Patient Satisfaction

Image Credit: Flickr

Author: Victoria Weston, MD
AAEM/RSA President '15-'16
Originally Published: Common Sense March/April 2016

Patient satisfaction. It feels like sometimes the concept is overemphasized, yet another addition to the countless expectations and constraints placed on doctors. I have felt this way at times, but recently my thinking has shifted. Instead of trying to meet arbitrary Press Ganey requirements, I have focused on trying to understand patients' wants and needs in order to better connect with them.

I recently had a shift with what seemed an unusually high number of patients with difficult personalities and “supratentorial pathology.”At times it was exceptionally frustrating, and although I started the shift feeling positive, by midway through the morning I could feel my spirits sinking. People had psychosomatic complaints. Some were drug-seeking and negotiating for narcotics. Some were demanding inappropriate care or tests. Some acted entitled and were rude to staff. I took this as a challenge, and tried to reframe my mind to see it as a learning experience in how to deal with difficult patients.

How Do I Know If I Go Too Slow? Improving Efficiency for Residents, Part 2

Originally Published: Common Sense, March/April 2016

Author: Gregory K. Wanner, DO PA-C
Senior Emergency Medicine Resident, Thomas Jefferson University

Author: Andrew W. Phillips, MD Med
Critical Care Fellow, Stanford University, Division of Critical Care
Staff Emergency Physician, The Permanente Group

In “Improving Efficiency for Residents, Part 1” (Common Sense, Mar/Apr 2016), we discussed patients per hour (pt/hr), factors influencing efficiency, and the value of efficiency. In this article we will share advice on how to safely improve efficiency.

Recap of Part 1
Our review showed that PGY-1 residents average between 0.73 and 1.06 pt/hr, PGY-2 residents range from 0.85 to 1.33 pt/hr, and senior residents see between 1.05 and 1.41 pt/hr.1 These numbers may seem a little low, but they are averages across several studies that include different shift lengths and practice environments. Some of the factors that influence efficiency are shift length (longer shifts appear to reduce productivity) and distractions (emergency physicians are interrupted every 5.8 minutes and are required to unexpectedly switch tasks every 8.7 minutes).2,3

Speed versus Efficiency
Learning to be efficient is more important than learning to be fast, and there is a difference. The number of patients seen per hour, while important, does not tell the whole story. Avoiding discussions with patients, minimal documentation, and hurrying through procedures are not appropriate ways to increase patients per hour. Efficiency, however, makes use of all available resources to help move patients through the ED without cutting corners. It takes practice — lots of practice. As residents, we can all improve our efficiency.

How Do I Know If I Go Too Slow? Improving Efficiency for Residents, Part 1

Image Credit: Flickr

Originally Published: Common Sense, March/April 2016

Author: Gregory K. Wanner, DO, PA-C
Thomas Jefferson University

Author: Andrew W. Phillips, MD, Med
Stanford University, Division of Critical Care

Read part 2 here: Improving Efficiency for Residents


Residency is a time for improvement. Improving procedural skills, gaining clinical acumen, and growing knowledge are chief goals during residency. Efficiency is also a necessary skill for the budding emergency physician. After learning the core knowledge of emergency medicine and becoming competent in procedures, efficiency is the next item for residents to emphasize. How can efficiency be improved? How can residents tell if they’re moving too slowly or too quickly? How can a resident improve efficiency without missing important details or skimping on documentation? We will answer these questions in a two-part series. In this first article, we will review the average patient volume seen by residents, the concept of relative value units (RVUs), and touch on the idea of efficiency. In part two, in the next issue of Common Sense, we will discuss methods for improving efficiency based on expert recommendations and research.

Patients Per Hour
Residents often ask, “How many patients should I see per hour?” The answer is complicated. A resident’s patients per hour (pts/hr) rate depends upon many factors. Table 1 provides a general idea about the average number of pts/hr seen by residents. Several studies indicate that the pts/hr increases from intern year to senior year. However there is some overlap between each year of training. Across all included studies, interns (PGY1) averaged from 0.73 to 1.06 pts/hr; PGY2 residents ranged from 0.85 to 1.33; and senior (PGY3) residents ranged from 1.05 to 1.41.[1-8] Administrative and supervisory responsibilities also increased for senior residents, perhaps reducing the number of pts/hr for PGY3 residents to some degree.[3-4] As a comparison, two studies evaluated patients seen per hour by attendings. A retrospective study of 912 attending physicians at 61 EDs showed an overall average of 1.72 (SD=+/- 0.44) pts/hr, with physicians at higher volume (over 45,000 visits/year) EDs seeing 2.07 (SD=+/- 0.32) pts/hr.[9] Another study of attending physicians indicated an average of 1.87 pts/hr while working alone and 1.99 pts/hr while working with residents.[10] Bear in mind that this is at academic centers — by definition, since we’re discussing residents. Moreover, the numbers reflect not only physician speed but also patient demographics, such as whether or not pediatric patients are included or if there is a Fast Track that siphons away less complex patients – factors which are generalized in our summary.

How to Give a Great Presentation to Your EM Attending Physician

Image Source: Bigstock

Author: Jennifer Stancati
Midwest Regional Representative
AAEM/RSA Medical Student Council '14-'15

Most students would agree that presenting a patient on rounds or to your attending is one of the scariest parts of being a third or fourth year medical student. Whether you are in a group or one-on-one, all eyes and attention are on you. There is the potential to do or say something incorrect, embarrassing, or perhaps you might not know the answer to a question that you are asked. Also, depending on the level of responsibility that you are given, what you say can have a large impact on the course of a patient’s visit. As if this was not enough, there is the fact that you are being evaluated. And in a busy environment like an emergency department (ED), this may be the only interaction that you have with your attending physician.

Being in the environment of the ED adds a few more factors into the equation. You may have been rushed and your history or physical may feel incomplete. Or as you are getting ready to present, your attending may say, “just give me the pertinent information; nothing else.” And last but not least, your patient may be really sick and in need of immediate help. If your patient is truly sick and needs immediate attention, it is important to get your attending (or resident) in the room before you even complete your history and physical. Not only is this the right thing to do for your patient, but also you will demonstrate your ability to recognize an unstable patient.

Notes from the Night Shift: Single Parents as Patients

Source: Flickr

Author: Heather Boynton, MD
UC San Diego Health System
Originally Published: Modern Resident February/March 2016

With pediatric cases, we often say that we have two patients: the child and the parent. How does our approach change when the parent is the patient, and the kids are in the room too?

On a recent string of overnight shifts, I noticed I was seeing a lot of single parents who told me they decided to come to the ED at night so that their children would sleep through most of the visit. My first patient was a young, single, working mother with two small children. In tears she told me how she had been having rectal bleeding for over a week. During the day she worked at a new job, and was afraid to take time off to go to a clinic; at night she had no one to watch her kids, and money was tight, making a babysitter feel like a sacrifice. Her toddler had been outfitted with headphones and was deeply engrossed in a cartoon; the older child, a girl maybe five or six years old, looked at her shoes. My sexual history taking, usually easy with frank, plain language, halted and stumbled. I put off a bimanual exam. When I returned with a pelvic cart and someone to watch the kids, they were asleep in the bed I wanted to use for my patient, and she was in a chair.

Another patient, also a single mother, was roomed with her two young children around 11:00pm while her two older children waited in the waiting room. She, too, had been having symptoms for about a week, complaining of a bad headache with nausea. I sent labs and started fluids. I decided to order Compazine without Benadryl, concerned that the combination would be too sedating. When I checked on my patient twenty minutes later, she was standing on her bed, screaming and pulling her clothes off. Now all four children were in the room, and the youngest two were crying. Fortunately, more fluids and a small dose of benztropine resolved things.

A few pearls:

• Make sure your patient is in the right room. A room with a door helps keep young children calm in an otherwise chaotic environment. A small family camped out for the night can wreak havoc on department flow, so think early about your plan for discharge or admission.

• Identify up-front what parts of your assessment would be best completed without children. Ask your ancillary staff for help when you need a sexual history, pelvic or rectal exams. Twenty minutes may be hard to come by, but five minutes is usually doable.

• Use the equipment available to you. Paper, pens, warm blankets and small containers of milk from the patient food refrigerators go a long way to smooth over a late-night visit. If your ED has reclining chairs, try to get one into your patient’s room. Encourage the patient to tuck a child into a soft chair or cot instead of the patient bed.