Emergency medicine provider efficiency: the learning curve, equilibration and point of diminishing returns

This study described the spectrum of emergency department (ED) physician performance correlating annual workload, experience and facility issues.

Retrospective review reported physician hours worked comparing productivity measures--patients per hour (PPH) or relative value unit (RVU) per hour, as 'best fit' trend line and facility volume subgroups by analysis of variance.

912 physicians evaluated 2,407,833 patients in 61 ED. Staff productivity was 1.72±0.44 PPH (1.2±0.30-2.1±0.32 PPH) and 4.43±1.21 RVU/h (2.9±0.80-5.4±0.82 RVU/h). There was less variation with facility size 2.58±0.36 (2.41±0.22-2.72±0.37 RVU/visit) from smaller to larger (p<0.001). Maximal efficiency occurs at 5.0 RVU/h generated at 1550 annual hours (130 monthly) compared with 1800 h full-time equivalent (FTE) physicians (R(2)=0.084). Productivity begins at 4.0 RVU/h for casual (<250 h/year), 4.4 RVU/h for part time (<500 h), achieving equilibrium (5.0 RVU/h) for three-quarters to full time (1250-1800 h) with a decline in full-time providers (2000-2500 h/year). Efficiency was less in smaller ED less than 15,000 (1.22±0.30 PPH, 2.95±0.80 RVU/h) compared with larger greater than 45,000 (2.07±0.32 PPH, 5.43±0.82 RVU/h; p<0.001). The RVU/visit generated were less varied (2.41±0.22) in smaller versus (2.64±0.38) larger facilities with a 2.8 RVU/h equilibration point (p<0.001).

Maximal productivity is reached at 86% (1550 h) annual workload and efficiency declines at conventional FTE (≈ 1800 h). A distinct 'learning curve' was found in newer, casual providers and smaller facilities.