Lazy colleague etiquette?

[larpleston]

I am at a 40k visit a year place that does staggered double or triple coverage and has midlevels that see fast track. Many of the docs are semi retired/non EM and will simply not sign up for their ‘share’ of patients. This place is hourly, non rvu however raises are based on productivity. I am at the high end of pph with about 2.5, the majority of docs hover at 1-1.5 and are happy to let the waiting room and department explode. Admin doesn’t care. What’s the etiquette here? In a place like this do you keep signing up for patients til the bitter end and sign them out to the other doc who is already on? Wind down 2 hours before the end of the shift and possibly leave early if wrapped up? I have been winding down in the last few hours and often end up with no patients 30 minutes before my shift is over while the other doc has the same 5 they’ve been seeing for 4 hours and 5 90 year olds with belly pain to be seen. Problem is the department always looks like it is being slammed and I feel a little obligated to clear people out even though if the other docs saw 2 an hour the place would be calm. Solution is to find a new job but in the meantime what do you do about dead weight colleagues when they form most of the roster?

---

Members don't see this ad.

 

[JacobMcCandles]

They have no incentive or desire to work harder so I’d do whatever I could to make sure I’m walking out that door right when my shift ends. This isn’t your problem, it’s your medical director’s problem.

 

[WilcoWorld]

I am at a 40k visit a year place that does staggered double or triple coverage and has midlevels that see fast track. Many of the docs are semi retired/non EM and will simply not sign up for their ‘share’ of patients. This place is hourly, non rvu however raises are based on productivity. I am at the high end of pph with about 2.5, the majority of docs hover at 1-1.5 and are happy to let the waiting room and department explode. Admin doesn’t care. What’s the etiquette here? In a place like this do you keep signing up for patients til the bitter end and sign them out to the other doc who is already on? Wind down 2 hours before the end of the shift and possibly leave early if wrapped up? I have been winding down in the last few hours and often end up with no patients 30 minutes before my shift is over while the other doc has the same 5 they’ve been seeing for 4 hours and 5 90 year olds with belly pain to be seen. Problem is the department always looks like it is being slammed and I feel a little obligated to clear people out even though if the other docs saw 2 an hour the place would be calm. Solution is to find a new job but in the meantime what do you do about dead weight colleagues when they form most of the roster?

If you are seeing more pph than average and not signing out cases at the end of your shift, then you're doing it right.

 

[larpleston]

They have no incentive or desire to work harder so I’d do whatever I could to make sure I’m walking out that door right when my shift ends. This isn’t your problem, it’s your medical director’s problem.

I never stay late. I guess the question is what do you do when you’ve seen more than your ‘share’ of patients, it’s 45 minutes til the end of your shift, you have dispoed everyone and there are 10 to be seen but none of them are quick dispos? Leave early? Twiddle thumbs til the clock hits the end of the shift? I worked in a single coverage place where this wasn’t an issue and a double coverage place where we would send each other home early when wrapped up but where I am now the competence level is low and announcing you’re all done a little before the end of your shift gets slack jawed stares

 

[DeadCactus]

Admin doesn’t care.

Then why do you? A 40k shop with no fast-track patients - sounds like you could see a respectable 2 pph of relatively high-acuity patients, leave on time, and still be a shining start in the department. Physicians need to stop killing themselves to make up for poor staffing and bad management.

 

[larpleston]

Then why do you? A 40k shop with no fast-track patients - sounds like you could see a respectable 2 pph of relatively high-acuity patients, leave on time, and still be a shining start in the department. Physicians need to stop killing themselves to make up for poor staffing and bad management.

I don’t care too much about that. I mostly care about leaving on time/early and getting a big raise. I just want to know if leaving a little early when you have no patients and there are multiple to be seen that have 3 hour work ups is defensible in this kind of environment/what other people do when they find themselves patient-less in a double or triple coverage shop before the end of their shift.

 

[gutonc]

I don’t care too much about that. I mostly care about leaving on time/early and getting a big raise. I just want to know if leaving a little early when you have no patients and there are multiple to be seen that have 3 hour work ups is defensible in this kind of environment/what other people do when they find themselves patient-less in a double or triple coverage shop before the end of their shift.

Type slower. Voila...you're working right up to the buzzer.

Alternatively, you can try to fix what is clearly a s***acular comp plan.

But option 1 is going to be a lot easier to accomplish.

 

[DeadCactus]

I don’t care too much about that. I mostly care about leaving on time/early and getting a big raise. I just want to know if leaving a little early when you have no patients and there are multiple to be seen that have 3 hour work ups is defensible in this kind of environment/what other people do when they find themselves patient-less in a double or triple coverage shop before the end of their shift.

What can anyone say if you're in the top pph?

 

[DoctorJDO]

I don’t care too much about that. I mostly care about leaving on time/early and getting a big raise. I just want to know if leaving a little early when you have no patients and there are multiple to be seen that have 3 hour work ups is defensible in this kind of environment/what other people do when they find themselves patient-less in a double or triple coverage shop before the end of their shift.

As long as you keep the patients moving it shouldn't be a problem. You could consider doing an RME/triage exam or throw in some blind orders on those patients waiting. you still leave early but you take some load off the oncoming docs. If anyone accuses you of "leaving the dept a mess" or not doing your fair share, then there should be easily reference metrics that you're doing more than everyone else.

 

[JacobMcCandles]

I never stay late. I guess the question is what do you do when you’ve seen more than your ‘share’ of patients, it’s 45 minutes til the end of your shift, you have dispoed everyone and there are 10 to be seen but none of them are quick dispos? Leave early? Twiddle thumbs til the clock hits the end of the shift? I worked in a single coverage place where this wasn’t an issue and a double coverage place where we would send each other home early when wrapped up but where I am now the competence level is low and announcing you’re all done a little before the end of your shift gets slack jawed stares

Why would you intentionally see a patient you know you’re going to check out at a place with at least double coverage? It’s different at a single coverage department but check outs are where mistakes happen. Look at the chart and put reasonable orders in. Chances are the blood won’t even be drawn in that 45 minutes.

 

[Birdstrike]

I am at a 40k visit a year place that does staggered double or triple coverage and has midlevels that see fast track. Many of the docs are semi retired/non EM and will simply not sign up for their ‘share’ of patients. This place is hourly, non rvu however raises are based on productivity. I am at the high end of pph with about 2.5, the majority of docs hover at 1-1.5 and are happy to let the waiting room and department explode. Admin doesn’t care. What’s the etiquette here? In a place like this do you keep signing up for patients til the bitter end and sign them out to the other doc who is already on? Wind down 2 hours before the end of the shift and possibly leave early if wrapped up? I have been winding down in the last few hours and often end up with no patients 30 minutes before my shift is over while the other doc has the same 5 they’ve been seeing for 4 hours and 5 90 year olds with belly pain to be seen. Problem is the department always looks like it is being slammed and I feel a little obligated to clear people out even though if the other docs saw 2 an hour the place would be calm. Solution is to find a new job but in the meantime what do you do about dead weight colleagues when they form most of the roster?

They're paying you salary to see 1.5 pph or the same to see 2.5 pph. So why are you seeing 2.5? By choice? Yes, by choice. It might feel like "the right thing to do." But it's also the absolute perfect way to burn out in record time.

Fast track to burnout, or slow road to pay day?

I'd say, "Choose," but it looks like you already have.

 

[BoardingDoc]

I am at a 40k visit a year place that does staggered double or triple coverage and has midlevels that see fast track. Many of the docs are semi retired/non EM and will simply not sign up for their ‘share’ of patients. This place is hourly, non rvu however raises are based on productivity. I am at the high end of pph with about 2.5, the majority of docs hover at 1-1.5 and are happy to let the waiting room and department explode. Admin doesn’t care. What’s the etiquette here? In a place like this do you keep signing up for patients til the bitter end and sign them out to the other doc who is already on? Wind down 2 hours before the end of the shift and possibly leave early if wrapped up? I have been winding down in the last few hours and often end up with no patients 30 minutes before my shift is over while the other doc has the same 5 they’ve been seeing for 4 hours and 5 90 year olds with belly pain to be seen. Problem is the department always looks like it is being slammed and I feel a little obligated to clear people out even though if the other docs saw 2 an hour the place would be calm. Solution is to find a new job but in the meantime what do you do about dead weight colleagues when they form most of the roster?

If I were in this exact setup I would
1: Consider finding a new job
2: See if salary could be based on actual productivity or have an RVU bonus on top of existing salary
3: See 1.5 - 2 pph so you're the golden child. Have everything wrapped up on time. Pick up no remotely complex patients in the last 1-2 hrs. If all patients waiting to be seen are super complex and you have 45 min left? I guess they sit unseen or the other doc can see them.

 

[Janders]

(1) I wouldn’t want to work in that culture
(2) I would hope with other people we could change said culture
(3) I’d wrap my stuff up. I would NOT leave early (that just looks bad if there are charts in the rack). I’d try to be useful by putting orders in, or doing a procedure, or getting an interpreter to talk to a complex family. I just imagine if there are 10 to be seen and 45 minutes left in my shift I could put a big dent into 1-2 of those and sign out a reasonably tidy package. I’d at least look for someone actually sick and maybe help them?

 

[thegenius]

How much more a year are you making seeing 2.5/hr vs 1.5/hr? I hope it’s at least 100K/year

 

[turkeyjerky]

I get where the OP is coming from. These situations can be difficult to deal with. It's an odd feeling when you are internally motivated to see patients and try to maintain a clean dept, but the overall situation and colleagues are not conducive. It sounds like picking up new patients and signing them out doesn't fit w/ the overall culture, so I wouldn't do it. I also wouldn't leave early, imho that's a no-no when your paid hourly (unless built in overlap w/ expectation that you'll do so). I would probably just slow roll my charting during the shift and leave on time while minimizing signouts.

 

[EctopicFetus]

I don’t care too much about that. I mostly care about leaving on time/early and getting a big raise. I just want to know if leaving a little early when you have no patients and there are multiple to be seen that have 3 hour work ups is defensible in this kind of environment/what other people do when they find themselves patient-less in a double or triple coverage shop before the end of their shift.

Let me be the bearer of some real bad and honest news. You are not about to get a "big raise". You are likely to see your income drop. You may ask.. what is this idiot EF talking about.

1) Consider you work at a place that sets the wages based on MGMA or some other BS survey. Avg Em pay is about to go down.
2) Hospitals are really struggling financially with limited to no relief in the short term, hence they need to save on costs. You are a cost
3) Medicare is cutting pay for docs, dont think this wont hit you as well.
4) States are also about to get squeezed and as such its more bad reimbursement


Not to be too big of a prick but you sound like someone fairly fresh out of residency. I am sorry for bringing this reality to light. Given inflation you should expect an effective paycut for 2023. I wont predict much beyond that but see points 1-4 above and I know there are more like MLPs etc

Good luck young fella and get your $$$ right before its too late.

 

[Brigade4Radiant]

At our shop we leave early but we are mostly RVU. Also seeing 1 more patient an hour is about 9-10 more patients thats 100 more patients in a month so basically you are seeing 1000+ patients with minimal pay and more malpractice risk. You practically work for free

 

[emergentmd]

his place is hourly, non rvu however raises are based on productivity. I am at the high end of pph with about 2.5, the majority of docs hover at 1-1.5 and are happy to let the waiting room and department explode. Admin doesn’t care.

Reality check, Admin doesnt care b/c the place is likely a dump/hard to find coverage thus the soon to be retiree/Non EM.
1. You guys sound like you are on an hourly rate which only works if single coverage sites.
2. You have a choice to either accept reality and continue to move the meat OR see alittle above standard practice.
3. Admin doesn't care =you can't fight an uphill battle and only piss off your other EM docs

I remember interviewing at a busy community double coverage site where they alternate pts on an "A" and "B" rack. I am super efficient and can safely see 3-4pph if I wanted. I could not image sitting while My rack is always cleared and the "B" rack having 10 pts to be seen.

 

[RuralEDDoc]

Dead weight colleagues seems like a pretty strong term. Sounds to me like they are doing the job they are paid to do and no one else with any power has a problem with it.

 

[EctopicFetus]

Agreed. Why kill yourself in this stupid ass system. Relax. It’s boring. But being way outside of the norm will only have your colleagues hate you.

 

[Tenk]

Be careful. When you’re the guy who always works way harder than everyone else, nurses are gonna slap you with every sick patient.

“Can you go see this guy? He’s very sick.”

It’s nice to feel like people trust you but it definitely increases both your liability and burn out.

 

[EctopicFetus]

Be careful. When you’re the guy who always works way harder than everyone else, nurses are gonna slap you with every sick patient.

“Can you go see this guy? He’s very sick.”

It’s nice to feel like people trust you but it definitely increases both your liability and burn out.

And for what? Same pay Yet more headaches. No thanks.

 

[Arcan57]

I feel like a lot of the responses come off as cold or mercenary to someone in your stage of practice. Realize that a lot of them are being typed out by people that are on the other side of what you're going through. Especially early on when you're building your sense of confidence and competence, seeing the department melt around you and being the one to singlehandedly save it during that shift feels like an affirmation. Eventually you start realizing that you have to be firing at 100% all shift every shift and people are still having bad outcomes related to care delivery that you can't prevent. This is exacerbated by a sense of unfairness related to compensation. There are numerous studies that show that total amount of money above a certain threshold doesn't effect job satisfaction but perceived unfairness in compensation is a huge dissatisfier. I know it stuck in my craw that the Romanian prison doc who would literally read the paper T-sheet verbatim as their form of doing an H&P made the same amount of money as me seeing literally 2.5 times as many patients.

You can start staying later, watch your non-work life slide out from under you, and maybe make a difference that matters in 1 patient every 3-4 weeks. Most of us eventually look at that trade-off and realize that our loved ones and sanity deserve better.

 

[Kryptocoin]

Sage advice: Don't be the fastest or the slowest. Stay within the average. This isn't residency where you're rewarded for being fast and expeditious with glowing attending reviews. Unless you're 100% RVU, there's really no benefit of being super fast. Don't carry the burden for the group's poor ER staffing. Let the LWOTs increase. That's when hospitals respond to staffing issues.

 

[GonnaBeADoc2222]

Many in my group are incredibly unproductive and make significantly more than me.

I'm straight chillin most of the time and still crushing productivity metrics.

You bet I'm leaving early once all my work is cleaned up.

 

[emergentmd]

Sage advice: Don't be the fastest or the slowest. Stay within the average. This isn't residency where you're rewarded for being fast and expeditious with glowing attending reviews. Unless you're 100% RVU, there's really no benefit of being super fast. Don't carry the burden for the group's poor ER staffing. Let the LWOTs increase. That's when hospitals respond to staffing issues.

This is so true with so much in life. If you are a superstar, then go open your own business or shoot to being a CEO. Otherwise in 99% of most jobs, shoot to be around the 55-80% productivity. Below 50% and you can be marked. Be over 90% or top, you will bear the brunt with a bad outcome. Something bad happens, they see you are 2 standard deviation above the norm, and you will be faulted for being reckless.

No one cares about the 55-80% and will make excuses for them all the time. I was always the fastest doc in our group, saw the most pph/hr. Few younger docs came on that stressed out over pph, and became faster than me but sacrificed staying back 1-2 hrs to chart. I was much happier being the 2nd or 3rd fastest doc and happy to let the gunners shoot for the moon.

 

[Brigade4Radiant]

It’s also unacceptable to stay late charting. In residency, I know it’s considered “being a team player” yes, it happens sometimes when you have some really sick patients or something weird happens yes

but that I’m talking regularly you are working for free charting is included and is needed for billing. If you’re doing charts at home, you need to step up the pace.

 

[thegenius]

Many in my group are incredibly unproductive and make significantly more than me.

I'm straight chillin most of the time and still crushing productivity metrics.

You bet I'm leaving early once all my work is cleaned up.

If you are more productive than many in your group, AND you are sitting around chillin and somehow seeing more pph than others, AND they make more than you…what kind of crack-pot ER is being run there?

 

[emergentmd]

I would say avoid groups where there are double coverage and everyone is hourly based. All it takes is one doc to make everyone around them lazy. You will find that everyone becomes lazy and the place falls apart.

 

[WilcoWorld]

It’s also unacceptable to stay late charting. In residency, I know it’s considered “being a team player” yes, it happens sometimes when you have some really sick patients or something weird happens yes

but that I’m talking regularly you are working for free charting is included and is needed for billing. If you’re doing charts at home, you need to step up the pace.

It also makes for less useful charts! People need to know what happened in the ED on hospital day 1. By hospital day 4 no one (except the billers and the lawyers) care what happened in the ED.

 

[WilcoWorld]

I would say avoid groups where there are double coverage and everyone is hourly based. All it takes is one doc to make everyone around them lazy. You will find that everyone becomes lazy and the place falls apart.

That's a very interesting heuristic. I think you're onto something. While this model does work in certain settings - mainly academic - this forum disdains academic medicine, so let's set that aside. You make a great point that in this setup "[a]ll it takes is one doc to make everyone around them lazy". I really rankle when people complain about how much work they're doing compared to others. If you have enough time to monitor other's work, you have time to do more work. I never hear the most productive people talking about how others aren't working hard enough...because they're too busy working to complain!

 

[GonnaBeADoc2222]

If you are more productive than many in your group, AND you are sitting around chillin and somehow seeing more pph than others, AND they make more than you…what kind of crack-pot ER is being run there?

A very "unicorn" esque place that has a pomzi scheme pay structure. I cut back my effort and still producing more. The legacy of laziness runs deep here.

 

[Birdstrike]

A very "unicorn" esque place that has a pomzi scheme pay structure. I cut back my effort and still producing more. The legacy of laziness runs deep here.

Enough said. Unless you can get to the top of this ponzi-pyramind very quickly, then get out.

 

[thegenius]

Enough said. Unless you can get to the top of this ponzi-pyramind very quickly, then get out.

Sounds like they key is to work less and make more. Great gig. He might make $500/hr seeing 0.15/hr.

 

[GonnaBeADoc2222]

I mean I make more hourly than any job I know of in the state and can effectively disappear into the chaos.

 

[ScepticSkeksis]

At hourly places I've seen the department divided into "zones" staffed by one physician. You get all the patients assigned to your "zone". Theoretically it should evenly distribute the patients, but if you are quick to discharge then you can still end up seeing more than your fair share. Some people do tend to hold on to patients with 6-8 hour workups. Whether or not that is laziness or just a slower work process depends.

 

[emergentmd]

At hourly places I've seen the department divided into "zones" staffed by one physician. You get all the patients assigned to your "zone". Theoretically it should evenly distribute the patients, but if you are quick to discharge then you can still end up seeing more than your fair share. Some people do tend to hold on to patients with 6-8 hour workups. Whether or not that is laziness or just a slower work process depends.

I interviewed at a Zone place. I asked the director what happens if I am efficient, have an empty box, and the other guy's box is full. He said, they will fill my box up.

If I worked in a zoned place, I would make sure my box had one less patient as the other guy. I would be quickly finding a new job as its against my nature to be lazy, order needless tests, or have patients wait for no reason.

I have not seen a place that is full hourly double coverage not become a race to the bottom. The motivation to be a star or efficient disappears quickly. Now single coverage is a different story.

 

[Kryptocoin]

I interviewed at a Zone place. I asked the director what happens if I am efficient, have an empty box, and the other guy's box is full. He said, they will fill my box up.

If I worked in a zoned place, I would make sure my box had one less patient as the other guy. I would be quickly finding a new job as its against my nature to be lazy, order needless tests, or have patients wait for no reason.

I have not seen a place that is full hourly double coverage not become a race to the bottom. The motivation to be a star or efficient disappears quickly. Now single coverage is a different story.

I worked at a place where the pph is openly published every month. So everyone knows who the slowest guy is. It was kind of a passive aggressive way of calling someone out.

 

[ScepticSkeksis]

I interviewed at a Zone place. I asked the director what happens if I am efficient, have an empty box, and the other guy's box is full. He said, they will fill my box up.

If I worked in a zoned place, I would make sure my box had one less patient as the other guy. I would be quickly finding a new job as its against my nature to be lazy, order needless tests, or have patients wait for no reason.

I have not seen a place that is full hourly double coverage not become a race to the bottom. The motivation to be a star or efficient disappears quickly. Now single coverage is a different story.

Exactly correct. It would definitely be interesting to compare metrics in an RVU department versus an hourly.

 

[emergentmd]

I worked locums at hourly without RVU and the full timers were terrible. Locums docs were hit or miss but overall better.

You know the full timers suck when I got offered the Med director job after 10 shifts and the nurses thank me when I showed up.

 

[Brigade4Radiant]

With CMG hourly only works if the patients aren’t sick and you have good resources.

There is no incentive to move above average or do more work. In makes you hold on to patients

 

[retro]

Hey OP, I used to work at a place that runs very similarly to what you described above. Fixed hourly salary, no RVU, bunch of old timer IM/FM docs competing to be as lazy as they can be. When I first started, I was motivated and hard working. I would average 2.4 pph while the lazier ones saw 0.5-1 pph (no joke). These doctors were able to get away with this because the admin didn't care. There was absolutely no penalty for being lazy and slow. But the hospital still being high volume / high acuity, the hard/fast working docs ended up picking up the slack all the time. I brought up how unfair this system was multiple times, but the admin couldn't care less. The chairman himself was also that lazy doc who's sole interest was to do minimum work and get paid. I hate to say this, but the only way to survive in such shops is to become the same lazy, slow doctor. Yes, I do feel bad for holding onto my patients for hours. Yes, I do feel bad for having the patients wait for hours before signing up for them. But if the system isn't going to change, your best bet is to protect yourself from burn out / malpractice by doing the same until you can find a better gig and move.

 

[NYEMMED]

At hourly places I've seen the department divided into "zones" staffed by one physician. You get all the patients assigned to your "zone". Theoretically it should evenly distribute the patients, but if you are quick to discharge then you can still end up seeing more than your fair share. Some people do tend to hold on to patients with 6-8 hour workups. Whether or not that is laziness or just a slower work process depends.

FWIW I hate Zoned EDs.

Nurses do a terrible job of spreading out acuity. You could be getting hit with "worst headache ever" "Fever and head/neck pain" "Respiratory Distress" "Trauma 1" "2 week old fever/sepsis"

The other guy is seeing Toe pain and ankle pain, Some rule out chest pains.

Very unequal

 

[emergentmd]

Hey OP, I used to work at a place that runs very similarly to what you described above. Fixed hourly salary, no RVU, bunch of old timer IM/FM docs competing to be as lazy as they can be. When I first started, I was motivated and hard working. I would average 2.4 pph while the lazier ones saw 0.5-1 pph (no joke). These doctors were able to get away with this because the admin didn't care. There was absolutely no penalty for being lazy and slow. But the hospital still being high volume / high acuity, the hard/fast working docs ended up picking up the slack all the time. I brought up how unfair this system was multiple times, but the admin couldn't care less. The chairman himself was also that lazy doc who's sole interest was to do minimum work and get paid. I hate to say this, but the only way to survive in such shops is to become the same lazy, slow doctor. Yes, I do feel bad for holding onto my patients for hours. Yes, I do feel bad for having the patients wait for hours before signing up for them. But if the system isn't going to change, your best bet is to protect yourself from burn out / malpractice by doing the same until you can find a better gig and move.

Classic race to the bottom. Happens in all jobs where there are no incentives to do a good job.

 

[ScepticSkeksis]

Classic race to the bottom. Happens in all jobs where there are no incentives to do a good job.

There is also a word for an economic system structured the same way.

 

[Apollyon]

There is also a word for an economic system structured the same way.

Hey, if you were a "company man", you would do your part, because it's the right thing to do! /sarcasm

 

[Simba1711]

Sad to see medicine like this and how laziness is rewarded. I’m not an em. I’m an anesthesiologist but can definitely relate. My old job was like this how my colleagues were lazy since pay wasn’t rvu based. My colleagues would be slow, drag their feet to start cases, delay cases for bull**** reasons , or take forever to relieve other people. I ended up quitting that job as I couldn’t deal with the culture. My new job is rvu based and much more fair imo.

 

[emergentmd]

Sad to see medicine like this and how laziness is rewarded. I’m not an em. I’m an anesthesiologist but can definitely relate. My old job was like this how my colleagues were lazy since pay wasn’t rvu based. My colleagues would be slow, drag their feet to start cases, delay cases for bull**** reasons , or take forever to relieve other people. I ended up quitting that job as I couldn’t deal with the culture. My new job is rvu based and much more fair imo.

Its human nature and only takes one to bring the whole group down. Just one. Its all about longevity.

I could see twice as many patients as typical EM docs and hold charting for the end of my shift adding another 3 hrs without pay. Yeah, the ER would be cleared, nurses happy, on coming doc happy but what was the point when I walked into the ER and there are 15 pts to be seen?

Only takes a few shifts to figure the hard work only benefits others.