Consults- Memorable/Dismal/Ridiculous/Unique

[notinkansas]

The only thing I want to hear from a consult anymore is: Name, Medical Record Number, patient's bed, reason for consult. Faster to figure it out from there than to talk/argue.

Amen to that. Even though I'm phasing out of surgery, I'm in a moonlighting type job that still requires me to see consults sometimes, mostly vascular. Most common goes something like this: one foot slightly cooler than the other, the medical person can't feel pulses, claims s/he can't doppler pulses (or simply says, "I don't do that, don't know how". I can usually get a signal and write a note that ends "no need for vascular surgery intervention"

My most memorable consult in residency: As PGY 2, I was called to MICU. Pt was declining hemodynamically, with something like 50 bands on WBC. She had a pretty big ventral hernia. The MICU had done a CT scan 3 days prior, and the report said "hernia contains colon, not incarcerated". WTF? I thought, "since when is incarceration a radiologic diagnosis??" I examined the pt and the hernia was non reducable. The medical team had rounded on the pt for the past two days, writing, "non reducable hernia, not incarcerated per radiology report" Somebody wasn't paying attention during their surgery rotation!

Upon opening, we were able to treat the medical student on our rotation to the smell of dead bowel, as a very black transverse colon was the first thing visible in the hernia. Pt died a couple days later.

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[filter07]

What did the MICU think was wrong with the patient? Scary to think attendings rounded on this patient for several days and signed off on notes saying "non reducible not incarcerated per radiology".

 

[JackADeli]

...there is not a lot of EBM for routine CXR...

Apologies, what is EBM?

 

[Winged Scapula]

Apologies, what is EBM?

EBM = evidence based medicine

 

[JackADeli]

EBM = evidence based medicine

Ok, I agree cxr is a waste in almost all situations.

Unfortunately, attornies do not always go by EBM and juries can see what is in the book and will not appreciate the lack of articles. They often will say, you did a consult and an operation and the cxr was part of the data. I don't necessarily agree, but....

The other issue is that maybe the chest xray was done after the consult. If the patient was emergent abd OR, then to ICU, in theory I see a chest film as part of the routine post-op. So, fortunate again. However, if admit, OR, post-op, sign-off and then chest xray.... OK. But, a post abdominal surgery patient, critical care post-op, regardless whose service they are on, chest film can be easily deemed part of surgeon (consulting or primary service) responsibility too.

 

[glade]

Actually, what you are describing is not a gatekeeper but a "vault" keeper. It is well known in the community that this practice is a method by which the hospitalist directs funds to their friends. Their friends.... I am certain are NOT upset by this practice cause they make bank every time they round... or used to. Non-procedural specialists make (or used to) their wealth off of these 3 page initial consults followed by daily rounding. I don't know how the new consult code issue will effect the medical folks and this corrupt practice of milking the healthcare system.

Whatever the case, the practice you describe is not the result of poor medical knowledge. It is actually deliberate means to suck large sums from the other party payers. If you got roped into the chain of love, just drop your note and move on...

I agree that it's a method of maximizing drainage of money from "the system." However, I disagree that it's not reflective of poor medical knowledge. A lot of these "vault keepers," as you call them, aren't that bright. If you talk to them, it's not like they're walking around with vast amounts of knowledge that they keep to themselves. The system facilitates their lack of knowledge, by encouraging consultation. It's sort of a symbiotic relationship. I firmly believe that if tomorrow you said "guess what, you're no longer allowed to consult anyone for anything," it would cause most of them to run around screaming in terror before they jumped out of the nearest window.

 

[JackADeli]

...However, I disagree that it's not reflective of poor medical knowledge. A lot of these "vault keepers," as you call them, aren't that bright...

I am not going to debate the intelligence of the primary medical attendings, etc... You have experience in your community in which you believe they consult out of lesser intellect... great. You believe an internest consults endocrine for management of well controlled diabetes or pulmonologist for mild copd because they aren't very bright...great. I'm just not going to steer this conversation onto a path of sparring.

 

[glade]

...except that you just did, only in a passive-aggressive way.

 

[JackADeli]

...except that you just did, only in a passive-aggressive way.

whatever.

 

[goooooober]

You two should get married, you have a lot of chemistry.

 

[glade]

Neat, I'd be the man and he'd be the battered wife.

 

[VincentAdultman]

This is just a general observation of my residency program, not a specific consult.

At my program, you order consults in the computer/on paper just like you order a bolus or a UA. This means that when I get a consult it comes from a clerk with no medical training whatsoever who just reads off whatever the order says i.e. "knee pain." Of course they have no idea who the patient is or whether or not patient recieved x rays. And of course the lack of physician-physician interaction in this system reduces accountabilty and drives up BS consults.

Awesome.

I'm trying to just get in the habit of getting name, MRN, room, and cheif complaint and go from there, but damn it's frustrating.

 

[Pir8DeacDoc]

This is just a general observation of my residency program, not a specific consult.

At my program, you order consults in the computer/on paper just like you order a bolus or a UA. This means that when I get a consult it comes from a clerk with no medical training whatsoever who just reads off whatever the order says i.e. "knee pain."

The Pedi service where I am has the pedi floor desk clerk call us for consults. That's weak sauce. If you want something from another physician then you should call them directly and discuss it. It maximizes my ability as a consultant if you tell me what question you want help with. We've all read consult notes that don't really answer the burning question we had -that's on the primary team for not talking over with the consultant what they want answered.

 

[glade]

Getting called for consults by clerks is standard, but only because you're a resident. A lot of times, it would be like I go and see the patient and the attending already knew about it because the attending placing the consult felt fit to call him (but not me). Which was fine with me, I did my best with no information or insight as to what their concern was, which is usually fine because a lot of primaries don't know what is relevant or not to me. But in the few instances where I completely missed their concern, it didn't bother me in the slightest. That's not my prob.

 

[VincentAdultman]

Getting called for consults by clerks is standard, but only because you're a resident. A lot of times, it would be like I go and see the patient and the attending already knew about it because the attending placing the consult felt fit to call him (but not me). Which was fine with me, I did my best with no information or insight as to what their concern was, which is usually fine because a lot of primaries don't know what is relevant or not to me. But in the few instances where I completely missed their concern, it didn't bother me in the slightest. That's not my prob.

Well this wasn't standard at my medical school or where I did my internship, so I'm not sure my being a resident has anythiong to do with it. And seldom do the attendings communicate with each other about consults. In fact I can see a consult, make recs, and have that patient e d/c'd without the attending even knowing about it (especially if the consult was BS).

 

[Winged Scapula]

I wouldn't assume the ward clerk communique has anything to do with residency.

I can tell you that every single hospital I have privileges at the ward clerk is doing the calling on consults; rarely do the admitting physicians call me directly. Last week I got a consult for chest wall pain status post mastectomy (not a post-op patient of mine); yes...she had pain, probably from neurovascular invasion but they wanted me to evaluate the skin lesions on her chest wall when I called to say, "I ain't pain management".

I agree its lame, but with the era of EHR, its even easier to put a consult in..click, click, sign, save.

 

[SocialistMD]

I wouldn't assume the ward clerk communique has anything to do with residency.

Actually, I had never heard of the unit clerk or patient nurse calling consults for physicians until I entered the private practice world. At my medical school and my current location, residents are expected to make all consultation calls personally.

 

[smq123]

Actually, I had never heard of the unit clerk or patient nurse calling consults for physicians until I entered the private practice world. At my medical school and my current location, residents are expected to make all consultation calls personally.

At my hospital, unit clerks call in the consults, too. Actually, if there are several private practice groups for that particular specialty, and you don't specify who you want, the unit clerk will pick who you'll be consulting - generally, the group that has the "nicest" physicians (i.e. the group least likely to snap at you over the phone when you call them).

 

[glade]

I take it nobody is in private practice, or else they'd be quite upset that a unit clerk was determining who was getting business.

 

[JackADeli]

At my hospital, unit clerks call in the consults, too. Actually, if there are several private practice groups for that particular specialty, and you don't specify who you want, the unit clerk will pick who you'll be consulting - generally, the group that has the "nicest" physicians (i.e. the group least likely to snap at you over the phone when you call them).

Unfortunately, unit clerks and nurse calling of consults is all too common in communities. Most hospitals have developed bylaws specifying physician to physician consulting but community tradition has left these old clerical consulting still in place. There have been a few major lawsuits over the last 10 yrs specifically about this. The consultant was being sued for failure to consult in a timely manner or something. He/she was eventually removed from suit. Apparently it was clerk call consult situation. The hospital bylaws said needed to be physician to physician. The requesting physician ate the suit cause he/she stated never spoke to consultant and just wrote and order.... never even explained to clerk (not sure would help). Consultant's response, never got a call in accordance with hospital policy!

The other important point is the "nice" consultant. That goes very, very far in garnering business. Nice to requestor be it clerks and/or physicians. A clerk calls you for consult, be polite and make sure you call the requesting physician directly to discuss your findings.....

 

[Winged Scapula]

Actually, I had never heard of the unit clerk or patient nurse calling consults for physicians until I entered the private practice world. At my medical school and my current location, residents are expected to make all consultation calls personally.

I too had never heard of it, or only to make disparaging comments, as it wasn't allowed in our residency. Now out in practice...

Unfortunately, unit clerks and nurse calling of consults is all too common in communities. Most hospitals have developed bylaws specifying physician to physician consulting but community tradition has left these old clerical consulting still in place. There have been a few major lawsuits over the last 10 yrs specifically about this. The consultant was being sued for failure to consult in a timely manner or something. He/she was eventually removed from suit. Apparently it was clerk call consult situation. The hospital bylaws said needed to be physician to physician. The requesting physician ate the suit cause he/she stated never spoke to consultant and just wrote and order.... never even explained to clerk (not sure would help). Consultant's response, never got a call in accordance with hospital policy!

You are correct; many hospitals do have such policies but they seem to be ignored. Just two weeks ago I apparently was consulted. Ward clerk claims they called my office; no one in the office will "fess up" to receiving consult. Its quite possible that when a ward clerk calls, my office doesn't understand what a consult means or the significance of it is (not that that is an excuse, but they know if a physician calls for me that they are to give them my cell #). Hospital has some sort of follow-up policy that if consults aren't seen within 24 hours of call (hospital policy) that another call is made. Of course by the time I received that call, I'd been at that particular hospital 3 times since the reported first call (as I was operating all day, came back to round x 2). Long story short, this was the patient that I was reportedly being consulted on for "pain" - which was NOT the reason the oncologist wanted me to see the patient.

I think having the ward clerk call consults is bad practice for all the reasons above - they don't know the real reason, how urgent the consult is, etc. but the practice (which I wasn't aware of) has led me to educate my front office on what a consult is and how important it is (if only so I don't have to drive back - 30 min each way - to that Fing hospital on a Sunday, when I'd been there 3 times already and could have seen the consult).

/rant

 

[glade]

...came back to round x 2

That means she left her purse in a patient's room, just so everyone is clear.

 

[AbbyNormal]

Is it not common for attendings to have their own private nurses or PAs where y'all practice? Most of the cardiologists and CV surgeons where I work have nurses that we can call unless it is an emergent situation. There are times I need to update a doctor regardless whether he is in cath lab or surgery but often his nurse can take the information and inform him when his attention does not need to focus on his immediate patient.

 

[glade]

Physicians only have PAs if they want to hire one. It's physician choice, based on a cost analysis. A lot of independent physicians couldn't justify it. Cardiology usually consists of large groups and CV surgeons are in the OR for prolonged periods, so I could see that being more the norm in those fields.

 

[JackADeli]

...Most hospitals have developed bylaws specifying physician to physician consulting but community tradition has left these old clerical consulting still in place...

...You are correct; many hospitals do have such policies but they seem to be ignored. ...my office ...know if a physician calls for me that they are to give them my cell # ...

Is it not common for attendings to have their own private nurses or PAs ...I work have nurses that we can call unless it is an emergent situation. There are times I need to update a doctor regardless...

Couple of things....

yep, most hospitals have bylaws on this thing. They can actually help the consultant in a legal suit if the requesting physician has a practice of ignoring these bylaws. Hopefully you don't need to get out of a legal suit in this fashion and thus trying to impose adherence to the bylaws can make referring physicians a little miffed and not consult you. But, requesting physician makes the trade off of convenience over "legal safety".

I am definately surprised at the fact that most residencies I know have a physician to physician call practice. Yet folks get into the community and think it is so wonderful and/or convenient to write/enter and order and then just forget about it. It just isn't great for multidiscipline care of patients and/or interactions between pros.

WS makes a good point. The trend to pseudo-overcome the ignoring of physician to physician requirements is to get you requesting physicians to use your cell line. It is good practice and good business to be on speed dial with you referral base.

The other thing is that even if I am scrubbed when consult request arrives, I can then delegate it as necessary to mid-level to investigate and start the ball rolling. It then saves me time between cases and I might add a patient on for a procedure before 5pm. Going through clerks and secretaries adds levels of confusion and balls are dropped. With communication tech so advanced, cell phones so small, texting being possible, your cell phone can be the "white house hotline" or the "bat phone" for consults which = pipeline for money.

 

[Winged Scapula]

As glade notes, it is not common for general surgeons to have mid-levels especially in PP. I was speaking to a friend recently who turned down a job here in town with a PP group because they "did it all themselves". She was coming from academics and didn't understand the way most PP GS groups, especially smaller ones work.

I see midlevels mostly in Ortho, Urology, and non-surgical specialties.

One reason is size of group, another is reimbursement.

A large group can subsidize the cost of a mid-level; with fresh grads earning between 70 and 90K per year (locally, YMMV), its a tough cost to swallow.

It makes sense for an Orthopod to have a PA who accompanies them to the OR; the reimbursement for those assists is high, and comes right back to the group. The reimbursement for GS cases (those that allow) an assist is pretty low; the mid-level can often be of more use by being in the office, IF they can afford one in the first place.

 

[Winged Scapula]

WS makes a good point. The trend to pseudo-overcome the ignoring of physician to physician requirements is to get you requesting physicians to use your cell line. It is good practice and good business to be on speed dial with you referral base.... Going through clerks and secretaries adds levels of confusion and balls are dropped. With communication tech so advanced, cell phones so small, texting being possible, your cell phone can be the "white house hotline" or the "bat phone" for consults which = pipeline for money.

Absolutely.

When I market myself or speak to good referring physicians, I always give them my cell and email. I give their referral coordinator our back line number as well.

I have never had someone abuse it, and I find that they really appreciate being able to get ahold of me after hours or without going through the office "press 1 for X, press 2 for Y, etc." ridiculousness.

 

[glade]

I also help her out by writing her number on bathroom stalls.

 

[smq123]

Absolutely.

When I market myself or speak to good referring physicians, I always give them my cell and email. I give their referral coordinator our back line number as well.

I have never had someone abuse it, and I find that they really appreciate being able to get ahold of me after hours or without going through the office "press 1 for X, press 2 for Y, etc." ridiculousness.

As one of those "referring physicians," I loooove when they tell us how to get ahold of the physician directly. It is so frustrating when you have a fairly urgent issue with one of the patients that they're seeing, and the office staff puts you on hold for FORTY-FIVE minutes.

 

[45408]

As glade notes, it is not common for general surgeons to have mid-levels especially in PP. I was speaking to a friend recently who turned down a job here in town with a PP group because they "did it all themselves". She was coming from academics and didn't understand the way most PP GS groups, especially smaller ones work.

What's a large group to you? The GS rotation I did (that convinced me I wanted to be a surgeon) was with a PP group with 6 very active guys (and 2 more, but more "emeritus" status), and they had two PAs in the hospital all of the time and one RN in their office all of the time.

 

[glade]

There's no set rule. It really is based on your need for a PA, so that would depend on how busy you are. If you have a practice of ten surgeons, that's huge. But if the group isn't very busy and/or the members can cover each other (e.g., let's say four of them were just covering the office and hospitals certain days), they still wouldn't need a PA. The PA is used as a second hand when you're tied up in the OR or at another hospital. That's why it's all based on a cost analysis.

As a side-note, I'd say that a group of four surgeons is getting pretty large, considering even one busy surgeon can do a large volume of cases. But it all depends on how active each is. Definitely six surgeons would likely need a PA, unless they allocated their office time appropriately.

By the way, if I put my hand cursor in the middle of your avatar, it looks like you have a nose.

 

[Winged Scapula]

What's a large group to you? The GS rotation I did (that convinced me I wanted to be a surgeon) was with a PP group with 6 very active guys (and 2 more, but more "emeritus" status), and they had two PAs in the hospital all of the time and one RN in their office all of the time.

There's no set rule. It really is based on your need for a PA, so that would depend on how busy you are. If you have a practice of ten surgeons, that's huge. But if the group isn't very busy and/or the members can cover each other (e.g., let's say four of them were just covering the office and hospitals certain days), they still wouldn't need a PA. The PA is used as a second hand when you're tied up in the OR or at another hospital. That's why it's all based on a cost analysis.

As a side-note, I'd say that a group of four surgeons is getting pretty large, considering even one busy surgeon can do a large volume of cases. But it all depends on how active each is. Definitely six surgeons would likely need a PA, unless they allocated their office time appropriately.

I agree with glade. A surgical group of 4 or more surgeons is getting on the larger side and can have the resources to afford a mid-level. Even here, in a large city, many surgical groups are 3 or fewer surgeons. The "super groups" will often have 1 person who is MIS trained, another CRS, and so on - they clearly have PAs, RNs or NPs on staff.

That being said, my partner has a PA but she is entirely responsible for her salary, as I am able to get my work done without one so am not willing to split the costs. So you have to evaluate the cost-benefit analysis; if a midlevel allows you to spend more time with your family, less time answering calls during the day, less paperwork, then perhaps its worth the cost.

 

[SLUser11]

I agree with glade. A surgical group of 4 or more surgeons is getting on the larger side.....

Well, I think I can beat that.....there's about 40 in that group....

I've been told that they are the largest free-standing surgical group in the nation....lovingly referred to by us as "The Firm." However, I shouldn't say more, so as to not be found drowned in the bathtub....

All jokes aside, some of our best bosses, including our PD and chairman, are from that group. The overhead is likely very high, but they have some serious bargaining power with the insurance companies, and an entire army of coders.

 

[JackADeli]

...A surgical group of 4 or more surgeons is getting on the larger side and can have the resources to afford a mid-level...

Yeh, generally got to agree. But, I think part of it really depends on your scope of practice. I suspect breast surgery is a somewhat refined niche. Things may have changed with new billing codes and such.... but this is what I found over the previous 4-5 years.

GSurgeons that do broad care and emergency care such as perforated viscous would use PAs even in groups under 4 in size. Their PAs were able to pretty much cover (or markedly subsidize) their costs with consults, central lines, arterial lines, and other such procedural things including OR assisting. Also, some of these practices would routinely use the mid-levels as "first-call" during parts of the week. Now, obviously, if your practice does not involve much need for minor procedural work appropriate for mid-levels, you may be limited. I suspect for WS it is a really, really bad day when her patient needs an arterial line

 

[Winged Scapula]

Yeh, generally got to agree. But, I think part of it really depends on your scope of practice. I suspect breast surgery is a somewhat refined niche. Things may have changed with new billing codes and such.... but this is what I found over the previous 4-5 years.

It IS a refined niche (which is why I am always amazed when our billing company can't get the oh, 10 codes we use right). At any rate, I was referring to local groups I know that are smaller than 4 straight up general surgeons who don't use midlevels. I see it much more in Ortho and Uro in these parts and I suspect it has to do with reimbursements being generally higher in those fields.

GSurgeons that do broad care and emergency care such as perforated viscous would use PAs even in groups under 4 in size. Their PAs were able to pretty much cover (or markedly subsidize) their costs with consults, central lines, arterial lines, and other such procedural things including OR assisting. Also, some of these practices would routinely use the mid-levels as "first-call" during parts of the week. Now, obviously, if your practice does not involve much need for minor procedural work appropriate for mid-levels, you may be limited. I suspect for WS it is a really, really bad day when her patient needs an arterial line

True, although some sick patients still get breast cancer - so even I still round in monitored units post-op and some even get art lines intra-op. At least that's what I think that plasticy tube thing is in their wrist!

 

[Winged Scapula]

Well, I think I can beat that.....there's about 40 in that group....

I've been told that they are the largest free-standing surgical group in the nation....lovingly referred to by us as "The Firm." However, I shouldn't say more, so as to not be found drowned in the bathtub....

All jokes aside, some of our best bosses, including our PD and chairman, are from that group. The overhead is likely very high, but they have some serious bargaining power with the insurance companies, and an entire army of coders.

We've got a new MSG out here that some of the smaller surgical groups are considering joining. As you note, the larger groups tend to have bargaining power, although the buy-in is not cheap.

 

[core0]

I agree with glade. A surgical group of 4 or more surgeons is getting on the larger side and can have the resources to afford a mid-level. Even here, in a large city, many surgical groups are 3 or fewer surgeons. The "super groups" will often have 1 person who is MIS trained, another CRS, and so on - they clearly have PAs, RNs or NPs on staff.

That being said, my partner has a PA but she is entirely responsible for her salary, as I am able to get my work done without one so am not willing to split the costs. So you have to evaluate the cost-benefit analysis; if a midlevel allows you to spend more time with your family, less time answering calls during the day, less paperwork, then perhaps its worth the cost.

You are right to some extent. Less than 5% of general surgery PAs work in solo practices while more than 10% of ortho PAs for example work in solo practices. The majority of PAs in both general surgery and orthopedics work in either group practices of some type. Bariatrics is also a huge area for surgical PAs right now.

From a reimbursement standpoint there are three ways that surgical PAs bring in income for a practice.
1. First assist fees
2. Office procedures
3. Physician additional downstream revenue.

In orthopedics, these are about equal. Ortho provides lots of in office procedures as well as many surgeries that reimburse for first assist. The downstream revenue is a bit more difficult to quantify but it essentially is productivity by the physician allowed by shifting poorly reimbursed items to the PA. For example if the PA sees followups that are not reimbursed because of the global period this frees up the physician to see more new consults. Consults not only produce the consult fee, but also more procedures and surgeries.

In breast first you have the problem that many surgeries such as lumpectomies do not reimburse for first assist. You also probably don't have many in office procedures to pawn off on the PA. Finally depending on how busy you are you may not have enough business to generate downstream revenue.

You also touch on the reasons for hiring a PA.
1. You are too busy for one provider. You have to be careful here. In surgery you will still have to have a surgeon on call no matter what so if you are really busy with surgery then it may be better to add another surgery. On the other hand if you are backed up with follow ups and can't see new consults then a PA will allow you to see more consults and do more surgery without splitting the number of procedures with another surgeon.

2. You are getting things done but with a significant social cost - ie you are getting home every night at 9pm. In this case unlike the first you are not counting on full reimbursement to offset the cost of the PA. You are essentially paying money to enhance your lifestyle.

3. The third reason if for patient safety. This is most common in academic settings. There are too many patients for the current team to handle but there won't be any more income by adding another provider.

Most cases are some combination of these. Of course in big groups with PAs you also get into issues with "sharing" the PA. YMMV.

David Carpenter, PA-C

 

[Winged Scapula]

In breast first you have the problem that many surgeries such as lumpectomies do not reimburse for first assist. You also probably don't have many in office procedures to pawn off on the PA. Finally depending on how busy you are you may not have enough business to generate downstream revenue.

Whhile you are correct that there are very few operative procedures for which a first assist will be reimbursed, we do a significant amount of in office procedures. As a matter of fact, the bulk of my income comes from in office biopsies, placement of brachytherapy catheters and sonographic examinations along with consults. Additionally, breast has a lot of repeat business so the potential for downstream revenue does exist. There is no global period for in office biopsies and stereotactic biopsies, so they are all coming back for repeat examinations and potentially surgery (for positive or high risk lesions on biopsy). But I am not willing to "pawn off" these in office procedures to a midlevel when the potential for error and litigation is so high. Few surgeons are trained in image guided biopsy; I'd venture even fewer midlevels are. Miss a 3 mm cancer and the liability is high.

You also touch on the reasons for hiring a PA.
1. You are too busy for one provider. You have to be careful here. In surgery you will still have to have a surgeon on call no matter what so if you are really busy with surgery then it may be better to add another surgery. On the other hand if you are backed up with follow ups and can't see new consults then a PA will allow you to see more consults and do more surgery without splitting the number of procedures with another surgeon.

This is why I was hired and then became partner. She was too busy for 1 surgeon and didn't want to alienate her referring physicians by being unable to see their patients; I don't think she thought about the idea of a midlevel at that time, nor would a hospital have provided the salary guarantee. The PA allows her to see more new patients and to have followup patients come in on days when she is in the OR, rather than jamming her office schedule.

2. You are getting things done but with a significant social cost - ie you are getting home every night at 9pm. In this case unlike the first you are not counting on full reimbursement to offset the cost of the PA. You are essentially paying money to enhance your lifestyle.

This is the situation for my partner. She has two small children and the work, especially the volume of paperwork, meant she was doing charts at midnight; frankly the PA is serving more of an administrative role than a clinical role (although the current one has MUCH more clinical duties than the first one, as my partner has let some things go).

There are lots of good reasons to hire a midlevel, but to answer the question that was asked above, it is not common in small general surgery practices.

 

[core0]

While you are correct that there are very few operative procedures for which a first assist will be reimbursed, we do a significant amount of in office procedures. As a matter of fact, the bulk of my income comes from in office biopsies, placement of brachytherapy catheters and sonographic examinations.

The issue is how much of that would you (could you) offload. I would think the liability would be considerable. Its one thing to have a PA doing a joint injection or a skin biopsy vs what you do. Also from the sound of it the procedures reimburse better than other things so it wouldn't make sense to offload them. Its really about being able to do something more profitable with your time (in the global scheme of things). Of course if you are totally procedure based you can use a different model. Derm will frequently use two PAs per physician doing nothing but taking off skin lesions. This pays fairly well.

David Carpenter, PA-C

 

[45408]

We've got a new MSG out here that some of the smaller surgical groups are considering joining. As you note, the larger groups tend to have bargaining power, although the buy-in is not cheap.

How does that work? Do you have to have cash up front, make installment payments, or have your wages garnished? And what's a "not cheap" buy-in? What does the buy-in entail, and do you ever get bought out when you leave or retire?

As you can imagine, this stuff isn't covered in med school, so I really have no idea about this sort of thing. Thanks for your input!

 

[JackADeli]

How does that work? Do you have to have cash up front, make installment payments, or have your wages garnished? And what's a "not cheap" buy-in? What does the buy-in entail, and do you ever get bought out when you leave or retire?

As you can imagine, this stuff isn't covered in med school, so I really have no idea about this sort of thing. Thanks for your input!

The MSGs I have looked at had varying buy ins.... However, even those with upwards of 100k buy in have recent historical profit share returns in the first year as full partner that often equal 50-100% of what you paid in buy in. Unless something unusual has gone down, generally there hasn't been much buy out. If you own percentages of actual real estate and other durable assets, you can sell your share. but, being full partner does not always mean you own part of the property.

PS: Some years ago, I knew of a practice with a $250 buy in.... it was definately a bad deal. It was a bloated practice with a PA for each senior partner. You were getting none of those PAs. However, as a "partner" you would pay a "equal" split of ALL overhead and staff. The senior partners owned the building. The buy in was not going to get you any share of the property. However, the senior owners were expecting after buy in that you would pay a "equal" split of the mortgage on said building. This was divided between you and the other two (~>30% was yours). It was an ugly scene.

 

[masterofmonkeys]

A good general surgeon should know enough about acute medical issues that they rarely have to consult a general medicine service.

Which is not to say medicine does not get BS consults. Ortho works very hard to see to that.

Psychiatry resident here. Call me crazy but this is how I feel about all specialties. We really shouldn't be consulting medicine for management of HTN or DM2, but it's scary how often it happens. Nothing makes me grit my teeth more than an attending saying 'but I'd like to have a formal consult in the chart.' Or 'I'm just not comfortable with treating HTN or starting metformin'.

 

[Winged Scapula]

How does that work? Do you have to have cash up front, make installment payments, or have your wages garnished? And what's a "not cheap" buy-in? What does the buy-in entail, and do you ever get bought out when you leave or retire?

The details vary widely.

Some groups will pay you a low salary for the first few years and put a certain amount aside each month for the buy-in, in some cases its a loan from a bank or the practice (the latter is what I am doing, paying a little each month for a year until the buy in is paid off), and some don't have a buy-in. You also have to negotiate what happens if you leave or die.

Residency also teaches you nothing about this, especially in academic institutions because most of the attendings know nothing about it. You learn by asking, by experience, etc.

You need to ask about buy ins, what that entails, whether you are given your AR when you become a partner or if you have to buy it, etc. I didn't know enough to have it negotiated upfront and for some reason my highpriced attorney didn't do it either, so it created a very drawn out painful process in becoming partner.

 

[45408]

You need to ask about buy ins, what that entails, whether you are given your AR when you become a partner or if you have to buy it, etc. I didn't know enough to have it negotiated upfront and for some reason my highpriced attorney didn't do it either, so it created a very drawn out painful process in becoming partner.

what's an AR?

 

[Winged Scapula]

what's an AR?

AR is accounts receivable.

 

[opr8n]

ER docs still amaze me

got called at 1am for a biliary colic in the ER
ER doc says Gallbladder wall was thick (at 3mm, umm no), and AST/ALT up mildly, possible sludge based on PGY2 radiology resident read

go down to see the patient
they describe a 3w h/o generalized malaise, fatigue, weakness, myalgias, fever, NO ABDOMINAL Pain!!??
On Exam they have LAD in neck and groin, no abd tenderness
Looking at labs, TB and alk phos normal, WBC normal, but 68% lymphs and 3+ atypicals on smear
anyone see where i am going with this ...


got a heterophil ab test, and sure enough it was positive

Patient asked me why the ER consulted a surgeon to diagnose his infectious mononucleosis, i didnt have an answer for him.



this consult is much tougher to take at 1am in the morning and especially when i found out the ER doc who called me left their shift the second they got off the phone with me and didnt pass off much info to the ER doc coming on, so they new ER doc didnt know why i wasent going to admit the patient and take their gallbladder out that moment

ive gottne much better at just letting this roll of my back and taking the political high road, but i still steam on the inside

 

[Apollyon]

ive gottne much better at just letting this roll of my back and taking the political high road, but i still steam on the inside

If it was an EM resident, pass it up your chain. However, if you're at a place with a surgical residency, a radiology residency, and no EM residency, and the doc would take off without signing this patient out ("DC'd to GenSx" is lame), then there's some piece missing.

 

[redbeans]

My favorite consult from the MICU was for lactic acidosis.
No workup, no fluids, no urine output, cirrhotic/hepatitis/ascites, and intubated so I couldn't do a history or physical.
The best part is my program doesn't allow surgery residents to refuse consults, so I had to call my attending in the middle of the night, even though there is no in house MICU attending and the residents had not staffed it with their own attending.
The idea of "getting surgery on board early" is completely beyond me. Same thing goes for "potential difficult airways". All you need to do is stat page overhead if there's actually an issue and we come running...

 

[Buzz Me]

My favorite consult from the MICU was for lactic acidosis.

Patient with abdominal pain in the ER? Get ready for the non-contrast CT abdomen/pelvis.

Patient with abdominal pain on the Medicine service? Get ready for serial lactate levels.

 

[maxheadroom]

The idea of "getting surgery on board early" is completely beyond me.

Nothing used to piss me off more than the "we just need you on board" consult. Really?? You just want me to round on a non-surgical patient just in case? <sigh>