There is a magical number we rarely talk about, and that's how many patients every doctor can see and still take good care of all them.

It's vastly different depending on patient mix and level of illness. Of course, if I have an ankle sprain clinic for stable patients who need follow up on their straight forward ankle sprains and then go home, I can see dozens of these in a day.

But in the hospital, when there are sick patients in the mix who need high intensity care, that number is limited. Some patients need more, some need less, but let's say in the ED, during an 8-hour shift, a doctor working alone can see around 2.5 patients/hr or 20 patients.

In a crisis situation, you can ramp up from there, but not by much. And as you pour in more and more patients, but your space and staffing is fairly fixed, things start to function less well.

When there's not enough transport, you can't get patients to radiology and back. When nurses, in turn, are taking care of 5 or 6 patients each instead of 3 or 4, IV access, lab draws, meds, and other orders take longer. Rooms get empty but the cleaning queue is backed up. etc.

Throw in some more variables - like new protocols for PPE that mean we can't move as quickly in and out of rooms; more patients boarding in the ER since the hospitals are full; pop-up care places where we don't have the same familiarity with the space...

And now keep on adding patients. Because cases beget hospitalizations. And cases are climbing without end. But hospitals and humans cannot accommodate without end. So what happens when all those Thanksgiving cases come calling?

This leads to a lot of uncomfortable decisions. Like, who do we send home who we ordinarily would have admitted to the hospital? Who do we discharge today, when tomorrow would be better? Who do we let sit in the waiting room?

And what are we doing about risk mitigation? If doctors are seeing 40 patients when they ordinarily see 24, and we are forced to change usual practice to conserve resources, and patients are harmed in the process, who is sharing the responsibility for that? Anyone? Anyone?

But back to the original question… How many patients is simply not safe? What is that number if someone is seeing patients outside of the specialty that they’ve been trained in? What is that number if someone’s been working 15 days in a row, without a break?

Whatever the number is, what do we do when we get there and fly right by it? What does it mean, functionally, to cry “enough” in these circumstances, if the public just keeps on sending us more and more patients?

The safety threshold is close to what I’ve outlined above, since the system squeezes us to near-max efficiency at baseline ... but the social expectation is *infinity*: that no matter what, we accommodate, without compromise in care.