Am I a nobody?

[Splenda88]

Without chemo, the specialty would mostly be E&M. Think outpatient IM/FM income.

Do you think hem onc would be less competitive if that were to happen? Lol

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[NewYorkDoctors]

Do you think hem onc would be less competitive if that were to happen? Lol

FM/IM can do 99213-5 fairly easily and quickly
start a mill.
no goals of care talks
no "fixing problems"
doing routine workup and referring out
very fast
just document 12 problems and how the patient is getting referred out for all 12
done easiest 99215 ever

oncology doing all that without the chemo money? cannot run a mill like that.

 

[sloh]

FM/IM can do 99213-5 fairly easily and quickly
start a mill.
no goals of care talks
no "fixing problems"
doing routine workup and referring out
very fast
just document 12 problems and how the patient is getting referred out for all 12
done easiest 99215 ever

oncology doing all that without the chemo money? cannot run a mill like that.

Ya no doubt cancer is big money and they order a lot of imaging but the patients also require way more TLC compared to run of the mill IM/FM patients. A really efficient FM doc can churn out 30-40+ visits per day especially if they convert most inbox message replies to virtual visits hitting around at least 400-500k (of course the issue here is a lot of FM docs choose the W2 route and get shafted by their employers lol).

 

[Mehena]

all of them passionate about research/academia and 100% wanting to be in academics aka primary care salaries.

Advice to future applicants: To secure the coveted residency or fellowship, it is essential to demonstrate at least a feigned interest in academia

 

[Mehena]

These guys/gals in our cancer center are making 600-800k/yr working 4 1/2 days a week. We (hospitalist) admit their almost dead patients and most of the times, we are the ones initiating goal of care discussion with them and their families.

How many of these guys/gals work twice as many days as you do and take half as much vacation? Imagine, when they work, they don't get to see their kids go to bed, let alone watch EPL/Europa L on a random workday afternoon at 1 PM.

Do you happen to know the foot traffic to your cancer center, i.e., the number of patients per year? What percentage of these patients end up on your list past the ER at any given time?

How certain are you that these patients you claim did not have appropriate GOC discussions indeed have in the clinic? Do you know how many sick patients these guys/gals have enrolled in hospice after appropriate GOC discussions, saving them the rigmarole of hospital grounds?

If you're weary of caring for acutely ill cancer patients, how certain are you that your job will be secured?

In cancer treatment, there aren't many home runs, but the incremental changes have gotten us here. If we relegate every Stage 4 patient with pneumonia to hospice and comfort measures, then we won't progress anywhere.

 

[Splenda88]

How many of these guys/gals work twice as many days as you do and take half as much vacation? Imagine, when they work, they don't get to see their kids go to bed, let alone watch EPL/Europa L on a random workday afternoon at 1 PM.

Do you happen to know the foot traffic to your cancer center, i.e., the number of patients per year? What percentage of these patients end up on your list past the ER at any given time?

How certain are you that these patients you claim did not have appropriate GOC discussions indeed have in the clinic? Do you know how many sick patients these guys/gals have enrolled in hospice after appropriate GOC discussions, saving them the rigmarole of hospital grounds?

If you're weary of caring for acutely ill cancer patients, how certain are you that your job will be secured?

In cancer treatment, there aren't many home runs, but the incremental changes have gotten us here. If we relegate every Stage 4 patient with pneumonia to hospice and comfort measures, then we won't progress anywhere.

There is one of them I usually talk to on a personal level. He actually thinks my job is harder than his. He told me he usually sees 15-20 patients for a full day and half of them are hematology.

GOC discussion is not a complaint of mine ONLY. It's a complaint coming from the whole hospital including our palliative care service NPs.

Not weary at all. We (I am talking about the whole hospital) would like them to do a better job in discussing GOC with these patients/families. It's not fair to someone that is admitted to the hospital 3 times in a month w/ significant ascites stage IV ovarian CA with peritoneal carcinomatosis.

I was told one of these docs was reprimanded before I got here because of giving "false hope" to patients/families. Not sure how true is that.

They are all great doctors IMO and they are very accessible.

In all fairness, it might because of the patient population (the south). I trained at an academic center where attending would say no more treatments even if families threaten to sue. But here, the attending are reluctant to do that.

For instance, we had a patient that was brain dead in the ICU for 6 weeks getting dialyzed 3X a week.

 

[gutonc]

There is one of them I usually talk to on a personal level. He actually thinks my job is harder than his. He told me he usually sees 15-20 patients for a full day and half of them are hematology.

I would 100% agree with this. I wouldn't be a hospitalist for what I make now, let alone what I would actually get paid as a hospitalist.

GOC discussion is not a complaint of mine ONLY. It's a complaint coming from the whole hospital including our palliative care service NPs.

It's a universal problem. Some of us are better at it than others, but even those of us who are good at it struggle with it. The biggest issue is that patients and families see us (wrongly IMO) as the miracle workers, and when we run out of miracles, they feel like we're giving up on them. I try to start the conversations early, like when I recommend first line chemo for incurable cases, but sometimes the treatment works too well and they forget that original conversation 2 or 3 years later when things go completely pear shaped.

The other thing that happens is that people (appropriately) want to go meet with super sub-specialist experts. The problem is that these experts rarely have a meaningful interaction with them, often it's virtual or phone only, and they don't get the whole story about how while the patient looks OK on Zoom today, they need a 2 person assist to get to the bathroom and haven't been able to get to the clinic without EMS transport in the last 6 months. I recently ran into this with an elderly AML patient who barely tolerated Vidaza, requiring transfusion support 4 days a week, but had a decent response and a 6 month treatment free interval. Now that his disease is back I had 2 long talks with him about hospice, as did my SW and my hospice coordinator. But then he met with the regional leukemia specialist who told him, "Dr. Gutonc just needs to do a bone marrow biopsy, send molecular testing and you'll be able to get another 3 or 4 years out of treatment". I actually stepped out of the exam room to call Dr. Subspecialist and said "dude, what the serious f***? Did you see him? (no, it was just a phone visit), he's an ECOG 3 on his best day", to which Dr. Subspecialist replied "Oh...yeah, hospice is probably best then"). But now we're forced to do a bone marrow biopsy while waiting for him to crump even further.

But there's a decent chance that he'll get admitted to the hospital before he comes back to see me next week. And I guarantee that nobody will bother to read my notes on the discussions we had, they'll just document that he's not currently on hospice (despite multiple referrals and 2 in person consults) and not DNR (despite multiple documented discussions).

Bottom line, GOC discussions are hard. I honestly really appreciate when my hospitalist colleagues (or any other physician TBH) has the same discussion with them. It can be really helpful to hear the same thing from multiple people.

 

[NewYorkDoctors]

I would 100% agree with this. I wouldn't be a hospitalist for what I make now, let alone what I would actually get paid as a hospitalist.

It's a universal problem. Some of us are better at it than others, but even those of us who are good at it struggle with it. The biggest issue is that patients and families see us (wrongly IMO) as the miracle workers, and when we run out of miracles, they feel like we're giving up on them. I try to start the conversations early, like when I recommend first line chemo for incurable cases, but sometimes the treatment works too well and they forget that original conversation 2 or 3 years later when things go completely pear shaped.

The other thing that happens is that people (appropriately) want to go meet with super sub-specialist experts. The problem is that these experts rarely have a meaningful interaction with them, often it's virtual or phone only, and they don't get the whole story about how while the patient looks OK on Zoom today, they need a 2 person assist to get to the bathroom and haven't been able to get to the clinic without EMS transport in the last 6 months. I recently ran into this with an elderly AML patient who barely tolerated Vidaza, requiring transfusion support 4 days a week, but had a decent response and a 6 month treatment free interval. Now that his disease is back I had 2 long talks with him about hospice, as did my SW and my hospice coordinator. But then he met with the regional leukemia specialist who told him, "Dr. Gutonc just needs to do a bone marrow biopsy, send molecular testing and you'll be able to get another 3 or 4 years out of treatment". I actually stepped out of the exam room to call Dr. Subspecialist and said "dude, what the serious f***? Did you see him? (no, it was just a phone visit), he's an ECOG 3 on his best day", to which Dr. Subspecialist replied "Oh...yeah, hospice is probably best then"). But now we're forced to do a bone marrow biopsy while waiting for him to crump even further.

But there's a decent chance that he'll get admitted to the hospital before he comes back to see me next week. And I guarantee that nobody will bother to read my notes on the discussions we had, they'll just document that he's not currently on hospice (despite multiple referrals and 2 in person consults) and not DNR (despite multiple documented discussions).

Bottom line, GOC discussions are hard. I honestly really appreciate when my hospitalist colleagues (or any other physician TBH) has the same discussion with them. It can be really helpful to hear the same thing from multiple people.

i hope you are billing the **** out of 99497 and 99498


heck as PCP just have a talk "up to" 30 minutes. document full code or im undecided ill talk about it over the holidays with family hand them a MOLST form to review document and bill an easy 99497 as PCP lol

 

[HemeOncHopeful19]

There is one of them I usually talk to on a personal level. He actually thinks my job is harder than his. He told me he usually sees 15-20 patients for a full day and half of them are hematology.

GOC discussion is not a complaint of mine ONLY. It's a complaint coming from the whole hospital including our palliative care service NPs.

Not weary at all. We (I am talking about the whole hospital) would like them to do a better job in discussing GOC with these patients/families. It's not fair to someone that is admitted to the hospital 3 times in a month w/ significant ascites stage IV ovarian CA with peritoneal carcinomatosis.

I was told one of these docs was reprimanded before I got here because of giving "false hope" to patients/families. Not sure how true is that.

They are all great doctors IMO and they are very accessible.

In all fairness, it might because of the patient population (the south). I trained at an academic center where attending would say no more treatments even if families threaten to sue. But here, the attending are reluctant to do that.

For instance, we had a patient that was brain dead in the ICU for 6 weeks getting dialyzed 3X a week.

There is some truth to what you say but I do have to LOL at the “palliative care NPs” complaining, and ovarian cancer doesn’t typically fall under IM - H/O.

I would echo most of what GutOnc said above but add that some patients/families simply have unrealistic expectations and only want to hear what they want to hear.

I’ve never been in a situation where family threatens to sue if no more treatments but I might be inclined to be less confrontational with a family like that and I’m not sure why that’s a bad thing

 

[Splenda88]

There is some truth to what you say but I do have to LOL at the "palliative care NPs" complaining, and ovarian cancer doesn’t typically fall under IM - H/O.

I would echo most of what GutOnc said above but add that some patients/families simply have unrealistic expectations and only want to hear what they want to hear.

I’ve never been in a situation where family threatens to sue if no more treatments but I might be inclined to be less confrontational with a family like that and I’m not sure why that’s a bad thing

"Palliative care NPs". I was told that they do have a supervising attending but I have never seen the guy in the hospital.

We are the 'biggest' cancer center (4 hem onc and 1 radonc) in probably 80-100 miles radius. Unfortunately, that is all these patients can get. We dont have GYN-ONC here.

 

[chessknt]

In cancer treatment, there aren't many home runs, but the incremental changes have gotten us here. If we relegate every Stage 4 patient with pneumonia to hospice and comfort measures, then we won't progress anywhere.

But does doing CPR on them produce good outcomes? Why not discuss that they have a life-threatening condition and while the goal is to maximize life, if that life comes to an end whether by pneumonia or MI or whatever that expensive ICU care does not result in them getting back on chemo and living a long life. DNR is not the same as hospice but rather a form of respect that dying is part of life and you don't have to die in an ICU hooked up to every form of life support while the cancer ravages your body.

CPR in Advanced Cancer).

 

[NewYorkDoctors]

one oncologist I speak with who is HemeOnc and Palliative care boarded explained to me that he does not talk about end of life care during active treatment unless the patient brings it up and talks about it. I can buy that. A patient is searching for hope and a cure (or at least containing and managing the cancer). hearing about end of life care in the beginning of that journey may turn the patient off.

But once the patient ECOG hits 3 or 4 he does shift into palliative care mode while also talking about clinical trials. Once said patient is hospitalized, he does shift into palliative mode and it's really quite helpful for the patient to have the same patient's long term provider have that discussion
Then again, not every Hemeonc is palliative care boarded

 

[MD46]

one oncologist I speak with who is HemeOnc and Palliative care boarded explained to me that he does not talk about end of life care during active treatment unless the patient brings it up and talks about it. I can buy that. A patient is searching for hope and a cure (or at least containing and managing the cancer). hearing about end of life care in the beginning of that journey may turn the patient off.

But once the patient ECOG hits 3 or 4 he does shift into palliative care mode while also talking about clinical trials. Once said patient is hospitalized, he does shift into palliative mode and it's really quite helpful for the patient to have the same patient's long term provider have that discussion
Then again, not every Hemeonc is palliative care boarded

I agree with you on most points however majority of hematologist oncologist dont need to be boarded in Palliative care to palliate the patients in an effective manner. We have palliative care electives during fellowship and subsequently a lot of on job experience to do the job properly, and definitely better than any mid level palliative care person.

Also, when a hospitalist or an intensivist sees the patient in the hospital, they are looking at the current picture not the whole journey or struggle as a whole.

They dont know what sort of response the patient has had etc etc
Maybe they just need to get over this pneumonia and resume treatment and potentially survive another 2 years. Attend a graduation or a wedding of a loved one etc.

Many times I see ICU or Hospitalists consult palliative care and have discussions with the patients without the primary oncologist being made aware. This is a disservice to the patient in my opinion.

 

[DrMetal]

The other thing that happens is that people (appropriately) want to go meet with super sub-specialist experts.

What's even worse, is when these 'super sub-specialists' open up a 'holistic' cancer center in Mexico, and charge S4 patients $25,000 a pop (all cash of course), to pump them full of IVIG, Vitamin Bs, thiamine and folate, convincing them that'll cure cancer. If you happen to work in a nearby border town (San Diego, Yuma, El Paso), you get all their transfers (when the patient finally starts to die). Humanity doesn't deserve it's existence.

 

[Splenda88]

I agree with you on most points however majority of hematologist oncologist dont need to be boarded in Palliative care to palliate the patients in an effective manner. We have palliative care electives during fellowship and subsequently a lot of on job experience to do the job properly, and definitely better than any mid level palliative care person.

Also, when a hospitalist or an intensivist sees the patient in the hospital, they are looking at the current picture not the whole journey or struggle as a whole.

They dont know what sort of response the patient has had etc etc
Maybe they just need to get over this pneumonia and resume treatment and potentially survive another 2 years. Attend a graduation or a wedding of a loved one etc.

Many times I see ICU or Hospitalists consult palliative care and have discussions with the patients without the primary oncologist being made aware. This is a disservice to the patient in my opinion.

If the patient has been in and out of the hospital 5+ times in the past 2-3 months, with poor performance status, I think it's time to have frank discussions with patient/family. That is the situation we always find ourselves into.

I am not exaggerating. The ED docs have been complaining about that since I got here 2 1/2 yrs ago.

 

[chessknt]

I agree with you on most points however majority of hematologist oncologist dont need to be boarded in Palliative care to palliate the patients in an effective manner. We have palliative care electives during fellowship and subsequently a lot of on job experience to do the job properly, and definitely better than any mid level palliative care person.

Also, when a hospitalist or an intensivist sees the patient in the hospital, they are looking at the current picture not the whole journey or struggle as a whole.

They dont know what sort of response the patient has had etc etc
Maybe they just need to get over this pneumonia and resume treatment and potentially survive another 2 years. Attend a graduation or a wedding of a loved one etc.

Many times I see ICU or Hospitalists consult palliative care and have discussions with the patients without the primary oncologist being made aware. This is a disservice to the patient in my opinion.

I would argue that how they conquered cancer and got a lot better has absolutely no relevance to their ability to recover from CPR. Same thing for 'healthy' 85 year olds who want CPR because they are so functional except of course they aren't after getting cpr.

In terms of 'getting over' a pneumonia bad enough to put you in the ICU that is not straight forward either and, again, CPR is not going to be effective to be there either. Intubation is far from benevolent as well given rapid deconditioning and multiple icu-related complications that can occur--if they have to go to an ltach or a snf for months and are too weak to get chemo for 4-6 months (assuming nothing else bad happens) is that not a reasonable discussion to have with someone in the context of palliation of suffering in someone nearing the end of their life?

How many of your patients came back to continue treatment plans after receiving CPR in a hospital?

 

[MD46]

I would argue that how they conquered cancer and got a lot better has absolutely no relevance to their ability to recover from CPR. Same thing for 'healthy' 85 year olds who want CPR because they are so functional except of course they aren't after getting cpr.

In terms of 'getting over' a pneumonia bad enough to put you in the ICU that is not straight forward either and, again, CPR is not going to be effective to be there either. Intubation is far from benevolent as well given rapid deconditioning and multiple icu-related complications that can occur--if they have to go to an ltach or a snf for months and are too weak to get chemo for 4-6 months (assuming nothing else bad happens) is that not a reasonable discussion to have with someone in the context of palliation of suffering in someone nearing the end of their life?

How many of your patients came back to continue treatment plans after receiving CPR in a hospital?

I am not talking about your hypothetical patient with cancer that codes and requires CPR

Also not all cancers are same
Not all patients with cancer are in the same age group or have same comorbidities

I am talking about my patient demographic, may not apply to your side.

And yes I have a small cell lung cancer patient that recovered after a CPR and is more than 3 yrs out maintained on chemo q3weeks
There arent many, you are correct on that.

 

[chessknt]

I am not talking about your hypothetical patient with cancer that codes and requires CPR

Also not all cancers are same
Not all patients with cancer are in the same age group or have same comorbidities

I am talking about my patient demographic, may not apply to your side.

And yes I have a small cell lung cancer patient that recovered after a CPR and is more than 3 yrs out maintained on chemo q3weeks
There arent many, you are correct on that.

But that is the discussion that oncologists (and honestly most specialists) aren't having. You're talking about hospice vs full code, I am talking about encouraging patients with incurable serious diseases associated with dismal CPR outcomes to at least making a decision to allow a life ending event be just that instead of a protracted ICU battle post arrest. Every patient I deal with post arrest is a 'hypothetical' until it actually happens. I am having this discussion either peri-code or immediately post code for the first time with someone who has no ability to process the information. I am literally the worst person to be having this discussion yet that seems to always be the case.

Since we can't reasonably predict it why not start talking to your patients about it early?

 

[HemeOncHopeful19]

If the patient has been in and out of the hospital 5+ times in the past 2-3 months, with poor performance status, I think it's time to have frank discussions with patient/family. That is the situation we always find ourselves into.

I am not exaggerating. The ED docs have been complaining about that since I got here 2 1/2 yrs ago.

In my experience the patient who has come to the hospital 5 times in 2 months either a) has not actually made it to their outpatient appointment for this mythical discussion we’re supposed to have and/or b) does not want to hear reality (more often their spouse or children do not want to hear reality)

 

[Mehena]

The problem is that hospice and comfort measures are often recommended on the GIM ward without much thought. Often without consulting the primary oncologist. When you're dealing with critical illnesses, especially those that could lead to cardiac arrest, we've got to handle things with care.

During my IM residency, I had loads of discussions about GOC in both the MICU and CCU, dealing with cases related to cancer and other conditions. For instance, trying CPR on a vasculopath patient with florid endocarditis who's already maxed out on three pressors is probably not going to pan out. Let's be real, in-hospital cardiac arrest usually comes with a dismal prognosis.

As @MD46 mentioned, most IM residencies put a lot of emphasis on palliative care and GOC discussions in their curriculum. With extra training during fellowship and just dealing with this stuff day-to-day to finesse the skill, most oncologists can handle these situations without needing green palliative NP's verbal jujitsu to say "you are dying".

 

[whoknows2012]

The problem is that hospice and comfort measures are often recommended on the GIM ward without much thought. Often without consulting the primary oncologist. When you're dealing with critical illnesses, especially those that could lead to cardiac arrest, we've got to handle things with care.

During my IM residency, I had loads of discussions about GOC in both the MICU and CCU, dealing with cases related to cancer and other conditions. For instance, trying CPR on a vasculopath patient with florid endocarditis who's already maxed out on three pressors is probably not going to pan out. Let's be real, in-hospital cardiac arrest usually comes with a dismal prognosis.

As @MD46 mentioned, most IM residencies put a lot of emphasis on palliative care and GOC discussions in their curriculum. With extra training during fellowship and just dealing with this stuff day-to-day to finesse the skill, most oncologists can handle these situations without needing green palliative NP's verbal jujitsu to say "you are dying".

Highly agree. Also the necessary side effect of the above is misunderstanding the disease or prognosis bc you didn’t speak to the oncologist first.

 

[osprey099]

But that is the discussion that oncologists (and honestly most specialists) aren't having. You're talking about hospice vs full code, I am talking about encouraging patients with incurable serious diseases associated with dismal CPR outcomes to at least making a decision to allow a life ending event be just that instead of a protracted ICU battle post arrest. Every patient I deal with post arrest is a 'hypothetical' until it actually happens. I am having this discussion either peri-code or immediately post code for the first time with someone who has no ability to process the information. I am literally the worst person to be having this discussion yet that seems to always be the case.

Since we can't reasonably predict it why not start talking to your patients about it early?

Those conversations aren't had because they take too long. Even the most relaxed oncology setups are seeing around 15 patients per day. Most places, including my group, see 20-25 per day. We are already always behind schedule because managing side effects and consenting for treatment takes a lot of talking and explaining. If we were to have code status or advanced directive discussions on top of that, there simply won't be enough time in a clinic day for that.

This is why we need more outpatient palliative care. Ideally, every metastatic cancer patient is hooked up with palliative care before they even start treatment. Palliative care provides that extra layer of support and can address all of the above issues.

 

[chessknt]

Those conversations aren't had because they take too long. Even the most relaxed oncology setups are seeing around 15 patients per day. Most places, including my group, see 20-25 per day. We are already always behind schedule because managing side effects and consenting for treatment takes a lot of talking and explaining. If we were to have code status or advanced directive discussions on top of that, there simply won't be enough time in a clinic day for that.

This is why we need more outpatient palliative care. Ideally, every metastatic cancer patient is hooked up with palliative care before they even start treatment. Palliative care provides that extra layer of support and can address all of the above issues.

Sure just split that chemo revenue you generate from seeing so many people with them so they stop making $32/rvu. Im sure they'd love to help support you.

 

[Ubba]

Why should we be splitting any of our revenue with Palliative Care NPs?

 

[osprey099]

Sure just split that chemo revenue you generate from seeing so many people with them so they stop making $32/rvu. Im sure they'd love to help support you.

There is a scarcity of outpatient palliative care docs. Honestly, I feel like most groups will gladly cut pall care a healthy percentage of revenue if they can provide the comprehensive supportive measures and longitudinal care -> transition to hospice/comfort care for our patients. In fact, under the new EOM model, value based care mandates groups having a 24/7 patient assistance service in addition to social determinants/pall care stuff in order to qualify for the MEOS payments.

The reality is that there is no outpatient pall care docs, especially in more rural settings. So onc assumes the pall care aspect and most groups will just hire a midlevel to do this busy work while the onc docs focus on chemo admin.

 

[dgdg]

Why should we be splitting any of our revenue with Palliative Care NPs?

They would do the home visits for those who are technically homebound, but not yet hospice eligible. It would be an additional service, not a shared revenue.

 

[Ubba]

They would do the home visits for those who are technically homebound, but not yet hospice eligible. It would be an additional service, not a shared revenue.

That's a fine proposal, and it's different from what was suggested above.