Clinic workflow - Gedankenexperiment

[kimplera]

Curious to pick your brains about how you would structure a clinical physician/APP workforce in a large practice (say 5 or more physicians) if you were designing from the ground up. Goal to improve QOL for physicians and staff while maximizing quality patient care. Feel free to throw out ideas but i'll provide some starters:
Assume subsite specialization not all generalists. Treatment hours 730-630 ideally (extending either direction PRN). Min 3 machines. Mix of SBRT, SRS, brachy, external beam and inpatient consults.

1) covering beam-on time - doc of day vs everyone expected to stay vs. on-call doc
2) inpatient and add ons -
3) checking new starts, SBRTs, SRS
4) expectations for in clinic time vs. office vs. work from home
5) opportunity to design use of APPs to fit optimal care
6) OTV scheduling - separate day, consult day, followup day - mix of all
7) expectation from sim to IMRT start

I'm sure there are a ton of other issues i haven't mentioned... add your own.

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[Pointless]

Goal to improve QOL for physicians and staff

Treatment hours 730-630 ideally

These things are diametrically opposed IMO. If you are designing a new clinic model, consider more benign work hours? 8-4:30 with each clinician working 4 day weeks... this is a much better starting point

 

[Chartreuse Wombat]

Curious to pick your brains about how you would structure a clinical physician/APP workforce in a large practice (say 5 or more physicians) if you were designing from the ground up. Goal to improve QOL for physicians and staff while maximizing quality patient care. Feel free to throw out ideas but i'll provide some starters:
Assume subsite specialization not all generalists. Treatment hours 730-630 ideally (extending either direction PRN). Min 3 machines. Mix of SBRT, SRS, brachy, external beam and inpatient consults.

1) covering beam-on time - doc of day vs everyone expected to stay vs. on-call doc
2) inpatient and add ons -
3) checking new starts, SBRTs, SRS
4) expectations for in clinic time vs. office vs. work from home
5) opportunity to design use of APPs to fit optimal care
6) OTV scheduling - separate day, consult day, followup day - mix of all
7) expectation from sim to IMRT start

I'm sure there are a ton of other issues i haven't mentioned... add your own.

Not enough details.

Need to know what are the expectations of the faculty. Academic?

Need to know expected revenue for department and the FTE along with salary expectations for faculty.

 

[Chartreuse Wombat]

Curious to pick your brains about how you would structure a clinical physician/APP workforce in a large practice (say 5 or more physicians) if you were designing from the ground up. Goal to improve QOL for physicians and staff while maximizing quality patient care. Feel free to throw out ideas but i'll provide some starters:
Assume subsite specialization not all generalists. Treatment hours 730-630 ideally (extending either direction PRN). Min 3 machines. Mix of SBRT, SRS, brachy, external beam and inpatient consults.

1) covering beam-on time - doc of day vs everyone expected to stay vs. on-call doc
2) inpatient and add ons -
3) checking new starts, SBRTs, SRS
4) expectations for in clinic time vs. office vs. work from home
5) opportunity to design use of APPs to fit optimal care
6) OTV scheduling - separate day, consult day, followup day - mix of all
7) expectation from sim to IMRT start

I'm sure there are a ton of other issues i haven't mentioned... add your own.

Sorry not more helpful but consider the following.

Assume 120k wRVU for entire practice; depending on contracts this can be $6-9M annual revenue in prof fees.

Is this 8 people doing 15K wRVU annually or 16 people doing 7.5K wRVU or 20 people doing 6K each?

The other variable is where is the $$ coming from to pay APPs?

 

[deleted1111261]

Presuming OP is discussing an academic practice, it doesn’t seem feasible that they’d keep all that money ? Also, if it is academic, where in the scheme is underpaying productive young physicians? I kid .. kinda.

The hours you are listing are horrendous. For docs, for staff, for everyone. That would be modified. 8-4, with allowable 30 min earlier and later when busy, otherwise increase wait times to start or send to other nearby centers.

Evenly distributed doctor of the day, with chair taking as many days as the incoming physicians. My chief at Banner taking more call than the rest of us paid dividends in how I feel about him as a leader. Evenly distributed call and holidays - keep track of holidays and who takes how many. This same guy took every Christmas so we wouldn’t fight about it.

DoD takes inpatients. No whining. And new starts/SBRTs if the actual doc is on admin day or PTO. No whining.

Add-ons - sticky situation. Is there a true non inpatient emergency? If this is truly needed, maybe “back up” DoD does this? But if site specific it’s useless. Let’s come back to this later.

Privilege of 1 day work from home. Accessible by phone/email/messaging. Don’t ask questions about where they are at. Caveat- in emergency situation may need to come in (everyone else has Covid), so can’t be treated like vacation day and be 5 hours away, until morning time. Then, don’t ask questions about location. Be available by phone within 30 minutes, otherwise WFH privileges may be revoked. Don’t be a jerk about it.

Scheduling - let doctor and nurse decide. This frustrates me when someone else decides the template. Let doctor decide all of this, but if they are a disorganized mess and it’s chaos, privilege may be revoked. Preferable for me to have OTV on a specific day and then just populate everything else as the puzzle pieces fit.

Sim to start - idk about separating imrt from 3D. Ask dosi what’s easier - CW + nodes including IMN or 70/28 to prostate? Unless slow clinic, I would have 3 bins - emergency (same day or next), urgent - within 7 days, routine within 14 days. I would have a meeting to discuss what emergency and urgent mean and what goes in that box. Rules are fixed. Senior leaders forbidden from “jumping the line” for social emergency prostate. If you violate this you have to read all of @TheWallnerus posts for an afternoon, even the really meandering ones.

APP - have no idea to use effectively. Inpatients probably and then staff with DoD. 90 day follow ups. Idk. I like my follow ups. Leave this for later.

Comp - flatten it out. The number one cause of resentfulness I see is the extreme salary differences between senior and junior people. This is what drives people batty. First 3 years, slow ramp up. By year 4, everyone has same base. Shared bonus pool. If you have outliers, give them two years and figure out if it’s them or the system. If it is them, part ways. If it is system, fix the problem. Measure productivity with consults, new starts, teaching, etc. Weigh manuscripts and RVUs lower.

That’s a start

 

[pikachu]

“Everyone expected to stay” for required 11 hour days, every day, where all
staff has to be on site for the full treatment day would be a… hard sell at best

 

[kimplera]

appreciate thoughtful comments. As i said - important details lacking - purposefully didn't include residents in here - they clearly matter for an training department and don't matter at all for one without a residency program. I'd argue they make things a bit slower on the clinic side and perhaps (but not always) faster on the planning side (as far as MD time goes).

Agree that those hours are not ideal, but for many academic practices they are a fact of life. If large enough therapists and nurses can do early or late shift (or 4 x10 hr days etc... this is clearly a logistical nightmare.
Don't like the idea of off loading to another practice if busy. as this group certainly knows that will likely be less of an issue in years to come.

We currently do full day DOD coverage which tomorrow means 715 -~6pm. Makes for a long day, but an even longer week when we covered the entire week.

Should DOD have a regular clinic schedule? Right now i try to do DOD on my clinic day (20% FTE) but it can be a cluster if a long view-ray case comes in or a multi-site SBRT patient at the same time as a consult. Our institution shares call and DOD responsibilities equally between all faculty including chair and physician scientists, includes holidays which overall rotate pretty fairly - would not think of arguing against this. Advantage of DOD being OTV day is that you may be staying til end of day anyway and OTVs much more reasonable to have to go check new starts etc...

APP is challenging - $ could come from combination of MD share and own billing. See OTVs? 1 month followup, alternate visits? i currently alternate f/u with ENT so i'm not sure how APP integrates but could perhaps have them do H&P and step in for scope.

like simul's thoughts about WFH - and most importantly - don't be a jerk...

 

[kimplera]

“Everyone expected to stay” for required 11 hour days, every day, where all
staff has to be on site for the full treatment day would be a… hard sell at best

11 hours is child's play - if people don't follow orders it will be 14 h days for all...

 

[Palex80]

Some clinics use intersecting shifts. So, you would have one doctor come in at 7:30 and work until 15:30, while the other one comes in at 10:30 and works until 18:30 (considering 8 hour shifts including 30‘ break).

All serious activity happens 10:30-15:30, the time before/after that the sole doctor babysits the linac.

Is this working model common in the US?

 

[communitydoc13]

11 hours is child's play - if people don't follow orders it will be 14 h days for all...

Opposite of child's play. 11 hours is not playing with child. Add commute, call it a 12 hour day away from home. Factor in kid's real life schedules and this is one absentee parent.

Again, a system set up for either the childless, the professional class that does not raise their own children, or the person whose partner is raising the kid.

A 4 day/week 10 hour/day schedule is acceptable as a flex option and preferable for some. More than that is unnecessary for what we do.

As an aside, I have no expectation that these docs will not work outside of clinic hours from home for 10-20 hours/week. Also an acceptable professional expectation for well paid Doctors.

 

[Neuronix]

Goal to improve QOL for physicians

11 hours is child's play - if people don't follow orders it will be 14 h days for all...

 

[theradiator]

View attachment 356666

the floggings will continue until morale improves

 

[pikachu]

Opposite of child's play. 11 hours is not playing with child. Add commute, call it a 12 hour day away from home. Factor in kid's real life schedules and this is one absentee parent.

Again, a system set up for either the childless, the professional class that does not raise their own children, or the person whose partner is raising the kid.

A 4 day/week 10 hour/day schedule is acceptable as a flex option and preferable for some. More than that is unnecessary for what we do.

As an aside, I have no expectation that these docs will not work outside of clinic hours from home for 10-20 hours/week. Also an acceptable professional expectation for well paid Doctors.

100% this. There’s no earthly reason why 100% of physician staff would have to be on site for 100% of machine operating hours. Most MDs are fine with long hours, but not long pointless hours. A setup like this is a recipe for burned out, frustrated, miserable staff.

 

[Mandelin Rain]

1 doc per day comes early/stays late on rotating basis. This is your OTV day so you can see all your own early/late OTVs and help with inpatient issues, etc....

When scheduling, fill 11AM then 1PM then 10AM then 2PM then 9AM then 8:30AM then 3PM in that order.

Meetings at 8AM or noon. Everyone leaves when their work is done except doc of the day.

 

[deleted1116990]

Privilege of 1 day work from home. Accessible by phone/email/messaging. Don’t ask questions about where they are at. Caveat- in emergency situation may need to come in (everyone else has Covid), so can’t be treated like vacation day and be 5 hours away, until morning time. Then, don’t ask questions about location. Be available by phone within 30 minutes, otherwise WFH privileges may be revoked. Don’t be a jerk about it.

Call it a 4 day workweek. 4 days presence in clinic. The other 3 days of the week is nobody's business but yours.

There's no reason we need to justify WFH or prove to whoever we report to that we are actually doing "work" when not in the office during the week. We are professionals. Either the work gets done or it does not. If we get the work done at 3 AM, why should anyone care if we are at the beach all day Friday and not at home writing papers, studying the literature, or mindlessly scrolling through the EMR to appear to be "working"? Do we really need mom making sure we are doing our homework and not playing video games after school? This idea that our time and physical presence is owned by our boss from 8-5 M-F and find something to do if we have nothing to do is an American anachronism and a result of the bizarre aversion and guilt many type A overachievers (who naturally climbed the academic ladder or went into admin) cannot shake about vacation and time off.

Being "on call" to come in for an emergency is something different, but there is no reason we need that during the week, or even on the weekend in many practices.

Even in a single physician practice, I see no problem with only being on site 4 days a week. I treat 30 at a time and get all my work done in 4 days right now. Sometimes those days are long, but that's my choice. A 2 physician practice with 20 each? Easy. One is off Friday, one is off Monday. MD always on site. If you can't handle 20 in 4 days, something is wrong. Why anyone has a problem with this is beyond me.

 

[RadOncDoc21]

Call it a 4 day workweek. 4 days presence in clinic. The other 3 days of the week is nobody's business but yours.

There's no reason we need to justify WFH or prove to whoever we report to that we are actually doing "work" when not in the office during the week. We are professionals. Either the work gets done or it does not. If we get the work done at 3 AM, why should anyone care if we are at the beach all day Friday and not at home writing papers, studying the literature, or mindlessly scrolling through the EMR to appear to be "working"? Do we really need mom making sure we are doing our homework and not playing video games after school? This idea that our time and physical presence is owned by our boss from 8-5 M-F and find something to do if we have nothing to do is an American anachronism and a result of the bizarre aversion and guilt many type A overachievers (who naturally climbed the academic ladder or went into admin) cannot shake about vacation and time off.

Being "on call" to come in for an emergency is something different, but there is no reason we need that during the week, or even on the weekend in many practices.

Even in a single physician practice, I see no problem with only being on site 4 days a week. I treat 30 at a time and get all my work done in 4 days right now. Sometimes those days are long, but that's my choice. A 2 physician practice with 20 each? Easy. One is off Friday, one is off Monday. MD always on site. If you can't handle 20 in 4 days, something is wrong. Why anyone has a problem with this is beyond me.

You need to go to the Admin’s office and apologize for such blasphemous behavior… you are out of line young man!

 

[Palex80]

Even in a single physician practice, I see no problem with only being on site 4 days a week. I treat 30 at a time and get all my work done in 4 days right now. Sometimes those days are long, but that's my choice. A 2 physician practice with 20 each? Easy. One is off Friday, one is off Monday. MD always on site. If you can't handle 20 in 4 days, something is wrong. Why anyone has a problem with this is beyond me.

I believe this has a lot to do with a) what kind of patients you are treating, b) how you are treating them, c) are you providing any additional services that are time consuming.

a) if 13 ( about 2/3) of those 20 patients are breast and prostate cancer patients getting standard EBRT, then that's easy doable, regardless of how sick and complicated the other 7 patients are.
b) if you do not use hypofractionation a lot, then you are seeing less new patients per year.
20 prostate patients getting 4 weeks of treatment, means one new patient per day to keep that level at 20 patients on beam. 20 prostate patients getting 8 weeks of treatment, means 1 new patient every two weeks.
c) are you doing LDR-/HDR-brachytherapy on top of EBRT, are you inserting fiducials (or even a spacer) on your own, do you have lot's of H&N patients who require endoscopy, ...

 

[Neuronix]

Talked to one admin who said if you don't have enough patients to be busy Monday-Friday you need to spend that extra time schmoozing with other physicians and working on marketing until you do.

 

[pikachu]

100% this. There’s no earthly reason why 100% of physician staff would have to be on site for 100% of machine operating hours. Most MDs are fine with long hours, but not long pointless hours. A setup like this is a recipe for burned out, frustrated, miserable staff.

Just thinking about this theoretical working arrangement stresses me out. Like why would you ever propose this even idk

Internet time over for today

 

[RO28]

11 hours is child's play - if people don't follow orders it will be 14 h days for all...

I'm not sure I want to wade into this can of worms, but are you serious?

Help me understand.

 

[jondunn]

Perhaps you could mention what are your major issues with the current setup - if you could change something what would it be?


cool that your chair does DOD duties

 

[elementaryschooleconomics]

I'm not sure I want to wade into this can of worms, but are you serious?

Help me understand.

11 hours/day, 5 days/week, base salary $275k for RVU target 9,000/year with "generous" RVU bonus incentive, $35/RVU over 9,000, bonus capped at 50% base salary ($412k max).

How close am I?

 

[kimplera]

I'm not sure I want to wade into this can of worms, but are you serious?

Help me understand.

totally not serious about this. forgot the sarcasm font.

also want to be clear this is not the current approach at my institution. No-one cares when i come and go except my DOD days and that i am see my OTVs and clinic visits. The rest is up to me to manage like an adult/professional

 

[kimplera]

Perhaps you could mention what are your major issues with the current setup - if you could change something what would it be?


cool that your chair does DOD duties

I have nothing to complain about current setup, good time for our dept to think about how we could do things differently with program evolution. switched to DOD a couple years ago (and people are generally really pleased with it) so long as we have sufficient notice to adjust schedules (i.e. can't do parent/teacher conf at noon on DOD day unless you find someone to cover, which is usually easy to do)

 

[kimplera]

Just thinking about this theoretical working arrangement stresses me out. Like why would you ever propose this even idk

Internet time over for today

proposed as an absurd boundary to frame the discussion - not meant as a realistic solution

 

[deleted1116990]

Talked to one admin who said if you don't have enough patients to be busy Monday-Friday you need to spend that extra time schmoozing with other physicians and working on marketing until you do.

This is basically every academic practice. To some extent, you will be a medical student forever if you remain in the system. It's a bizarre mix of refusing to let go of antiquated academic traditions yet at the same time forcing ultra progressive nonsense from the university (with the one glaring exception of progressive ideas about work life balance and PTO as is common in Europe). And people voluntarily want to be a part of this? Especially to be 100% clinical "faculty."

 

[Neuronix]

This is basically every academic practice. To some extent, you will be a medical student forever if you remain in the system. It's a bizarre mix of refusing to let go of antiquated academic traditions yet at the same time forcing ultra progressive nonsense from the university (with the one glaring exception of progressive ideas about work life balance and PTO as is common in Europe). And people voluntarily want to be a part of this? Especially to be 100% clinical "faculty."

I've spent my career in academics and never had someone tell me to go drum up business. Sure they have an RVU target for you, but get out there and drum up more patients above and beyond RVU target has never come up. It's pretty rare to have salary cut or be fired over RVU target misses as well.

There are plenty of other issues in academics, don't get me wrong. But if you're not that ambitious to make a lot of money or move up the academic food chain there are plenty of people with fairly cush lifestyles within academics out there.

 

[deleted1116990]

I've spent my career in academics and never had someone tell me to go drum up business. Sure they have an RVU target for you, but get out there and drum up more patients above and beyond RVU target has never come up. It's pretty rare to have salary cut or be fired over RVU target misses as well.

There are plenty of other issues in academics, don't get me wrong. But if you're not that ambitious to make a lot of money or move up the academic food chain there are plenty of people with fairly cush lifestyles within academics out there.

Sorry, what I meant was the concept that you have to be appear to be productive 8-5 M-F the same way med students were expected to sit around with nothing to do for hours at a time on 3rd year rotations as the "can I leave" question would tank your grade. Yeah, networking in the community definitely sounds like something cooked up by admin for a hospital-employed doctor as that would mean being out of the clinic. My old job made me do things like this (I actually was able to get a PCP in town to send me some benign and skin stuff, not that I was rewarded for that at all)

Faculty where I trained were told that they were expected to use their "nights and weekends" to be academically productive if their clinic schedules were too busy. Getting all your work done and leaving early or not coming in on Friday was not a thing in any academic practice I have ever heard of.

 

[RO28]

totally not serious about this. forgot the sarcasm font.

also want to be clear this is not the current approach at my institution. No-one cares when i come and go except my DOD days and that i am see my OTVs and clinic visits. The rest is up to me to manage like an adult/professional

ok thanks! sometimes on here you never know.

 

[IonsAreOurFuture]

Regarding NP or PA midlevels, I have them see my breast and prostate followups.

95% of the time these patients are doing well and the management is very formulaic. If the PSA is rising significantly or there's a new finding on mammogram they let me know. For a disease with 95% cure rate, and 10 follow-up visits over 5 years per patient, you'd have to see about 200 followup visits to catch one recurrence.

For diseases with higher relapse rate or more difficult examinations (H&N, GI, CNS, Lung, GYN) and mets, I see those personally.

 

[evilbooyaa]

Curious to pick your brains about how you would structure a clinical physician/APP workforce in a large practice (say 5 or more physicians) if you were designing from the ground up. Goal to improve QOL for physicians and staff while maximizing quality patient care. Feel free to throw out ideas but i'll provide some starters:
Assume subsite specialization not all generalists. Treatment hours 730-630 ideally (extending either direction PRN). Min 3 machines. Mix of SBRT, SRS, brachy, external beam and inpatient consults.

1) covering beam-on time - doc of day vs everyone expected to stay vs. on-call doc
2) inpatient and add ons -
3) checking new starts, SBRTs, SRS
4) expectations for in clinic time vs. office vs. work from home
5) opportunity to design use of APPs to fit optimal care
6) OTV scheduling - separate day, consult day, followup day - mix of all
7) expectation from sim to IMRT start

I'm sure there are a ton of other issues i haven't mentioned... add your own.

1) Doc of day split evenly across physicians. Up to you whether you do full day shift (5 shifts per week) or half day shift (10 shifts per week). Pros and cons to both, depends on # of attendings in department and expected amount of coverage.
2) Inpatient goes to Doc of day first. This means Doc of day should ideally not have a fully packed clinic to allow flexibility for urgent palliative inpatients. Any inpatient requiring definitive sub-specialty specific or non-urgent can lead to direct doc-to-doc discussion of whether somebody else can and will accomodate seeing patient.
Add on outpatient consults are up to each physician including doc of day. If doc of day can't see an 'urgent' outpatient, he/she can't see them. If another physician (not doc of the day) wants to see an add on consult, that is their prerogative. Again, the importance of flexibility if 'add-on' consult to no specific physician is regularly necessary.
3) Doc of day covers all imaging needs as first call if main attending is known to be not available, or if main attending does not respond to the text or show-up within 5 minutes.
4) Be in clinic during doc of day time. See scheduled patients without making the 8am scheduled patient wait until 9. Besides that, no other obligations for in clinic or in office time.
5) APPs can be helpful on an inpatient service to assist with coordination of care, seeing 'easier' OTVs in a resident-style role to help out Doc of day, or seeing prostate/breast follow-ups.
6) OTVs ideally on doc of day. If busy, given doc of day responsibilities, no other consults. If slow (< 10?) can have a consult or two as well as tolerated by doc of day.
7) 2-3 days from completion of physician contours to start of RT. If patient is scheduled to start a non-urgent IMRT on Monday and physician doesn't complete contours until the Friday morning before, patient is automatically delayed. Urgent IMRT has a differently timed workflow that is tracked by a lead from dosimetry or physics and monitored to avoid abuse by the physician staff.

Main thing is to keep things as equal as possible. If a small department then yes, chair should be helping equally. If larger then having chair be the 'covering' when somebody is out may be useful. Having a chair that does zero doc of day responsibilities, I presume, breeds resentment, especially for any chair who is in clinic 2-3 days a week or more. If the chair is mostly research/dangerous to be allowed to clinically practice and thus only has one half day in clinic, then yeah, don't bother having them be doc of the day...

Makes me think... boomer academic chairs can be just as good (or bad) as clinical radiation oncology as the permalocums boomers in the midwest... and the respect level is so interestingly different.

I think bonus should be tied in part to RVUs but also # of new starts, including if patients are seen at the mothership but then farmed out to a community site (basically keeping reimbursement within the system should be rewarded, not as an expectation for free) as part of the bonus pool, to avoid physicians 'holding onto' sub-specialty patients who could get similar treatment closer to home.

Great question, OP. Glad to hear the 11 hour work-day x 5 days for all physicians was sarcasm. I'd definitely quit my job if that was required as part of my contract.

 

[deleted1116990]

This is all assuming ideal workflow for a multi-physician practice in a single site.
How do most people feel about the workflow if the practice has multiple sites? Say, 4 physicians in a practice with 2 sites. Is there anyone who sees a benefit to having all physicians split time equally between sites? Having patients under treatment at multiple sites sucks IMO. I have yet to hear a good explanation why it is preferable, but I know some people actually want their practice to be like this.

 

[evilbooyaa]

This is all assuming ideal workflow for a multi-physician practice in a single site.
How do most people feel about the workflow if the practice has multiple sites? Say, 4 physicians in a practice with 2 sites. Is there anyone who sees a benefit to having all physicians split time equally between sites? Having patients under treatment at multiple sites sucks IMO. I have yet to hear a good explanation why it is preferable, but I know some people actually want their practice to be like this.

Sure - multiple sites requires a different workflow.

In your theoretical scenario, are you suggesting an equal distribution of 2 physicians at one site, 2 physicians at another site, like two equal centers? Or more like a main hub + a regional site, like 3 physicians at one site, 1 one physician at another site?

 

[deleted1116990]

Sure - multiple sites requires a different workflow.

In your theoretical scenario, are you suggesting an equal distribution of 2 physicians at one site, 2 physicians at another site, like two equal centers? Or more like a main hub + a regional site, like 3 physicians at one site, 1 one physician at another site?

Suppose you have an equal number of patients at each site all in the same city. Not a main site with 100 on treat and a small clinic 60 miles away treating 10. In the latter situation, maybe it makes sense to have someone go out there 2-3 days a week, as I've seen this done multiple places.

 

[evilbooyaa]

Suppose you have an equal number of patients at each site all in the same city. Not a main site with 100 on treat and a small clinic 60 miles away treating 10. In the latter situation, maybe it makes sense to have someone go out there 2-3 days a week, as I've seen this done multiple places.

OK. Say you have 4 physicians, A, B, C, and D. 2 clinics, 1 and 2. Let's assume that the goal is to have an on-site physician who can reliably see consults and create treatment plans without significant fragmentation of care.

One option is that physicians A and B staff clinic 1 fully (however you want to split it is fine), physicians C and D staff clinic 2 fully. This means if physician A or B take vacation, the other one ideally should not. Physician C and D know the staff very well at clinic 2 but won't know the staff as well at clinic 1 since they never see them. Reverse is also true.

Now, let's say physician A is full time at clinic 1, D is full time at clinic 2, and B and C do 50/50 split at both sites. Each site now knows 3 physicians well. Now any 2 of the 4 physicians can take vacation simultaneously without it affecting workflow since 3 of the physicians know the workflow at each of the two sites.

There can certainly be some downsides to this model as I'm sure you'll tell me - for example, a patient can't see his/her physician on a non-OTV day for an urgent issue as otherwise could. But I do think the flexibility of vacation coverage is of some value here. At my institution, if somebody is covering a site they do not usually go to, that usually means they just babysit the machines for the day (if feasible based on consult requests). Because you won't have continuity of care of the person doing a consult on a covering day then doing the sim, planning etc. Some things are easily transferrable or can be done with physician-to-physician communication, but IMO ideal to minimize that as possible. I don't think this is the right answer for 100% of practices, but something to consider.

 

[Mandelin Rain]

A split practice is less efficient for everyone; docs, staff, and patients. Would try to minimize as possible.

 

[evilbooyaa]

A split practice is less efficient for everyone; docs, staff, and patients. Would try to minimize as possible.

Why do you say that?

 

[Neuronix]

Why do you say that?

I used to cover 3-4 sites a week. It's a jumbled mess trying to deal with a schedule that's all over the place and often triple booked to get it all in (OTVs, consults, follow-ups, sim/new starts/stereos, inpatient consults), procedure scheduling, patients calling who need things when you're not there... Much more efficiency and quality of life if at 1 facility. Can set up a team and schedule the way you want and any issues you're always there except vacation.

I still cover 2 facilities that are close to each other and it can be quite frustrating at times. Staff at the minority site don't know me well or my preferences, patients asking for things when I'm elsewhere, complicated machine issues that are easier if I'm present, etc...

 

[deleted1111261]

Agree with 1 site being remarkably easier to manage.

30 at one center easier than 20-25 at two centers.

 

[evilbooyaa]

I used to cover 3-4 sites a week. It's a jumbled mess trying to deal with a schedule that's all over the place and often triple booked to get it all in (OTVs, consults, follow-ups, sim/new starts/stereos, inpatient consults), procedure scheduling, patients calling who need things when you're not there... Much more efficiency and quality of life if at 1 facility. Can set up a team and schedule the way you want and any issues you're always there except vacation.

I still cover 2 facilities that are close to each other and it can be quite frustrating at times. Staff at the minority site don't know me well or my preferences, patients asking for things when I'm elsewhere, complicated machine issues that are easier if I'm present, etc...

Something between 1 and 3. 3 or 4 on a weekly basis... yeah I agree. I would want at least 2 days if there was any serious volume at each site.

I don't disagree that 1 may be best looking at just efficiency and physician happiness. I'm just trying to play devil's advocate from a systems standpoint of making sure a place doesn't completely collapse if one physician goes on vacation, or ends up on maternity leave, out on medical leave, etc. etc. If you are the only doc who staffs one location it will basically be perma locums (even if in house) from the covering attendings during any of the above leaves of absence.

Depends on the volume, I suppose. Same EMR across institutions allowing messages to be sent about place 1 patients when at place 2.