Is outpatient really that bad?

[PikminOC]

Would love to see a GI doc in the ED. Let them triage the crowd that they condemn to hospital purgatory...pt is too sick to scope or not sick enough to scope -- they may be bleeding from their whatever but either way GI can't scope any time soon.

He did it during COVID to get paid. He is board certified in Im also. As are most Gi doctors. He did fine and is glad to be back to gi now. He did em, not GI in the er.

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[PikminOC]

So I assume someone has brought this up. What does CMS say? Trying to kill private practice?

Yes they are always trying to kill private practice. Government wants everyone in corporate

 

[PikminOC]

I dont have my finger to the pulse of other specialties, but at least with regards to hospital medicine- you can take any salary survey across any 10-20 year range since the 90s and you'll find that our salaries have risen by close to double the rate of inflation. 200k in 2005 is 313k today, which happens to be right around the nation wide average total compensation. Obviously I don't think this that rate is sustainable. I also do think that trend has decelerated since 2020 and future surveys will probably show some flattening, but for now it's tough to argue with these strong numbers.

I do think that comparison is the thief of joy.
It was particularly frustrating in March 2020 when my spouse who is in health care was the only one of their friend group to have been furloughed. The rest are in sales, marketing, business, finance, tech, law. Most of them are in the 150-250k range. They've been making 6 figures since their mid 20s. They were all thriving working from home spending all the time in the world with their kids while I was changing in the garage and took a full shower before I could even see mine. But it doesn't take more than looking at the wide layoffs in tech this past year to appreciate the utter rock solid job security. My dad's a software engineer, his salary is probably on par with a hospitalist except he only had to get a bachelor's degree to make it. But every single year since I've known him, it's always been "this is the year I'll be laid off". Ageism is also a huge issue in tech, and he's always mentioned how difficult to impossible it would be to find a job at his age. Ask your older non medical friends what is was like to live through 2008-2010 and youll get some perspective. I feel fortunate that layoffs in medicine are virtually unheard of and age/experience aren't a liability.

I will say what I appreciate financially about this job is the ability to dial in exactly what I want to make. If I want to make an extra 100k, all I have to do is pick up 3-4 extra shifts a month. want to make an extra 100k in any of those other fields? you'll need to switch jobs or get a promotion.

If any doc is making more year after year it's because the hospital is squeezing more work out of them, having they supervise more midlevels, etc. It's not out of cola

 

[Nocturnist]

If any doc is making more year after year it's because the hospital is squeezing more work out of them, having they supervise more midlevels, etc. It's not out of cola

Not the case at all, at least in my experience.
When I first started 7 years ago, rounder censuses were 20-22, now the department's stated target is 12-14. As far as us nocturnists, our productivity thresholds for bonusing have been significantly reduced through the years to account for non productive time such as cross coverage. As a result my productivity bonuses have more than doubled. To that extent, we've also hired signficant midlevel support to handle most of our cross coverage, death pronouncements, triage etc so there is much less scut than when i started.

Perhaps other hospitalists can chime in as well, but competition for hospitalists is so fierce, I suspect you'll find any hospital that tries to squeeze more work has found out pretty quickly nobody wants to work there.

 

[Splenda88]

Not the case at all, at least in my experience.
When I first started 7 years ago, rounder censuses were 20-20, now the department's stated target is 12-14. As far as us nocturnists, our productivity thresholds for bonusing have been significantly reduced through the years to account for non productive time such as cross coverage. As a result my productivity bonuses have more than doubled. To that extent, we've also hired signficant midlevel support to handle most of our cross coverage, death pronouncements, triage etc so there is much less scut than when i started.

Perhaps other hospitalists can chime in as well, but competition for hospitalists is so fierce, I suspect you'll find any hospital that tries to squeeze more work has found out pretty quickly nobody wants to work there.

I agree. Census at my place is ~17 average now and the people that have been there for 5+ years told me it used to be 20+ most of the time. Once census is >18, they start calling other hospitalist for help.

If one listens to the over exaggeration in SDN, you will never become a hospitalist.

Competition is fierce now. I got a 20k raise in May of this year and I am already asking them for another 20k while I am spreading rumors that I might quit (they called me out on my bluff by the way. Lol).

My lifestyle is good. Got to my job by 7:15 am and I am home most of the time before 5 pm. The job itself is 6-7 hrs and the of the time is spent horsing around.

For people here that are on the fence about HM, try for a year first and if you don't like it, go on and do a fellowship.

 

[end stage fibro]

So I assume someone has brought this up. What does CMS say? Trying to kill private practice?

People bring it up all the time. Essentialy, only the American Hospital Association and ilk want more payments for the hospital, this is an example why. I am actually not sure what CMS says exactly (searching their archives is annoying, though I am kinda curious now so I will edit this if i check). the gist of it is that HOPDs have more financial and regulatory overhead and therefore should get higher payments. this is probably true, but what is going on now is a bastardized version of that. MedPAC, a governmental body that advises congress on issues related to CMS, has for YEARS said that site neutral payments are the way to go to no avail.

the cynics among us might say that this is a plot by the medical Illuminati to kill private practice and siphon money from physicians -->MBAs. and i am a cynic...

 

[end stage fibro]

right on. the Managed Medicaid or Medicare usually pays 100%+ for me but that's only because I am part of a large IPA that negotiated top rates for serving the "underserved communities."

but for some physicians who do not have such collective bargaining power and "went at it alone" they may get far less than the Medicare rate for the "private" insurances

here in NYS (though I am sure this must be the same in all stats), straight Medicaid pays $70 or so for 99213 while Medicare will allow $106 or something for 99213 (along with the 20% copay)

but the straight Medicaid used to be $30 for 99213 last year. I am not exactly sure why it increased by more than double. but one can see how straight medicaid paid peanuts before.

NYS was one of the 4 states that I know where medicaid blows. didn't realize there was an increase in payments.

 

[NewYorkDoctors]

NYS was one of the 4 states that I know where medicaid blows. didn't realize there was an increase in payments.

it did happen last year and coincidentally occurred when there was a large influx of new....... permanent residents lol....

wont get too political. but needless to say all of the new.... permanent residents.... all get managed medicaid haha.

the elephant on the right shoulder tells me - that is so unfair to those with commercial insurance and middle class and have to pay for their high deductible plans
the donkey on the left shoulder tells me - you get paid more now (indirectly that is) so pipe down

this i why I will never enter politics. I am compromised.


addendum: on a follow up, new york state medicaid (whether straight Medicaid or managed medicaid only) formulary is set now such that a lot of things are fully covered now with no PA.
If you were curious you can check this link

Medicaid Member Portal

member.emedny.org

for pulmonary things like Nucala, Dupixent, Fasenra, are all no PA. just prescribe and itll be covered. for these medicadi or managed medicaid patients they have ZERO COPAY.
it's also easier to get Trelegy ellipta than it is breo or arnuity ellipta.
for Ofev it is no PA either and fully 100% covered.

Ozempic is also no PA now and fully free. it's flying off the shelf for off label weight loss. though those patients are NOT learning good eating habits or engaging in daily exercise (which can be as simple as walking over 10,000 steps a day. heck i put a pedometer on myself and i average 15,000 a day right now and I have an 80 hour a week job) to sustain the weight management.. but I digress.

isn't free stuff great?

 

[PikminOC]

Not the case at all, at least in my experience.
When I first started 7 years ago, rounder censuses were 20-22, now the department's stated target is 12-14. As far as us nocturnists, our productivity thresholds for bonusing have been significantly reduced through the years to account for non productive time such as cross coverage. As a result my productivity bonuses have more than doubled. To that extent, we've also hired signficant midlevel support to handle most of our cross coverage, death pronouncements, triage etc so there is much less scut than when i started.

Perhaps other hospitalists can chime in as well, but competition for hospitalists is so fierce, I suspect you'll find any hospital that tries to squeeze more work has found out pretty quickly nobody wants to work there.

The hospitals I see just keep hiring more midlevels since they are cheaper

 

[dozitgetchahi]

I see these Bs patients also for cpet proven anxiety dyspnea whose pmd keep gaslighting then to come back to see me . If I decline they got nuts and threaten to review bomb me (to which I said I’ll just community note review you back try it lol ) .

But rather than be antagonistic I tell them let’s email all the time in my hipaa secure email server. Then I bombard them with “helpful update patient education,” YouTube links , joe Rogan links (lol) until I thoroughly exhaust them . I have gotten some people to stop bothering me as a result

This is what the step 1 usmle board question answer of “establish frequent visits “ means lol

In my large multispecialty group, the vast majority of physicians refuse all outside Medicaid referrals (they’re supposed to take any internal Medicaid referrals that come along, but most of them try their best to get out of those too). Now it’s pretty clear to me why they were doing that. After having been here for a while, I’ve come to realize that group doesn’t care if Medicaid patients complain, especially when their complaints are generally complete poppycock. So I have no qualms with blocking Medicaid referrals. Everyone else is doing it too.

 

[dozitgetchahi]

Mid levels as physician extenders : do ancillary supportive things for example for us in Onc , chemotherapy education/ consent, followup on some patient calls to triage their need to be seen in clinic, see simple anemia followups to make space in our schedule for new cancer patients that need to be seen asap, as we nor the patients (with cancer) have a luxury to wait as they do for other specialist with 6-9 months wait times, to see a rheum for positive ANA or neuro for headache etc

Mid levels as physician replacement: nope, not happening, cant compete.

They have their role, need to be utilized in a way that makes your life easier as a physician while providing better and more comprehensive care for the patient.

My 2 cents…

Rheumatology here.

If you’re sick and you have lupus, vasculitis, bad RA, etc etc (hell even a nasty gout flare), I’ll see you this week. Often, same day.

Those bull**** ANA referrals you guys in onc love to chuck our way? They’re waiting 6 months.

The silly ANA consult is our equivalent of the “simple anemia patient” (or maybe even less than that, given that the anemia patient actually has something wrong with them other than a lab value of often dubious significance). A nasty case of lupus is often every bit as threatening as cancer, and we (or at least I) don’t sleep on it.

 

[Drrrrrr. Celty]

The hospitals I see just keep hiring more midlevels since they are cheaper

Administrators unfortunately have no idea what they're doing. They increasingly see the hospitalist as a field ripe for terraforming. They see the resident - attending model and think that's reproducible here and they see hospitalists are just referratologists which can be reproduced in less complex patients by NPs.

 

[PikminOC]

Administrators unfortunately have no idea what they're doing. They increasingly see the hospitalist as a field ripe for terraforming. They see the resident - attending model and think that's reproducible here and they see hospitalists are just referratologists which can be reproduced in less complex patients by NPs.

Bean counters just looking at 💰💰💰

 

[hotsaws]

Rheumatology here.

If you’re sick and you have lupus, vasculitis, bad RA, etc etc (hell even a nasty gout flare), I’ll see you this week. Often, same day.

Those bull**** ANA referrals you guys in onc love to chuck our way? They’re waiting 6 months.

The silly ANA consult is our equivalent of the “simple anemia patient” (or maybe even less than that, given that the anemia patient actually has something wrong with them other than a lab value of often dubious significance). A nasty case of lupus is often every bit as threatening as cancer, and we (or at least I) don’t sleep on it.

I always feel guilty about these. In fellowship, most allergists wouldn't order much of a lab work up for chronic spontaneous urticaria. In PP, because of the customer service nature of things, most of us send of a lab panel. In that panel, there is typically an ANA w/ reflex buried in there. Frankly, I could take it out each time, but I'm getting busy and it's much simpler to just go with the standard panel for our group. Every now and then we get some low titer ANA that I know is generally meaningless in this clinical context. Anyways, off to rheum you go to bless away the liability from me. Realistically, though, being that I am a subspecialists, I don't actually make any formal referral. I document my recommendation but I have a very frank discussion with the patient about how I think Rheum is most likely just going to reassure you that this is a irrelevant finding and nothing else needs to be done....so at least I set the stage.

It is interesting how patients with weeks to months of spontaneous hives want a whole bunch of testing even if I tell them it's very likely idiopathic and you just need a high dose of generic antihistamine. 9.9/10 want testing panels.

 

[NewYorkDoctors]

Rheumatology here.

If you’re sick and you have lupus, vasculitis, bad RA, etc etc (hell even a nasty gout flare), I’ll see you this week. Often, same day.

Those bull**** ANA referrals you guys in onc love to chuck our way? They’re waiting 6 months.

The silly ANA consult is our equivalent of the “simple anemia patient” (or maybe even less than that, given that the anemia patient actually has something wrong with them other than a lab value of often dubious significance). A nasty case of lupus is often every bit as threatening as cancer, and we (or at least I) don’t sleep on it.

hey look what showed up in my inbox ..lol

I get this panel for patients with Usual Interstitial Pneumonia. I explained to this patient that 1:80 is not clinically significant. I state the lab marks anything "not perfect" as red so they don't get into trouble. The patients seem to buy this explanation.

I tried to explain how 5% of the population might normally get ANA up to 1:320 and how you would need more ACR criteria to get a diagnosis of SLE... but this flies over most patient's heads.

For this patient I said rheumatology cannot help you in this case. Take the Ofev now.

 

[dozitgetchahi]

I always feel guilty about these. In fellowship, most allergists wouldn't order much of a lab work up for chronic spontaneous urticaria. In PP, because of the customer service nature of things, most of us send of a lab panel. In that panel, there is typically an ANA w/ reflex buried in there. Frankly, I could take it out each time, but I'm getting busy and it's much simpler to just go with the standard panel for our group. Every now and then we get some low titer ANA that I know is generally meaningless in this clinical context. Anyways, off to rheum you go to bless away the liability from me. Realistically, though, being that I am a subspecialists, I don't actually make any formal referral. I document my recommendation but I have a very frank discussion with the patient about how I think Rheum is most likely just going to reassure you that this is a irrelevant finding and nothing else needs to be done....so at least I set the stage.

It is interesting how patients with weeks to months of spontaneous hives want a whole bunch of testing even if I tell them it's very likely idiopathic and you just need a high dose of generic antihistamine. 9.9/10 want testing panels.

I actually don’t mind the urticaria and previously mentioned UIP consults - they’re interesting and I’m often able to be helpful. My local pulms send me a lot of ILD situations and I’m very happy to evaluate them.

Hematology, on the other hand…hematologists have a habit (in my experience) of attributing anemia, leukopenia, etc etc to autoimmunity whenever they run out of ideas. Patient has consistently had a plt of 110 for years and has a 1:40 ANA…time to declare in the note that this must be “autoimmune”, and off to rheumatology the patient goes. At least 80% of the time (in my experience), it isn’t. (Never mind that in the 2019 ACR SLE criteria, your platelet count needs to dip below 100 to even tick the box for “thrombocytopenia”. Chronic plt count of 120-130, like a patient I saw the other day, means no dice.)

I actually am really happy to see most rheum consults from subspecialists because they’re often very legit in terms of pathology. With heme, though…the batting average is usually really low.

 

[futureapppsy2]

It's crazy how we always seem to ask, "Which is the lesser of all the evils, which will I hate the least?!"

Does anybody like this profession?

Does anyone like any job? As my parents always say, "it's called work for a reason."

 

[gutonc]

I actually don’t mind the urticaria and previously mentioned UIP consults - they’re interesting and I’m often able to be helpful. My local pulms send me a lot of ILD situations and I’m very happy to evaluate them.

Hematology, on the other hand…hematologists have a habit (in my experience) of attributing anemia, leukopenia, etc etc to autoimmunity whenever they run out of ideas. Patient has consistently had a plt of 110 for years and has a 1:40 ANA…time to declare in the note that this must be “autoimmune”, and off to rheumatology the patient goes. At least 80% of the time (in my experience), it isn’t. (Never mind that in the 2019 ACR SLE criteria, your platelet count needs to dip below 100 to even tick the box for “thrombocytopenia”. Chronic plt count of 120-130, like a patient I saw the other day, means no dice.)

I actually am really happy to see most rheum consults from subspecialists because they’re often very legit in terms of pathology. With heme, though…the batting average is usually really low.

I so rarely refer to rheum (I think I can count on 3 fingers the number of times it's happened in the last 11 years) that I can't quite understand this.

That said, I saw a patient in f/u this week (new to me, but seen by the practice in the past) who was referred to both us and rheum by PCP for Hgb of 11, new diffuse arthralgias and elevated ESR/CRP. Heme w/u negative by us except for the elevated ferritin and haptoglobin. Rheum went big and SSA/Ro, ANA were high and CCP was 270. Recommended sulfasalazine (because she refused steroids and biologics and wasn't a candidate for MTX because she drinks a bottle or 3 of wine daily. She came back to me to complain about all the side effects of sulfasalazine she read about and then she and her gym-bro son went on an anti-vax tirade blaming her COVID booster for this and demanded that I come up with solutions for them.

My solution was to discharge from clinic and suggest follow up with her PCP and maybe rheum...but I felt bad about that one.

 

[DrMetal]

I so rarely refer to rheum

And nor does anyone else. But, at least they're trained internists. You know a subspecialty is in trouble when they revert back to doing general IM (or hospitalist).

Now neurology, there's a truly worthless specialty.

 

[Splenda88]

And nor does anyone else. But, at least they're trained internists. You know a subspecialty is in trouble when they revert back to doing general IM (or hospitalist).

Now neurology, there's a truly worthless specialty.

I know one that does both general IM and rheum. I have not seen rheum doing hospital medicine (HM). However, I know 2 nephrologists that are doing HM exclusively

 

[Drrrrrr. Celty]

I know one that does both general IM and rheum. I have not seen rheum doing hospital medicine (HM). However, I know 2 nephrologists that are doing HM exclusively

I honestly don't know what to think about Nephro anymore.
My friend out of fellowship is signed out with a PP with a solid start and then likely will make 400k+ a year in 3-5 years.

Alternatively I am seeing Nephros absolutely destroyed in the game.

 

[Splenda88]

I honestly don't know what to think about Nephro anymore.
My friend out of fellowship is signed out with a PP with a solid start and then likely will make 400k+ a year in 3-5 years.

Alternatively I am seeing Nephros absolutely destroyed in the game.

Wait until he/she makes partner... which might never happen.

 

[MD46]

Rheumatology here.

If you’re sick and you have lupus, vasculitis, bad RA, etc etc (hell even a nasty gout flare), I’ll see you this week. Often, same day.

Those bull**** ANA referrals you guys in onc love to chuck our way? They’re waiting 6 months.

The silly ANA consult is our equivalent of the “simple anemia patient” (or maybe even less than that, given that the anemia patient actually has something wrong with them other than a lab value of often dubious significance). A nasty case of lupus is often every bit as threatening as cancer, and we (or at least I) don’t sleep on it.

Well if we have a neutropenia patient, panel will include RA and ANA with reflex.

Mostly in the african american demographic patients may have a benign ethnic neutropenia which is a diagnosis of exclusion.

If ANA is anything above 1:640, I recommend to PCP to consider a referral to Rheum, its still at their discretion.

Anything less than that, I usually repeat ANA one more time and just monitor ANC unless it really starts to trend in the wrong direction.

Also my point was Oncology vs Rheum, over all we have a more sicker population with life threatening things going on that require more immediate attention hence cant punt things like a new DLBCL , Small cell etc etc .

 

[DrMetal]

I know one that does both general IM and rheum. I have not seen rheum doing hospital medicine (HM). However, I know 2 nephrologists that are doing HM exclusively

Yeah, again, that's when you know a subspec is in trouble. Do you ever see a Cardiologist or a GI practicing GIM, or HM? Nope. Although who knows, maybe those days are coming. It also depends on your geography of course. Here in SoCal, you throw a rock on the beach and you hit a subspecialist. It's so saturated.

Rheumatology here.

If you’re sick and you have lupus, vasculitis, bad RA, etc etc (hell even a nasty gout flare), I’ll see you this week. Often, same day.

Never in my life have I seen a Rheum see a patient same day. No matter. I'm a doctor. I can and will write for Solumedrol or PO Prednisone.

 

[BicepsTriceps]

I honestly don't know what to think about Nephro anymore.
My friend out of fellowship is signed out with a PP with a solid start and then likely will make 400k+ a year in 3-5 years.

Alternatively I am seeing Nephros absolutely destroyed in the game.

Probably working 60+ hours a week.

Nephrologist at my hospital makes close to 400k.

He works two weeks of inpatient a month 24/7 on call then Monday - Friday clinic the other two weeks.

They're over worked for sure.

 

[Splenda88]

Probably working 60+ hours a week.

Nephrologist at my hospital makes close to 400k.

He works two weeks of inpatient a month 24/7 on call then Monday - Friday clinic the other two weeks.

They're over worked for sure.

I will stick with HM. That's a lot of work.

 

[NewYorkDoctors]

Probably working 60+ hours a week.

Nephrologist at my hospital makes close to 400k.

He works two weeks of inpatient a month 24/7 on call then Monday - Friday clinic the other two weeks.

They're over worked for sure.

see Nephro is Dead thread.

basically there are easier ways to grind out money. If one is going to grind that hard, one should expect closer to 7 figures (for real)

also not every graduating nephrologist has access to that "rare commodity" of ESRD patients. hence not every nephrologist can be successful with high volumes like that

 

[Drrrrrr. Celty]

Yeah, again, that's when you know a subspec is in trouble. Do you ever see a Cardiologist or a GI practicing GIM, or HM? Nope. Although who knows, maybe those days are coming. It also depends on your geography of course. Here in SoCal, you throw a rock on the beach and you hit a subspecialist. It's so saturated.



Never in my life have I seen a Rheum see a patient same day. No matter. I'm a doctor. I can and will write for Solumedrol or PO Prednisone.

The amount of people who won't though is pretty high.

Honestly in my community I've had people refuse to do even the most basic of medicine because "they've referred". I have patients who go to their PCPs and are told they won't give them a 1 month refill of meds because "it's endo's job" or will notice the patient had discontinued medications and not advise them to talk to us or restart it.

 

[NewYorkDoctors]

The amount of people who won't though is pretty high.

Honestly in my community I've had people refuse to do even the most basic of medicine because "they've referred". I have patients who go to their PCPs and are told they won't give them a 1 month refill of meds because "it's endo's job" or will notice the patient had discontinued medications and not advise them to talk to us or restart it.

lol. yeah that happens a lot.

in my consult notes I usually write something like

"COPD - stable without exacerbations or increasing symptom burden. c/w Anoro Ellipta - 5 refills provided.
If stable, then the next visit will be during annual lung cancer screening in one year.
Can RTC PRN if symptoms worsen and patient will be plugged in right away. I informed patient not to bother PMD for these issues if acute worsening. Otherwise, is stable PMD can renew Anoro Ellipta for the patient later on if no issues."

if I write and send something clear cut and the PMD still gaslights the patient into returning, then I know the PMD does not read notes (or the PMD secretaries are quite bad and do not upload notes.... with many older non tech saavy doctors around now it happens...)"

while some private pulms like to get these stable easy patients in every 3 months for a checkup and PFT (and insurance will pay for it), I would like to move onto the next new patient who actually needs the help (and make money helping out someone new)

 

[Drrrrrr. Celty]

lol. yeah that happens a lot.

in my consult notes I usually write something like

"COPD - stable without exacerbations or increasing symptom burden. c/w Anoro Ellipta - 5 refills provided.
If stable, then the next visit will be during annual lung cancer screening in one year.
Can RTC PRN if symptoms worsen and patient will be plugged in right away. I informed patient not to bother PMD for these issues if acute worsening. Otherwise, is stable PMD can renew Anoro Ellipta for the patient later on if no issues."

if I write and send something clear cut and the PMD still gaslights the patient into returning, then I know the PMD does not read notes (or the PMD secretaries are quite bad and do not upload notes.... with many older non tech saavy doctors around now it happens...)"

while some private pulms like to get these stable easy patients in every 3 months for a checkup and PFT (and insurance will pay for it), I would like to move onto the next new patient who actually needs the help (and make money helping out someone new)

That's the thing that bothers me tbh. When I get a nothing burger that is set back because their PCP didn't care and then I don't get to take care of someone new who needs it.

 

[NewYorkDoctors]

That's the thing that bothers me tbh. When I get a nothing burger that is set back because their PCP didn't care and then I don't get to take care of someone new who needs it.

not to bash all PMDs as there are a lot of good ones out there. i am certain the vast majority of PMDs are preventing most of the "garbage" from reaching the subspecialists. but for those "needy" patients who demand a subspecialist... it would be nice if the PMD send an actual referral note stating

"this is probably nothing. but the patient insist on seeing you. this is what I did so far. thank you for your help."

that would set the stage better for more reassurance

most of the referrals I get have NOTHING sent in my PMD. i dont reall need PMD notes (as those are pretty bland and pointless) but some work would be fine.

the patients dont bring anything and tell me to "check the computer." Although I am not linked up in a network, I have access to the vast majority of the major hospital networks in NYC (affiliation with multiple hospital groups) which gives me EMR access to most of the patients who live in the local underserved area I work in, the local lab provider portal to search labs, and the local radiology portals for imaging.

but I am doing resident level prep work most of the time... that's how I do a better consult


when I refer out (whether as PMD or specialist to cardiology or something), you bet im sending my note with rationale of why as well as all of my workup. it's always satisfying when I approach an undifferentiated dyspnea first and have ruled out all pulmonary disease and refer to cardiology with my note, imaging reports, PFTs, EKG stress test and CPET test and say "yep its definitely cardiovascular limitation. thanks!"

 

[gutonc]

not to bash all PMDs as there are a lot of good ones out there. i am certain the vast majority of PMDs are preventing most of the "garbage" from reaching the subspecialists. but for those "needy" patients who demand a subspecialist... it would be nice if the PMD send an actual referral note stating

"this is probably nothing. but the patient insist on seeing you. this is what I did so far. thank you for your help."

that would set the stage better for more reassurance

^This (which I used to get from a couple of the PCPs in my last job), or a phone call/InBasket/E-consult asking what workup I'd recommend or if they need to see me or have more workup at all. I like an easy boat payment as much as the next doc, but a lot of times it's just a waste of time and money for the patient and can prevent me from seeing someone who really needs to be seen urgently.

In my new position, it's pretty typical to have patients drive 50-150 miles to see me (I'm the only hem/onc in a roughly 5000 sq mile area and the next closest are 60 miles West, 150 miles South, 200 miles East and 125 miles North. For a benign heme issue, it would be nice if I could have them get local labs and then just do virtual visits (or none at all) and save them a bunch of time and money.

 

[Osteoth]

^This (which I used to get from a couple of the PCPs in my last job), or a phone call/InBasket/E-consult asking what workup I'd recommend or if they need to see me or have more workup at all. I like an easy boat payment as much as the next doc, but a lot of times it's just a waste of time and money for the patient and can prevent me from seeing someone who really needs to be seen urgently.

In my new position, it's pretty typical to have patients drive 50-150 miles to see me (I'm the only hem/onc in a roughly 5000 sq mile area and the next closest are 60 miles West, 150 miles South, 200 miles East and 125 miles North. For a benign heme issue, it would be nice if I could have them get local labs and then just do virtual visits (or none at all) and save them a bunch of time and money.

If you put anything in the EMR about the visit maybe not being necessary insurance might catch it and not cover the visit.

If we call it’s likely going to the secretary then you’re playing telephone.

Even for consultants I know, in a typical week you’re sending so much stuff all over it’s hard to not only get it through but also communicate directly.

 

[NewYorkDoctors]

this is an EOB from one a mid 30s male I see for primary care (son of an older patient with CAD, COPD, CHF, CKD, etc...) who has obesity and hypertension (secondary causes ruled out, has moderate OSA but opted for weight management) who used the Noom app, got a pedometer to get those steps up, and did some gym work. No GLP1 agonists or sympathomimetics required and lost 30 lbs over 1 year. A lot of talking was required. I did most of this via email. Why?

it would have been a big waste of office time as you see. He has a work sponsored commercial insurance and he reports he bought the "cheapest one to save money."
the home sleep study I performed for her was not even covered by this insurance. He refused going to an in center sleep lab and I would have never been able to figure that part out. in fact one of the biggest barriers to OSA diagnosis is how many patients just refuse to go to an in lab sleep center.

 

[gutonc]

If you put anything in the EMR about the visit maybe not being necessary insurance might catch it and not cover the visit.

I'm not an idiot. Once you're in my office, I'm going to do what needs to be done. It's usually nothing (I fix about 75% of my "pancytopenia, r/o leukemia" consults with a repeat CBC before I even walk in the room.

If we call it’s likely going to the secretary then you’re playing telephone.

Not in my office. A physician calls for anything, they pull me from a room or send it straight to my phone if I'm not in the office.

Even for consultants I know, in a typical week you’re sending so much stuff all over it’s hard to not only get it through but also communicate directly.

It certainly helps if you're all in the same EMR. But I give my # to any physician I come in contact with and have told my staff to do the same.

I get that it's easy to just turf this stuff to someone else, but that's not always the best thing for the patient.

 

[Splenda88]

Hospitalist compensation: early data from our 2023 survey

Hospitalist compensation is still going up; data on nonacademic adult hospitalists to pediatric hospitalists.

www.todayshospitalist.com

That is in line with where the market is right now. But I want them to pay at least 400k/yr.

 

[CCM-MD]

Hospitalist compensation: early data from our 2023 survey

Hospitalist compensation is still going up; data on nonacademic adult hospitalists to pediatric hospitalists.

www.todayshospitalist.com

That is in line with where the market is right now. But I want them to pay at least 400k/yr.

Looks like $ dropped for hospitalists employed by corporate groups and hospitals, which probably represents majority of hospitalists. This fits with the general trend and saturation in my area. Something to watch, I wouldn't be surprised if it continues. The rise seems to be coming from private primary care/multispecialty groups (surprised this model still exists) and academics, which may be a sampling error. The university in my city pays hospitalists a base of 190k for 1.0 FTE. $290k seems very high for academia, maybe BFE type places are offering that.

Depending on group type, hospitalists saw big ups and downs in pay

A look at the winners and losers when it comes to pay over the year among hospitalists working for different types of groups.

www.todayshospitalist.com

 

[Splenda88]

Looks like $ dropped for hospitalists employed by corporate groups and hospitals, which probably represents majority of hospitalists. This fits with the general trend and saturation in my area. Something to watch, I wouldn't be surprised if it continues. The rise seems to be coming from private primary care/multispecialty groups (surprised this model still exists) and academics, which may be a sampling error. The university in my city pays hospitalists a base of 190k for 1.0 FTE. $290k seems very high for academia, maybe BFE type places are offering that.

View attachment 376193

Depending on group type, hospitalists saw big ups and downs in pay

A look at the winners and losers when it comes to pay over the year among hospitalists working for different types of groups.

www.todayshospitalist.com

I just need another 8-10 yrs. My eyes are on the FI of FIRE

Base of 190k w/ no RVUs?

 

[chessknt]

I just need another 8-10 yrs. My eyes are on the FI of FIRE

Base of 190k w/ no RVUs?

Don't you have kids? You think you can hit FI with all of family's health insurance covered? Including college in that too?

 

[Splenda88]

Don't you have kids? You think you can hit FI with all of family's health insurance covered? Including college in that too?

I will not retire. I like HM, so I will work PT (7-8 days/month) and many HM jobs offer Insurance to part time employees.

I have two kids and I plan to save ~150k for each by the time they finish HS. The plan is for them to do 2-yr CC and 2-yr state university.

I did that and paid out of my own pocket working FT at a grocery store, and things turn out ok at the end.

 

[chessknt]

I will not retire. I like HM, so I will work PT (7-8 days/month) and many HM jobs offer Insurance to part time employees.

I have two kids and I plan to save ~150k for each by the time they finish HS. The plan is for them to do 2-yr CC and 2-yr state university.

I did that and paid out of my own pocket working FT at a grocery store, and things turn out ok at the end.

Ah makes sense now that I re-read your post on the FI only part. Agree with the kids college part although your target is much higher than mine, if I get to 100k by accident by the time they are ready then good for them.

 

[CCM-MD]

I just need another 8-10 yrs. My eyes are on the FI of FIRE

Base of 190k w/ no RVUs?

No productivity. One gets the honor of being assistant professor instead and honor of having residents.

Agree with the FI sentiment. I’m 2 years away from my number. No kids yet but plan on having. Goal is transition to VA or academics at less than full time.

 

[bronx43]

Looks like $ dropped for hospitalists employed by corporate groups and hospitals, which probably represents majority of hospitalists. This fits with the general trend and saturation in my area. Something to watch, I wouldn't be surprised if it continues. The rise seems to be coming from private primary care/multispecialty groups (surprised this model still exists) and academics, which may be a sampling error. The university in my city pays hospitalists a base of 190k for 1.0 FTE. $290k seems very high for academia, maybe BFE type places are offering that.

View attachment 376193

Depending on group type, hospitalists saw big ups and downs in pay

A look at the winners and losers when it comes to pay over the year among hospitalists working for different types of groups.

www.todayshospitalist.com

My previous fakedemic institution is probably paying close to that 290k range but that’s with a ton of extra shifts.

But overall I agree with the general downward trend for HM. Fakdemia is usually a few years behind the market, so once hospital medicine gets squeezed by the hospital admin and staffing companies, then they too will shift gears and drop pay.

 

[dozitgetchahi]

not to bash all PMDs as there are a lot of good ones out there. i am certain the vast majority of PMDs are preventing most of the "garbage" from reaching the subspecialists. but for those "needy" patients who demand a subspecialist... it would be nice if the PMD send an actual referral note stating

"this is probably nothing. but the patient insist on seeing you. this is what I did so far. thank you for your help."

that would set the stage better for more reassurance

most of the referrals I get have NOTHING sent in my PMD. i dont reall need PMD notes (as those are pretty bland and pointless) but some work would be fine.

the patients dont bring anything and tell me to "check the computer." Although I am not linked up in a network, I have access to the vast majority of the major hospital networks in NYC (affiliation with multiple hospital groups) which gives me EMR access to most of the patients who live in the local underserved area I work in, the local lab provider portal to search labs, and the local radiology portals for imaging.

but I am doing resident level prep work most of the time... that's how I do a better consult


when I refer out (whether as PMD or specialist to cardiology or something), you bet im sending my note with rationale of why as well as all of my workup. it's always satisfying when I approach an undifferentiated dyspnea first and have ruled out all pulmonary disease and refer to cardiology with my note, imaging reports, PFTs, EKG stress test and CPET test and say "yep its definitely cardiovascular limitation. thanks!"

You can tell when the PCP is thoughtful and gives a damn (they include all that stuff in the referral) vs when they’re asleep at the wheel and/or are just dumping an issue they don’t want to deal with or put more effort into (none of those things are included).

I’ve lost count of the number of times I’ve gotten a referral with a PCP note that doesn’t even mention the referral, and half the time doesn’t even discuss the issue they referred the patient for! Useless.

 

[NewYorkDoctors]

You can tell when the PCP is thoughtful and gives a damn (they include all that stuff in the referral) vs when they’re asleep at the wheel and/or are just dumping an issue they don’t want to deal with or put more effort into (none of those things are included).

I’ve lost count of the number of times I’ve gotten a referral with a PCP note that doesn’t even mention the referral, and half the time doesn’t even discuss the issue they referred the patient for! Useless.

yeah i find that behavior inexcusable. the PMD was too lazy to tell his/her secretary to write a basic slip and fax some stuff
10 cents a page whoa.. that'll really break the bank for efax
use the free doximity efax sheesh.

i tell most patients NEVER go see an OLDER doctor unless its an academic doctor for a rare disease or a surgeon/proceduralist whose hands on experience matters.

seeing a nonprocedural physician and non academic physician for "experience" is useless most of the time. The only "experience" is how to take shortcuts to get home on time to do non-medical work lol

 

[Osteoth]

yeah i find that behavior inexcusable. the PMD was too lazy to tell his/her secretary to write a basic slip and fax some stuff
10 cents a page whoa.. that'll really break the bank for efax
use the free doximity efax sheesh.

i tell most patients NEVER go see an OLDER doctor unless its an academic doctor for a rare disease or a surgeon/proceduralist whose hands on experience matters.

seeing a nonprocedural physician and non academic physician for "experience" is useless most of the time. The only "experience" is how to take shortcuts to get home on time to do non-medical work lol

Can’t blame them. The system is broken, the promises unkept.

No doctors I talk to have a positive imprint of the future of medicine, and so we are forced to enjoy the decline.

Not exactly an environment which encourages going above and beyond.

 

[PikminOC]

Can’t blame them. The system is broken, the promises unkept.

No doctors I talk to have a positive imprint of the future of medicine, and so we are forced to enjoy the decline.

Not exactly an environment which encourages going above and beyond.

I'm looking forward to the future. It's two tiered healthcare

 

[Splenda88]

No productivity. One gets the honor of being assistant professor instead and honor of having residents.

Agree with the FI sentiment. I’m 2 years away from my number. No kids yet but plan on having. Goal is transition to VA or academics at less than full time.

Lol. That is insane. I thought Emory was bad with their 210-220k (census 12-14 and hospitalists can leave at 4pm), but apparently there are worst places out there..

 

[gutonc]

Lol. That is assassin. I thought Emory was bad with their 210-220k (census 12-14 and hospitalists can leave at 4pm), but apparently there are worst places out there..

Not sure if you meant insane or asinine here, but either way...yes

 

[Splenda88]

Not sure if you meant insane or asinine here, but either way...yes

Autocorrect. I meant say insane.