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Staying late... can’t... do it... anymore.

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I just wrapped up a fourteen hour day today. I am frigging exhausted. My shifts are twelve hours, but I stayed late charting. I only saw about 26 patients, but a lot of them were nightmares and very labor and time intensive (huge dog bites on the legs, two distal radius and ulnar styloid fractures that required multiple attempts at reduction, a cervical laceration that would not stop, a hypotensive upper GI bleed... I could go on and on). 

I have been staying super late in the last year, and I am sick of it. Usually an hour, two in a blue moon. I think it all started when we started to get RVU pay. I make an additional 30 to 55 per HOUR just for the RVUs, so it’s tempting to try to pick up an extra patient here or there. We don’t get paid for the hours we stay late, but you’d assume the RVUs would more than make up for it. That’s what I have been telling myself but I am sooooo tired of staying late.

I have been blaming myself for “picking up too many patients for the RVU” but here’s the weird thing; I am not actually seeing significantly more patients than I did before we got RVUs. So I am staying substantially later because... God knows why... I don’t know.

Does anyone have any tricks for getting out on time? I don’t think what I am doing is sustainable.

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I was never very good about getting out on time at my old FT job either.  I felt that averaging (pt + procedures + 30 min increments of critical care time) of 2/hour was plenty.  Don't know what your total hour compensation is, but I found that in my last 90 minutes of a shift I did best if I only picked up patients that wouldn't involve much of a workup or likely need admission.  In my last 45 minutes, I'd only do level 4's & 5's, and no procedure that wasn't simple.

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Agree with ohio; I'm careful not to pick up complex patients near the end of my shift. Also, you should look into whether you can finish your charting from home via VPN. It's a lot nicer to finish those charts in your own environment with a cold beer than being stuck at the hospital under fluorescent lights.

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I try to do most of my documentation in real time. I don't chart from home ever. when I worked with an RVU bonus structure I pretended it didn't exist. you can't depend on it, so don't. Once I have 4 open charts(the most you can have on epic), I don't start a new patient unless they are dying or all the charts are up to date. That being said, I will stay late for disasters at shift change(codes, etc)  or if the night provider will be totally overwhelmed. I either work solo coverage or dual coverage, never more than 2 providers, so if I am leaving and it is just the night guy and there are 15 pts I generally won't leave. they generally make this up to me by kicking me out early another night. My primary job is solo coverage and a busy day is 15 pts in 24 hrs. my part time job is double coverage and I typically see 65 pts in the 3 days in a row I work once/month. I don't ever want to be busier than that again. I did 15 years of the 25-50 pts/12 hrs thing. never again. 

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It depends on the day as I could be managing 8-10 rooms or things may be flowing and I’ve got everyone nice and packaged, but 2 hours prior to sign out I’m only picking up patients that I can get a good start on. Levels 3 typically that don’t say “history of renal transplant” or something else I know is going to require soul crushing specialist consult as these people are notoriously slow to implement their plan. One hour before I’m only picking up people that are young level 4. There is almost no such thing as level 5 here at my tertiary care center.

I try force my myself to get the HPI and physical done before I see my next patient. I often don’t because I’m working with an off service intern and have to pick up the slack of them seeing only 6 in a shift. When it works out though my charts are easy at the end of the day. I’m almost always staying late though to wrap up patients for the next team, as I feel too guilty to hand off work to another resident who is just as overworked as I am.

like Emed, I’m done with this rat race and can’t wait for my low volume high acuity rural job.

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almost done with a 24 right now. have seen 7 patients including a dissecting AAA, a recurrent syncope, and a septic patient with diverticulitis. high acuity, low volume. love it. at my last job I would manage an entire hallway(10 rooms) and be expected to help out in fast track if they got busy or be a procedure guy on traumas if that team got busy. I am done with that. 

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I now work in a low volume variable acuity rural critical access hospital.  I feel so much better, even though I'm a nocturnist.  My wife feels like I'm back to being me, vs the constantly stressed out barely communicative person I was before.

That said, I'm the only provider in the ED from 20:00-08:00 and the only one in the hospital from 20:00-07:00, when the inpatient docs round.  So, if anything comes through the door, I'll start it unless it sounds very minor and it's the last 10 minutes of my shift.  However, signouts are expected unless the patient will be ready for discharge a few minutes after the normal end of your shift.

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