How many follow-up visits per day is it reasonable to ask a midlevel to see?

[TeslaCoil]

I run a busy pain mgmt practice with two midlevels and a scribe. We do injections and see patients simultaneously, mon-fri. I see all the new patients (6 slots per day, but averaging 5 in the end), and do all the new pt documentation and mgmt. My two midlevels are seeing approximately 45-50 med refill or block pts between the two of them. Obviously I do all the procedures which is approx 10-15 per day. Up to how many follow-up visits is reasonable to ask of my midlevels? The scribe helps us all with pulling forward visit info etc. They are paid $125k per year.

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[callmeanesthesia]

That sounds pretty reasonable to me. My mid-levels see 15 minute f/u, 30 minute new patient slots, 8 hours a day. Have you tried having the new patients see the mid-level for most of the eval and documentation, then you to review and confirm the plan? You can do a lot more procedures per day that way. Sounds like you must have a pretty med-heavy practice though to have that many follow ups with only 10-15 injections per day.

 

[deleted472101]

I would keep the news to the physician and easy follow ups to Midlevels

 

[TeslaCoil]

It is a little med heavy. But those procedures include RFA’s and about a stim trial a week… my goal for them was to see a maximum of 25 follow-up visits per day. The scribe helps me with new patients and usually thats pretty sufficient to get the job done. I also use dragon dictation.

 

[lobelsteve]

Sounds like a well oiled machine. Would never send my family to you.

 

[TeslaCoil]

Sounds like a well oiled machine. Would never send my family to you.

Its funny you say that because my own mother gets knee injections in my clinic and she couldnt be happier. Some of my staff are also my satisfied patients. I feel like a family doc since my patients are constantly referring their family members to me. So why the judgey reply?

 

[lobelsteve]

“My two midlevels are seeing approximately 45-50 med refill or block pts between the two of them.”

 

[callmeanesthesia]

“My two midlevels are seeing approximately 45-50 med refill or block pts between the two of them.”

Stable med refills and MBB follow ups? Seems like a pretty conservative use of mid-levels.

 

[TeslaCoil]

“My two midlevels are seeing approximately 45-50 med refill or block pts between the two of them.”

And? My midlevels are both ex military combat medics with extensive careers, who are very well trained. The patients love and respect them. As do I.

 

[RoloTomassi]

Seems on par with what I've seen. Any more and they'll probably get burnt out. Big factor is if they feel they are well supported with MAs etc

 

[GoBeers]

8hr, 15min slots = 32 patients. so, 25-30 pts seems fair.

 

[painfree23]

“My two midlevels are seeing approximately 45-50 med refill or block pts between the two of them.”

If u drop the mid levels and u can drop the med refills, then no opiates. Then u don’t need mid levels.

 

[lobelsteve]

If u drop the mid levels and u can drop the med refills, then no opiates. Then u don’t need mid levels.

Looks like they are there to deliver lower level care for profit. How to build an empire. Not how I would want my family to be treated. Combat medics have ACGME level pain training? Not my mom. IMNSHO.

 

[TeslaCoil]

Looks like they are there to deliver lower level care for profit. How to build an empire. Not how I would want my family to be treated. Combat medics have ACGME level pain training? Not my mom. IMNSHO.

The patients seem very satisfied. The money is just a perk. No possible way you could determine the quality of care we deliver from anything Ive said here. What is it specifically that you think you’re doing or getting done that we arent?

 

[Ducttape]

it would be great to have a model where all the care is from the physician.

however, in order to generate sufficient profit margin, it also means that the new patient: procedure and the procedure: follow up rates must be high, probably artificially so. follow up appointments are by far the least money generating.

imo, it is entirely reasonable to have an APP see follow up patients who are stable but still require care. while it would be preferable for follow up patients to go back to their primary care physician, in many situations, that is not reasonable from the PCP standpoint. now spine programs may really not require many follow ups, but chronic pain patients do benefit from continued longitudinal care.

 

[lobelsteve]

The patients seem very satisfied. The money is just a perk. No possible way you could determine the quality of care we deliver from anything Ive said here. What is it specifically that you think you’re doing or getting done that we arent?

Guess the care you deliver is no netter than your PA. So that’s that.

 

[Agast]

How do you feel about you and your family members seeing midlevels when you’ve made an appointment to see a specialist? Pain isn’t necessarily high stakes (although easy to mismanage) but I’m seeing midlevels in neurology, cardiology, peds specialties and I feel like the risk of missing something important or not explaining things correctly is way too high.

 

[SSdoc33]

i cant stand the model of a NP or PA seeing the patient first, then referring for an injection. how the eff will a midlevel know which shot to recommend, and prepare the patient adequately?

best model is that the doc sees the patient, doc does the shot, midlevel does the follow-up as long as it is straightforward.

running high numbers of follow ups for med management is not only a recipe for disaster, but pretty sleazy IMHO

 

[GoBeers]

i cant stand the model of a NP or PA seeing the patient first, then referring for an injection. how the eff will a midlevel know which shot to recommend, and prepare the patient adequately?

best model is that the doc sees the patient, doc does the shot, midlevel does the follow-up as long as it is straightforward.

running high numbers of follow ups for med management is not only a recipe for disaster, but pretty sleazy IMHO

how is it sleazy?
if patient sees physician for initial consultation, relationship is established over the course of a few visits (whether via PT, injections, multimodal agents, education), and the ultimate decision of medication/opioid management is agreed upon, then why shouldn't the patient be seen by a midlevel for routine, stable med refill?

of course, if there's any new issue or potential medication adjustment issue, then this should be punted back to the physician.

 

[DOctorJay]

the only patients I've even considered having our midlevels see first would be those who are referred in without any work up at all.

but even in that case I'm nervous they wouldn't adequately rule out red flags and most times patients are being referred in from a midlevel who also hasn't ruled out any red flags.

 

[SSdoc33]

how is it sleazy?
if patient sees physician for initial consultation, relationship is established over the course of a few visits (whether via PT, injections, multimodal agents, education), and the ultimate decision of medication/opioid management is agreed upon, then why shouldn't the patient be seen by a midlevel for routine, stable med refill?

of course, if there's any new issue or potential medication adjustment issue, then this should be punted back to the physician.

med management -- chronic med management -- is sleazy. starting or continuing opioids indefinitely is sleazy. filling an entire busy clinic worth of opioid patients is sleazy. providing opioids only whilst doing injections (pills for pokes) is sleazy.

pick your poison

 

[callmeanesthesia]

Some of this depends on local practice pattern. I’m in the largest city in a rural part of the state. For 2-3 hours north, west, and east, and an hour south, everyone comes to my city. There are 2 other board certified interventional pain doctors in town, and one non-ACGME spine guy. In the four years I’ve been in town, the formerly busiest guy moved far away, another stopped practicing to do some sort of non-medical business and just does EMGs now, and two more retired this month. For growth we’ve had one guy hired by one of the other board certified guys, but his practice is mostly in the city to the south, and only part time here.

It’s great for business, but if I tried to see all these patients myself, I’d have to limit my follow ups to 5 minutes and my new patients to 10, and I still couldn’t keep up. I already do no opioid management, and my next available new patient appointment that isn’t a cancelation slot is 7/21. And that’s with my PA also seeing new patients. So do I have a PA see and screen new patients, and grab me when a patient is complicated, or do it all myself and patients just wait 3 months to be seen? Or should I spend more time in clinic but patients have to wait 3 months for a medial branch block? Sure, I could get a partner. Probably need to start looking. It takes us on average several years to hire someone though because the area isn’t great, and a lot of doctors seem to leave the area after a few years.

 

[TeslaCoil]

Guess the care you deliver is no netter than your PA. So that’s that.

My PA's have 20 years of medical experience (10 of which are in pain) and they have read all the same textbooks of pain I have. They may not have ACGME credentials, but they definitely make sound judgements. I supervised them very closely for a long time before they gained my trust, and I always verify their assessments before I perform any intervention. Our opioid maximum is pretty damn low compared to most other pain practices I know. Most of our pts are well below 100 MME's. Other clinics dump their opioid patients on us to get them off or down on pills. We are well versed in managing withdrawal from other peoples bang up jobs. Your assessment, in my opinion is shortsighted and highly pretentious. So every practice using midlevels is evil and unethical? Thats your take?

 

[TeslaCoil]

med management -- chronic med management -- is sleazy. starting or continuing opioids indefinitely is sleazy. filling an entire busy clinic worth of opioid patients is sleazy. providing opioids only whilst doing injections (pills for pokes) is sleazy.

pick your poison

I disagree. Not all med mgmt is sleazy. We have very regulated med mgmt. And we have a regular contact at the DEA/DHEC agencies to keep a pulse on how we're doing. We do a healthy amount of med mgmt. Doing opioid ONLY mgmt may be sleazy. I would never EVER "provide opioids only whilst doing injections". And thats illegal btw. Some guy in the midwest lost a 100 million dollar medicare fraud suit for doing just that.

 

[GoBeers]

med management -- chronic med management -- is sleazy. starting or continuing opioids indefinitely is sleazy. filling an entire busy clinic worth of opioid patients is sleazy. providing opioids only whilst doing injections (pills for pokes) is sleazy.

pick your poison

got it. you are a no opioid provider. must suck for the 82 yo with severe multilevel stenosis non surgical candidate with poor response to epidurals or 89 yo with PVD with recurrent stent/graft complications.

i do envy your practice though.

 

[Ducttape]

i do not ever have the patient see the midlevel for initial evaluation. ever.

after that initial appointment, if the patient is appropriate to be seen in follow up by an APP, then i tell the patient that they may be seeing the APP at their follow up.

i dont hold a magic license that says that only I can determine that an MBB had >80% reduction of pain for the appropriate duration of local anesthetic used. anyone who believes that is delusional and egotistical. i also do not need to be in the room to determine if the gabapentin the patient has taken for the past 6 months that the PCP will not prescribe or the PT that helped last year should be refilled.

OTOH, if the patient needs to be seen after MRI to determine if they should be referred for surgical intervention or be teed up for SCS or referred elsewhere for PRP, then they need to see a physician.


there are some practices in which the APP is the primary pain "specialist" and the physician is a pure interventionalist. i know of these practices. block shop. needle jockey. probably the beset model from a pure financial standpoint. the patients say they dont have a pain doc - they have an APP that sees them, and then the doc is the guy doing the injection.


i use APPs as a physician extender. and this task they can do extremely well.

 

[TeslaCoil]

i do not ever have the patient see the midlevel for initial evaluation. ever.

after that initial appointment, if the patient is appropriate to be seen in follow up by an APP, then i tell the patient that they may be seeing the APP at their follow up.

i dont hold a magic license that says that only I can determine that an MBB had >80% reduction of pain for the appropriate duration of local anesthetic used. anyone who believes that is delusional and egotistical. i also do not need to be in the room to determine if the gabapentin the patient has taken for the past 6 months that the PCP will not prescribe or the PT that helped last year should be refilled.

OTOH, if the patient needs to be seen after MRI to determine if they should be referred for surgical intervention or be teed up for SCS or referred elsewhere for PRP, then they need to see a physician.


there are some practices in which the APP is the primary pain "specialist" and the physician is a pure interventionalist. i know of these practices. block shop. needle jockey. probably the beset model from a pure financial standpoint. the patients say they dont have a pain doc - they have an APP that sees them, and then the doc is the guy doing the injection.


i use APPs as a physician extender. and this task they can do extremely well.

Precisely. Thank you.

 

[SSdoc33]

got it. you are a no opioid provider. must suck for the 82 yo with severe multilevel stenosis non surgical candidate with poor response to epidurals or 89 yo with PVD with recurrent stent/graft complications.

i do envy your practice though.

5mg TID for the LOL with stenosis isnt the issue. neither arethe acute compression fractures. what about a semi-acute disc herniation? chronic myofascial pain? chronic bursitis? its the gray areas. the bargaining. the excuses. the comp and medicaid patients. contracts and pills counts.

it is just a thoroughly draining, non-fulfilling, and burnout-inducing way to practice. plus, we all know opioids dont work for chronic nonmalignant pain.

 

[RoloTomassi]

plus, we all know opioids dont work for chronic nonmalignant pain.

It's funny how we always quote that but most of us practice to the contrary

 

[SSdoc33]

It's funny how we always quote that but most of us practice to the contrary

same reason i let my kid stay up late or let him have ice cream after dinner. sometime its just easier not to fight

 

[MitchLevi]

Dang yall. Chill out.

An MD doesn't need to see every single pt that comes in the clinic.

Modern healthcare unfortunately cannot function without midlevels. There are not enough doctors for that.

Midlevels can EASILY schedule routine procedures FFS.

 

[jsammi245]

I disagree. Not all med mgmt is sleazy. We have very regulated med mgmt. And we have a regular contact at the DEA/DHEC agencies to keep a pulse on how we're doing. We do a healthy amount of med mgmt. Doing opioid ONLY mgmt may be sleazy. I would never EVER "provide opioids only whilst doing injections". And thats illegal btw. Some guy in the midwest lost a 100 million dollar medicare fraud suit for doing just that.

Agreed. Pain is multidisciplinary this includes med management. Just because you don't deal with opioids and do injections doesn't mean you aren't "sleazy". I can't tell you how many "second opinion" referrals I get from other pain providers who had implanted a stimulator, placed vertiflexes did every single bread and butter injections x 5 on a patient and just dumped them. What happens to the patient who fails injections or are not candidates for injections or surgery?

 

[Agast]

same reason i let my kid stay up late or let him have ice cream after dinner. sometime its just easier not to fight

Show me the study that says kids should not be eating ice cream after dinner

 

[manowar rules]

Some of these comments are a little harsh. If you are in an underserved area with constant referrals, it will eventually be impossible to see all pain patients by yourself. In my area, many primary care clinics are being taken over by larger healthcare systems which are severely restricting controlled substances that the PCPs can write, even things like tramadol and Lyrica.

I see nothing wrong with midlevel follow-ups for med mgmt. I actually love when these are on my schedule because it's usually such a quick and easy 99214. The real key, before that can occur, is identifying which patients are the ones who can benefit from opiate therapy. That takes a good medical breadth of knowledge and understanding of psychology (eg weeding out those with self-control issues and poor coping skills) that most midlevels don't have. For that and other reasons, like correlation of imaging with pain, I agree physicians should see all new patients.

But I am not one of those guys who will come in on a Saturday to offload his patient schedule. So if a good midlevel can help out with straightforward follow-ups, I see no issue with that.

 

[MitchLevi]

The PA who works with me can refill meds that I've started, but we're not increasing meds or starting new ones unless that pt sees me in the clinic.

Routine refills shouldn't be done by an MD.

Routine procedures in pts meeting specific criteria are perfectly fine for a midlevel to order and put on my procedure schedule. When they show up for that MBB, if it isn't the correct procedure it's not performed.

Advanced procedures - PA mentions the procedure and if the pt wants to do it he or she is put on my clinic schedule within 1-2w and I see them and schedule the procedure.

If anyone has a problem with this setup, please understand the problem is yours and yours alone.

 

[Ducttape]

What happens to the patient who fails injections or are not candidates for injections or surgery?

they get referred to see me.

 

[smarterchild]

I disagree. Not all med mgmt is sleazy. We have very regulated med mgmt. And we have a regular contact at the DEA/DHEC agencies to keep a pulse on how we're doing. We do a healthy amount of med mgmt. Doing opioid ONLY mgmt may be sleazy. I would never EVER "provide opioids only whilst doing injections". And thats illegal btw. Some guy in the midwest lost a 100 million dollar medicare fraud suit for doing just that.

Just out of curiosity, how were you able to get a contact at the DEA to review things? Is that something any of us can do?

That sounds like a good idea to see how you’re doing relative to other docs.

 

[TeslaCoil]

Just out of curiosity, how were you able to get a contact at the DEA to review things? Is that something any of us can do?

That sounds like a good idea to see how you’re doing relative to other docs.

Yea we just called and asked…

 

[SSdoc33]

The PA who works with me can refill meds that I've started, but we're not increasing meds or starting new ones unless that pt sees me in the clinic.

Routine refills shouldn't be done by an MD.

Routine procedures in pts meeting specific criteria are perfectly fine for a midlevel to order and put on my procedure schedule. When they show up for that MBB, if it isn't the correct procedure it's not performed.

Advanced procedures - PA mentions the procedure and if the pt wants to do it he or she is put on my clinic schedule within 1-2w and I see them and schedule the procedure.

If anyone has a problem with this setup, please understand the problem is yours and yours alone.

IOW: "I am right and nobody else's opinion is correct"

the only person who knows what procedure a patient needs is the experienced proceduralist. not a midlevel, and not a surgeon. no such thing as a "routine" procedure. and no such thing as "specific criteria" for all of the different stuff we do. are you just doing SIJ and ESIs q3 months forever? a patient should be prepared for the nuances of a L5 TFESI vs an ILESI. they should be prepped on what to do after a mbb, and that they shouldnt take a percocet right beforehand. they should have their blood thinners reviews and a discussion on holding them vs. not should take place. they should be made aware of the risks v. benefits.

you can do some of that on injection day, but it is not good practice. but i guess that is just "MY" problem to deal with.

 

[MitchLevi]

IOW: "I am right and nobody else's opinion is correct"

the only person who knows what procedure a patient needs is the experienced proceduralist. not a midlevel, and not a surgeon. no such thing as a "routine" procedure. and no such thing as "specific criteria" for all of the different stuff we do. are you just doing SIJ and ESIs q3 months forever? a patient should be prepared for the nuances of a L5 TFESI vs an ILESI. they should be prepped on what to do after a mbb, and that they shouldnt take a percocet right beforehand. they should have their blood thinners reviews and a discussion on holding them vs. not should take place. they should be made aware of the risks v. benefits.

you can do some of that on injection day, but it is not good practice. but i guess that is just "MY" problem to deal with.

Not worth the debate.

 

[deleted131481]

I've worked with 7 midlevels between fellowship and after with varying levels of experience.

I will not inject someone only seen by a midlevel.

 

[Baron Samedi]

One of my PAs has sent me knee steroid injections on patients with TKAs more than once...

 

[SSdoc33]

Direct injection referrals from midlevels should be the exception, not the rule. Ill still do the shot, but they get it wrong and i have to tweak expectations > half the time

 

[bedrock]

The PA who works with me can refill meds that I've started, but we're not increasing meds or starting new ones unless that pt sees me in the clinic.

Routine refills shouldn't be done by an MD.

Routine procedures in pts meeting specific criteria are perfectly fine for a midlevel to order and put on my procedure schedule. When they show up for that MBB, if it isn't the correct procedure it's not performed.

Advanced procedures - PA mentions the procedure and if the pt wants to do it he or she is put on my clinic schedule within 1-2w and I see them and schedule the procedure.

If anyone has a problem with this setup, please understand the problem is yours and yours alone.

For those of us who don't do med management, the best use of a PA is to see all the new patients without MRI/PT. This is how I structured things in my practice. Any patient without an MRI in past 3 years or PT/chiro in the past 2 years is scheduled with my PA, who orders both and then the patient sees me the physician, once they have those things and I can actually do something to help them.

My PA also sees all the post MBB patients to document % relief etc, and other simple followups.

Agree that routine refills can definitely be done by a PA.

I completely disagree with having PAs order procedures. It will enrich you because the PA will be wrong much of the time, and so you'll have to do another (correct) procedure later. I have seen so many wrong procedures ordered by PAs I can't keep track.

IOW: "I am right and nobody else's opinion is correct"

the only person who knows what procedure a patient needs is the experienced proceduralist. not a midlevel, and not a surgeon. no such thing as a "routine" procedure. and no such thing as "specific criteria" for all of the different stuff we do. are you just doing SIJ and ESIs q3 months forever? a patient should be prepared for the nuances of a L5 TFESI vs an ILESI. they should be prepped on what to do after a mbb, and that they shouldnt take a percocet right beforehand. they should have their blood thinners reviews and a discussion on holding them vs. not should take place. they should be made aware of the risks v. benefits.

you can do some of that on injection day, but it is not good practice. but i guess that is just "MY" problem to deal with.

agree

 

[SSdoc33]

Its a good point about the lack of
of workup. All new patients dont necessarily need to be seen by the doc, esp acute strains, ER referrals, etc.

 

[MitchLevi]

I have seen so many wrong procedures ordered by PAs I can't keep track.

...but pain doctors don't do that.

 

[deleted131481]

...but pain doctors don't do that.

Hopefully you do it less than your mid-levels.

 

[MitchLevi]

Hopefully you do it less than your mid-levels.

The enemy of good is perfect, and we're talking about a field of medicine whose doctors already don't agree on any one topic.

Opinions are all over the place about the most trivial ways to manage pts and you have a problem with a PA ordering an L4-S1 MBB when Mrs Smith has LBP with facet loading and moderate-severe spondylosis?

Please...