Hate outpatient

[Spodermin]

MS3 here. I'm interested in a lot of things tbh.
I liked neuroscience in preclinical years, but soon realized there was little neuroscience in neurology. I liked radiology, reading studies was amazing. Anesthesia and critical care was brilliant. I liked inpatient medicine and surprisingly, I loved rounds.
Now I'm on outpatient medicine and if I have to see another metabolic syndrome patient I will most likely OD on insulin.
I posted earlier on how I wanted to pursue a rheumatology fellowship, but now I'm wondering if I'd make it through medicine residency given that the vast majority of internal medicine work is metabolic syndrome/COPD. Should I forget about medicine altogether and pursue radiology or anesthesia? Or should I just stick it through IM residency and hope that I don't burn out?

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[QualityProcess]

Lots of us are toughing out general IM so we can get to the specialty of choice

 

[IM2GI]

If you dont like outpatient medicine perhaps rheumatology is a bad fit. Lots of clinic time. I would try to get into a rheumatology elective to see if you like the patient population better.

 

[bashwell]

MS3 here. I'm interested in a lot of things tbh.
I liked neuroscience in preclinical years, but soon realized there was little neuroscience in neurology. I liked radiology, reading studies was amazing. Anesthesia and critical care was brilliant. I liked inpatient medicine and surprisingly, I loved rounds.
Now I'm on outpatient medicine and if I have to see another metabolic syndrome patient I will most likely OD on insulin.
I posted earlier on how I wanted to pursue a rheumatology fellowship, but now I'm wondering if I'd make it through medicine residency given that the vast majority of internal medicine work is metabolic syndrome/COPD. Should I forget about medicine altogether and pursue radiology or anesthesia? Or should I just stick it through IM residency and hope that I don't burn out?

1) It sounds to me more like the ICU is for you. You can get to the ICU via many different routes (including anesthesia), but the one that gives you the most options in terms of current job market and variety is arguably IM > pulmonary/critical care. You split your time between pulm and ICU as an attending, pulm has inpatient as well as outpatient components, depending on how you want to build your pratice, or if you change your mind as you get older and want to focus more on one component over another. If you browse the pulm/ccm and ccm forums, it seems like recent pulm/ccm fellows are being offered jobs all across the nation paying very handsomely ($300-$400K to start + production, etc.). I think you might even be able to work in a neuro ICU too if you like, which might scratch your itch for neuro stuff. So it seems like there are lots of options with pulm/ccm.

2) I know lots of people who hate IM but did it to pursue a fellowship. If you're a US allopathic med student, you have a good chance of matching into a fellowship from IM, so it's reasonable to think IM is just temporary, and you will likely match into a fellowship someday, though for some fellowships you may have to work harder to match than others (e.g., GI). Here's this year's (2017) fellowship match data from NRMP for US allopathic grads only:

Cards
482/537 (89.8%)

Endo
103/108 (95.4%)

GI
319/377 (84.6%)

Heme/Onc
287/332 (86.4%)

ID
162/169 (95.9%)

Nephrology
64/68 (94.1%)

Pulm/CCM
289/323 (89.5%)

Rheum
94/114 (82.5%)

3) For anesthesia, a lot of anesthesiologists seem worried about future challenges (e.g., CRNAs, AMCs), though if you truly love it, then these challenges should not necessarily deter you. For example, see what Richard Novak (Stanford) predicts are 10 trends for the future of anesthesiology:

1. Lower income (as adjusted for inflation). There will be multiple causes for this: a) An aging population, with the significantly lower pay for attending to Medicare patients, b) Obamacare and other governmental payment cuts, c) Bundled insurance payments to hospitals, requiring anesthesiologists to negotiate for every nickel of that payment due to them, and d) Corporate anesthesia (see #9 below).
2. More care team anesthesia and more Certified Nurse Anesthetists (CRNAs). Hospital systems will have increased incentives to perform anesthetics with cheaper labor. Rather than physician anesthesiologists personally performing anesthesia, expect to see CRNAs supervised by physician anesthesiologists in an anesthesia care team, or in some states, CRNAs working alone.
3. There will be a paucity of new drugs to change the practice of operating room anesthesia. A few years ago I had a conversation with Don Stanski, MD, PhD, former Chairman of Anesthesiology at Stanford and now a leading pharmaceutical company executive, regarding new anesthetic drugs in the pipeline. Dr. Stanski’s reply was something along the line of, “There are almost no new anesthetic drugs in development. The ones we currently have work very well, and the research and development cost in bring an additional idea to market is high. Don’t expect much change in the coming years.” Consider sugammadex, a new drug for the reversal of neuromuscular blockade, recently approved by the Food and Drug Administration. The drug is more effective in reversing a rocuronium or vecuronium block than is neostigmine, but the cost is high. The acquisition cost of the smallest available vial of sugammadex is over $90, far exceeding the cost of neostigmine. In certain instances, faster reversal by sugammadex will be critically important, but for routine cases the cost is prohibitive. This trend of fewer new anesthesia drugs isn’t only a futuristic phenomenon. In my current private practice, I see my colleagues using the same medications that they used 25 years ago: propofol, sevoflurane, rocuronium, fentanyl, and ondansetron.
4. An aging population, an increased volume of surgery, and an increased demand for anesthesia personnel. As the baby boomers age, there will be an increased number of surgeries on older, sicker patients. Anesthesia personnel will be in great demand.
5. Anesthesiology will become more and more a shift-work job. A generation ago an anesthesiologist started a case and finished that case. An on-call anesthesiologist came to work at 7 a.m., took 24-hour call, and finished their last case as the sun came up the next morning. Certain instances of this model may persist, but as more anesthesiologist become corporate employees, expect more anesthesia practitioners working 8-hour or 12-hour shifts, just like employees in other jobs.
6. Increased interest in the specialty of anesthesiology amongst medical students. Although several items on my list may seem discouraging, take heart, because the career of anesthesiology will remain extremely popular. Why? Because the other fields of medicine have problems, too. Bigger problems. Many future doctors will shun the primary care fields of family practice, internal medicine, and pediatrics. The primary care fields offer long days in clinics, dealing with a new patient every 10 – 15 minutes, and they suffer from low pay. Because of the higher reimbursement in procedural specialties, careers in surgery, anesthesia, cardiology, and invasive radiology will always be popular.
7. Expect improved safety statistics regarding anesthesia mortality and morbidity. Anesthesia has never been safer. See “How Safe is Anesthesia in the 21st Century?” Expect further improvements in monitors, protocols, education, and the analysis of Big Data that will make anesthesia safer than ever.
8. There will still be a non-zero incidence of anesthesia-related fatalities. There will still be disasters, particularly airway disasters. Some anesthesia clinical situations will always remain extremely difficult and challenging, and human error will not be eradicated.
9. Large national corporations will continue buying up private anesthesia practices, perhaps eliminating the current model in which groups cover one hospital or one city alone. In the last three months, Sheridan, the physician services division of AmSurg, Corp has purchased the 60-physician, 140-anesthetist Northside Anesthesiology Consultants in Atlanta, and the 240-physician Valley Anesthesiologists & Pain Consultants in Phoenix. In these purchases, senior board members and partners receive seven-digit checks to sell their practice, then all physicians in the practice’s future labor for a discounted wage, perhaps as low as 50% of the prior income. If this trend becomes widespread, this subset of the anesthesia workforce will become low paid practitioners, while the purchasing corporations will make significant profits for their stockholders.
10. Continued fascination with anesthesia practice, a discipline which makes all surgical treatments and cures feasible. Without anesthesia, there can be no major surgical procedures. Medical care without major surgical procedures is unthinkable. Whether as anesthesia providers, as patients requiring surgery, or just as observers of the process, we will all continue to value and marvel at the field of anesthesia.

 

[sloh]

Potential solution

The Doctor Is In. Co-Pay? $40,000.

 

[bronx43]

MS3 here. I'm interested in a lot of things tbh.
I liked neuroscience in preclinical years, but soon realized there was little neuroscience in neurology. I liked radiology, reading studies was amazing. Anesthesia and critical care was brilliant. I liked inpatient medicine and surprisingly, I loved rounds.
Now I'm on outpatient medicine and if I have to see another metabolic syndrome patient I will most likely OD on insulin.
I posted earlier on how I wanted to pursue a rheumatology fellowship, but now I'm wondering if I'd make it through medicine residency given that the vast majority of internal medicine work is metabolic syndrome/COPD. Should I forget about medicine altogether and pursue radiology or anesthesia? Or should I just stick it through IM residency and hope that I don't burn out?

I would consider IR if you're really into procedures, but diagnostic radiology has too many potential downsides such as the job market and the looming ability of AI to at least pick off the low hanging fruit.

Do anesthesia if you want to be employed by an AMC who cares little about your existence other than to supervise CRNAs, who are increasingly encroaching on your field. Pain would be a decent option if you can stomach the chronic pain patient.

I think the medicine subspecialties are a good gig, and are varied enough to fit whatever professional or lifestyle criteria you have. I'm completely happy in rheumatology, and wouldn't trade it for any of the above fields. Income potential is what you make of it.

 

[niblet]

So do you hate outpatient in general or just this particular rotation because of the preponderance of metabolic syndrome/chronic lifestyle-related diseases?

Rheum is almost entirely outpatient, so if you hate outpatient, you wouldn't like rheum.

Rheum
94/114 (82.5%)

Rheum had the lowest match rate of all? Weird. Here I was thinking it wasn't competitive. Or can someone tell me why this number is deceiving? Fewer spots than most of the other specialties, plus not having the go-getter "rockstar" applicants that cards, GI, and the like tend to get—I can see that factoring in. How competitive does this make rheum really?

 

[Spodermin]

I don't necessarily hate all outpatient. I just hate this rotation because almost all patients we see are diabetes, COPD, hypertension.

I realize that rheum is almost entirely outpatient, but I feel like it would be more challenging than managing someone's diabetes medicine. I realize that rheumatoid arthritis patients still need long-term management, but diagnosing someone with diabetes isn't nearly as difficult as diagnosing someone with lupus. I might be wrong, but I guess I'll never know until I do an elective later on in the year.

Diagnostic rads is still high on my list. No annoying insurance company bs. No mountains of unnecessary paperwork. The only thing that's really stopping me from committing to rads is the way I've seen some referring docs treat the radiologists.
If the report is detailed, they'll complain about how useless some of the findings are. If it's concise, they'll complain that it's not detailed enough. Oh and don't even get me started on the amount of doctors who think they can read MRIs, it drives me insane. The radiologists I've met don't seem to care that some of the referring docs see their work as meaningless. I guess I'm afraid that I won't get much satisfaction knowing that my reports are being thrown away.
The speciality isn't going anywhere and if AI replaces radiologists then I'd happily retire and go live in the mountains and read Plato for the rest of my life.

I hate the "anesthesia team" model, and I think I'm too narcissistic to ever accept that some nurse with "advanced training" is my peer.
Someone told me that I wouldn't last long in anesthesia residency with that mentality.
Nurses are great, as long as they do nursing. Once they think they can do more than that, things get a little messy.

IM > pulmonary/critical care

I actually never thought of this and I think I'm gonna look into it a bit more.

 

[rokshana]

I don't necessarily hate all outpatient. I just hate this rotation because almost all patients we see are diabetes, COPD, hypertension.

I realize that rheum is almost entirely outpatient, but I feel like it would be more challenging than managing someone's diabetes medicine. I realize that rheumatoid arthritis patients still need long-term management, but diagnosing someone with diabetes isn't nearly as difficult as diagnosing someone with lupus. I might be wrong, but I guess I'll never know until I do an elective later on in the year.

Diagnostic rads is still high on my list. No annoying insurance company bs. No mountains of unnecessary paperwork. The only thing that's really stopping me from committing to rads is the way I've seen some referring docs treat the radiologists.
If the report is detailed, they'll complain about how useless some of the findings are. If it's concise, they'll complain that it's not detailed enough. Oh and don't even get me started on the amount of doctors who think they can read MRIs, it drives me insane. The radiologists I've met don't seem to care that some of the referring docs see their work as meaningless. I guess I'm afraid that I won't get much satisfaction knowing that my reports are being thrown away.
The speciality isn't going anywhere and if AI replaces radiologists then I'd happily retire and go live in the mountains and read Plato for the rest of my life.

I hate the "anesthesia team" model, and I think I'm too narcissistic to ever accept that some nurse with "advanced training" is my peer.
Someone told me that I wouldn't last long in anesthesia residency with that mentality.
Nurses are great, as long as they do nursing. Once they think they can do more than that, things get a little messy.
I actually never thought of this and I think I'm gonna look into it a bit more.

rheum...you will have your fibromyalgia patients...frankly, i'm much happier to deal with the diabetes pts than with fibromyalgia. (and FYI, its never lupus

you need to think about what you think about what you do and not how others see you...every field is going to have detractors and only you can decide which is more important to you...looking like a rockstar to everyone else, or enjoying (for the most part) what you do for a living.

and realize that many specialties will have a great deal of exposure to certain imaging modalities and can actually read them...I don't require a radiologist to either do or interpret my neck ultrasounds...its part of my training...and while i don't interpret them , I've seen enough pituitary MRIs to know what a micro/macro - adenoma looks like...

 

[chessknt]

You're also an MS3 and your experience interacting with patients (all comers) changes drastically at every level of your training. At your level you have to talk to them at length to write stupid long H&Ps for attendings to praise you over your ddx powers. As an intern you talk to them much less and write a note that is shorter than a MS3 note but still with too much detail that dwindles as time goes on and you realize nobody is grading you on notes anymore. By the time you are an attending that super cool ESR 280 in a healthy 24 y/o male with no sx other than a small rash and a swollen tongue is what induces a groan instead of yet another easy COPD exacerbation because they pay the same but one is much higher risk and takes more time to make sure you dont **** up.

 

[bronx43]

Rheum had the lowest match rate of all? Weird. Here I was thinking it wasn't competitive. Or can someone tell me why this number is deceiving? Fewer spots than most of the other specialties, plus not having the go-getter "rockstar" applicants that cards, GI, and the like tend to get—I can see that factoring in. How competitive does this make rheum really?

We did have the lowest match rate, but I wouldn't label us as a "competitive specialty." Not by a long shot. If you compare the average rheumatology applicant and the average GI applicant, it's night and day. If you're a US grad, you'll match at your top 3. If you're a foreign grad, you'll also likely match, but at a crappy program.

 

[bronx43]

rheum...you will have your fibromyalgia patients...frankly, i'm much happier to deal with the diabetes pts than with fibromyalgia. (and FYI, its never lupus

Given the supply shock that rheumatology is currently seeing and will continue to see, you have the total option of punting ALL your fibromyalgia patients back to the PCP. Honestly, I only have a small cohort of hand picked fibromyalgia patients that I see only because they're truly reasonable and pleasant people. Now, if they have both an autoimmune disease AND fibromyalgia, then I'll see them, but I make it very clear that I'm only here for their RA/SLE/PsA etc.

 

[rokshana]

Given the supply shock that rheumatology is currently seeing and will continue to see, you have the total option of punting ALL your fibromyalgia patients back to the PCP. Honestly, I only have a small cohort of hand picked fibromyalgia patients that I see only because they're truly reasonable and pleasant people. Now, if they have both an autoimmune disease AND fibromyalgia, then I'll see them, but I make it very clear that I'm only here for their RA/SLE/PsA etc.

yeah, but you will have plenty of PCP sending you these patients...and in smaller, more rural areas, i can certainly see many PCPs sending them as a "consult and assume care" and don't necessarily have the option to return them to the PCP.

 

[VA Hopeful Dr]

yeah, but you will have plenty of PCP sending you these patients...and in smaller, more rural areas, i can certainly see many PCPs sending them as a "consult and assume care" and don't necessarily have the option to return them to the PCP.

As a PCP, I can tell you that specialists can and do refuse to take over care all the time.

 

[Successor12]

Given the supply shock that rheumatology is currently seeing and will continue to see, you have the total option of punting ALL your fibromyalgia patients back to the PCP. Honestly, I only have a small cohort of hand picked fibromyalgia patients that I see only because they're truly reasonable and pleasant people. Now, if they have both an autoimmune disease AND fibromyalgia, then I'll see them, but I make it very clear that I'm only here for their RA/SLE/PsA etc.

Sweet

 

[rokshana]

As a PCP, I can tell you that specialists can and do refuse to take over care all the time.

really? this is news to me!

i've discharged people from the clinic if the issue has resolved and they can have labs or U/S done on a yearly basis (i.e. thyroid nodules of hypothyroid stable on a dose, etc), maybe diabetes that is at goal an stable over a year, but in general once a diabetes pt comes to the clinic, they usually stay with us (though I have had pts who don't want to do anything different in regards to their DM and those I will say that since i'm not doing anything for you, then you can be managed by your primary doctor.

 

[sangria1986]

I think that pcps can do more than just mere metabolic diseases. I also thought pcp was just seeing patients for htn, hld, labs and discharge but this is not the case.

I think, unfortunately, due to the pressures of volume to make enough money pcps have been punting patients to specialists for a long time because they dont have the time to see a variety of pathologies. But there are so many cases where i have rotated with GI, cardio, rheum, neuro etc where they repeatedly tell me they wish the pcp took care of something like 50% of their cases so they werent overwhelmed with basic management. If pcps were taking care of your average rheumatology case that didnt require biologics (ie increased risk), GI patients who come for dyspepsia witout warning features etc etc on a routine basis and did not just send them to the specialist clinics your average caseload would be varied and interesting.

Obviously if you are pressured to see 4 patients an hour this is tough and I'm still a resident so Im hoping that my hypothesis is correct but I plan to see 3 patients an hour and 20 minute visits (ie 15-17 minutes and 3-5 minutes for the note) should give me time to take care of a variety of cases.
My plan is to make copies of all my H and P notes of the various specialty clinics Im at and learn how to document and mange them/ get a ddx/ and rule out warning signs for each condition and make a document and put it in a binder so I can manage cases for these patients when I do become an attending with a quick cheat sheet. In no way am I advocating cookie cutter medicine. My intention is to supplement my eyes and ears with a more efficient system.

 

[bronx43]

I think that pcps can do more than just mere metabolic diseases. I also thought pcp was just seeing patients for htn, hld, labs and discharge but this is not the case.

I think, unfortunately, due to the pressures of volume to make enough money pcps have been punting patients to specialists for a long time because they dont have the time to see a variety of pathologies. But there are so many cases where i have rotated with GI, cardio, rheum, neuro etc where they repeatedly tell me they wish the pcp took care of something like 50% of their cases so they werent overwhelmed with basic management. If pcps were taking care of your average rheumatology case that didnt require biologics (ie increased risk), GI patients who come for dyspepsia witout warning features etc etc on a routine basis and did not just send them to the specialist clinics your average caseload would be varied and interesting.

Obviously if you are pressured to see 4 patients an hour this is tough and I'm still a resident so Im hoping that my hypothesis is correct but I plan to see 3 patients an hour and 20 minute visits (ie 15-17 minutes and 3-5 minutes for the note) should give me time to take care of a variety of cases.
My plan is to make copies of all my H and P notes of the various specialty clinics Im at and learn how to document and mange them/ get a ddx/ and rule out warning signs for each condition and make a document and put it in a binder so I can manage cases for these patients when I do become an attending with a quick cheat sheet. In no way am I advocating cookie cutter medicine. My intention is to supplement my eyes and ears with a more efficient system.

There are no incentives in place for the PCP to take care of problems which they can easily punt to a specialist. There also are no incentives in place for the specialist to refuse them. Honestly, if I see a "dumb" consult that is low hanging fruit, I would take it with glee. Quick level 4 consult that I would be able to knock out in 15 minutes. For the PCP, there is more than enough business to keep them busy, so if there's something that they can say "let me refer you to a specialist," then not only does it save the PCP time but the patient also loves that. It's a win all around situation.

 

[sangria1986]

Im confused. I thought pcps want more complex visits so they can bill at a higher level instead of low level metabolic stuff. High level-equals more pay. Im specifically referring to internal medicine.

 

[Mad Jack]

MS3 here. I'm interested in a lot of things tbh.
I liked neuroscience in preclinical years, but soon realized there was little neuroscience in neurology. I liked radiology, reading studies was amazing. Anesthesia and critical care was brilliant. I liked inpatient medicine and surprisingly, I loved rounds.
Now I'm on outpatient medicine and if I have to see another metabolic syndrome patient I will most likely OD on insulin.
I posted earlier on how I wanted to pursue a rheumatology fellowship, but now I'm wondering if I'd make it through medicine residency given that the vast majority of internal medicine work is metabolic syndrome/COPD. Should I forget about medicine altogether and pursue radiology or anesthesia? Or should I just stick it through IM residency and hope that I don't burn out?

Neuro fellowships can lead to a neuroscience heavy career. As to staying inpatient, going to echo CCM. Regardless of the path you take to get there, it's as inpatient as it gets, and the patients that you normally dread are at least sick enough to be somewhat interesting. You'll hate outpatient CCM though, so much COPD for daaaaays.

 

[VA Hopeful Dr]

Im confused. I thought pcps want more complex visits so they can bill at a higher level instead of low level metabolic stuff. High level-equals more pay. Im specifically referring to internal medicine.

Nope. Most of us specifically don't want super complex. Those cases take more time per dollar.

Let's say a level 3 visit pays $70 and a level 4 pays $90. The former takes 10 minutes while the latter takes 20. Even if you only do 4 level 3 visits an hour (instead of the 4-6 that's possible) that's still more money than the 3 level 4 visits in that same hour.

 

[neoevolution]

Rheum had the lowest match rate of all? Weird. Here I was thinking it wasn't competitive. Or can someone tell me why this number is deceiving? Fewer spots than most of the other specialties, plus not having the go-getter "rockstar" applicants that cards, GI, and the like tend to get—I can see that factoring in. How competitive does this make rheum really?

Match rate is very deceiving because applicants select fields they think they're competitive for. That's why ENT was 89% and one of the most competitive, yet psych was 90% and is the easiest along with FM. Looking at median Step 1 or average number of research experiences gives you a much better idea.

 

[USCguy]

Nope. Most of us specifically don't want super complex. Those cases take more time per dollar.

Let's say a level 3 visit pays $70 and a level 4 pays $90. The former takes 10 minutes while the latter takes 20. Even if you only do 4 level 3 visits an hour (instead of the 4-6 that's possible) that's still more money than the 3 level 4 visits in that same hour.

Depends on your contract structure. If you are paid based on wRVU; the 3 level 4's (4.5) will be higher than the 4 level 3's (4.0)

I would also make the case that a level 4 doesn't require much complexity at all, and you could potentially have 4 level 4's per hour (only takes 3 stable chronic diseases (HTN, HLD, DM) or a new problem (UTI, give ABx).

The interesting complicated patients are getting into level 5 territory or prolonged outpatient codes. These are fun, but exhausting; can't take more than 1 or 2 of these a day, with plenty of A1c, CKD, HTN, HLD, thyroid, obesity, preventive care interspersed...

Actually, I find preventive care to be exhausting as well. I hate having a bunch of annual wellness visits per day. Doing it right with proper counseling takes way more time than the codes reimburse

The complex patients are fun to work up; but at some point it's just easier to outsource some of the problem list to others

 

[VA Hopeful Dr]

Depends on your contract structure. If you are paid based on wRVU; the 3 level 4's (4.5) will be higher than the 4 level 3's (4.0)

I would also make the case that a level 4 doesn't require much complexity at all, and you could potentially have 4 level 4's per hour (only takes 3 stable chronic diseases (HTN, HLD, DM) or a new problem (UTI, give ABx).

The interesting complicated patients are getting into level 5 territory or prolonged outpatient codes. These are fun, but exhausting; can't take more than 1 or 2 of these a day, with plenty of A1c, CKD, HTN, HLD, thyroid, obesity, preventive care interspersed...

Actually, I find preventive care to be exhausting as well. I hate having a bunch of annual wellness visits per day. Doing it right with proper counseling takes way more time than the codes reimburse

The complex patients are fun to work up; but at some point it's just easier to outsource some of the problem list to others

That's an even better point. If every UTI or sinus infection with antibiotics is a level 4, why waste your time with a complicated patient who is going to pay you the same amount for much more work?

 

[sangria1986]

That's an even better point. If every UTI or sinus infection with antibiotics is a level 4, why waste your time with a complicated patient who is going to pay you the same amount for much more work?

Personally as a newly graduating resident who is about to enter the real world I want to feel that my work is more valued than the oft stated 'even PAs and NPs can do this'. Dealing with complex patients makes me feel valued and know that all this knowledge I carry is important and validates my profession.

Otherwise i cant help but feel the death march of midlevels being legally allowed to take over pcp work one day because 'we arent reducing costs' since the patients are all turfed to specialists.

 

[bronx43]

Personally as a newly graduating resident who is about to enter the real world I want to feel that my work is more valued than the oft stated 'even PAs and NPs can do this'. Dealing with complex patients makes me feel valued and know that all this knowledge I carry is important and validates my profession.

Otherwise i cant help but feel the death march of midlevels being legally allowed to take over pcp work one day because 'we arent reducing costs' since the patients are all turfed to specialists.

Then start your own concierge practice. That is a model where you can keep everything and manage everything, and you have the time to deal with all the complexity you want. The alternative is stay in the regular system, and make little money. It's really up to you.

 

[sangria1986]

Then start your own concierge practice. That is a model where you can keep everything and manage everything, and you have the time to deal with all the complexity you want. The alternative is stay in the regular system, and make little money. It's really up to you.

How likely is this? Im not pedigreed. Communitu trained etc etc. is this a barrier?

 

[bronx43]

How likely is this? Im not pedigreed. Communitu trained etc etc. is this a barrier?

Not really. Most of the good FMs are "community trained," since academia usually means you get to do close to nothing, since all the specialists are doing it.

But it's more dependent on how good you are, how much pts like you, and how good you can market yourself. If you fail to get a good patient panel, I would look to those deficits before blaming things like pedigree.

 

[USCguy]

Personally as a newly graduating resident who is about to enter the real world I want to feel that my work is more valued than the oft stated 'even PAs and NPs can do this'. Dealing with complex patients makes me feel valued and know that all this knowledge I carry is important and validates my profession.

Otherwise i cant help but feel the death march of midlevels being legally allowed to take over pcp work one day because 'we arent reducing costs' since the patients are all turfed to specialists.

that is an interesting statement that I think gets to the heart of a larger matter that has been discussed ad nauseam on SDN over the years. I use the level 4 UTI as an example of how simple a problem can be yet still achieve a level 4 code. If all you did all day was UTIs and URIs, life as an internist would be boring. However, if you want to be able to meet the demands of your "boss" (who or whatever that may be) you need some of the easy stuff thrown in the mix to offset the more time consuming patients. Even HTN can be "interesting" when a patient comes in with systolics over 160 and on 4 meds necessitating workup for hyperaldo, etc. Plus you look like a hero when you put them on aldactone and suddenly the BP that no one could control bends to your will...unless the male patient gets gynecomastia...then they want to go back to having high BP and no boobs

For me, the beauty of IM lies in the ability to 1) take a history 2) perform an adequate exam and 3)formulate a differential diagnosis for a problem and sometimes have to think of the zebras everyone else has forgotten. This is not something you can get from a 2 year masters program or online FNP program. Hell, even most doctors I know in town can't or won't formulate a differential.

Patient constipated? Easy, give them some miralax! But unless you talk to them and see that they are having decreased PO intake and that is due to a swollen tongue which has been worsening for the past 6 months which leads you to work them up for amyloid, you will miss the diagnosis. (This is a real example, patient had seen 3 prior providers)

For the current residents, remember this when you are looking for a job and find a place that you can practice how YOU want. You may have to dig a little further than just the classifieds in NEJM or the recruiter from XYZ firm; and possibly trade off some money/time/location/amenities.

I think at the end of the day you want a practice of mostly "goldilocks" patients. Complex enough to keep you engaged yet simple enough that you can manage them appropriately. Then the outliers on either side to keep the easy money flowing and you mentally stimulated.

 

[IM2GI]

Nope. Most of us specifically don't want super complex. Those cases take more time per dollar.

Let's say a level 3 visit pays $70 and a level 4 pays $90. The former takes 10 minutes while the latter takes 20. Even if you only do 4 level 3 visits an hour (instead of the 4-6 that's possible) that's still more money than the 3 level 4 visits in that same hour.

Well see the trick is to see the less complex stuff, but click enough buttons in your EMR software so the billers can code it a level 4.

As a new grad in the real world I find billing to be very challenging and super subjective.

 

[sangria1986]

that is an interesting statement that I think gets to the heart of a larger matter that has been discussed ad nauseam on SDN over the years. I use the level 4 UTI as an example of how simple a problem can be yet still achieve a level 4 code. If all you did all day was UTIs and URIs, life as an internist would be boring. However, if you want to be able to meet the demands of your "boss" (who or whatever that may be) you need some of the easy stuff thrown in the mix to offset the more time consuming patients. Even HTN can be "interesting" when a patient comes in with systolics over 160 and on 4 meds necessitating workup for hyperaldo, etc. Plus you look like a hero when you put them on aldactone and suddenly the BP that no one could control bends to your will...unless the male patient gets gynecomastia...then they want to go back to having high BP and no boobs

For me, the beauty of IM lies in the ability to 1) take a history 2) perform an adequate exam and 3)formulate a differential diagnosis for a problem and sometimes have to think of the zebras everyone else has forgotten. This is not something you can get from a 2 year masters program or online FNP program. Hell, even most doctors I know in town can't or won't formulate a differential.

Patient constipated? Easy, give them some miralax! But unless you talk to them and see that they are having decreased PO intake and that is due to a swollen tongue which has been worsening for the past 6 months which leads you to work them up for amyloid, you will miss the diagnosis. (This is a real example, patient had seen 3 prior providers)

For the current residents, remember this when you are looking for a job and find a place that you can practice how YOU want. You may have to dig a little further than just the classifieds in NEJM or the recruiter from XYZ firm; and possibly trade off some money/time/location/amenities.

I think at the end of the day you want a practice of mostly "goldilocks" patients. Complex enough to keep you engaged yet simple enough that you can manage them appropriately. Then the outliers on either side to keep the easy money flowing and you mentally stimulated.

Thank you! This is precisely what I mean. Now tell me, are you in IM outpatient and how long have you been doing it? What should I study/prepare for my career as internist in a year?

 

[USCguy]

Thank you! This is precisely what I mean. Now tell me, are you in IM outpatient and how long have you been doing it? What should I study/prepare for my career as internist in a year?

I've been in practice for 3 years. I'm currently > 90th percentile production. I do a split practice of ~1/4 hospitalist (my group's patients only) and ~3/4 clinic. I find this to be a good balance for me in terms of cognitive stimulation, change of pace, etc. I do a few other things as well (SNF, ALF) to keep life interesting.

My day today: rounded on 8 patients in rehab at SNF (mostly post op knee/hip work, but also a lady with improving CHF, guy with recent stroke) saw 8 follow-ups in office this AM. Worked in new patient at lunch for unexplained weight loss (good differential) saw 9 follow ups in afternoon followed by another work in new patient with recent syncope vs seizure this weekend. I pretty well don't take new patients at this point (such as "just want to get established") unless there is some word of mouth referral for a specific problem where I think I can intervene (such as my patient telling me last week her husband has been losing weight and no one knows why).

For preparation, besides the obvious answer of studying for boards; I used EM university to learn outpatient and inpatient coding. Also, thehappyhospitalist blog has good info on billing and coding. As a non-procedural speciality, it is important to learn how to be paid appropriately for your cerebral labors.