Time management/efficiency

Discussion in 'Emergency Medicine' started by Rendar5, Jun 4, 2008.

  1. Rendar5

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    So I jumped into the pool today for my first EM shift ever. I thought I understood something about time management, but after I finished my shift, I realized that I gotta figure out how to really speed things up so that I can juggle more patients and move things along faster. Anyone have any tips they'd like to share on how to become a lot more efficient other than practice?
     
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  3. roja

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    Time management is learned over time. As a medical student, you really shouldn't be working on juggling a lot of patients. Interns are usually expected to see one patient an hour. Maybe a little less if they pick up a sick septic shock patient who needs a lot of stuff.

    Maybe 2 if all the patients have are URI or sprained ankle.

    As a fourth year, you should be seeing your patient, writing a good note and giving your attending/senior a good differential and some kind of plan. Not moving meat. You should also be asking to help with IV placement, suture repair, etc if its slow.
     
  4. Rendar5

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    Thanks for the advice roja. Makes me feel better. I was concerned I was slowing things up for the residents and attendings since I was going slow trying to work through patients completely. I'll just keep doing what I"m doing then and help out as I best can.
     
  5. southerndoc

    southerndoc life is good
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    The thing I learned that improves efficiency is to learn to document quickly. Seriously, the majority of our time seems to be spent documenting thanks to to the lawyers and the bean counters (that would be Joint Commission).
     
  6. DrQuinn

    DrQuinn My name is Neo
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    Meh. If you are still in medical school the LAST thign you should be worrying about is your time management / efficiecny. Your only priority should be learnign what the disease process is and hte management (as well as learning to have good patient rapport).

    I would say when you enter your PGY2 year you should START to work on your efficiency, and by middle to end of PGY2 year you've got most of hte basics down pat and can begin to really push yourself to see more patients without compromising care or documetation or the ever-present "oh crap I forgot to order cardiac enzymes."

    Q
     
  7. GeneralVeers

    GeneralVeers Globus Hystericus
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    Did anyone else see the poster at SAEM this year looking at resident efficiency? They were comparing the number of patients/hour seen by every level of resident. The R1s were seeing 0.87 pts/hour, but the R3s were only seeing 1.13 patients/hour. Does this seem low to anyone?

    On any busy day most of our R3s can easily see 2 pts/hour. Even at MLK I was seeing 1.5 pts per hour as an intern.
     
  8. GeneralVeers

    GeneralVeers Globus Hystericus
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    Also, doing a concise h&p is essential. There's no reason that it should take 30 minutes to complete an H&P on a patient who comes in with a sore throat or runny nose. Learning the "focused exam" is what takes the most practice to master.
     
  9. EM2BE

    EM2BE Elf
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    It seems this question keeps coming up. Any way we can make this a sticky (esp since the responses so far are very helpful)?
     
  10. Dr. Will

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    A lot of the increase in efficiency will occur once you understand the system/resources that you have at your disposal. Other jumps in efficiency will be due to pattern recognition for certain chief complaints, increased procedural skill, and increased knowledge. It all takes time and you will see how you progress through residency.

    As I come to a close during my intern year, I remember back to my first shift in early July when I saw only 4 patients total during a 10 hour shift. Now I'm able to see on average 1-1.5 per hour and can carry around 8 patients at one time. Next year, I will learn to juggle flying and doing the majority of procedures in the department on top of managing my own 8 bed area. It comes with time and experience. Focus on what others have said while you're a med student...learning! You aren't a meat mover...just learn about EM and what we do.
     
  11. Arcan57

    Arcan57 Junior Member
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    I would agree with Dr. Will if you are a third year student. If you are planning to make EM your life's work then it's important to be able to see if you can multitask. And the only way to determine that is to move the meat.
     
  12. roja

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    I was in Vancouver at CME congress. However, that does seem low to me. Our senior residents see on average 3 pts an hour. It will drop if its not busy but on average they carry 3-4.
     
  13. gutonc

    gutonc No Meat, No Treat
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    Kind of OT but this reminds me of a conversation I had w/ one of our ED attendings the other day. One of his colleagues is doing a sabattical at an ED in the UAE somewhere (Qatar I think) that sees ~1400 patients a day. They have ortho/ophtho/OB/neurology in the ED 24/7 which I would imagine speeds up dispo quite a bit.

    Talk about time management.
     
  14. Hawkeye Kid

    Hawkeye Kid Senior Member
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    How about the poster (maybe the same one, even) from Christiana that showed that EM R3s saw more pts and generated more RVUs than EM/IM R4/5s? Seemed a bit odd to me.

    At any rate, agree that 1.13 for R3s isn't great, unless there just aren't pts to see, which is another issue all together.
     
  15. jazz

    jazz Senior Member
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    something to consider -- if the setup is that the R3 runs the whole ER and has to oversee all the intern cases (i.e. act as an attending), then their own pts/hour may be much less.

    it's much easier to see your own patients. once you start supervising, you get interrupted a lot and your flow gets screwed up and your own pt/s hour become much less.
     
  16. GeneralVeers

    GeneralVeers Globus Hystericus
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    That was the same poster. Those residents clearly aren't busy enough.
     
  17. AmoryBlaine

    AmoryBlaine the last tycoon
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    To the OP:

    When I was starting my EM rotations as an M4 the thing that I realized quickly is that you are going to have to figure out which set of questions work for you to get a complete H/P as expeditiously as possible.

    The biggest thing for me personally was to fine tune an ROS that I could run through in about a minute that included 9 systems and covered all the big bases.

    My spiel was some variation of "I'm going to ask you a bunch of yes/no questions going head to toe about your general health, it's entirely possible that the answer to every question is going to be 'no' ok?"

    As far as picking up patients goes, at one of my rotations (at which I did very well) my attending pulled me aside and said something like "I realize that you can handle alot of patients and do it well but to tell you the truth it would be a lot easier on me if you could try to only do 2 at once because it slows me down to have to co-sign orders and stuff like that." It may sound a little sh!tty when I type it out but it totally wasn't, he was giving me a nice compliment but reminding me that I wasn't going to earn my grade by trying to keep the department flowing.
     
  18. GeneralVeers

    GeneralVeers Globus Hystericus
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    If only I could find such a patient with negative ROS. Most of my patients answer "yes" to every question, then follow it up with a story about what happened to them last week.
     
  19. AmoryBlaine

    AmoryBlaine the last tycoon
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    Lift some weights, look meaner, and ask it like "you haven't had any headaches RIGHT?"
     
  20. GeneralVeers

    GeneralVeers Globus Hystericus
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    I'm already the right level of meanness. Our attendings are predicting that the hospital's Press-Ganey scores will improve once I leave.
     
  21. turtle md

    turtle md Hardware Included
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    I am an EM-3 at Christiana. We are definately busy enough. Those numbers do not accurately reflect our true productivity. As EM-3, we oversee all Trauma's, but do not get credit for them as "our" patient. We oversee all medical codes and do not get credit. We supervise procedures but get no credit. Plus, the hours they count include our conference/JC hours, so are not really accurate. At the end of any 9 hour shift, I have usually seen anywhere from 18-25 patients. We have several "cores," so those are 25 sick people, not a mix of urgent and emergent, but over 90% emergent cases. And 1 hour was for a morning conference, and maybe 8-10 of the patients were me supervising, but not getting credit.
     
  22. The White Coat Investor

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    You can get a lot faster by asking your ROS questions like this:

    Do you have any chest pain, shortness of breath, vomiting, or huge sores on your penis? (4 systems and a guaranteed no if you include that at the end. Who would answer that question "yes"?

    Or how about this one: Any pain with urination, easy bruising, diabetes, or nasty rashes?

    Any weakness, numbness, visual problems, trouble swallowing, or recreational drug habits?

    Three questions, ten systems, and three guaranteed "no" answers.

    RE the comment about Qatar...I've been to that ED. It is absolutely huge. The US military patient I accompanied there with a WHOML (I didn't have a CT scanner at the base) did not have his vitals taken or receive a neurologic exam. Very interesting. I guess that's another way to get "more efficient." :) They use the British A&E system too in that there really aren't any emergency docs. If it is an ortho complaint, they go to the ortho room and are seen by the orthopod. If it is a trauma complaint, they go to the trauma room and are seen by the surgeon. Medical? Go to either major medical room or minor medical room and be seen by the internist. The model works fine at huge hospitals/EDs, but wouldn't work in small town America or at anything less than about a 30 or 40 bed ED.
     
  23. WilcoWorld

    WilcoWorld Senior Member
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    Brilliant!
     
  24. arctic187

    arctic187 Junior Member
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    On a similar note, because the attending (or upper year resident) is basically co-managing the patient you are adding to their own patient load. It is much more effective if you have less patients but stay on top of things. And I mean you must be the one to point out that the labs/xray are back not the other way around. Offer to call in the admission, etc. That is MUCH more impressive then picking up 5 active patients and having the attending bail you out when you get overwhelmed. Manage 2-3 active patients at a time, do it well and you will impress the attending.

    Other ways to impress the attending besides seeing more patients:

    -Recognize the "sick" patient and let the attending know: the best student eval I wrote was on a student who recognized that her stroke patient was getting sicker on the way back from CT. The patient got immediately intubated. Happy to say that student stayed with us for residency and is now one of our chief residents ;)

    -Listen out for procedure possibilities and be proactive...say I know how to do ABG's can I help? Or I've never done that before, can I watch? (which will likely turn into you doing)

    -ask intelligent questions that are clinically relevent

    -If during a discussion a clinical question arises.....look it up and share the answer
     
  25. roja

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    and bring your attending food and more importantly, coffee. :D
     
  26. Jeff698

    Jeff698 EM/EMS nerd
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    Roja, I must have missed it but your tag line seems to indicate you've got a new job. Congratulations! Hope you enjoy San Fransisco.

    Take care,
    Jeff
     
  27. roja

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    Thanks. I did. I finished (finally) my fellowship and got a new job. I love SF and am sad that I have to go to NYC and pack up. Sad to have to go back to NYC but also to say goodbye to all my friends. *sniff* and sad that I am not all settled into the beautiful, cool SF weather. :)
     

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