EM Mindset: Pearls from Efficient Emergency Physicians; Why They Still Love Coming to Work

Author: Elliott Trotter, MD, (Emergency Physician, Former Chief Division of Emergency Medicine at THR Harris Methodist Fort Worth, TX) // Edited by: Alex Koyfman, MD (@EMHighAK) and Brit Long, MD (@long_brit)

Elliot Trotter MD is a 30-year veteran of Emergency Medicine (EM) who is renowned as one of the most efficient physicians at one of the most efficient Emergency Departments (ED) in the country. In 1995, he began to push back the boundaries of physician extender strategies, using medical scribes to vastly increase the efficiency and job satisfaction levels of not only himself, but for hundreds of other emergency medicine physicians who adopted his approach. Further pursing his passion for efficient patient care, Dr. Trotter also created the staggered acuity (pulse) EM physician staffing model. This highly innovative approach uses a “difficulty cascade” that ensures providers see their toughest cases when they’re fresh and their easiest to end their day. His expertise in emergency provider workflows has caused physicians from around the country to ask to help improve their practices.

In the pages that follow, Dr. Trotter shares his perspectives on how the efficient practice of emergency medicine can serve as the basis to combat one of the toughest challenges medicine faces today – physician burnout. As any healthcare provider today knows only too well, the recent avalanche of new regulation, computerized medicine, social media, new payer models, and a host of other factors all contribute to a growing epidemic. Many providers today simply feel too embattled to get satisfaction from the very career they so passionately chose. Dr. Trotter describes in detail how by beginning with an efficiency mindset model, clinicians can change the way they work to keep burnout at bay.

 

Most efficient emergency physicians love chaos; the more the better.  They have developed a keen sense of patient risk and rapidly calculate how likely “is this not a horse but in fact a zebra” and what test, if any, willthey need to prove this satisfactorily.  Some of these physicians are also extreme sport participants and are considered “daring” in both life and at work. However, they are always subconsciously calculating risk.

EM physiciansare not only watching their own trackboard, but are loosely monitoring all patients in the ED. They will see patients in “their area” within 2 minutes of arrival (even if there are 10 new arrivals within10 minutes), see new patients in the waiting room, see patients in other physicians’ pods as needed,and would even see patientsin the parking lot if asked.

 Efficient physicians have mental protocols and algorithms that they use for boththe most simple benign and the most serious patients. They constantly watch for any subtle deviation from the expected patterns of the most frequent complaints.  Decades ago, written protocols were created for critical (trauma, cardiac, sophisticated, etc) patients.By categorizing patients into the “not sick” or “sick,” that leaves more time to think about the third category; “not sure yet.”

Only 10% of emergency doctoring is getting the correct diagnosis (dx)and treatment.  The other 90% is managing expectations from patients, families, nursing staff, and consultants. Therefore, you must learn to anticipate everyone’s needs and concerns.  As soon as you know a patient is going to be admitted, tell everyoneinvolved(patient, family, nurse, bed control, consultants) so they can make plans accordingly.  Even tell the patient and family what to expect over the next few days or weeks.  For example, “your hip fracture will likely be operated on in a day or two, then after a few more days, you will go to a rehab hospital for a few weeks.”

Strive to always treat all patients equally. Treat all patients as if they are your actual family.While that might sound straightforward and easy, it’s difficult for most in healthcare to stay level headed with the arguing patient, the unsophisticated patient, or the manipulative patient.  Don’t take it personally if patients are non-compliant or over utilize ED resources.  Understand that service excellence is what sets you apart from all the other EDs. That alone can also get the correct diagnosis and treatment.  Don’t do it for a satisfaction score; that’s being fake and will eat at your soul.

History

Thirty years ago, my practice of pushing the efficiency envelope was seen as an anomaly: “you can’t see patients before I get report from EMS,” in the waiting room,” or ” before triage.”  Years later, it was seen as best practice, and now it’s standard of care at our institution.  All physicians see patients at triage, before triage, in the waiting room, and in other physicians’ pods.  Over the years, we have recruited 30% of our ED physicians who are high efficiency physicians.  See this ACEP article from March 16, 2016.  Many of these efficient physicians are our former scribes from the mid-1990s and later.

Efficient physicians love coming to work. They thrive on the challenge to keep up, organize the chaos, and work in the “zone.”  The “zone” is what professional sports players describe as an ultra-focus feeling. During these (typically waves) of focus zones, other staff may become frustrated because they cannot keep up, want more of a discussion than a simple “yes or no”, and may not even sense there is a tidal wave coming. Some describe an ED shift as “a marathon not a sprint,” but for efficient physicians it’s not a marathon.  It is, in fact, a series of multiple sprints during the shift: tidal waves of tasks and patients.  They sense the wave starting, paddle hard and fast, get up on the board (zone), and enjoy the ride down.

Residents

The Parkland ED residents do their community ED rotations with us. We have focused the R3s to hone their multitasking skills with our most efficient physicians. Here are some pearls that we share with them:

R3 Objectives

  • Learn the concept of a “breathing” ED.
  • Manage the entire trackboard, not just “my patients.”  Learn why our average door to physician time is 9 minutes with 130k ED visits per year.
  • Learn Physician Triage and Advanced Triage concepts for improving flow.
  • Identify what the variable “rate limiting flow factor” is (triage, RN, inpatient holds, discharges, lab, radiology, EM physician, consultants) and solutions to fix (i.e. DDOG (doctor, discharge,orders,green aka post triage chairs)).
  • Learn to rapidly manage multiple high acuity incoming patients (initial triage and multiple re-evaluations (re-evals)) while maintaining high level patient satisfaction.
  • Learn techniques for highly efficient history taking.
  • Develop patient disposition (dispo) statistics based on the initial 60 second encounter (while avoiding premature closure).
  • Learn to recognize early, the most critical dx based on chief complaint – from fast track to critical patients.
  • Learn HMFW original unique staggered acuity/pulse shifting (see referenced article above).
  • Learn innovative flow methods – vertical sitting patients, encounter and discharging from the waiting room, procedure doctor, and advanced triage done by a RN or MD.
  • Physician flex into various ED areas depending on department needs while maintaining sensitivity to other emergency physicians – 30 minute rule(door to doctor, leave your pod to see patients in other pods if necessary, permanently assign yourself or at least advance triage).
  • Learn from the birthplace 22 years ago of the modern scribe how to most correctly/effectively use 2 scribes (1/3 time for documentation; 2/3 time for flow and bird dogging).
  • Learn how to hone skills on admission work flow, including succinct communication with hospitalist and consultants, and writing 12-hour courtesy hold orders to tide patient over until patient seen by those admitting physicians.

Here are some of my personal efficiency pearls for R3s:

  1. Don’t sit at a work station, stand. DO sit it patient’s room.
  2. Fewer strokes/steps.
  3. Look at chart (triage, past) prior to entry room. If not able (i.e.seeing patients at the ambulance bay or upon walking into triage), look prior to ordering tests.
  4. So there are 10 new patients. First visit should be 60 seconds to determine what to order and dispo to get there. Use “sick,not sick” gestalt. Tell patient the timeline: tests, pain control, and dispo if known, yet, without premature closure or framing. Come back for multiple re-evals.
  5. Tell scribe, RN, patient, and family the probable dispo, dx, and prescriptions (rx).
  6. Order tests in parallel.Do not test, then when all these tests are negative, order more tests.
  7. Ask yourself, “What’s the worst thing?” and “How is this not a horse?,” not “how is this a zebra?”.
  8. In the patient’s room, sit on the stool. You become more personable.
  9. Assume all tests will be normal when you order them. If in 2 hours they are all normal, then what? You already decided this 2 hours ago!!!!!
  10. Best use of scribes: bird dog and delegate (2/3), not just documentation (1/3). Give the scribe a running work list especially when you are in a procedure.
  11. Decision making – Ddx from tests: most likely and worst.
  12. Take EMS report directly from paramedic if at all possible.
  13. Multitask aka rapid switch. Take the long pause at discharge and writing hold orders.
  14. Call admission physician early.
  15. On the difficult patient interaction, call social services, patient advocate, or charge nurse. Help the patient. Get a different perspective and maybe you need a witness for patient / family behavior or expectations.
  16. For the unclear dx or dispo and also to avoid premature closure/framing,slow ….way ….down, or better yet, perform multiple rechecks, talk to family, and talk to the nurses.
  17. Listen to your nurses. If they are concerned, don’t take it personally. If they don’t think you should send this patient home, then don’t!!!
  18. Slow way down at final dispo. Review all tests and abnormal physical exam items. Are all admission or discharge orders covering all abnormalities?
  19. On final patient encounter, anticipate all patient questions and answer them before they even ask including results, dx, rx, and f/u. Everyone age 1 to 99 gets a 2 days off note. Then ask if any they have any other questions.
  20. Take a 10 minute break out of the department every 4 hours.
  21. Make sure you are running the department track board (done by charge nurse and doctors), DDOG: Doctor, Discharge, Orders, Grey (waiting room). Address which of the above is the log jam in that order.
  22. Make sure you are running your personal track board, NIRIT: Red (New), pended orders (Icon), green (Re-eval), yellow (In process), and grey (Triaged i.e. waiting room). *** Note if you have a sea of re-evals let others start the new patients. Your re-evals are causing the log jam!!!
  23. For any physician, there is a limit. You cannot be that fast physician with higher misses and lower patient satisfaction. Find your balance. Learn to sense when you are at your 90% limit AND ask for help. Everybody needs help. It is a sign of weakness to NOT ask for it, and especially to not ACCEPT it.

 

Personal Schedule

Here are my personal scheduling tips which may help with career longevity and reduce burn out:

  1. Follow your over nights with an afternoon shift… short shift yourself and then take a real day off. It’s a much better day off than a “day off” after night shifts. Try it. I have taught this to many docs who love it!
  2. Don’t do night shifts, then 24 hours off, and then start day shifts. Alternatively, after nights and then a day off, start with afternoon shifts, then short shift yourself to day shifts.
  3. Take a big block of time (4-6 or more days) off every month or two and travel even if it’s just a few miles away. Get away. If you just can’t leave, then do NO WORK! No CME. No emails.
  4. Take real days off. No meetings. No emails.
  5. As a corollary to #4, schedule a shift to follow meetings (hospital, school, or whatever meetings).
  6. Understand that at least 1/3 of your shifts will be nights.
  7. Understand 3/7 (more than 1/3) of your shifts will be weekends. At 15 shifts times 3/7 equals 6.4 (round up to 7) shifts will be Fri, Sat, Sun. That’s just the simple math.
  8. This is team play. Don’t be selfish but be a team player.  Help others.  Agree to schedule switches PRN.
  9. Longevity advice: Work the number of shifts that is a good balance for you. Then do a financial budget from that with plenty left over PERIOD.  DO NOT, instead, work the number of shifts that you require to catch up to your expenses. It will make you start to count shifts and lead to burn out.
  10. Some people like a little ritual routine (meditation) before they go to work (not me, but surprisingly many). Do that routine just before work. Put it on an alarm.  Don’t watch your watch all day in anticipation of work. It leads to dreading.
  11. Sleeping days. Build a dark room. Closet. Use a white noise maker. No cell phone. Take a Melatonin and Benadryl.

 

“OCD vs ADD”

Efficient physicianstend to not let confrontation bother them. Instead, they learn not to argue and to let things roll off their back. It’s part of the job. Most importantly, they leave the department knowing they are not perfect but feeling they impacted the lives they encountered because they did the best they could. They frequently let it all melt away on the drive home. By the time they do get home, partnersinquiring about interesting cases requires a door recall as the work day has already left their focus.

One great analogy Dr. Erik Ledig shared describes efficient physiciansas ADD physiciansand others as OCD. It’s hard for OCD physiciansto become more ADD, even if just for 10 minutes of a shift at a time. Other efficient physiciansand I have witnessed a couple of OCD physiciansreally learn these techniques with huge success, however, most OCD physicianstalk about wanting to change but rarely take the initial steps to do so. ATTITUDE is a decision. Make it happen. Your day and life will be easier.

EM burnout is not new. When I started 30 years ago, EM burnout was 50% at 5 years and a whopping 90% at 10 years. Physicians rarely chose EM as a career, it was just a temporary gig. But a few of us 30 year veterans found it to be the perfect job, have stuck with it, and try to share our pearls of longevity with the younger physicians. Some new physicians have mistakenly chosen EM for lifestyle, salary, or an ill-conceived perception of aloof emotion to patients because of no long-term patient relationships. Actually, it’s quite the opposite; EM physicians must be exceptional at connecting with patients to make them feel comfortable within literally 60 seconds.  Which brings me to the final and most important reward of EM, mentoring.  As Dr. Vishal Bhakta, our former scribe and now physician with our group says to our current premed scribes ” pass it forward.”Mentor. Coach.

And so, I just did.

Elliott Trotter, MD

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Addendum/Epiphany

Since writing the above, locally, we have all been recently touched by the service separate passing of two of our former scribes who took their own lives.  Although these two physicians are not in our EM group, they were still our mentees and it has given me an epiphany.  I knew my EM Mindset article shared words of efficiency wisdom, but it seemed incomplete. I held its release for the last 2 years as there was yet an unknown message to include.

So, I am adding this most dire message. 3 years ago, our 300 physician group formed a Wellness (Burnout) Committee. We focus on preventing burnout for our new grads, intervening for our middle-aged physicians beginning to burn out, and attempt to salvage those who are miserable. It now appears evident that we need to start preaching to premed students that although they will spend lots of dollars and years training in medicine, if you later find EM (or medicine in general) too unbearable, it’s not that you failed medicine but, in fact, medicine has failed you!

First, try some of the advice and techniques above, seek counseling, and talk to your peers and family about your need for help. Next, please work in a low volume ED, urgent care, hospice, clinic for the low income or medical uninsured, or something else in medicine before you just can’t stand to go to work any longer. If even that is not fulfilling, or you struggle with keeping a job or your license, then I implore you to unload that expensive house and car, downsize, and find a job as a realtor, garden center,do something that contributes beneficially to a change in your life in an area that is needed. Yes, you spent hundreds of thousands of dollars and many years, but perhaps it did not work for you.  EM physicians, look to your left, and now to your right.  Two out of the three of you are currently burned out in EM.  All three of you will be in a personal / career crisis at some time in your life. I challenge you all in the next two weeks to reach out to four of your colleagues. Take them to lunch.  Ask how you can personally help themin any aspect of their life. Share this EM Mindset article. Help them to seek other advice and counseling. Take the online QPR training to learn to ask colleagues about suicide.

FFFG, By Sanjiv Chopra MD

  • Friends and family. Balanced life.
  • We have all been injured by others. You must forgive to heal.
  • For others. Do things for others without any expectation of return.
  • Give forward mentor.

In summary

  1. Learn to love the fact that you have the best job in the world, one where you can make huge impact in the lives of others every day. Focus on being grateful for what you have and stay positive. Attempt to recenter your Ikigai, the Japanese term for center of your calling or what gives you happiness. Look to follow FFFG (referenced above).
  2. Learn to tolerate your job more and learn to mitigate the things that drive you crazy at work. Learn resiliency techniques.  Attempt to be more ADD. Let the stresses of your day roll off your back.  This includes the GLEBS: Government and insurer bureaucracy, Lawsuits and/or fear of same, EHR, Benchmarks from some alleged authority that will change 180 degrees in 6 months, and of course, satisfaction scores.
  3. If steps 1 and 2 are unsuccessful then change locations. Try a low volume or low acuity ED or an urgent care.  Volunteer at a free indigent clinic.
  4. Consider administrative position or another major alternative medical pathway.
  5. If you can’t tolerate medicine any longer as it is just toxic to your soul, then walk away.  Medicine has failed you. Always know that despite your fear of lost “Doctor” identity, getting completely out of the medical field might just save your life. Anyone who judges you is too shallow and does not deserve to be in your life. Start a new career and life. Please!!!!

Remember the challenge to reach out to 4 colleagues who you think may be struggling in the next two weeks and to mentor many for the rest of your life. It will be the best thing you have ever done. It’s a key to everyone’s success.

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