The lack of control of Emergency medicine

[cyanide12345678]

The more i practice as an attending, the more I'm understanding why I'm burning out.

Maybe this is a rant, but i want to share a story.

I work at a 20k volume shop, 24 hours physician and 8 hours PA coverage. We have a couple of family medicine trained docs that work here. Recently, the traveling younger EM trained guys who were fast, efficient, and good got sent elsewhere. And instead came on these slower inefficient docs, most of whom are FM trained. And yes, i work for a CMG, team health.

Apart from all of the other factors that have been discussed here. I think one factor that is over looked is burn out when you have to clean up the mess of your fellow doctors. Doctors who essentially check out and leave a mess because it's night shifts problem.

Here is how my day was yesterday.

I walk in at 7 pm. 19 people on the board. 14 of them roomed, that's how many beds we have. 5 in the waiting room. 6 out of these 19 had assigned providers - the out going attending had 3, PA had 3. 8 people roomed and "red" in epic meaning waiting on provider, been there for hours, have protocol orders back that my awesome nurse just kept ordering because no one was seeing anyone.

And then i just start seeing patients. I look to my left, the PA is texting. Oh and not to mention the out going attending has a habit of not seeing any one for his last 2-3 hours of shift. There were at least 3 people in rooms that had all protocol orders back, and literally needed someone to go in, say hi, do a quick exam, and discharge. Seriously... The abdominal pain that had not been seen for 3.5 hours by anyone just didn't have to be there -_-

In the next 90 minutes, i saw 10 new people and also got sign offs from the out going attending. These are the sign offs:

1) middle aged BRBPR per sign off report. waiting on repeat INR. Plan to discharge if INR goes lower after the oral vitamin K that was given. According to this attending, minimal bleeding, she's good to go. Length of stay 9 hours - initial inr 7.9, next inr 8.3, apparently still waiting on a 3rd with plan to discharge. See why department was full? This is the easiest disposition for an ER doc and should have been done 6 hours ago. In fact, The real clinical picture was the following:

Heart rate 105-115 for last 3-4 hours, Sbp 90s and trending down, hemoglobin 8 today, baseline 12.7 20 days ago. This was an easy ICU patient that i was told to discharge if repeat inr was better. Needless to say, she got 2 units, PCC, and a transfer to a place with GI. This disposition needed to be done 6-7 hours ago.

2) old covid pos, hypoxic lady, with new acute renal failure. Length of stay 8 hours. Septic picture. Still no disposition. I don't even know why, but waiting on repeat blood gas -_- We don't have nephrology. This lady needed emergent dialysis and needed to be transferred 6 hours ago to a place with dialysis capabilities and needed a quinton to be placed emergently. She was uremic, bun 150, confused, and acidotic with ph 7.0. she had two indications for emergent dialysis and still 8 hours length of stay with no disposition.

3) hypercarbia resp failure. length of stay only 4.5 hours. Pco2 100. Low setting Bipap was done. No breathing treatments, no steroids, no mag no nothing. Repeat gas that took forever was obviously worse and needed a lot of medical optimization.

So in summary, i saw 10 patients in 90 minutes, and still had to take care of 3 critical patients that the other attending didn't take care of for hours and just sat on them. Plus some of the ones i saw were sick too.

The point is.... Being an ER doctor sucks. You're truly at the mercy of others. A surgeon can say "hell no I'm not touching that patient, send him back to his surgeon". A pcp can just discharge any patient they want. We don't have control over our patients or the work ethic of others. If the doc before me says screw it, I'm not seeing anyone, this is night shifts problem, then you are just left picking up the pieces. I'm just getting tired and frustrated of picking up the pieces. And i truly think that is the biggest reason for my burn out.

I'm so glad I'm changing jobs soon.

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[GeneralVeers]

Leave. Go to another job. That sounds ripe for burnout. Try a place that has overlapping shifts. That minimizes burnout and the number of crappy cases. Also RVU places give people incentive to dispo quickly and not sign out.

 

[RustedFox]

Add on to all of this the fact that admin needs all these customers to be "satisfied".

 

[cyanide12345678]

Add on to all of this the fact that admin needs all these customers to be "satisfied".

Hard to satisfy when you haven't seen a doctor for multiple hours. Id be frustrated too if i hadn't been seen for 2-3 hours.

 

[ERDude]

oof. reading that was painful. I can't imagine taking that sign-out my head would explode.

You need to get out of there asap.

In general terms, what is the situation of your next job?

 

[cyanide12345678]

Leave. Go to another job. That sounds ripe for burnout. Try a place that has overlapping shifts. That minimizes burnout and the number of crappy cases. Also RVU places give people incentive to dispo quickly and not sign out.

That's the plan. Contract in inbox, working out finer details, probably making things official soon. Working here until August at Max.

 

[cyanide12345678]

Leave. Go to another job. That sounds ripe for burnout. Try a place that has overlapping shifts. That minimizes burnout and the number of crappy cases. Also RVU places give people incentive to dispo quickly and not sign out.

I think it's incapability. I've been here 1.5 years. Some people were meant to be family medicine and weren't meant to juggle multiple critical patients because they shut down.

oof. reading that was painful. I can't imagine taking that sign-out my head would explode.

You need to get out of there asap.

In general terms, what is the situation of your next job?

My goal for my next job was quality of life.

Getting out of CMG grind. Hospital employed. Pseudo assistant professor faculty title at a place considered one of the best EM programs in the country. I'm not going to be at the mothership, not cool enough for that.

Out of their 10 hospitals, i will work 80 percent at their rural shops, 0.9 patients per hour. And 20 percent at a busy community shop, 1.7 pph, scribes, overlapping coverage, high acuity, almost every specialist coverage.

I'll take about a 10 percent paycut and likely see 30-35 percent less patients. My absolute pay after accounting for benefits will drop 50k essentially, but I'm thinking my job satisfaction and career satisfaction will go up.

 

[RustedFox]

I think it's incapability. I've been here 1.5 years. Some people were meant to be family medicine and weren't meant to juggle multiple critical patients because they shut down.

My goal for my next job was quality of life.

Getting out of CMG grind. Hospital employed. Pseudo assistant professor faculty title at a place considered one of the best EM programs in the country. I'm not going to be at the mothership, not cool enough for that.

Out of their 10 hospitals, i will work 80 percent at their rural shops, 0.9 patients per hour. And 20 percent at a busy community shop, 1.7 pph, scribes, overlapping coverage, high acuity, almost every specialist coverage.

I'll take about a 10 percent paycut and likely see 30-35 percent less patients. My absolute pay after accounting for benefits will drop 50k essentially, but I'm thinking my job satisfaction and career satisfaction will go up.

But... is it a P-O-W-E-R-H-O-U-S-E residency?

(Sorry, I had to.)

 

[cyanide12345678]

But... is it a P-O-W-E-R-H-O-U-S-E residency?

(Sorry, I had to.)

Lol by those who quote doximity, probably yes since it's in the top 10. They didn't even interview me when i had applied to their program 5 years ago. I wasn't good enough

 

[DrDrummer]

Your description of those sign out cases gave me a facial tic. That would not happen where I work, and if I did I would ask that the off-going doc admit the patients so they could explain their management to the hospitalist. Sounds very painful, dangerous and unsustainable. And like someone in your group needs some helpful feedback regarding their practice.

 

[RustedFox]

Your description of those sign out cases gave me a facial tic. That would not happen where I work, and if I did I would ask that the off-going doc admit the patients so they could explain their management to the hospitalist. Sounds very painful, dangerous and unsustainable. And like someone in your group needs some helpful feedback regarding their practice.

Sadly, I've had similar sign-outs at my one job site. FM trained guy wasn't sure that his intra-abdominal sepsis patient needed a central line or pressors and was circling the drain. Not a patient had been "signed-in" to for almost 2 hours. This kind of stuff highlights how admins are penny-wise/pound-foolish when it comes to creating coverage maps/assigning hours.

We should, as physicians, have the right to create "performance evaluations" for our admins. Once they say "But; you don't know how to do my job", we will then say "Really?! Samey-same to you, sir."

 

[JacobMcCandles]

These issues are magnified with CMGs. Not only is there a greater chance of working with subpar physicians (many who aren't even EM trained) but you've got many physicians who just want to clock in and clock out without any sense of ownership.

 

[GeneralVeers]

I was working at a non-RVU shop once. The outgoing doctor (who was EM trained but very slow) was going to sign out a young woman with dehydration. Fluids were done, she just wanted to wait for a "repeat UA to make sure the ketones in the urine are gone". I asked her if she'd like to discharge the patient now, or have me do it immediately.

 

[jw3600]

oof. reading that was painful. I can't imagine taking that sign-out my head would explode.

You need to get out of there asap.

In general terms, what is the situation of your next job?

Will be an attending in 6 months. I would flat out refuse those sign outs.

 

[cyanide12345678]

Will be an attending in 6 months. I would flat out refuse those sign outs.

Easier said than done in the community where it's a 1 to 1 sign off. That's just not how real life community medicine works. This attending also happens to be practicing here for 30+ years and used to be a medical director a few years ago.

 

[jw3600]

Easier said than done in the community where it's a 1 to 1 sign off. That's just not how real life community medicine works. This attending also happens to be practicing here for 30+ years and used to be a medical director a few years ago.

I hear you. I’m mostly all bite, no bark. But as you said if that behavior is tolerated and won’t be addressed if brought up then it’s time to leave that job (if feasible for you financially and family wise).

 

[GeneralVeers]

Easier said than done in the community where it's a 1 to 1 sign off. That's just not how real life community medicine works. This attending also happens to be practicing here for 30+ years and used to be a medical director a few years ago.

It's tough on those single-coverage 12 hour shifts to fight crappy sign out. There's not much you could do if you don't have a supportive medical director.

 

[turkeyjerky]

Man, I can see why you'd be crispy. That sounds absolutely atrocious. Good for you for getting out. If night shifts are routinely worse than days, it's a good sign that the ED is poorly run.

Will be an attending in 6 months. I would flat out refuse those sign outs.

Careful about that attitude. Refusing a sign out is a good way to get dumped on, and it's a zero-sum game at a single-coverage shop. One of the docs I work with is a giant pain to sign out to. Everyone else gets signed out patients who have been seen and have an actionable plan in place whereas she gets a board full of unseen patients and a quick signout of "Good news, I don't have anything for you. bye!" (Obviously the cases highlighted were especially egregious though)

Anyone else notice that Medical Directors are always the worst w/ this type of garbage?

 

[RoyBasch]

The more i practice as an attending, the more I'm understanding why I'm burning out.

...

I agree in general that as ER physicians we don't have a lot of control over things, but this is not the case here. You can choose not to practice with such incompetent people.

Any one of those sign outs you mentioned to me in my group would result in a formal complaint to our physician board. 3 in a row on shift would probably result in termination with cause. I would say you are describing a level of incompetence that is the exception not the norm in emergency medicine. It's not that hard to choose a group with better partners, because the average group would be better.

And I agree with you, based on what you described all of those cases were managed completely inexcusably.

This might surprise you but we are in a profession with A LOT of oversight. There are already plenty of formal mechanisms to reprimand such incompetence. If you really feel strongly about this physician consider referring their cases to the hospital medical exec committee or quality improvement committee.

I'm surprised that a CMG--as metric-focused as they are--can allow a physician to not see patients in the last 3 hours of their shift.

 

[cyanide12345678]

I agree in general that as ER physicians we don't have a lot of control over things, but this is not the case here. You can choose not to practice with such incompetent people.

Any one of those sign outs you mentioned to me in my group would result in a formal complaint to our physician board. 3 in a row on shift would probably result in termination with cause. I would say you are describing a level of incompetence that is the exception not the norm in emergency medicine. It's not that hard to choose a group with better partners, because the average group would be better.

And I agree with you, based on what you described all of those cases were managed completely inexcusably.

This might surprise you but we are in a profession with A LOT of oversight. There are already plenty of formal mechanisms to reprimand such incompetence. If you really feel strongly about this physician consider referring their cases to the hospital medical exec committee or quality improvement committee.

I'm surprised that a CMG--as metric-focused as they are--can allow a physician to not see patients in the last 3 hours of their shift.

The metrics for me are the ones that get screwed when i pick up these people after so long. My door to doc times are the ones that get affected.

I'm just waiting to finish my time and move on. Contract ends July. Local job market is pretty terrible otherwise right now as well. Either way, starting new gig October after my wife finishes residency and we move cities. Just a few more months.

 

[jw3600]

Man, I can see why you'd be crispy. That sounds absolutely atrocious. Good for you for getting out. If night shifts are routinely worse than days, it's a good sign that the ED is poorly run.


Careful about that attitude. Refusing a sign out is a good way to get dumped on, and it's a zero-sum game at a single-coverage shop. One of the docs I work with is a giant pain to sign out to. Everyone else gets signed out patients who have been seen and have an actionable plan in place whereas she gets a board full of unseen patients and a quick signout of "Good news, I don't have anything for you. bye!" (Obviously the cases highlighted were especially egregious though)

Anyone else notice that Medical Directors are always the worst w/ this type of garbage?

As I said I’m probably all talk. I really don’t have a problem with sign out culture. Love getting people home on time. Don’t mind dotting a few I’s to help a colleague out. As you mentioned, taken at face value those sign outs are atrocious.

 

[RoyBasch]

The metrics for me are the ones that get screwed when i pick up these people after so long. My door to doc times are the ones that get affected.

I'm just waiting to finish my time and move on. Contract ends July. Local job market is pretty terrible otherwise right now as well. Either way, starting new gig October after my wife finishes residency and we move cities. Just a few more months.

Right but I'm guessing the person you got sign out from must have atrocious metrics, it sounds like they are seeing a very small number of patients per hour. I'm surprised TH hasn't canned them.

If there really is no way to reprimand or remove physicians like that one, then I agree the only thing to do is go to a different hospital, as I imagine 90% of ER groups have better physicians on average than people like the ones you are describing.

I practice with over 60 different ER physicians in two different groups. Some are good, some are great. I have experienced some sub-optimal sign outs but NEVER one like you've described. You are describing physicians in your current group who are truly on the outlying worse end of practice. I don't think people like this reflect the norm in our field.

 

[Buckeye1992]

As a soon to be graduating resident that is terrifying. I wouldn’t leave a dumpster fire like that to my worst enemy.

I agree with reporting this. It’s not just a bad situation for you but obviously a dangerous situation for patients.

 

[UrbanEM2]

I worked with a bunch of IM/FM boarded docs who were grandfathered into EM. This was basically the norm with them. Garbage work-ups with dispo all turfed to the oncoming attending. What the OP describes above was about 70% of my shifts. After I realized I was being a total sucker, I started making the off going attending stay to dispo the patients they should have hours earlier. Eventually I the frequency of these garbage sign outs decreased.

All just goes to show how incompetent you can actually be and still have a long prosperous career as an ER doctor.

 

[GeneralVeers]

I worked with a bunch of IM/FM boarded docs who were grandfathered into EM. This was basically the norm with them. Garbage work-ups with dispo all turfed to the oncoming attending. What the OP describes above was about 70% of my shifts. After I realized I was being a total sucker, I started making the off going attending stay to dispo the patients they should have hours earlier. Eventually I the frequency of these garbage sign outs decreased.

All just goes to show how incompetent you can actually be and still have a long prosperous career as an ER doctor.

Barring equipment failure, like the CT scanner going down, there's little excuse to have a patient in the department longer than 3 hours without a dispo. It's a sign of indecisiveness and laziness.

 

[UrbanEM2]

Barring equipment failure, like the CT scanner going down, there's little excuse to have a patient in the department longer than 3 hours without a dispo. It's a sign of indecisiveness and laziness.

Ha! 3 hours would have been great. Some of these patients were there for 10+ hours.

Some of these docs were so bad and would order so many CT scans, the ER CT scanner would be so backed up, we'd have to send people to the inpatient CT scanner. I once had a patient signed out to me dispo pending REPEAT abdominal CT scan. I immediately discharged the patient then got a complaint filed that I didn't get them a second CT scan like the first compassionate doctor had ordered.

Luckily this was at a grimy city hospital so my chair and I had a good laugh about it.

 

[Vandalia]

The fundamental rule of life, the fundamental rule of medicine, the fundamental rule of Emergency Medicine:

You either trust the people you work with, or you don't.

If it is the latter, there is nothing you can do other than leave, or get everyone else to leave. There is absolutely no external structure that can replicate trust; be it in the practice of medicine, group finances, strategic decision making, or whatever else.

You either trust the people you work with, or you don't.

 

[RustedFox]

Barring equipment failure, like the CT scanner going down, there's little excuse to have a patient in the department longer than 3 hours without a dispo. It's a sign of indecisiveness and laziness.

I'll add "other factors beyond your control" to the list.

- nurse "can't get a line"
- laboratory can't laboratory.
- patient refuses blood/CT/leaving until their demands are met.

Etc.

 

[kumatie]

The doc you described should be fired, and has no place in emergency medicine.

 

[Frazier]

That is a really rough story. Hope things improve for you quickly!

 

[AlvinKamara]

Lol by those who quote doximity, probably yes since it's in the top 10. They didn't even interview me when i had applied to their program 5 years ago. I wasn't good enough

What does your resume have to look like to get a job at academic/academic affiliated programs like this? I’d love to work at a place like this but I can’t help but feel underqualified.

 

[turkeyjerky]

As a soon to be graduating resident that is terrifying. I wouldn’t leave a dumpster fire like that to my worst enemy.

I agree with reporting this. It’s not just a bad situation for you but obviously a dangerous situation for patients.

Report it to whom? The dip**** medical director who succeeded this dingus and obviously engenders this stuff, and, to boot, doesn't have the power to actually do anything about it? Or the regional director, who, in addition to likely not being an emergency physician (or for some CMGs, a physician at all) doesn't give a lick about the quality of care and only cares that the signer-outer doesn't complain about the schedule and is signed for 15 dollars an hour less than the OP?

What does your resume have to look like to get a job at academic/academic affiliated programs like this? I’d love to work at a place like this but I can’t help but feel underqualified.

Well, considering the fact that IU, UMMC and UPMC (one of which I'm assuming is the OP's future employer) have ads all over the place, and the fact that the OP, who obviously does not have some insane CV, ipso facto: not much.

 

[cyanide12345678]

Right but I'm guessing the person you got sign out from must have atrocious metrics, it sounds like they are seeing a very small number of patients per hour. I'm surprised TH hasn't canned them.

If there really is no way to reprimand or remove physicians like that one, then I agree the only thing to do is go to a different hospital, as I imagine 90% of ER groups have better physicians on average than people like the ones you are describing.

I practice with over 60 different ER physicians in two different groups. Some are good, some are great. I have experienced some sub-optimal sign outs but NEVER one like you've described. You are describing physicians in your current group who are truly on the outlying worse end of practice. I don't think people like this reflect the norm in our field.

This is a hard to recruit place. Had 3 travelers prior to covid. When i signed this place offered a 150k sign on over 3 years. It's just not an easy place to staff.

His total patients seen is usually significantly less, his total length of stay used to be one of the longest until another FM trained guy was recently hired 4 months ago. His median length of stay is 1 hour longer than mine. Having said that, this physician who i took sign off from is usually amongst the highest patient satisfaction scores. So he's not going anywhere

 

[cyanide12345678]

What does your resume have to look like to get a job at academic/academic affiliated programs like this? I’d love to work at a place like this but I can’t help but feel underqualified.

Nothing fancy on my resume. Nothing at all. 2019 graduate, will have two years of clinical experience in community medicine.

I am NOT going to be working at their big academic center where EM residents rotate. I'm essentially at a busy community shop 20 percent of the times where they mostly have med students and off service residents. This 20% got me dually employed by the school of medicine and the fancy title.

Their academic center has multiple people wanting to join, people with fellowships etc. I would not get there even if i tried.

 

[cyanide12345678]

Report it to whom? The dip**** medical director who succeeded this dingus and obviously engenders this stuff, and, to boot, doesn't have the power to actually do anything about it? Or the regional director, who, in addition to likely not being an emergency physician (or for some CMGs, a physician at all) doesn't give a lick about the quality of care and only cares that the signer-outer doesn't complain about the schedule and is signed for 15 dollars an hour less than the OP?


Well, considering the fact that IU, UMMC and UPMC (one of which I'm assuming is the OP's future employer) have ads all over the place, and the fact that the OP, who obviously does not have some insane CV, ipso facto: not much.

Yes, it's one of those 3. And yes, nothing fancy on my resume.

Regional director actually is EM trained and a very good doctor. But like you said, it's all about the dollars. Excluding the travelers, all of whom are now almost gone, i am now officially the highest paid with the highest hourly. I'm thinking the new people they hired make $30/hr less than me.

 

[emergentmd]

Some docs are just built to be good Er docs and some just are not. I never understood why it is soooooo hard to dispo a pt. I can safely say that after I walk out of the room on my initial visit that typically takes less than 3 minutes, I have disposition on 95% of them and labs typically will not change much.

1. You have nothing, nothing needs to be done, or here is your script. Done
2. Let me run some labs, xrays, imaging. When they come back they go home unless something glaring shows up. I RARELY, I REPEAT RARELY ever order more labs or imaging after my 1st round. ALL ER Docs need to learn this. For the majority of pts, order it once. Don't order a lab, come back order more or order imaging then go back and order more. Read this over and over until you do it.
3. Pt's hx/exam/vitals require admission. Order admission labs then call it in when stuff is back.

Do the above 3 and you will get 99% of your pts out in 3 hrs unless there are delays out of your hands.

I have been very fortunate to work in Great EM environment with Top notch Er docs. There were some weak ones but nothing that was terrible.

There were one Locums gig I took that went essentially the Same as OPs. I walk into knowing it will be a zoo so it tempers any frustration.

Typically walk in, place is full. 20+ waiting in triage over 2 hrs. Fellow ER docs typically have their names on 5-6 pts. Board has 10+ Pts to be seen.

On one horrendous signoff, I get. Pt in the hallways with weakness. "I ordered labs, and if everything looks good, pt probably can go home". Just looking at the board, pt is in their 70's. Click on Vitals and Pt tachy to 130, febrile, SBP 90. I think to myself, "Holy Hell, in what world will this pt ever go home". Labs WBC 20's, pt sick as $hit. Took me about 15 min to admit this pt that was in the hallway for 2+ hrs when I walked in. This doc should have had this pt on the launching pad to the floor an hr before I walked in.

You guessed it, it was a FM doc. They never surprise me.

I will say to OP that I would be out of that job within a month. My sucky environment was bearable b/c I was getting paid $500/hr. No way would I ever work in a similar place for less than than 350/hr.

 

[AlmostAnMD]

Just had a thought

I'll use only one patient as an example but you can do it for all your critical ones

The guy with the "INR recheck"....just keep rechecking it q4 hrs and transfuse for < 7 hb

sign the case back out to him when he comes back in 12 hours loooolll

"Hey frank, it's almost 6 now, it'll probably hit less than 3 on your shift!"

 

[thegenius]

The more i practice as an attending, the more I'm understanding why I'm burning out.

Maybe this is a rant, but i want to share a story.

I work at a 20k volume shop, 24 hours physician and 8 hours PA coverage. We have a couple of family medicine trained docs that work here. Recently, the traveling younger EM trained guys who were fast, efficient, and good got sent elsewhere. And instead came on these slower inefficient docs, most of whom are FM trained. And yes, i work for a CMG, team health.

Apart from all of the other factors that have been discussed here. I think one factor that is over looked is burn out when you have to clean up the mess of your fellow doctors. Doctors who essentially check out and leave a mess because it's night shifts problem.

Here is how my day was yesterday.

I walk in at 7 pm. 19 people on the board. 14 of them roomed, that's how many beds we have. 5 in the waiting room. 6 out of these 19 had assigned providers - the out going attending had 3, PA had 3. 8 people roomed and "red" in epic meaning waiting on provider, been there for hours, have protocol orders back that my awesome nurse just kept ordering because no one was seeing anyone.

And then i just start seeing patients. I look to my left, the PA is texting. Oh and not to mention the out going attending has a habit of not seeing any one for his last 2-3 hours of shift. There were at least 3 people in rooms that had all protocol orders back, and literally needed someone to go in, say hi, do a quick exam, and discharge. Seriously... The abdominal pain that had not been seen for 3.5 hours by anyone just didn't have to be there -_-

In the next 90 minutes, i saw 10 new people and also got sign offs from the out going attending. These are the sign offs:

1) middle aged BRBPR per sign off report. waiting on repeat INR. Plan to discharge if INR goes lower after the oral vitamin K that was given. According to this attending, minimal bleeding, she's good to go. Length of stay 9 hours - initial inr 7.9, next inr 8.3, apparently still waiting on a 3rd with plan to discharge. See why department was full? This is the easiest disposition for an ER doc and should have been done 6 hours ago. In fact, The real clinical picture was the following:

Heart rate 105-115 for last 3-4 hours, Sbp 90s and trending down, hemoglobin 8 today, baseline 12.7 20 days ago. This was an easy ICU patient that i was told to discharge if repeat inr was better. Needless to say, she got 2 units, PCC, and a transfer to a place with GI. This disposition needed to be done 6-7 hours ago.

2) old covid pos, hypoxic lady, with new acute renal failure. Length of stay 8 hours. Septic picture. Still no disposition. I don't even know why, but waiting on repeat blood gas -_- We don't have nephrology. This lady needed emergent dialysis and needed to be transferred 6 hours ago to a place with dialysis capabilities and needed a quinton to be placed emergently. She was uremic, bun 150, confused, and acidotic with ph 7.0. she had two indications for emergent dialysis and still 8 hours length of stay with no disposition.

3) hypercarbia resp failure. length of stay only 4.5 hours. Pco2 100. Low setting Bipap was done. No breathing treatments, no steroids, no mag no nothing. Repeat gas that took forever was obviously worse and needed a lot of medical optimization.

So in summary, i saw 10 patients in 90 minutes, and still had to take care of 3 critical patients that the other attending didn't take care of for hours and just sat on them. Plus some of the ones i saw were sick too.

The point is.... Being an ER doctor sucks. You're truly at the mercy of others. A surgeon can say "hell no I'm not touching that patient, send him back to his surgeon". A pcp can just discharge any patient they want. We don't have control over our patients or the work ethic of others. If the doc before me says screw it, I'm not seeing anyone, this is night shifts problem, then you are just left picking up the pieces. I'm just getting tired and frustrated of picking up the pieces. And i truly think that is the biggest reason for my burn out.

I'm so glad I'm changing jobs soon.

This is terrible, get the hell out of that place. It's a lawsuit every single day.

I can't believe the decisions being made? The INR one? All three? Just crazy. GET OUT.

Once you work with FT ER docs, you life will be a lot easier. I would get burned out there too.

 

[d2305]

One would think that he would of learned something in 30 years?

 

[Mushdoc]

One would think that he would of learned something in 30 years?

This is why EM residency is so important. You can work as an FM or NP/PA in the ER for 5, 10, 15 years but if you never learned it right the first time, no one ever taught you how to think the right and what to do, and questioned you over and over again about what you were going, and you don’t continue learning you will just keep doing things the wrong way

 

[bravotwozero]

This is a hard to recruit place. Had 3 travelers prior to covid. When i signed this place offered a 150k sign on over 3 years. It's just not an easy place to staff.

His total patients seen is usually significantly less, his total length of stay used to be one of the longest until another FM trained guy was recently hired 4 months ago. His median length of stay is 1 hour longer than mine. Having said that, this physician who i took sign off from is usually amongst the highest patient satisfaction scores. So he's not going anywhere

That's exactly it. You mentioned you were worried about your dispo times and door to doc times, but nobody gets canned for that. But low patient sat scores will get you tossed pretty quickly.

 

[Angry Birds]

This sounds terrible and I agree that dispo times should be prioritized over customer satisfaction. I have the same issue at the shop where I work. There is a doc who has a crazy long dispo time, but her customer satisfaction scores are high as are her RVUs (since she orders every test on earth). Meanwhile, no emphasis is placed on throughput or even proper clinical care. What's the point of having a good customer satisfaction report when you avoid central lines and other life-saving procedures when needed?

This is all a result of hiring non-EM docs.

In any case, one of the solutions to the soul-crushing nature of EM is to go rural and/or critical access.

 

[Birdstrike]

A feeling of lack of control is one of the biggest contributing factors to work related emotional exhaustion, otherwise known as burnout. Whether it's a lack of control over your schedule, hours, patient flow, patient selection, department safety, coworkers, policy, hiring staff, administrative policies, pathology seen, or workload, Emergency Medicine scores poorly on them all. Any way you can either increase your control over any of those factors, or at a minimum, reduce your exposure to the chaos of those uncontrolled factors, the better.

 

[Siggy]

This is why EM residency is so important. You can work as an FM or NP/PA in the ER for 5, 10, 15 years but if you never learned it right the first time, no one ever taught you how to think the right and what to do, and questioned you over and over again about what you were going, and you don’t continue learning you will just keep doing things the wrong way

You don't need an EM residency to learn that vit K doesn't rapidly correct an elevated INR and isn't an appropriate treatment for Coumadin toxicity in the setting of a GI bleed.

 

[thegenius]

You don't need an EM residency to learn that vit K doesn't rapidly correct an elevated INR and isn't an appropriate treatment for Coumadin toxicity in the setting of a GI bleed.

Well apparently you do. Any EM / critical care training teaches this (and perhaps even IM)...but why would an FM doc know this?

 

[cyanide12345678]

Well apparently you do. Any EM / critical care training teaches this (and perhaps even IM)...but why would an FM doc know this?

My wife pgy3 FM resident spends 2 months in adult ER and 1 month in peds ER in her entire residency. And then 1 month in ICU. That's about the critical care training they have. And that too as off service residents, they are never pushed like a EM resident will be, they likely won't have the sickest patients.

She cannot manage critical patients, just like i can't manage clinical patients because i have little to no chronic disease management training.

 

[AMEHigh]

Well apparently you do. Any EM / critical care training teaches this (and perhaps even IM)...but why would an FM doc know this?

Even I learned this in residency!
FM requires plenty of inpatient rotations (along with ICU, GI and surgery) which is where I learned this. Don’t think I learned this specifically during my ED rotations but would certainly know that about Vit K from those other rotations. I feel like GI bleed work up is a fairly common diagnosis that I saw a lot in residency. Same with managing Coumadin levels.

But yes def not EM trained, and would never want to work in one lol. But FM does give one a well-rounded education to know inpatient medicine, and there are plenty of FM doctors that work as hospitalists that know how to manage those sort of things. That was my only point

 

[Siggy]

Well apparently you do. Any EM / critical care training teaches this (and perhaps even IM)...but why would an FM doc know this?

I learned it at a podunk 200 bed hospital DO IM program...

...now if I can just get people to stop trying to FFP their way out of an elevated INR in liver failure.

 

[VA Hopeful Dr]

Well apparently you do. Any EM / critical care training teaches this (and perhaps even IM)...but why would an FM doc know this?

Except you don't. I'm FM and haven't set foot in an ED or hospital professionally speaking since residency and I know that.

 

[Mushdoc]

I mean I wasn't specifically talking about the Vitamin K thing - more all of the medical errors and lack of knowledge, dispo issues OP was talking about....