The Good Old Days of Residency

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Dear Director: I’m a young attending and while I enjoy work, I really don’t like all the focus on the metrics at our department meetings. I miss the interesting cases and the learning of residency. What can I do to survive in a metrics-driven world?

I remember my first staff meeting as a community-attending physician. I had heard how interesting and intense the faculty meetings were where I did residency and I had high expectations for my transition into attending-hood. I arrived early to find the docs reading the newspaper, doing charts (paper back then) and drinking coffee. It was already noticeably different as there wasn’t the camaraderie of residency. After a brief CME lecture, we spent time talking about patients who stayed longer than 6 hours and documentation. Where were the interesting cases, the teaching points, the excitement?

The objective of residency is medical education. There is a tremendous amount to learn and you’re in an environment that balances individual and group education. I loved being in a tertiary care hospital and taking care of the sickest and most complicated patients. I also loved the beers and breakfast platter at Jimmy’s Diner after nightshifts and being with a cohort of people who were cut from the same cloth as me. Unfortunately, keeping an emergency department up and running so that patients receive excellent and timely care and physicians are fairly compensated requires additional objectives and focus.


My priorities as a chair aren’t about education but rather about the business of the emergency department. I recognize that I have a small amount of time each month to get our staff in touch with the issues (non-clinical and clinical), discuss operations, and review our quality measures. While I live in the metrics on a daily basis, my goal is for the docs to focus on patient care during their clinical shifts, but get a deeper dive into the issues on a monthly basis.

The hot topic when I was a new attending was achieving the documentation to bill for a Level 5 chart. Between EMRs and scribes, we now have that down pretty well and everyone knows the requirements. The next trend was productivity – billing of RVUs per hour. These were the “metrics” conversations at staff meetings. Core Measures and then patient sat made their appearance in the early 2000s. Ten+ years later we take for granted that we’ll get reimbursed for the work that we do, we’re generating enough RVUs/hour, patients get treatment in the cath lab in under 90 minutes because “time is muscle,” and most residents get education on patient satisfaction.

We all went into medicine to take care of patients and we typically have personality traits where we like to work independently and don’t want someone looking over our shoulder telling us how to practice medicine. I understand, and I feel the same way. However, medicine is also a demanding business – and every job that pays an annual salary comes with some sort of performance expectations.


Why metrics matter
Certainly the emergency department lends itself well to metrics and we’re typically responsible for a large percentage of the hospital revenue (either directly or downstream because of testing and admissions). Having an EMR that time stamps everything just makes it that much easier to measure each component of the visit and extract the data. Mandatory public reporting of data has had its desired affect—placing emphasis from the C-suite on anything the public might see.

Healthcare seems to be exploding with new metrics to chase. I have previously admitted to being a data-driven guy and that I’ve accepted that metrics are just part of the world we live in. But I’ve also always believed that we need to put the patient first and certainly the pressure of publicly reported metrics makes us focus on the patient. It plays out in pain care – there is now pressure to get pain medications quickly for patients with extremity fractures. It also plays out in patient boarding. We know that having patients board in the ED can be detrimental to patient care, i.e. increasing wait times which can lead to delays in STEMI care and sepsis management. Many of us in ED administration are now getting unprecedented support from our C-suite to reduce boarding and improve flow because of the emphasis on metrics. On an individual doc basis, all of us know, including the nurses, that if a “slow provider” is on, the ED will be backed up. In this case, an appropriate focus on metrics is good for our patients and our staff. If metrics are forcing us to focus on the big picture (time to doc, length of stay, left without being seen), the ultimate outcome will be better and safer patient care.

Keep it fun
Residency is an amazing time but its goals and work environment are clearly different than being an attending emergency physician in a community ED. While the emphasis on metrics is necessary, it doesn’t mean you can’t have fun, spend some time on interesting cases, or keep some of the social features of residency. While medical education and discussion of interesting cases is a natural part of residency, as an attending physician, you have to take individual responsibility for this. We can still discuss interesting cases and findings at work with our colleagues. Medicine obviously involves lifelong learning. Take time each year to go to a high quality conference. There’s plenty of them out there.

There are also opportunities locally. Start by making sure you attend your department meetings. While I wish I could hold more of these, most sites and community docs have a hard time getting together once a month, let alone more often. You can offer to start/host a journal club for your group. I’ve done these at a couple sites I worked at and while they started out with good intentions, they quickly evolved into drinking wine with your colleagues—also fine, but not educational. You can offer to present an interesting case at the department staff meeting, or you can offer to provide education at a nursing staff meeting or to EMS. While flow metrics and patient satisfaction may be the hot topics now, it doesn’t mean they’ll always be. Every hospital has a variety of clinical committees (stroke, ICU, MI) and while I may not want a young doc as my only representative on the committee, most chairs would likely be open to having you join a committee as another emergency physician voice. Even something like the Pharmacy and Therapeutics Committee can be exciting if you can help get a life-saving drug like a prothrombin complex concentrate on formulary and then write the clinical policy on when, why, and how to use it.  I’m optimistic that in the future we’ll begin focusing on more outcome measures than just metrics. Picture tying the sepsis bundle to mortality reduction or stroke outcomes after endovascular interventions are implemented. These are just two of the hot topics for which each department needs at least one clinical champion, if not more. Also, be encouraged that the measures by which the quality of your care is graded will likely be improving in the future. CMS has shown that it is willing to retire measures that are ineffective or have unintended consequences (e.g. antibiotics within 4 hours for pneumonia.) Also, with the advent of emergency medicine’s first qualified clinical data registry (CEDR), we may as a specialty finally be able to design our own measures that are both better designed and more comprehensive.


And just because residency is over, it doesn’t mean you stop having a work social life. While you may be the only doc on the night shift, you can still take the nurses out for breakfast. A couple of my docs are in a bocce ball league together. Department social events may vary by how far everyone lives from the hospital and the age of the providers, but most people like getting together with people they work with. You may just need to be the social chair.

The priorities and responsibility you faced as a resident are different than what you experience as an attending (and the pay is better). Although you’ve always been responsible for providing high quality care, there’s a greater focus on productivity and length of stay metrics (not to mention just about anything else that can be measured). While this is a part of our current job environment, you can still find ways to promote education and have some fun times with your group. It may take some initiative on your part, but will be welcomed by your chair and your colleagues.


EXECUTIVE EDITOR Dr. Silverman is Chair of Emergency Medicine at VHC Health. He also taught a leadership development course for over a decade. Dr. Silverman’s practical wisdom is available in an easy-to-use reference guide, available on Amazon. Follow on Twitter @drmikesilverman

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