among 48 possible or 46% which works out to ~5.5 weekend shifts a month for a 12 shift month. Which can easily translate into every other month only having 1 full weekend off despite having 18 days off/month. These numbers look less grim if you talk the nocturnist into working Sunday nights or if there are more shifts/day.