A couple cool articles in Academic Emergency Medicine and Training (AET)

1. One simply surveyed residency programs to see if we try to impart efficiency skills to our residents. Overall yes programs do try to educate on this topic. “Results: We received a total of 133 responses out of 190 total programs (70%) with proportionate representation from 3- and 4-year programs and all regions of the United States. When asked to what extent teaching efficiency should be a priority compared to other educational goals, 65% of program leaders responded with “signifi- cant” or “moderate” priority. Most EM programs collect WFE data on their residents, either by tracking patients per hour (78%) or by written evaluations (59%). Common methods for providing WFE data to residents were: “individual data provided along with deidentified rank” (35%), “data provided only during private feedback meetings” (26%), and “no data or rank provided to residents” (16%). Regarding targeted WFE teaching to residents, 88% reported utilizing general on-shift teaching, 48% reported teaching WFE during formal didactics, and 45% during dedicated private feedback sessions.”

2. But the NEXT paper is much cooler. This one looked at what on shift behaviors actual correlate with improved efficiency of residents. Now the outcome metric they used was RVU/hour (they talk about using patients per hour but don’t really report the data in results). I am not sure if I would place your RVU per hour as a top priority. But in measuring efficiency and helping you in your job on graduation, I guess it is ok.

The results were interesting. Seven behaviors correlated with improved efficiency, three with worse efficiency, and a bunch with no difference. Now some of the more efficient ones were found to correlate with LESS efficiency in a study they did in community docs. And some of the less efficient ones were more efficient in community docs. So you have to read the discussion section of the paper.

But one major take home point that they wrote a whole paragraph about that you can do TODAY is “swarming.” This is when you go in with the nurse (and other staff) and take history with them while communicating your workup and treatment plan to the team. This improves your efficiency in seeing patients and everyone wins. I do this at Jewish, often at South the nurse wants to come in the room when the doc goes in. This communication helps and prevents the need to check back with the RN/Tech/RT to go over the plan. So today or on your next shift, try some swarming!

See below, as the variable increases, so does your RVU/hr. Makes sense on some, higher patient load means more RVU. But some cool ones like the more you use dictation, the more RVU. The more you use smartphone to communicate with people in the ED, the more RVU. Oddly, the more nonword tasks, the more RVU (might be that more efficient residents have leftover time to talk to people or do nonword tasks). Visiting the patient room multiple times meant less RVU per hour (but almost definitely happier patients!). Talking to the attending means less RVU (you aren’t billing patients when we talk), but likely more education for you. You see why using RVU/hour is a measure that does not equate to good patient care or even a good work experience for you. The business of medicine : /

More efficient: average patient load, taking initial patient history with nurse present (number/hour, number/new patient), running the board (number/hour), conversations with other care team members (number/hour, % time), dictation use (number/hour, % time), smartphone text communication (number/hour, % time), and nonwork tasks (number/hour).

Less efficient: visits to patient room (number/patient), conversations with attending physicians (% time), and reviewing electronic medical record (number/hour).