20 patients per hour is an easy throw away line that is not likely to ever
be tested.  The simple truth is that if one bottleneck in the system is
removed - eg the unlikely event that a doctor is able to see 20 patients per
hour - other bottlenecks will be revealed eg access to radiology, ability of
clerical staff to generate paperwork etc.

Whilst it may be possible to physically see 20 patients per hour, I question
whether:
* this is possible for anything but the most 'minor' complaints (should they
be in an ED in the first place?)
* this is possible to do across a whole shift - eg 180 patients in a shift!
* it is possible to practice high quality medicine in this manner - eg
documentation, vigilance for low frequency / high morbidity conditions

The US system is probably the best system to use for reference.  They are
set up so that the high cost individual (the doctor) has unimpeded access to
patients.  In this system, the usual across all shifts patient activity is
around 3.5 pph.

PB

-----Original Message-----
From: Accident and Emergency Academic List
[mailto:[log in to unmask]] On Behalf Of Dunn Matthew Dr. (RJC) A &
E - SwarkHosp-TR
Sent: Monday, 14 August 2006 5:26 PM
To: [log in to unmask]
Subject: Re: 20 patients an hour, easily[Scanned]

Don't know about Dr Cottingham, but the rate is achievable. I do from time
to time go at that rate or higher myself, although in a relatively small
department it is unusual to have 20 patient present at a time. It does rely
on having the patients present in the cubicles when you arrive; already on a
trolley if they are slow at getting on a trolley and with the appropriate
body part exposed. The way to combine it with teaching is to go in with the
F2, see the patient and tell them what to write while they write up the
notes. Or alternatively swap roles. The two doctor idea was one I came
across as an experiment in Stoke while I was a registrar- either Tony
Redmond's or Mark Prescott's idea, I think. I was initially sceptical about
efficiency but in fact the talking/ examining and writing take about the
same length of time. What struck me was that whether I was in with a doctor
of the same, higher or lower grade and whether I was the examining or
writing doctor it worked as a learning experience. 
Outside Emergency Medicine, things have changed but when I worked in General
Practice (in the days when no evidence of being adequately qualified to do
so as a locum was needed) it was not uncommon to have 3 minute appointments.

> "I could easily see 20 patients 
> an hour and teach an F2 in minors in such a system."
> 
> 
> I challenge Dr Cottingham to do this.
> 


Matt Dunn
Warwick


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