20 June 2007

Advice for EM Interns – Moving the Meat

Part Three

I am one of the more efficient docs in our group. Not the most efficient, but I do pretty well. Because of my leadership position within the group, I spend a lot of time thinking about operational processes and efficiency, and because of my reputation for being a “fast doc” I field a lot of queries from partners on how to do better. So I thought I would share some of my thoughts with you. The ability to move the meat effectively is really a win-win-win – you do better (both reputation and financially), the ED flows better, and the patients are happier and get more timely care.

Be motivated
It sounds stupid, but if you are not coming to your shift with energy and a strong motivation to clear out the rack, you are not going to. It’s not always easy to get yourself in this frame of mind every day, but the way I think of it is that we are paid more than 95% of all Americans to do this job, and it’s not supposed to be easy. You need to take a moment before you walk in the door to put on your game face and get yourself just a bit psyched up. Leave your home life at home. Most importantly, pay attention to your productivity – know what most docs at your facility do, know what you usually do. Set yourself a goal, and a stretch goal. Track your progress – within the shift, and over the longer time frame as well. If only via the Hawethorne Effect, this alone should increase your operational efficiency.

Be organized
“Never begin a shift with an empty stomach or a procedure with a full bladder.” So sayeth a wise elder partner. Try to bring a consistent approach to things. This is idiosyncratic, but find what works for you and do it every shift. Show up a few minutes early and spend some time assessing the state of the department before leaping into the fray. Make sure you have your favorite pen, or PDA, or whatever gadgets/accessories you find useful. I carry an index card with the name and sticker of every patient I have seen. This allows me to keep track of the patients’ progress, to-do items, location, etc. I do mental rounds with my list every twenty minutes or so. Whatever works for you. Pay attention to your work environment. Make sure your charting station meets your personal needs.

Focus with unwavering intensity upon achieving the disposition.
I joke, but it's not really a joke, that I am an unusual type of doctor, because I am not looking for a diagnosis; I'm looking for a disposition. Direct your workup towards the life threats and emergencies. The moment you know the patient cannot go home, start the process of bed assignment and transfer of care to the inpatient team, as these are usually the rate limiting steps. Avoid “the long goodbye.” Many times I have seen someone waste hours chasing their tail with multiple consults and tests when it was perfectly clear the patient needed to be admitted for a work-up. It’s a radical new concept in American medicine that the work-up does not end at the elevator. Note: this may take a little salesmanship. The admitting docs like things neatly packaged. See this post for advice on how to make the pitch to your consultants.

Initiate Treatment Early
A medicated patient is a happy patient. The sooner you get pain meds, anxiety meds, diuretics, etc, into the patient, the sooner they will feel ready to go home – and the higher your patient satisfaction scores will be! Every patient who comes in has some sort of agenda. You should be able to figure that out in the initial point of contact, and address it explicitly. Especially so if they are drug-seeking and you intend to decline to provide narcotics. Say so up front, get the fight out of the way, and you won’t find yourself hamstrung when it comes time for discharge. Stage your orders and let the nurses know what the plan is (i.e. Toradol and vistaril, if no relief of pain in 30 minutes, then dilaudid 2 mg IV q30 min till relief). That way the therapy can proceed on autopilot while you are doing something else, and you will have fewer interruptions.

Be selective in your testing strategy
When able, utilize point of care testing – istats and the like. Don’t order a full lab panel if the only data you care about will be in the istat. Don’t order ANY test unless a) it will be resulted while the patient is in the ED, and b) is required for the correct disposition. Defer urgent tests to the outpatient setting – that chronic pelvic pain patient doesn’t really need the ultrasound at 2AM. Enlist the PCPs, when available, as your allies in setting an outpatient work-up in motion. Be evidence-based in your ordering rationale. The toddler with a cough and fever doesn’t need that CXR if their oxygenation is 99% and the lungs are clear.

Your productivity is measured in patients per hour. This is impacted by your average length of stay and also by the number of patients you carry at a time. I think of it as water flowing through a pipe – the rate of flow and the diameter of the pipe determine the total volume capacity. Pay attention to the size of your pipeline and learn to carry one or two extra patients at a time. It can dramatically improve your personal throughput. When possible, try to intercalate all your complex patients with a couple of simple ones. It makes the shift more interesting and allows you to fill some idle time while waiting for the mega-work-ups to finish. And if allowed, cherry-pick like crazy the last hour of your shift. It can clear out the bottom of the chart rack and really put your productivity over the top wile helping you get out more or less on time.

Of course you should apply the usual caveats and disclaimers – not all of these prescriptions are applicable to all cases, all facilities, all practitioners. Look at your practice and see where the opportunities for improvement are. Use your judgment and pick the items from this list that make the most sense for you and your practice. Also, I should give credit where it is due: much of this as been cribbed from talks given at various seminars on ED operations. I don’t recall the lecturers’ names, and this is my own synthesis, but I cannot take credit in toto for the contents. More later.

Part One
Part Two


  1. You can dispense with ordering CXR in even more young patients (<2yo) if the diagnosis of bronchiolitis is clear from history. Do you really need a CXR to tell you that the 4 month old with sats of 86% has bronchiolitis? Not if you have a good history, and the disposition is an easy sell.
    Nice post. Word:qqxjb

  2. Very good advice.

    I would caution though that throughout my career some of the most "efficient" doctors that always kept their eye on looking good "by numbers" were some of the most annoying people to work with.

    Always looking for the "biscuit" sprained ankle or sore throat, and somehow strategically avoiding the Batshit crazy hemophiliac, son of the CEO, who took "some pills", fainted, then was bitten by a rabid skunk, and now has the "worst headache of his life"...........will never endear you to your colleagues.

  3. I find these posts fascinating, though I usually have little to add. Today I saw my primary care physician. I realize she's not under the same time pressure that an ER doc is and faces different challenges, but she does get you in and out very quickly, without seeming brisk and cold. She manages to be highly likable and give you the impression she really cares. It's kind of like being hit by a warm whirlwind, you leave a little dizzy but feeling good about the visit.

  4. Although I found this post to be outstanding, you seem to ignore the concept of defensive medicine. That "chronic pelvic pain patient (who) doesn't really need that ultrasound at 2 am" might just be the next Edith Isabel Rodriguez, and the hospitalists might not be too keen on just admitting her for the umpteenth time.

    I guess you covered it in your disclaimer section, but not everyone has a PCP, but even if they do have one, on a Friday night nobody is going to be able to follow them up for several days. Often these patients get a megaworkup either to dig for some objective indication to admit or to cover our asses in case nobody will just take them off our hands for us.

    I like to think my productivity is measured at least partly in the quality of care I give my patients. I could increase my patients per hour if I just MSE half of them, but I wouldn't enjoy what I do nearly as much.

    Nevertheless, you are right on for the most part. Well done.

  5. Jerry -- LOL -- you are right, of course, that if you pick the cherries and skip the turds you are helping nobody (and will be hated for it). I view it this way -- the sprained ankle is my 'reward' for first picking up the batshit crazy hemphiliac (...).

    Also, we have an agreement in our group that for the last hour of your shift you are allowed to cherry-pick all you want. It increases productivity, clears out the chart rack, and gets you home on time to boot!

  6. Scalpel -- agree in part. The PCP limitation is crucial. Too many of my patients have no meaningful access to primary care, in which case you are stuck doing a more comprehensive work-up.

    OTOH, I see a lot of people with chronic conditions which are well understood, who have had multiple CTs and sonos in the past few months, who re-present with the same complaint. when you can reliably exclude an emergency condition on clinical grounds, there is no value (neither therapeutic nor defensive) in repeating the work-up.

    It's an interesting perspective you bring, that about 'enjoying' the job. I really do get satisfaction from reassuring and d/c'ing the non-urgent complaints and moving on to the folks who really need me. done right, with compassion and the understanding that I really did give their complaint attention and thought, my patients seem quite grateful as well (not least because their LOS is 30 min instead of 360 min).

  7. I really appreciate your writing, doc!


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