The lack of control of Emergency medicine

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Birdstrike

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I've just stopped worrying about COVID. Let the admins deal with the disaster stuff. I put on my surgical mask, see the patients, end my shift and go home. I've realized that overcrowding and lobby medicine aren't things I can control at this point so don't waste my time worrying about it.
I wasn't talking about COVID necessarily, more about stress in general. But I hear, ya. I've over it, too.

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Birdstrike

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I'm an admin (associate medical director, chair of ED PIC committee, EMS medical director). I also have to improve things in the ER to keep an EMS unit available for 911 calls because of extended wall times. It's hard to not get overwhelmed when your average hospital ER in metro Atlanta is consistently running with an NEDOCS score >400 on a daily basis.

We're implementing multiple plans to help. Some docs have excellent ideas, and I always welcome input from them.
You're much more to the front of the front lines, with a lot more spinning plates in the air than me right now. So, I doubt I have any excellent ideas that haven't already occurred to you. But what's the biggest problem you're having? The obvious, like ED overcrowding, holds, no beds to admit to, short employees due to quarantining? Something else, less obvious?
 

GeneralVeers

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The biggest issue right now is a shortage of nursing, and unwillingness of administration to fix the problem. Yesterday it was 4.5 hours just to draw labs on our waiting room patients because the nurses were doing a work slowdown. No amount of begging on my part could make them work faster. My medical directors are sympathetic, but because it's a CMG there is very little they can do to help with any of the clinical issues.
 
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southerndoc

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The biggest issue right now is a shortage of nursing, and unwillingness of administration to fix the problem. Yesterday it was 4.5 hours just to draw labs on our waiting room patients because the nurses were doing a work slowdown. No amount of begging on my part could make them work faster. My medical directors are sympathetic, but because it's a CMG there is very little they can do to help with any of the clinical issues.
I can tell you administration at my shop doesn't have an unwillingness to fix the problem. The problem is the shortage of nurses, probably exacerbated by the nurses who have become nurse practitioners. Nurse administrators are being put in clinical roles at my hospital.
 
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namethatsmell

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The biggest issue right now is a shortage of nursing, and unwillingness of administration to fix the problem. Yesterday it was 4.5 hours just to draw labs on our waiting room patients because the nurses were doing a work slowdown. No amount of begging on my part could make them work faster. My medical directors are sympathetic, but because it's a CMG there is very little they can do to help with any of the clinical issues.

Having lived through this reality as well, I just chalk it up to reason #13,749,825 why our health system is maddening.
 
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Cinclus

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I can tell you administration at my shop doesn't have an unwillingness to fix the problem. The problem is the shortage of nurses, probably exacerbated by the nurses of nurses who have become nurse practitioners. Nurse administrators are being put in clinical roles at my hospital.
I swear that at least a quarter of my nurses have left to become travel nurses, leaving us needing more travel nurses...
 
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bravotwozero

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Yeah unlike us, RNs are in a bargaining position like never before, and are now realizing it. Some hospitals have had entire floors of RNs walk off the job because they didn't like what admin was doing. Nurses can kick the C Suite's @ss all day long if they wanted to.
 
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GassYous

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I swear that at least a quarter of my nurses have left to become travel nurses, leaving us needing more travel nurses...

I would too when the hospitals are paying travel nurses 4x more for the same job except with less bs
 
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namethatsmell

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Can you blame them? Many were getting laid off or furloughed in the spring. Loyalty's a two way street.

When interviewing at gigs I've been asking how many docs/staff were laid off or slapped with disproportionate pay cuts 2/2 covid. Figure it's a quick way to screen for a decent workplace culture, supportive admin environment, and a financially solid organization.
 
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Siggy

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I can tell you administration at my shop doesn't have an unwillingness to fix the problem. The problem is the shortage of nurses, probably exacerbated by the nurses who have become nurse practitioners. Nurse administrators are being put in clinical roles at my hospital.

I'm sure if they offered enough money they can score some travelers and agency nurses.
 

drunken_owl MD

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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.
Sounds like a place used to moonlight at. You find greener pastures?
 
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cyanide12345678

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Sounds like a place used to moonlight at. You find greener pastures?

I believe i have found slightly greener pastures. They are not perfect, but they are better.

It all came at the cost of some 50-60k a year, in exchange for this pay cut i now see probably 25-30 percent less patients on average.

An average day shift is around 14-17 patients in 12 hours, an average night shift is 8-12 patients in 12 hours.

My average compensation per patient seen is higher now and sign offs aren’t as stressful. My main shop where i do 70 percent of my hours is literally a 6 bed ER, so the number of active patients has a hard stop before people just sit around the waiting room and wait.

Though there are days where i would see 20+ on a day shift in 12 hours, it’s those days that i don’t enjoy as much.

Either way, i think i can squeeze in another 3 years before i drop down to 8-10 shifts per month from 13 shifts right now. My portfolio is on track to make me 100k this year by year end, so my ability to generate passive income even in a down market is reassuring. And i just purchased my 3rd website 3 days ago, about to hire people from India and pakistan to run marketing campaigns and customer service, and essentially will try to slowly convert this into a passive endeavor that generates a couple grand a month over time.
 
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NYEMMED

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My response to the OP in the first comment would be.

“Who is your medical director, and why aren’t they directing??”
 

cyanide12345678

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Which of your investments is giving this kind of passive income? Surely this can't be your options trading/selling?

It’s options plus real estate. Beating spy by 30% YTD.

I’ve become so comfortable with it that i barely make active trades. All trades in that account expire dec 30th 2022, not touching anything until then and letting it be, account should end 80k positive year end, if not more. The rest is rental income for syndication real estate.
 

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cyanide12345678

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Which of your investments is giving this kind of passive income? Surely this can't be your options trading/selling?

I also looked into buying a marcos pizza 2-3 weeks ago that made 6 figures but i chickened out. An established franchise is on sale 30 minutes from my home in one of the best areas of the entire state with the highest per capita income in the state, a very fast growing area as well. It’s making 107k per year and costs $250k. Revenue in 2021 was 700k, on track for 750k revenue so far this year. I just couldn’t pull the trigger because 250k is a lot and current owner is deeply integrated in running the business with his family being involved as well, so it wasn’t going to be a passive venture, at least in the beginning. It was a very solid business opportunity, i just chickened out, because the amount of work needed in the beginning kind of scared me - plus the sticker price of 250k scared me.
 

HemorrhagicShock

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It’s options plus real estate. Beating spy by 30% YTD.

I’ve become so comfortable with it that i barely make active trades. All trades in that account expire dec 30th 2022, not touching anything until then and letting it be, account should end 80k positive year end, if not more. The rest is rental income for syndication real estate.

What longer-term strategy are you using? Is it still the same stuff codified in some of your previous posts? From what I recall those options strategies were shorter term, but I'd have to go back and review your posts.

I wonder if I am just making excuses on my end because I am so overworked and burnt out. I want to get started on some sort of side hustle like this but with more than full-time clinical work, dad duties, and husband duties it seems like there's no time.
 
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bravotwozero

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I wonder if I am just making excuses on my end because I am so overworked and burnt out. I want to get started on some sort of side hustle like this but with more than full-time clinical work, dad duties, and husband duties it seems like there's no time.
Yeah that’s you and probably most of us on here, bold emphasis mine.

This is why i think long and hard about what I’m getting out of a side gig will be worth what I’m putting in and cutting out things I need to do like regular exercise. For me the answer seems to be no, as I’m quite content with taking my chances on an index fund.

Aside from syndications and REITs, real estate, especially direct ownership, isn’t passive Income, and requires quite a bit of time, effort, and debt.
 
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cyanide12345678

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What longer-term strategy are you using? Is it still the same stuff codified in some of your previous posts? From what I recall those options strategies were shorter term, but I'd have to go back and review your posts.

I wonder if I am just making excuses on my end because I am so overworked and burnt out. I want to get started on some sort of side hustle like this but with more than full-time clinical work, dad duties, and husband duties it seems like there's no time.

Same. Nothing different. Selling very out of the money naked puts.

Biggest position is 550 contracts for ewz with strike price of 25 that expires dec 30th. I opened this position 1 month ago. Total premium for this position alone is 63k. Seen ups and downs, but letting it be, it’s not going to $25 with such a low price to earnings ratio, high dividend yield and a Brazilian economy that is riding the commodity wave and benefiting from it. It starts getting a lot of support and buying activity the moment it drops below 30.

I also have 25 positions of meta with strike price at $110.

Meta is already very under valued. Extremely reasonable price to earnings ratio already. It makes boat loads of money with an amazing balance sheet. It shouldn’t drop to $110, if it does then i ‘hold the strike’.

I will actually end 90k positive ytd if ewz stays above 25 and meta stays above 110. That’s where i honestly fully expect to be years end with my taxable account.

If they actually drop that low, i might actually end up making a lot more money if i can hold the strike and keep rolling and stomach the short term negative account value.
 
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cyanide12345678

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What longer-term strategy are you using? Is it still the same stuff codified in some of your previous posts? From what I recall those options strategies were shorter term, but I'd have to go back and review your posts.

I wonder if I am just making excuses on my end because I am so overworked and burnt out. I want to get started on some sort of side hustle like this but with more than full-time clinical work, dad duties, and husband duties it seems like there's no time.

I’m also working full time and have dad duties to an extremely energetic almost 3 years old and ofcourse husband duties.

Honestly, the learning thing took time, maybe 30-40 hours of YouTube. But now it doesn’t. Barely 5-10 minutes a day which is just me checking to see how the markets are doing because i enjoy watching it. My trades expire in December and i don’t plan on touching them.

The website i bought is taking up so much time though and it’s barely making money right now. Ughhh i suck at digital marketing and social media -_-
 
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HemorrhagicShock

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The website i bought is taking up so much time though and it’s barely making money right now. Ughhh i suck at digital marketing and social media -_-

This seems to be the youtube/financial/tech/influencer side hustle du jour. The amount of digital marketing, DTC, and subscription-based digital business "how-to" videos has exploded over the last 6 months.

How did you get started on yours? Did you already have the idea or did you buy the website off somebody else with the idea that you thought you could lean it up, scale it up, and collect that nice margin?
 

HemorrhagicShock

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Honestly, the learning thing took time, maybe 30-40 hours of YouTube. But now it doesn’t. Barely 5-10 minutes a day which is just me checking to see how the markets are doing because i enjoy watching it. My trades expire in December and i don’t plan on touching them.

Sorry to double post but I find this interesting, and wonder if this is the difference between talent and hard work. I've easily watched 50+ hours of youtube videos on options trading, and I still haven't been able to come close to profitability with a small play account.

Either you are a savant and should have been a finance bro, or fall on the lucky end of the risk spectrum.
 

cyanide12345678

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This seems to be the youtube/financial/tech/influencer side hustle du jour. The amount of digital marketing, DTC, and subscription-based digital business "how-to" videos has exploded over the last 6 months.

How did you get started on yours? Did you already have the idea or did you buy the website off somebody else with the idea that you thought you could lean it up, scale it up, and collect that nice margin?

Nope. It's a niche I don't know anything about. It's an online website catering to the lgbtq community - think T shirts, hoodies, makeup, jewelry.

Bought it for 10k on flippa.com. It has 225k of sales in 2.5 years and roughly was making $1000-1500 net per month but that was through instagram ads. Dropshipping store. Was being run by someone in India. Has 36k insta followers, 22k Fb followers and an email list of 6700 customers. It seemed like a good deal when equivalent stores on flippa were being sold for 25-35k.

I literally bought it because the website is very slick, the insta account is near "influencer" status, someone spent A LOT of time building it, they have a conversion rate of 1.8% which is good. Things that need to be done - connecting the shopify store to etsy, ebay, amazon to increase sales channels - hire someone to do 10/hrs per week of insta/Fb postings. Hire a digital marketing guy for 10 hrs a week that creates insta/FB/Pintrest/google adwords campaigns. And eventually down the line hire someone that responds to customer service emails.

If you want the link to the website, just PM me and I'll show you what I bought. I'm not going to advertise it publicly here.
 
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cyanide12345678

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Sorry to double post but I find this interesting, and wonder if this is the difference between talent and hard work. I've easily watched 50+ hours of youtube videos on options trading, and I still haven't been able to come close to profitability with a small play account.

Either you are a savant and should have been a finance bro, or fall on the lucky end of the risk spectrum.

Are you selling puts as a strategy? That's the only strategy that has legit literature showing that it is a great way to cash flow. Is the account set for naked positions? Naked positions allow you to balance "leverage" and making the strike really really far away that you will usually win while still making enough money.
 

emergentmd

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To Ops post, if I worked in that environment something would have to give. Either they switch to RVU to compensate the hard working doc, get EM docs at higher rates, or I am out.

Place sounds miserable and I would have been out ASAP.

Worked in a busy ER with sick pts and remember a FP sign out who notoriously have poor clinical decision making.

Sign out doc, "Pt has fever and looks fine, labs pending, if it looks good can go home"

Me after clearing all the new pts, checked on sign out pt who was old with multiple medical issues. WBC 30's, SBP 80's, HR 120's, febrile. Quick sepsis admit. These pts should be teed up for admission after a 2 min assessment.

I think this may be the only thing that would make me go straight to the medical director to make a change or I am gone.
 
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thegenius

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It’s options plus real estate. Beating spy by 30% YTD.

I’ve become so comfortable with it that i barely make active trades. All trades in that account expire dec 30th 2022, not touching anything until then and letting it be, account should end 80k positive year end, if not more. The rest is rental income for syndication real estate.

what are your stock / derivative positions now?
 

cyanide12345678

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what are your stock / derivative positions now?

550 put contracts ewz strike price $25 and expiration dec 30th 2022.

25 put contracts meta strike $110 and expiration dec 2022 3rd week

40 put pins contracts strike $12.5, expiration 3rd week of December.

Sold 40 pins positions this Friday after massive spike in volatility. It was a great day to be a put seller.
 

TeddyBoomBoom

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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.
Bruh… this is an older post but I’m intentionally quoting the OP to clarify my response for others.

I’m sorry - that situation is terrible, 100% 🐄 💩 unacceptable. But it’s not like that everywhere.

We all have different practice patterns, but I (legitimately) think that my coworkers are pretty conscientious people. We may do things differently, but still practice good medicine.

And because we hire/train/retain our mid levels- they are pretty much ok. Everyone has strengths and weaknesses but in general I feel very fortunate and think they are very good 🤷‍♀️

I work for a small group in Florida, and none of that **** would fly. I’m sorry you are having that experience. As a small-ish group, our goals are to keep patients safe, keep the hospital admin happy, keep each other happy, and make money. We have zero issues signing out patients so we can each go home on time, but they are appropriate sign outs and I have no beef.

What you are describing is not ok.
 
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southerndoc

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Bruh… this is an older post but I’m intentionally quoting the OP to clarify my response for others.

I’m sorry - that situation is terrible, 100% 🐄 💩 unacceptable. But it’s not like that everywhere.

We all have different practice patterns, but I (legitimately) think that my coworkers are pretty conscientious people. We may do things differently, but still practice good medicine.

And because we hire/train/retain our mid levels- they are pretty much ok. Everyone has strengths and weaknesses but in general I feel very fortunate and think they are very good 🤷‍♀️

I work for a small group in Florida, and none of that **** would fly. I’m sorry you are having that experience. As a small-ish group, our goals are to keep patients safe, keep the hospital admin happy, keep each other happy, and make money. We have zero issues signing out patients so we can each go home on time, but they are appropriate sign outs and I have no beef.

What you are describing is not ok.
It's hard to believe that a physician was managing these patients quoted for sign out. I would say 2 of the 3 sign outs quoted are actually grossly negligent in their care. As an expert witness, I would certainly say that the delays in care were grossly negligent.
 

cyanide12345678

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It's hard to believe that a physician was managing these patients quoted for sign out. I would say 2 of the 3 sign outs quoted are actually grossly negligent in their care. As an expert witness, I would certainly say that the delays in care were grossly negligent.

This was an FM trained attending who had practiced medicine for longer than i was alive. In fact he was medical director at the facility for a long time as well. He was still EMS director for the county as well. I guess anything flies in small town Ohio 😂

The money was really nice there, but I’m glad I’m not there anymore. This post was actually made when things were like this almost every day, team health had dropped the NP/PA coverage while volume and acuity had gone up dramatically. Every single person in that ER was burned out. morale was at an all time low for everyone. It was around that time i had signed my new job contract and the end was in sight 😂

Believe it or not, that year this hospital was named as the best small community hospital in the country by fortune/ibm after an analysis of thousands of hospitals in the country 😂😂😂😂
 

thegenius

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This was an FM trained attending who had practiced medicine for longer than i was alive. In fact he was medical director at the facility for a long time as well. He was still EMS director for the county as well. I guess anything flies in small town Ohio 😂

He's a crappy ER doctor, that's for sure. All three are gross negligence. A hypotensive GI bleed with a supratherapeutic INR, new AKI with uremia and severe acidosis requiring immediate dialysis, and a COPD exacerbation getting basically no medical treatment except BiPap, and getting worse while on it. All three are gross negligence if I testify.
 
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southerndoc

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He's a crappy ER doctor, that's for sure. All three are gross negligence. A hypotensive GI bleed with a supratherapeutic INR, new AKI with uremia and severe acidosis requiring immediate dialysis, and a COPD exacerbation getting basically no medical treatment except BiPap, and getting worse while on it. All three are gross negligence if I testify.
Not going to side rail this thread, but there is a major difference between negligence and gross negligence. In the third case, BiPAP is an accepted form of treatment. It is negligent to not administer COPD meds, but it is not grossly negligent when treating the respiratory failure. With the first case, it was grossly negligent because the patient needed PCC/FFP (not vitamin K that doesn't work within 24 hours) and warranted admission/transfer to a GI-capable ICU. The second case is grossly negligent because the patient has two indicators for dialysis and did not get treatment that's needed.
 
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cyanide12345678

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Not going to side rail this thread, but there is a major difference between negligence and gross negligence. In the third case, BiPAP is an accepted form of treatment. It is negligent to not administer COPD meds, but it is not grossly negligent when treating the respiratory failure. With the first case, it was grossly negligent because the patient needed PCC/FFP (not vitamin K that doesn't work within 24 hours) and warranted admission/transfer to a GI-capable ICU. The second case is grossly negligent because the patient has two indicators for dialysis and did not get treatment that's needed.

Are the malpractice repercussions of just negligence significantly less than gross negligence? Or it eventually doesn’t make much of a difference in the courtroom?
 

Vandalia

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Are the malpractice repercussions of just negligence significantly less than gross negligence? Or it eventually doesn’t make much of a difference in the courtroom?
It depends on state law.

In a very small number of states, EM physicians are only liable for "gross negligence." I am pretty sure Texas adopted this standard recently, but don't know if this is true in other jurisdictions.

Even if it is not the legal standard in that jurisdiction, if there was "gross negligence" is a lot easier for the plaintiff to prove mere negligence, and a lot easier for a jury to award damages.
 

southerndoc

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Georgia is a gross negligence state. In order to sue for ordinary negligence, you have to show that the patient's condition was not emergent. It's very hard to bring litigation against an emergency provider (or someone on emergency call schedule) in Georgia due to our gross negligence clause. Not impossible, but highly unlikely. Most of the time expert witnesses say something is grossly negligent when in fact it's only ordinary negligence. Expert witnesses can (and have) been sanctioned and even sued for saying something is grossly negligent when it doesn't meet the standard.

Grossly negligent is basically something a layperson knows to do. Send home a STEMI: grossly negligent. Send home a chest pain with normal EKG and troponin who dies of a STEMI 6 hours later? Not grossly negligent no matter how many risk factors they have.
 
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MechEDoc

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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.
I've worked sites like that. There are better places for much identical pay. Look at critical access hospitals that are still independent. Many of them won't hire mid-levels either!
 

cyanide12345678

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I've worked sites like that. There are better places for much identical pay. Look at critical access hospitals that are still independent. Many of them won't hire mid-levels either!

It’s an old post from 1.5 years ago. Been working at critical access for last 10 or so months. In fact seen 2 patients in my last 5.5 hours today so far. It’s been an unusually good day so far. Probably going to go nap now. Making $200/hr w2 instead of $260/hr 1099, so a little bit of a pay cut.
 

emergentmd

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I worked at Critical care hospitals and really never liked it as the day seems to drag on. Plus you get the same old timer staff in these small cities which never was really fun to talk to.
 
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MechEDoc

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It’s an old post from 1.5 years ago. Been working at critical access for last 10 or so months. In fact seen 2 patients in my last 5.5 hours today so far. It’s been an unusually good day so far. Probably going to go nap now. Making $200/hr w2 instead of $260/hr 1099, so a little bit of a pay cut.

Some pay cut, but probably not terrible. My prior W2 was $225/hr but when I calculated it's equivalent 1099 it was just over $260/hr for the same total compensation. Switching to another W2 around $260/hr, but no benefits.
 

cyanide12345678

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Some pay cut, but probably not terrible. My prior W2 was $225/hr but when I calculated it's equivalent 1099 it was just over $260/hr for the same total compensation. Switching to another W2 around $260/hr, but no benefits.
It wasn’t too bad honestly when everything is accounted for.

$200/hr plus about 5k-ish quarterly bonuses plus 15k 403b match plus 5k cme plus plus 2k for fees like licensing and memberships plus $2500 towards hsa - then obviously benefits like health, vision, dental, disability, life insurance. And the greatest benefit of all that doesn’t get considered is the 1/2 employer contribution to ficaa taxes that one pays themselves when 1099. This is around 15-17k worth.

So yeah…all included it’s probably more like equivalent to 230/hr 1099. So not a bad pay cut for much less volume - last two night shifts i saw 3 patients and 6 patients in 12 hours each shift. So yeah…. Can’t complain. The day shifts are much busier though and yesterday’s shift was such an outlier with 3 patients all night.
 

MechEDoc

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It wasn’t too bad honestly when everything is accounted for.

$200/hr plus about 5k-ish quarterly bonuses plus 15k 403b match plus 5k cme plus plus 2k for fees like licensing and memberships plus $2500 towards hsa - then obviously benefits like health, vision, dental, disability, life insurance. And the greatest benefit of all that doesn’t get considered is the 1/2 employer contribution to ficaa taxes that one pays themselves when 1099. This is around 15-17k worth.

So yeah…all included it’s probably more like equivalent to 230/hr 1099. So not a bad pay cut for much less volume - last two night shifts i saw 3 patients and 6 patients in 12 hours each shift. So yeah…. Can’t complain. The day shifts are much busier though and yesterday’s shift was such an outlier with 3 patients all night.
For sure. I think I made about $900 last night while asleep. Of course it was 1.5 hrs -> see two patients (no labs, just d/c) -> 2.5 hrs -> wake up + breakfast -> go home.
 

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Jumping on when the resident was saying, I do agree a Hospitalist should know how to manage critical care at some capacity.

I do however believe there is a big difference between managing a differentiated critical care patient where everything’s already been done for you and the thought process is started in some capacity (even if it’s wrong) vs an undifferentiated critical care patient where they just roll in obtunded, hypoxic, hypotensive, etc with limited history and time to sit down and think about what you want to do. Hospitalists can arm chair medicine all day looking through labs asking “why wasn’t this done” when they are not the ones making the initial decisions. There’s a huge difference.
 
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RustedFox

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Jumping on when the resident was saying, I do agree a Hospitalist should know how to manage critical care at some capacity.

I do however believe there is a big difference between managing a differentiated critical care patient where everything’s already been done for you and the thought process is started in some capacity (even if it’s wrong) vs an undifferentiated critical care patient where they just roll in obtunded, hypoxic, hypotensive, etc with limited history and time to sit down and think about what you want to do. Hospitalists can arm chair medicine all day looking through labs asking “why wasn’t this done” when they are not the ones making the initial decisions. There’s a huge difference.

QFT.
 
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inspirationmd

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Honest question:
I know we all complain about the ED and the nonsense that can go along with it. But, would you all really leave it behind with no hesitation if you didn’t have to do it?

I did a EM/IM/CC program so I have a good amount of flexibility. I’m currently thinking of giving up my EM practice altogether and just doing ICU but I worry that I will miss it.

For those that do EM, no chance you’d miss it?
For those that do no EM anymore, do you miss it?

A PRN EM job with scheduling restrictions seems like it wouldn’t mess with circadian rhythms too much while still letting you have your primary practice outside of the ED. Is this not doable or desirable?
 

GonnaBeADoc2222

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Honest question:
I know we all complain about the ED and the nonsense that can go along with it. But, would you all really leave it behind with no hesitation if you didn’t have to do it?

I did a EM/IM/CC program so I have a good amount of flexibility. I’m currently thinking of giving up my EM practice altogether and just doing ICU but I worry that I will miss it.

For those that do EM, no chance you’d miss it?
For those that do no EM anymore, do you miss it?

A PRN EM job with scheduling restrictions seems like it wouldn’t mess with circadian rhythms too much while still letting you have your primary practice outside of the ED. Is this not doable or desirable?

I would do EM if:

Nurses carried out orders
Hospitalist didn't question
Consultants did the right thing
Physicians controlled hiring / firing of LLPs
Administration supported physicians
 
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