Cherry Picking Patients: Examining the Interval Between Patient Rooming and Resident Self-assignment

Resident Attitudes Toward Performing Pelvic Examinations in the Emergency Department

Mounting evidence suggests that emergency physicians tend to avoid patients with gynecologic chief complaints, and that avoidance may be higher for male physicians compared to females. One underlying reason could be discomfort with performing pelvic examinations. The goal of this study was to assess whether male residents report greater discomfort with pelvic examinations than females. We performed a cross-sectional, Institutional Review Board-approved survey of residents at 6 academic emergency medicine programs. Of 100 residents who completed the survey, 63 self-identified as male, 36 female, and one selected "prefer not to say" and was excluded. Responses were compared between male and females using chi-square tests. In secondary analysis, t-tests were used to compare preferences for various chief complaints. Self-reported comfort with pelvic examinations did not differ significantly between males and females (p = 0.4249). Barriers for male respondents in performing pelvic examinations included lack of training, general dislike, and concern the patient would prefer female providers. Male residents had a statistically significant higher aversion ranking towards patients with vaginal bleeding than female residents (mean difference = 0.48, confidence interval = 0.11-0.87). Aversion ranking was the same between males and females on other chief complaints. There is a gender disparity among male and female residents in attitudes towards patients with vaginal bleeding. However, the results from this study do not demonstrate a significant difference in self-reported comfort amongst male and female residents in performing pelvic examinations. This disparity may be driven by other barriers, including self-reported lack of training and concern about patients' physician gender preferences.

Comparing the Evaluation of Abdominal Pain in Adolescent Females at a Pediatric vs General Emergency Department

BACKGROUND

The objective of this study was to determine the rates at which gynecologic history and related exams are performed among adolescent females presenting with abdominal pain and whether the rates differ between patients seeking care at a pediatric compared with a general emergency department (ED).

METHODS

We conducted a retrospective cohort study of female patients aged 12-21 years who presented to the ED for a chief complaint of abdominal pain at either a single academic children's ED or a single general academic ED during 2016. We examined differences in the rates of gynecologic history and related exams between institutions, before and after adjustment with inverse probability weights.

RESULTS

A total of 837 females met the inclusion criteria for this study, and 627 patients were included in the adjusted analyses. Outcomes more commonly performed at the pediatric institution included documentation of contraception (28% at the general ED vs 43% at the pediatric ED, P < .001), sexually transmitted infection testing (32% at the general ED vs 42% at the pediatric ED, P = .04), and radiologic imaging (46% at the general ED vs 70% at the pediatric ED, P < .001). Outcomes that were more commonly performed at the general ED were pelvic exam (26% at the general ED vs 10% at the pediatric ED, P < .001) and complete blood count draw (67% at the general ED vs 39% at the pediatric ED, P < .001). No differences were observed between institutions in the documentation of menarche or sexual activity, the performance of a pregnancy test or CT scan, or the rate of subsequent ED/urgent care visits in the following year.

CONCLUSION

The rates at which gynecologic history and pelvic examination were performed in adolescent females presenting for abdominal pain at both a general ED and a pediatric ED were low and inconsistent. Providers should have a low threshold for testing for sexually transmitted infections and pregnancy. Pelvic examination and diagnostic lab testing should be performed when indicated in the setting of a clinically appropriate history. These efforts would ensure adequate evaluation of adolescent women and reduce unnecessary health resource utilization.

The effect of batched patient–physician assignment on patient length of stay in the emergency department

Objectives

Queuing theory suggests that signing up for multiple patients at once (batching) can negatively affect patients’ length of stay (LOS). At academic centers, resident assignment adds a second layer to this effect. In this study, we measured the rate of batched patient assignment by resident physicians, examined the effect on patient in‐room LOS, and surveyed residents on underlying drivers and perceptions of batching.

Methods

This was a retrospective study of discharged patients from August 1, 2020 to October 27, 2020, supplemented with survey data conducted at a large, urban, academic hospital with an emergency medicine training program in which residents self‐assign to patients. Time stamps were extracted from the electronic health record and a definition of batching was set based on findings of a published time and motion study.

Results

A total of 3794 patients were seen by 28 residents and ultimately discharged during the study period. Overall, residents batched 23.7% of patients, with a greater rate of batching associated with increasing resident seniority and during the first hour of resident shifts. In‐room LOS for batched assignment patients was 15.9 minutes longer than single assignment patients (P value < 0.01). Residents’ predictions of their rates of batching closely approximated actual rates; however, they underestimated the effect of batching on LOS.

Conclusions

Emergency residents often batch patients during signup with negative consequences to LOS. Moreover, residents significantly underestimate this negative effect.

Emergency Medicine Residents’ “Just World” Bias Is Not Associated with a Biased Case Mix

Introduction

Belief in a just world is the cognitive bias that “one gets what they deserve.” Stronger belief in a just world for others (BJW-O) has been associated with discrimination against individuals with low socioeconomic status (SES) or poor health status, as they may be perceived to have “deserved” their situation. Emergency medicine (EM) residents have been shown to “cherry pick” patients; in this study we sought to determine whether BJW-O is associated with a biased case mix seen in residency.

Methods

We assessed EM residents on their BJW-O using a scale with previous validity evidence and behavioral correlates. We identified chief complaints that residents may associate with low SES or poor health status, including psychiatric disease, substance use disorder (SUD); and patients with multidisciplinary care plans due to frequent ED visits. We then calculated the percentage of each of these patient types seen by each resident as well as correlations and a multiple linear regression.

Results

38 of 48 (79%) residents completed the BJW-O, representing 98,825 total patient encounters. The median BJW-O score was 3.25 (interquartile range 2.81–3.75). There were no significant correlations observed between BJW-O and the percentage of patients with multidisciplinary care plans who were seen, or patients with psychiatric, SUD, dental or sickle cell chief complaints seen; and a multiple linear regression showed no significant association.

Conclusion

Higher BJW-O scores in EM residents are not significantly associated with a biased case mix of patients seen in residency.

Association of resident characteristics with patterns of patient self-assignment

OBJECTIVE

We hypothesized that resident characteristics impact patterns of patient self-assignment in the emergency department (ED). Our goal was to determine if male residents would be less likely than their female colleagues to see patients with sensitive (e.g. breast-related or gynecologic) chief complaints (CCs). We also investigated whether resident specialty was associated with preferentially choosing patients with more familiar chief complaints.

METHODS

We performed a retrospective cross-sectional study at a tertiary academic medical center using data from all adult patients presenting to the ED between 2010 and 2019 with one of six CC categories (vaginal bleeding, breast-related concerns, male genitourinary [GU] concerns, gastrointestinal bleeding, epistaxis, and laceration). These CCs were chosen as they each require either an invasive medical exam or procedure, and cannot easily be evaluated with an exam in a hallway bed. We used logistic regression to assess the likelihood of being treated by a male resident compared to a female resident for each CC, adjusting for candidate variables of patient age, race, primary language, ESI score, bed location, time of day, day of week, calendar month, and resident specialty. We also similarly analyzed patterns of patient self-assignment according to resident specialty.

RESULTS

Male residents were significantly less likely than female residents to treat patients with breast-related CCs (adjusted OR 0.67, 95% CI 0.54-0.83, p < 0.001) or vaginal bleeding (adjusted OR 0.73, 95% CI 0.63-0.84, p < 0.001, reference group: epistaxis). Off-service residents were more likely to assign themselves to familiar chief complaints, for example surgery residents were more likely to see patients with lacerations (adjusted OR 2.11, 95% CI 1.71-2.61, p < 0.001) and OB/GYN residents were less likely to see patients with male GU concerns (adjusted OR 0.21, 95% CI 0.05-0.85, p = 0.029), compared to emergency medicine residents.

CONCLUSION

In a single facility, resident characteristics were associated with preferential patient self-assignment. Further work is necessary to determine the underlying reasons for patient avoidance, and to create work environments in which preferentially choosing patients is discouraged.

Association Between Emergency Physician Length of Stay Rankings and Patient Characteristics

OBJECTIVE

Emergency physicians are commonly compared by their patients' length of stay (LOS). We test the hypothesis that LOS is associated with patient characteristics and that accounting for these features impacts physician LOS rankings.

METHODS

This was a retrospective observational study of all encounters at an emergency department in 2010 to 2015. We compared the characteristics of patients seen by physicians in different quartiles of LOS. Primary outcome was variation in patient characteristics at time of physician assignment (age, sex, comorbidities, Emergency Severity Index [ESI], and chief complaint) across LOS quartiles. We also quantified the change in LOS rankings after accounting for difference in characteristics of patients seen by different physicians.

RESULTS

A total of 264,776 encounters seen by 62 attending physicians met inclusion criteria. Physicians in the longest LOS quartile saw patients who were older (age = 49.1 vs 48.6 years, difference = +0.5 years, 95% confidence interval [CI] = 0.3 to 0.7) with more comorbidities (Gagne score = 1.3 vs. 0.9, difference = +0.4, 95% CI = 0.4 to 0.4) and higher acuity (ESI = 2.8 vs. 2.9, difference = -0.1, 95% CI = 0.1 to 0.1) than physicians in the shortest LOS quartile. The odds ratio (OR) of physicians in the longest LOS quartile seeing patients over age 50 compared to the shortest LOS quartile was 1.1 (95% CI = 1.0 to 1.1); the OR of physicians in the longest LOS quartile seeing patients with ESI of 1 or 2 was also 1.1 (95% CI = 1.0 to 1.1). Accounting for variation in patient characteristics seen by different physicians resulted in substantial reordering of physician LOS rankings: 62.9% (39/62) of physicians reclassified into a different quartile with mean absolute percentile change of 25.8 (95% CI = 20.3 to 31.3). A total of 62.5% (10/16) of physicians in the shortest LOS quartile and 56.3% (9/16) in the longest LOS quartile moved into a different quartile after accounting for variation in patient characteristics.

CONCLUSIONS

Length of stay was significantly associated with patient characteristics, and accounting for variation in patient characteristics resulted in substantial reordering of relative physician rankings by LOS. Comparisons of emergency physicians by LOS that do not account for patient characteristics should be reconsidered.

Patient Assignment Models in the Emergency Department

Early assignment of patients to specific treatment teams improves length of stay, rate of patients leaving without being seen, patient satisfaction, and resident education. Multiple variations of patient assignment systems exist, including provider-in-triage/team triage, fast-tracks/vertical pathways, and rotational patient assignment. The authors discuss the theory behind patient assignment systems and review potential benefits of specific models of patient assignment found in the current literature.

Identifying Nonprovider Factors Affecting Pediatric Emergency Medicine Provider Efficiency

OBJECTIVE

The aim of this study was to create a multivariable model of standardized relative value units per hour by adjusting for nonprovider factors that influence efficiency.

METHODS

We obtained productivity data based on billing records measured in emergency relative value units for (1) both evaluation and management of visits and (2) procedures for 16 pediatric emergency medicine providers with more than 750 hours worked per year. Eligible shifts were in an urban, academic pediatric emergency department (ED) with 2 sites: a tertiary care main campus and a satellite community site. We used multivariable linear regression to adjust for the impact of shift and pediatric ED characteristics on individual-provider efficiency and then removed variables from the model with minimal effect on productivity.

RESULTS

There were 2998 eligible shifts for the 16 providers during a 3-year period. The resulting model included 4 variables when looking at both ED sites combined. These variables include the following: (1) number of procedures billed by provider, (2) season of the year, (3) shift start time, and (4) day of week. Results were improved when we separately modeled each ED location. A 3-variable model using procedures billed by provider, shift start time, and season explained 23% of the variation in provider efficiency at the academic ED site. A 3-variable model using procedures billed by provider, patient arrivals per hour, and shift start time explained 45% of the variation in provider efficiency at the satellite ED site.

CONCLUSIONS

Several nonprovider factors affect provider efficiency. These factors should be considered when designing productivity-based incentives.

Maggots, Mucous and Monkey Meat: Does Disgust Sensitivity Affect Case Mix Seen During Residency?

Introduction

Emergency physicians encounter scenarios daily that many would consider “disgusting,” including exposure to blood, pus, and stool. Physicians in procedural specialties such as surgery and emergency medicine (EM) have lower disgust sensitivity overall, but the role this plays in clinical practice is unclear. The objective of this study was to determine whether emergency physicians with higher disgust sensitivity see fewer “disgusting” cases during training.

Methods

All EM residents at a midsize urban EM program were eligible to complete the Disgust Scale Revised (DS-R). We preidentified cases as “disgust elicitors” based on diagnoses likely to induce disgust due to physician exposure to bodily fluids, anogenital anatomy, or gross deformity. The “disgust elicitor” case percent was determined by “disgust elicitor” cases seen as the primary resident divided by the number of cases seen thus far in residency. We calculated Pearson’s r, t-tests and descriptive statistics on resident and population DS-R scores and “disgust elicitor” cases per month.

Results

Mean DS-R for EM residents (n = 40) was 1.20 (standard deviation [SD] 1.24), significantly less than the population mean of 1.67 (SD 0.61, p<0.05). There was no correlation (r = −0.04) between “disgust elicitor” case (n = 2191) percent and DS-R scores. There was no significant difference between DS-R scores for junior residents (31.1, 95% confidence interval [CI], 26.8–35.4) and for senior residents (29.0, 95%CI, 23.4–34.6).

Conclusion

Higher disgust sensitivity does not appear to be correlated with a lower percentage of “disgust elicitor” cases seen during EM residency.

The Effects of Discrete Work Shifts on a Nonterminating Service System

Hospital emergency departments (EDs) provide around-the-clock medical care, and as such are generally modeled as nonterminating queues. However, from the care provider's point of view, ED care is not a never-ending process, but rather occurs in discrete work shifts and may require passing unfinished work to the next care provider at the end of the shift. We use data from a large, academic medical center ED to show that the patients' rate of service completion varies over the course of the physician shift. Further, patients that have experienced a physician handoff have a higher rate of service completion than non-handed off patients. As a result, a patient's expected treatment time is impacted by when in the physician's shift treatment begins. We also show that patients that have been handed off are more likely to revisit the ED within three days, suggesting that patient handoffs lower clinical quality. Lastly, we use simulation to show that shift length and new-patient cutoff rules can be used to reduce handoffs, but at the expense of system throughput.

Are testers also admitters? Comparing emergency physician resource utilization and admitting practices

OBJECTIVE

To describe the relationship between emergency department resource utilization and admission rate at the level of the individual physician.

METHODS

Retrospective observational study of physician resource utilization and admitting data at two emergency departments. We calculated observed to expected (O/E) ratios for four measures of resource utilization (intravenous medications and fluids, laboratory testing, plain radiographs, and advanced imaging studies) as well as for admission rate. Expected values reflect adjustment for patient- and time-based variables. We compared O/E ratios for each type of resource utilization to the O/E ratio for admission for each provider. We report degree of correlation (slope of the trendline) and strength of correlation (adjusted R² value) for each association, as well as categorical results after clustering physicians based on the relationship of resource utilization to admission rate.

RESULTS

There were statistically significant positive correlations between resource utilization and physician admission rate. Physicians with lower resource utilization rates were more likely to have lower admission rates, and those with higher resource utilization rates were more likely to have higher admission rates.

CONCLUSIONS

In a two-facility study, emergency physician resource utilization and admission rate were positively correlated: those who used more ED resources also tended to admit more patients. These results add to a growing understanding of emergency physician variability.

Interphysician Differences in Emergency Department Length of Stay

BACKGROUND

Emergency physicians differ in many ways with respect to practice. One area in which interphysician practice differences are not well characterized is emergency department (ED) length of stay (LOS).

OBJECTIVE

To describe how ED LOS differs among physicians.

METHODS

We performed a 3-year, five-ED retrospective study of non-fast-track visits evaluated primarily by physicians. We report each provider's observed LOS, as well as each provider's ratio of observed LOS/expected LOS (LOS_O/E); we determined expected LOS based on site average adjusted for the patient characteristics of age, gender, acuity, and disposition status, as well as the time characteristics of shift, day of week, season, and calendar year.

RESULTS

Three hundred twenty-seven thousand, seven hundred fifty-three visits seen by 92 physicians were eligible for analysis. For the five sites, the average shortest observed LOS was 151 min (range 106-184 min), and the average longest observed LOS was 232 min (range 196-270 min); the average difference was 81 min (range 69-90 min). For LOS_O/E, the average lowest LOS_O/E was 0.801 (range 0.702-0.887), and the average highest LOS_O/E was 1.210 (range 1.186-1.275); the average difference between the lowest LOS_O/E and the highest LOS_O/E was 0.409 (range 0.305-0.493).

CONCLUSION

There are significant differences in ED LOS at the level of the individual physician, even after accounting for multiple confounders. We found that the LOS_O/E for physicians with the lowest LOS_O/E at each site averaged approximately 20% less than predicted, and that the LOS_O/E for physicians with the highest LOS_O/E at each site averaged approximately 20% more than predicted.