Kind of random but im in the process of thinking how to streamline my notes. Can we essentially just write the HPI and MDM now? I know MDM is really the only essential thing for determining visit levels. I have areas in the note for templates for ROS and Exam but I am considering skipping those and just narrating a focused exam within the MDM. Any others doing the same?
Got behind on notes over the last week and today I am having to sign attestations to 40 something odd notes over the last couple of days. I've noticed that the vast majority, something like 70% of patients are the same archetype as described below:
"40-70 something yo female with chronic vague pain, chronic nausea following with a specialist who hasn't given any sort of definitive diagnosis presents to the ER for acute flare of chronic pain + nausea + diarrhea but also somehow constipation + some vague neuro complaint like full body paresthesia, brain fog, fatigue, etc. Symptoms have been going on for months to years yet somehow today are worse than they've ever been. They have not notified their PCP or specialist (or alternatively their PCP/specialist is tired of them and told them to come to the ER)."
They end up getting a $20,000 work up with labs, sometimes head CT or CT abdomen pelvis. Everything is pretty much negative and they get discharged home with zofran and sometimes bentyl.
Maybe it's just the area I'm in but this is such a common presentation it's basically a trope. Is this archetype common where you are if not, what is your average patient like?
I became an attending prior to covid. During the pandemic things were a bit uncertain at first, especially amongst our older more vulnerable staff. Those first couple months certainly seemed like out of a Hollywood script. However the day to day from a work standpoint was awesome.
There were so many PSAs about "flattening the curve" , "stay home" , "only go to the ER for emergencies" , etc. Volume dropped off a cliff and I was pretty much only seeing sick patients. I had some night shifts where I slept for hours on end. Our ER had lunch and dinner catered to us daily from local restaurants as a show of support. Leaving work and coming into work we were greeted by people in cars honking horns, clapping for us. Consultants were nice and approached us asking how they could support the ER.
Sometimes around late 2021 into 2022 things seemed like they changed after the introduction of the vaccine. After that it seemed like covid became more of a political issue, people just didn't give AF anymore and the toxicity that we see today began. I would argue that things are worse off now compared to pre covid. Wish people would show even 10% of the respect and consideration that they did during the pandemic.
I haven't been sued yet *knock on wood* but know plenty of people who have been. Most say it's a frustrating process but overall not a major career changer and in the state I work in none of your personal assets are ever at risk.
I know the process itself can be lengthy, depositions sound like just an opportunity for the opposing counsel to bully you and lawsuits go in the ominous NPDB but other than that what are other consequences for being sued? Couldn't you in theory just tell your counsel to settle so you don't have to go through all the bullshit?
I thought this may be a fun discussion. Curious what types of patients people are seeing.
Most patients I see fall into 1 of 4 categories:
The acute on chronically Ill. Think sick nursing home and rehab patients. They have a serious chronic illness and have repeated complications and are frequently in and out of the hospital.Think stage 4 cancer patients, advanced Parkinson's patients with frequent falls, immobile stroke patients, end stage COPD on chronic O2, etc.
The worried well. Think average health but extremely anxious. Poor coping mechanisms and no resources. Will come to the ER at the drop of a hat for any mild inconvenience or suspicion of ANYTHING being wrong. Think elderly folks checking their BP every hour and coming in if it's slightly elevated, most patients with palpitations, most ped fever patients, healthy young patients with mild colds, etc.
The feebleminded. These patients present with a completely avoidable issue or an issue due to their own poor thought process. Some overlap with type 2 patients but usually their presenting issue is directly related to their poor decision making. Think drugs, alcohol, cannabinoid hyperemesis, hyperglycemia from med and diet non compliance, med refills because they missed their PCP appointment, etc. It may be controversial but I think many psych patients fall into this category too.
The normal person with an unfortunate circumstance. Mostly healthy patients with adequate resources that present to the ER with an acute issue that needs prompt attention and there's no other reasonable options. Think most accidental lacerations, acute msk injuries, MVC, non frequent flier chest pain patients, miscarriages, etc.
I work in the Midwest of the US in a fairly impoverished area. I see mostly type 1 and 3 patients. On days I see mostly type 4 patients I feel less burned out. Days with mostly 2 and 3 suck. Curious what you're seeing out there and what area you're in.
Tonight we had a local nursing facility send a demented hospice patient at 3am because they took longer than normal to wake up. No other complaints, patient not sure why they are in the ER. Family is pissed. Why was the patient even being woken up at this hour?!
On the flip side we had another patient sent in from a different local facility. They were demented, septic as fuck. Diaper caked in old stool. They probably hadn't been changed in at least a couple of days. Raging UTI on work up. We made APS aware.
Are nursing homes this bad where you are located? Seems like there are few consequences for providing shitty nursing home care and dumping on the ER.
Tonight we had a local nursing facility send a demented hospice patient at 3am because they took longer than normal to wake up. No other complaints, patient not sure why they are in the ER. Family is pissed. Why was the patient even being woken up at this hour?!
On the flip side we had another patient sent in from a different local facility. They were demented, septic as fuck. Diaper caked in old stool. They probably hadn't been changed in at least a couple of days. Raging UTI on work up. We made APS aware.
Are nursing homes this bad where you are located? Seems like there are few consequences for providing shitty nursing home care and dumping on the ER.
Any docs actually planning to work until 65 or whatever traditional retirement age is?
In my group we don't have any docs that are above the age of 60. In my years with the group we had pretty much everyone retire before the age of 60 with most retiring in their late 50s. This job is just too hard to do as you get older. I realize it is a luxury that we have an opportunity to retire early but it would be nice to have a plan to keep busy as we age. What are your plans for near retirement/retirement age?
I was finding myself in need of a new primary care doctor recently. I was trying to schedule an appointment with a primary care physician through my local hospital network. I was on their website trying to see if I could request an appointment online but no such process exists. But rest assured there are plenty of advertisements about the ER wait times and how low they are and ads for their urgent care locations. There was a text box right by the primary care providers link that verbatim said "why wait to get care? Be seen today at xxxx urgent care. Wait time is currently 10 min!"
Of course it's impossible to request an appointment online. I had to call a number which took me to a convoluted answering service with significant hold times until I could finally be connected to a human scheduler. The scheduler seemed incredulous that I was trying to establish care as a new patient and was particularly short with me. Of course there were no available appointments within the next 3 months which I had anticipated. It's almost like health care systems just don't give a shit about primary care anymore and just want to suck people's healthcare dollars away by funneling them to urgent care or the ER for all of their issues.
I can't really blame primary care too much but more so the economic forces of the system we work in. I hate seeing people at work who come in for issues that could easily be managed by a PCP but I guess I have more sympathy now.
In my opinion notes are one of the worst parts of our job. I can see tons of patients, get lots of stuff done but to document it all accurately, bill properly for it, and protect myself legally it's super time consuming.
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I am that guy who almost always has at least several charts to finish after a shift. It doesn't help that our group is single coverage and our sign out times are during the busiest hours.
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I typically have to do between 20-40 notes per shift. Maybe 10-15 are my own notes for patients I see primarily, the rest are APP attestations which are less time consuming. I also have to sign for every EKG in the shift which is about a similar number and at times have to write a brief preliminary read on X-rays when we don't have rads reading. Not to mention I also typically have 1-5 patient callbacks per shift for culture results or STD testing which requires adding an addendum to previous notes.
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At the end of my shift I typically just go home to chart because I've found it not to be productive to be there afterwards charting as nursing will still ask you for things creating more work. I do try to get my notes done for all admitted and signed out patients. Notes are always done on patients transferred.
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Most of my partners have expressed they don't like charting at home and do everything they can to finish notes on shift. TBH they look miserable. I have worked side by side with someone during an observation and they seemed to be either seeing a patient or charting literally their entire shift. Ngl, for my mental health I find it more valuable to take 5 min to eat or drink a diet coke on shift so I can have the mental energy to keep grinding.
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What strategies do you find to increase efficiency in note writing? I've looked into AI scribes but the problem is most of them seem to need to be integrated into the EHR to be useful and our IT does not support this yet. Wondering what other recommendations folks have.
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For the last couple years or so I've started to not give as many fucks at work and my career has improved significantly.
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I was super burned out about 5 years or so after residency. Being a community ER doc in single coverage shops kind of sucks sometimes. I went to a very academic residency and tried to practice like I was trained but quickly found myself being frustrated at patients, local urgent cares, my partners, hospitalists, etc. I was so into being "evidence based", avoiding doing too much work up, being a good antibiotic steward, etc that it made me kind of frustrated. I was also working a ton of nights and quite frankly was just burned out with the system in general. I'd see complaints like asymptomatic hypertension at 0300 and immediately go into the patients room in a terrible mood.
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One of my partners told me a few years ago changed my perspective and told me that he just views working in the ER as a means to an end. Its just a job and there's nothing wrong with just being average at your job if it means your happier and still providing competent care.
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I took on this attitude and honestly it has been a game changer. If someone comes in with URI symptoms and is really wanting antibiotics despite it likely being a virus I don't really care anymore, "here's your z pack script" then I move on to other things. Hospitalist NP wants me to scan someone's chest prior to admit even though they are clearly hypoxic from their pna on CXR? "Ok whatever, at least they're accepting".
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Since I've adopted this attitude I feel more refreshed, relaxed at work and I feel like I can do this job longer. I know it sounds crazy but I feel like if others did the same then emergency medicine would have less burned out docs.
I've been reviewing a few malpractice cases recently and it seems like lawyers commonly add on EMTALA violations to their claims. Specifically, they claim the provider failed to provide an adequate MSE If there was later a bad outcome.
Obviously EMTALA requires us to provide a MSE to anyone that comes through the ER but what does that actually mean? Vitals, doorway exam, EKG? Labs?
It seems like MSE is always situational and defined retrospectively after a bad outcome.
I wish we as ER docs and/or ACEP could advocate for a defined MSE that would satisfy EMTALA.
I see a ton of non acute complaints, like everyone else daily. I wish I could just do a defined MSE and discharge them rapidly.
For example. 26 yo female with chronic abdominal pain. Nothing new today but she "just wants you to find an answer because no one else can". Vitals normal, exam without guarding or rebound tenderness. Next step dc home without any labs or imaging. Follow up with PCP, this is non emergent.
Anyone else agree?
For many years earlier in my career I worked in low volume single coverage, rural to semi-rual ERs and made bank. I had a couple of shifts where I had zero patients over 12 hours. It wasn't all a walk in the park though, at times I did have sick patients and had to manage things I wasn't as comfortable with while waiting for transfer. Overall though it was super chill. I estimate I made over a million dollars sleeping, watching movies and playing video games lol. What other job in medicine is it possible to do that?!
Now I work in a busier suburban center and have a lot more support but the volume and APP staffing are kind of annoying. Sometimes I think about going back. Anyone else find that rural EM is better?