Does Emergency Medicine Need A Warning Label Like Cigarettes?

[Birdstrike]

According to the CDC, working between the hours of midnight and 5 am (which Emergency Medicine requires) can lead to multiple health and psychosocial problems. Should EM textbooks, medical schools, residencies and EM employers, be required post the following warnings, due to EMs requirement of night shift work?

WARNING: Emergency Medicine can cause cancer

WARNING: Emergency Medicine has been associated with type 2 diabetes, heart disease, stroke

WARNING: Emergency Medicine has been associated with to metabolic and sleep disorders

WARNING: Emergency Medicine has been associated with irregular menstrual cycles, miscarriage, and preterm birth

WARNING: Emergency Medicine has been associated with digestive problems

WARNING: Emergency Medicine has been associated with fatigue which can lead to injuries and vehicle crashes

WARNING: Emergency Medicine has been associated with irritability, bad mood, stress and depression

WARNING: Emergency Medicine has been associated with poor performance (frequent mistakes, injuries, near misses)

WARNING: Emergency Medicine has been associated with unexplained weight gain or loss


Because according to the CDC, this is true of any career that requires working between the hours of midnight and 5 am.


Source: CDC: Night shifts, cancer & other health effects

h/t to @robellis for the source

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[deleted77919]

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[Taurus]

WARNING: Emergency Medicine has been associated with unemployment and underemployment by 2030.

WARNING: Emergency Medicine has been associated with working small community ER’s in tiny towns far from family and friends for pennies on the dollar.

WARNING: Emergency Medicine has been associated with replaced by independent NP’s working for 1/3 rate of emergency physician and 1/4 skillset. As long as the cost savings is greater than the cost of settling malpractice lawsuits, the CEO MBA is cool with it.

 

[Mount Asclepius]

Between 11p and 11p the ED should only deal with life threatening emergencies.

Have a single overnight person whose only job is to do a quick eval, take care of anyone who is critical, and for everyone else just put in orders. You write notes on patients who get admitted, go to the OR, or get transferred. Everyone else who is stable the morning docs come in and dispo.

Agree. The rest of the world puts off non-emergent situations until the morning. No one will replace my blown out tire at 2 in the morning. I think EDs should work the same way. It’s hard to tell what’s not an emergency and pick needles out of a haystack, but somethings clearly aren’t and we should make them wait until the morning. We should increase ED staff during the day and decrease at night with a truer triage system. People can at least learn to wait until business hours, even if they can’t wait for their PCP in a medicine on demand convenience system. If administrators are so desperate for patient satisfaction at night, then they could work a few night shifts as well every month to provide us the resources we need in the ED. Oh wait, we don’t usually need more administrators to staff the ED.

 

[thegenius]

There is no way to eliminate nights - but there are ways to minimize them.

Between 11p and 7a the ED should only deal with life threatening emergencies. Can it be hard to tell this from the door? Yes. So what do you do?

Have a single overnight person whose only job is to do a quick eval, take care of anyone who is critical, and for everyone else just put in orders. You write notes on patients who get admitted, go to the OR, or get transferred. Everyone else who is stable the morning docs come in and dispo.

You could really cut down on the requirements for night shift coverage with a model like this.

However, I foresee zero hospitals agreeing to this.

That would be nice...it's just full of problems. There are so many borderline symptoms that could be construed as potential emergencies.

Part of this whole thing is that "emergency medical conditions" have been morphed into "things that a doctor should 'evaluate' now". In reality there are few "true" medical or surgical emergencies. But that line is blurred. What would you do if a 62 yo man with HTN comes in at 0100 with severe diffuse abdominal pain, he is in moderate distress, has normal vital signs, and has a non-tender abdomen? By statistics (which I mean my own), this guy probably has a 10% of having a diagnosis that requires some sort of intervention NOW instead of 7 hours from now (e.g. antibiotics, surgery, tPA, etc). You could tell him to wait 7 hours until the hospital is up and running, or treat him now.

The current health care model of fee for service and everybody has a right to maximal health care at any time has failed. All the more reason that PEOPLE need to pay for their own health care (not insurance), OR we get rid of FFS and instead have something else that encourages rationing. I prefer people paying for their own health care. There will be a few decades of pain we will have preventable deaths until people get the proper education. but eventually we will reach a steady state where people don't rush to the doctor the moment their tooth itches. I like the idea of health care savings accounts that accrue every year from when you are born, and if you exhaust it at any time...you are on the hook for the bill and no further health care will be delivered until you pay it.

 

[Vandalia]

Never give an old man the chance to start babbling. One of my grandkids was kind enough to copy this from the cuneiform tablet on which I wrote this.

If you follow (American) football you often hear the phrase, "A RB has only so many carries in his body." This is the reason why they say a team shouldn't give a back a second, let alone a third contract, and why they should leave college early to get paid for those carries.

So let me say it here: An EM physician has a fixed amount of wRVU in his or her body.

Yeah, I lasted for a long time. I won't say how long. However, most of my career was in the military and a lot of admin work was also mixed in before and after that. My total amount of RVU was the same as everyone else, I just spread it out over a long time. So if you are young and think you can earn the big bucks doing 20 12 hour shifts a month with 2.5 pph and raking in the money, well, yeah, you can. But you had better plan for the fact that you won't last long.

Next, even ten years ago, for most normal, rational Americans, if they got sick on Saturday they would wait until they saw their primary care doc on Monday. Now, everyone wants immediate care. Along with the above, a lot of old guys preferred quasi-rural nights. Nights were bad, but they were easier on the body than the crazy days. I did a lot of the committee work at night and an old friend - in both senses - of mine claimed he was working on the "great American novel." So, sure, a lot of the old guys will say they worked nights in their time as well, but nights now are completely different. Even compared with ten years ago.

We will skip Press-Gainey and all the related administrative foolery that has popped up this century.

The final factor that people outside of EM - and even a lot in it - don't recognize is the emotional whiplash. Sure an intensivist has to do the same type of work, and now has to provide 24/7/365 coverage. But they are dealing with roughly the same types of patients. The same with surgeons, etc. But EM is really the only specialty that can take you from a college kid who has a C5/6 fracture from jumping into a river, to a cute kid who took a spill on his bike and needs a few stitches, to a 40 year old with a young family you can't resuscitate to someone too cheap to pay for a pregnancy test. In a couple of hours.

I used to think that the breaks - the cute kid - were a good thing. Now I think the opposite is true. I don't think "emotional whiplash" is in the DSM-V but it probably should be.

So, yeah, you used to be able to do this job exclusively for an entire career. But the old guys forget that EM is a totally, completely different world. Even when compared with 2010.

You can still practice EM as a career I think and survive. But remember "going hard" when you are young will bite you later on, and you should have something else to mix in - EMS, admin type stuff, teaching, whatever - both to mix in and to have options for later on.

It is sort of like there is nothing wrong with having a Big Mac - providing that isn't something you do every single day.

 

[RustedFox]

Never give an old man the chance to start babbling. One of my grandkids was kind enough to copy this from the cuneiform tablet on which I wrote this.

If you follow (American) football you often hear the phrase, "A RB has only so many carries in his body." This is the reason why they say a team shouldn't give a back a second, let alone a third contract, and why they should leave college early to get paid for those carries.

So let me say it here: An EM physician has a fixed amount of wRVU in his or her body.

Yeah, I lasted for a long time. I won't say how long. However, most of my career was in the military and a lot of admin work was also mixed in before and after that. My total amount of RVU was the same as everyone else, I just spread it out over a long time. So if you are young and think you can earn the big bucks doing 20 12 hour shifts a month with 2.5 pph and raking in the money, well, yeah, you can. But you had better plan for the fast that you won't last long.

Next, even ten years ago, for most normal, rational Americans, if they got sick on Saturday they would wait until they saw their primary care doc on Monday. Now, everyone wants immediate care. Along with the above, a lot of old guys preferred quasi-rural nights. Nights were bad, but they were easier on the body than the crazy days. I did a lot of the committee work at night and an old friend - in both senses - of mine claimed he was working on the "great American novel." So, sure, a lot of the old guys will say they worked nights in their time as well, but nights now are completely different. Even compared with ten years ago.

We will skip Press-Gainey and all the related administrative foolery that has popped up this century.

The final factor that people outside of EM - and even a lot in it - don't recognize is the emotional whiplash. Sure an intensivist has to do the same type of work, and now has to provide 24/7/365 coverage. But they are dealing with roughly the same types of patients. The same with surgeons, etc. But EM is really the only specialty that can take you from a college kid who has a C5/6 fracture from jumping into a river, to a cute kid who took a spill on his bike and needs a few stitches, to a 40 year old with a young family you can't resuscitate to someone to cheap to pay for a pregnancy test. In a couple of hours.

I used to think that the breaks - the cute kid - were a good thing. Now I think the opposite is true. I don't think "emotional whiplash" is in the DSM-V but it probably should be.

So, yeah, you used to be able to do this job as an entire career. But the old guys forget that EM is a totally, completely different world. Even when compared with 2010.

You can still do EM as a career I think and survive. But remember "going hard" when are young will bite you later on, and you should have something else to mix in - EMS, admin type stuff, teaching, whatever - both to mix in and have an option later on.

It is sort of like there is nothing wrong with having a Big Mac - providing that isn't something you do every single day.

Birdstrike-caliber post.

 

[GeneralVeers]

Between 11p and 7a the ED should only deal with life threatening emergencies. Can it be hard to tell this from the door? Yes. So what do you do?

Have a single overnight person whose only job is to do a quick eval, take care of anyone who is critical, and for everyone else just put in orders. You write notes on patients who get admitted, go to the OR, or get transferred. Everyone else who is stable the morning docs come in and dispo.

You could really cut down on the requirements for night shift coverage with a model like this.

Birdstrike-caliber post.

My RVUs are completely spent. Empty. Gone.

 

[deleted77919]

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[GeneralVeers]

Easy - you work the guy up, don’t find anything? Dispo in AM.

Again - I don’t think this model will ever happen in this country, but it would be nice.

It shouldn't be hard. Patients with normal VS, and a complaint of "abdominal pain" or other nonsense can get protocol labs, and a CT. Nurses notify MD of any critical findings on labs or CT and the patient is dispoed in the morning.

 

[Apollyon]

It is sort of like there is nothing wrong with having a Big Mac - providing that isn't something you do every single day.

This guy might disagree with you!

 

[thegenius]

This guy might disagree with you!

Is that what eating a big mac every day does? Give you a bad haircut and sideburns?

 

[Apollyon]

Is that what eating a big mac every day does? Give you a bad haircut and sideburns?

He looked like a beatnik at 15k. Just coincidence!

 

[xaelia]

The whole "11p to 8a" is just for emergencies is pretty much how it works outside of the U.S. – because staffing drops off to the point where the level 4s and level 5s languish eternally (or until something manifests and they become more urgent, and thus, an actual emergency).

In the U.S., as long as the folks checking in are paying your salary, not much gonna change. About the only place in the U.S. I can think of that sort of functions like that is the VA system – my experiences attempting to transfer someone to the VA are dramatically less successful at night, to put it mildly.

 

[GeneralVeers]

I'd love it if we could charge a "convenience fee". I give you your EMTALA-mandated MSE and then if you still want to be seen for your dental pain or sore throat then it's $200 cash to me. Otherwise wait until 6AM.

 

[Apollyon]

I'd love it if we could charge a "convenience fee". I give you your EMTALA-mandated MSE and then if you still want to be seen for your dental pain or sore throat then it's $200 cash to me. Otherwise wait until 6AM.

That's what my first job did, at the "Mother Ship". 4 or more visits in the past 4 months for ESI 4 or lower complaints got an MSE and a visit from a financial counselor. If they didn't choose to pay a larger copay (or just "pay", if uninsured), they could leave. Never once had a pt stay. This did not apply to the MedicAid folks, who were, by this definition, abusing the system, and I don't know if they got a facility fee charged.

 

[Birdstrike]

The whole "11p to 8a" is just for emergencies is pretty much how it works outside of the U.S. – because staffing drops off to the point where the level 4s and level 5s languish eternally (or until something manifests and they become more urgent, and thus, an actual emergency).

In the U.S., as long as the folks checking in are paying your salary, not much gonna change. About the only place in the U.S. I can think of that sort of functions like that is the VA system – my experiences attempting to transfer someone to the VA are dramatically less successful at night, to put it mildly.

This is an extremely important point.

 

[skougess]

Guys, the 3am chronic back pains are what keeps us in demand. It’s like we learned nothing from the COVID volume drop. Stop thinking of them as your enemy and realize they are what keeps your hours on the schedule and you’ll get less annoyed at them.

 

[BJJVP]

Guys, the 3am chronic back pains are what keeps us in demand. It’s like we learned nothing from the COVID volume drop. Stop thinking of them as your enemy and realize they are what keeps your hours on the schedule and you’ll get less annoyed at them.

I think the real problem is that the hospital and physicians do not get paid enough to care for the MIs, CVAs and septic patients. Therefore, all interested parties encourage ED visits for non-emergent conditions.

 

[RustedFox]

I think the real problem is that the hospital and physicians do not get paid enough to care for the MIs, CVAs and septic patients. Therefore, all interested parties encourage ED visits for non-emergent conditions.

Oh, I think that they get paid enough.
It's just that there's so many zero-value-added people with their hands in the cookie jar.

 

[Birdstrike]

Oh, I think that they get paid enough.
It's just that there's no many zero-value-added people with their hands in the cookie jar.

Damn, this is so true.

 

[GeneralVeers]

Oh, I think that they get paid enough.
It's just that there's no many zero-value-added people with their hands in the cookie jar.

You are wrong. All these people consume clipboards, which keep the clipboard companies in business. Besides, if they don't track "the numbers" then how will they know which VP of Diversity to give a bonus to? You have such a limited understanding of how hospitals REALLY run.

 

[RustedFox]

You are wrong. All these people consume clipboards, which keep the clipboard companies in business. Besides, if they don't track "the numbers" then how will they know which VP of Diversity to give a bonus to? You have such a limited understanding of how hospitals REALLY run.

I've said it before, and I'll say it again.
Every single one of these non-clinical employees, no matter their "rank", needs to write a proposal justifying their salary to the clinical staff, in real dollars-and-cents language. Can't do it? Bye.

 

[Rad2013]

 

[Dral]

I've said it before, and I'll say it again.
Every single one of these non-clinical employees, no matter their "rank", needs to write a proposal justifying their salary to the clinical staff, in real dollars-and-cents language. Can't do it? Bye.

Seriously.

"I'm in IT, when the computers go down, I fix them so the clinical staff can keep going and see patients"
YES, stay!

"I walk around and check in on things as well as work on a weekly newsletter about the going ons around here and send it out as an email to everyone"
🤨

 

[thegenius]

Oh, I think that they get paid enough.
It's just that there's no many zero-value-added people with their hands in the cookie jar.

God isn't that the truth.

 

[RustedFox]

God isn't that the truth.

I would take credit for it; but it was Veers who first pointed out this inarguable fact here to the SDN crowd.