* * Anonymous Doc

Monday, January 17, 2011

I have three patients right now that I could discharge.

But I'm not.

See, the system here creates very perverse incentives. Our team is capped at a certain number of patients. You reach that cap, and they can't give you any new ones. So new ones end up with a different team. You discharge patients, and it frees up spots for new ones.

Every new patient you get means at least an hour and a half of work. Taking the history, getting the initial labs, figuring out the plan, seeing if they're stable. You get 4 or 5 new admissions in a day, and that's a full day of work on top of whatever you need to do for your patients that are still around. It means your work gets backed up, it means you can end up staying late, it can really make the day pretty impossible.

There's a point in the day after which you can't get new patients-- depends on the rotation, but usually 5:00 or 5:30-- patients who come in after then get processed by the night teams and then given out in the morning. This saves the day team a ton of time-- you come in, pick up your new patients, and they've already been worked up, you get to skip that hour and a half you'd normally have to spend on them.

So there's a great incentive to hold your discharges as long as you can. If you can wait to get rid of your patients until after the 5:00 admit clock rings, you don't have to do the extra work. The night team gets screwed, but at least you get to go home at a reasonable hour.

Of course, if the night team doesn't get to the new admission, you get them delivered to you first thing in the morning-- a patient who's been sitting in the ER all night, without anything done for them, waiting for a doctor to finally get to them.

But a new admit at 7AM is slightly better than a new one at 5PM, because you're there anyway. I mean, it screws things up for the rest of your patients, who have two extra hours to go downhill before you finally have time to come see them, new admit processed. But at least you can go home for dinner.

Everyone's always trying to push admits to the next team. No one wants to ever admit there's room on their team, or acknowledge they had a discharge. And, I mean, it doesn't really matter because the only people actually hurt are the patients. The patients who have to chill in their rooms for an extra 6 hours because I don't want to discharge them before 5:00, wondering why this is taking so long. And the patients who end up sitting in the ER all night because the night team was too busy with the leftover day admissions to ever get to them.

So if you're wondering why your discharge is taking 7 hours, that's the story.


  1. This is really interesting to me, its frustrating to see the manipulation of the system driven by personal motives. I am though still only in my didactic year of my physician assistant program so I am naive to how the system actually works considering I am in a classroom the majority of my days. I have a feeling it will be only more frustrating once I am out there experiencing it for myself.

  2. I find it interesting that your previous post was regarding the ethics of paying someone to get into medical school. Great, you're the hero.

    Now this post is about an unethical way to get out of work earlier by passing off the work, and even worse, making patients and families wait to either go home OR get care! Really? Who's the hero now?

  3. So much for the noble motives of wanting to help others. Nope, let's all be lazy, I've helped all those I need to.

    Never mind that the patients want to go home, that they hate sitting in the hospital. Never mind that waiting until after 5 typically costs them an extra day on their hospital bill, which isn't cheap at all.

    You can't stand bodily fluids, you don't want to work, you don't seem to care for patients at all, why in the world are you trying to be a doctor? It sounds to me like you're just a douche bag who want the glory of signing MD after your name.

  4. @Brit - OK, let's deconstruct your post here.

    1. Hospital bill - No. Billing does not work on a per day basis, this is a gigantic myth - at least in the USA. It costs the hospital a lot more money to keep a patient an extra day. It costs you, the patient, nothing. So the people pushing for discharges are hospital administration, not patients. And they push for discharges before 12pm because that's pretty much when the cutoff is for "next day".

    2. Bodily fluids are for surgeons, ER docs, and ob/gyns; maybe pediatricians too. I can treat patients without touching fluids.

    3. Work - Residents at many hospitals are usually overworked. If one team starts taking on all they can, they will be taken advantage of, and it quickly becomes a catch-22. To fix this requires an institution-wide policy change. But yes, I agree that Anon shouldn't be pulling this kind of crap.

    4. Caring - It's pretty clear to me that Anon cares for his patients, but he's burning out. I think you're starting to lean toward the ad hominem. Bitter much?

    5. Douchebag - can't argue with that one.

    Alright then, cheers. :)

  5. Anonymous - my insurance billing does work on a per day basis. That's how it appears in my hospital bill. Spent X hours = X days, Charge is $$$ per X days =$$$$$. So you say it's a myth but I've been there and been charged like that, so either my insurance or my hospital is mythical.

    Yes you don't have to touch the fluids, but mild tolerance is expected. If you check Anon Doc's previous posts he mentions how it disturbs him even through gloves while doing exams.

    No, I'm not bitter towards the establishment or Anon. Doc in general. I don't know which one you were trying to point towards me being bitter about. However this post disgusted me. Not taking on 3 patients - there is a balance between avoiding all work since all of his patients could've been discharged, or avoiding swamping yourself. It's not an all or none thing, however having no patients that really need work is being lazy. He could've discharged one, than spent his remaining time doing all he can with the one new patient and the paperwork.

  6. Mr. Anon Doc weren't you just, in the previous post, complaining about rich kids "gaming the system"?

    Wouldn't this be the same thing? Why not pay a group of people $2000 to sit and fill out your team's cap for the day? They all get up at 5 and walk out, you get to go have an early dinner and everyone is good!