30 April 2007

What I do with my time

I see, on average two patients for every hour I work, give or take some. This is about average for ER docs in general. I am a little on the fast side for our group. This breaks down to about 30 minutes per patient; simple patients take much less, while complex or critical patients take substantially more. Yet when we review patient complaints, one of the most common themes is "I only saw the doctor for a minute." I think that's a underestimation, but not too far off the mark. A complex patient, I may be with them on and off for half an hour, cumulatively. Moderately complex patients I may spend five to ten minutes at the bedside. Ankle sprains and simple matters may truly get a minute or two, depending on whether they need much in the way of instructions.

So, you may wonder, what is it I do with the other 25 minutes for each patient? Here are the common tasks (in no particular order):

  • review old medical records
  • enter orders in the computer, and via the unit clerk
  • write up the chart -- history, exam, medical decision-making
  • chase down labs
  • chase down x-rays
  • call answering service to page primary care doc, consultants, admitting docs
  • wait for call-backs
  • phone conversations with primary care doc, consultants, admitting docs
  • receive phone call from outside doctor or clinic
  • base station control for ambulances
  • conversations with nurses (patient care-related)
  • conversations with nurses (social)
  • write up discharge instructions and prescriptions
  • field phone calls from pharmacies about prescriptions written by other providers
  • write up admitting orders
  • bother charge nurse about when inpatient beds will be ready
  • visit bathroom (maybe)
  • follow up abnormal culture results
  • consult with psychiatric social worker
  • dictate records in some cases
  • fend off approximately 24 interruptions per hour (really)
  • eat (maybe)
So, yes, I am sorry that I only had a couple of minutes to spend with you. I know you spent a long time in the ER waiting for the test results, and you felt cheated that I was in and out briskly. I tried to communicate a lot in that short time and maybe you didn't follow it all. There are so many things to do that I wonder how I manage as it is. I can't omit (or escape) any of the above tasks, and I routinely go an entire shift without eating and sometimes without voiding. It's not as if I was lazing around. But you didn't see any of it, and you overheard an extended personal conversation between two nurses in the hall, so you have concluded that we were all too busy socializing to take care of patients. That is very frustrating, I understand.

But we are, after all, very busy.


  1. Hospital administration would no doubt like us to all wear foleys to improve productivity

  2. As I get older, I can't go an entire shift without voiding anymore. Especially if I require a bit of caffeine.

  3. you should get a scribe!

  4. We work in a system that sets us up for failure. For the amount critical decision making that we do there is no other occupation on the planet that that even comes close to the amount of multitasking and interruptions we must endure. It is not unusual to get interrupted 5 times during a 3 minute dictation that will be dissected relentlessly for years in case of a lawsuit.

  5. My favorite patient complaint so far was the woman who looked into the team center and complained we were all "typing away on computers instead of taking care of people."


  6. "extended personal conversation between two nurses in the hall"

    If I could finish even an abbreviated personal conversation during a shift, I would be amazed. Heck, if I could finish an abbreviated professional conversation I'd be happy. If you have something to say that takes longer than 2 minutes to get out, you end up following the other party around the ER in order to get a response.

    And yes, the patients still complain. Because that was THEIR two minutes, dammit!

  7. No ma'am, that wasn't just a phone, it was a dictaphone, I was dictating a chart, not chatting on the phone with someone else.

    No sir, I was not on eBay and surfing the internet. It's our electronic medical record.

    No sir, I was not "playing on the computer." I was looking at xrays and CT scans on the PACS system.

    Ma'am, I wasn't just chatting with anyone on the phone. I was consulting the cardiothoracic surgeon about a sick patient with a ruptured aortic aneurysm. Your toothache will just have to wait while we attend to the sicker folks first.

  8. I could never work in an ER. I don't know how you folks can work there without going postal on some patients and their wacky family members.


  9. When you say 2 patients per hour, do you mean 2.0? I had always heard the average was at 2.4, and I've been seeing 2.6 for my first nine months as an attending.

    21 patients in an 8 hour shift is usually not too bad depending on the acuity, but I start feeling stretched at 3.0pt/hr and above, which is about a quarter of my shifts.

    Wonder if I'm working too hard? At 2.0/hr, I almost (gasp) enjoy work, having a chance to chat with the nurses, sign charts, pee, etc.


  10. ten/ten:
    ACEP's Guidelines recommend 2-2.25 patients per hour. It will vary a lot based on acuity. If you are pushing three or more, the acuity had better be pretty low! Our real-life standards are:

    High acuity site with 25-30% admits: 1.8 pph group average
    Low acuity site with 5-8% admits: 2.2 pph group average. (we should be doing better here)

    It also depends on how efficient your shop is; if you have adequate nurses, inpatient beds, and scribes you can indeed go quite a lot faster. Conversely, if you have a lot of barriers to care, well, you'll have to work for the extra volume.

    At our site, I have never seen someone straight out of residency >2.5. If you can do it without feeling like you are putting yourself at risk of missing things, well, good for you. OTOH, you might want to cool it a bit just to get comfortable as an attending and make it less likely that you will miss something out of inexperience. I generally let folks work a year or so with us before we really start critically examining their numbers. New attendings don't need that sort of pressure right out of the gate.

    And for your sake -- if you're performing that well, I hope you're getting paid by productivity!

  11. Interesting.

    Having only worked in three emergency departments, (2 in residency and my current post) it is hard for me to comment on the acuity -- I would say moderate, certainly lower than residency, especially for major trauma as we are bypassed by EMS but still I see plently of sick medical patients.

    I was not aware of ACEP's guidelines. I did a quick google search and found this emedicine site (http://www.emedicine.com/emerg/topic661.htm) putting the number of patient's seen at 2.8-3.1/hr, although this data looks pretty old. I don't have enough experience to know if staffing for 2.0-2.25 is considered profitable enough by various groups, even with high acuity.

    Cooling it is not really an option -- we have a fast track run by a midlevel but I'm the only doc for the rest of the ED so my numbers are really dictated by how many people decide to come. I wait about a week to sign all charts and follow up on all of my patients by computer, and will make the occasional phone call to check in on a borderline discharge. To my knowledge I do not have a bad outcome, although it is certainly possible for a patient I discharged to have worsened and then gone to another hospital. Still, I find that the decision-making process even for the tough patients is usually a matter of minutes -- on the busy days I tend to worry more that I will have a subarachnoid sitting in the waiting room for 2 hours more than worrying that I will miss it once I have a chance to see them.

    I am compensated for this. In residency, when I was salaried, I could feel myself already starting to resent the not-sick patients for being there. I felt like it was pretty important for me to find a job where I was paid by patient seen vs. hourly so that at least if I'm getting killed I am rewarded for it.

    Thanks for your detailed response and the opportunity for me to ramble on about it. The transition from resident to attending with the accompanying concerns of worrying about whether I'm doing an adequate job obviously play on my mind quite a bit, and there are only so many people you can talk to who really understand what you're going through.


  12. 10/10:
    I'm also a recent grad, worked at high-volume county hospital for 2 years (about 2.5/hr with poor efficiency and mid-level acuity), then switched to something a little different. I currently see about 1.2/hour. I have to admit, it's fantastic. I find my patients more interesting and engaging, because I have more time to spend with them. Sometimes, on a night shift, I sleep for 3-4 hours at a stretch. Now this is something I could do for the rest of my career. I guess I'm glad I made the switch before I burned out. I still supplement with shifts at the local trauma center to keep skills up.


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