Is outpatient really that bad?

[sloh]

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.

😂

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[NewYorkDoctors]

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 hear ya.

The primary motivating factor for me to go above and beyond are to get the patients to stop shrieking so loud. The only way to do so is to "get them better" or at least "make them think they are better."

Many patients run into the front desk area unscheduled and unannounced just to shriek about something and demand to see the doctor unscheduled and unannounced. its very loud and annoying. (I see a lot of immigrants of all kinds in the underserved NY area and they just waltz in like they own the place to shriek) many of these immigrants do not speak english or minimally. they have no time to go online to leave a online review so it's not even about that.

it's often about something that could have been handled over the phone but the patient did not want to wait on hold as other people are being addressed (like asking why no one from the DME company called about delivering their CPAP when in fact the DME company called multiple times but the patient did not pick up the phone citing they do not speak english... when my staff explicitly told them the DME company will use a translator line to call them.. but they have to pick up... then they tell me they are afraid of robocalls.... seriously you can't make this stuff up in NYC... or maybe you can.... )

But I will admit that thanks to the rates my IPA negotiated, the more work I do the more I get paid. so that's the salve.

 

[VA Hopeful Dr]

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.

Hi, I'm VA Hopeful and I'm pretty excited for the future. We're getting more emphasis on good primary care (long overdue).

 

[dozitgetchahi]

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.

Except that sending me a referral with a random note that mentions nothing about the referral and no reason for a referral is way below “above and beyond”…it is piss poor, lazy as **** and there is no excuse for it IMO (whether anyone’s “promises were kept” or not).

It happened again today…patient comes in and asserts that he has no idea why he’s here to see me. I read the note and relate to him that I have no idea either - the note doesn’t even mention a referral to me, or anything that sounds like a rheumatologic issue. “So…do any of your joints hurt?”

This happens at least several times a week.

PCPs: pull your pants up and do better. It’s not that hard.

 

[chessknt]

Except that sending me a referral with a random note that mentions nothing about the referral and no reason for a referral is way below “above and beyond”…it is piss poor, lazy as **** and there is no excuse for it IMO (whether anyone’s “promises were kept” or not).

It happened again today…patient comes in and asserts that he has no idea why he’s here to see me. I read the note and relate to him that I have no idea either - the note doesn’t even mention a referral to me, or anything that sounds like a rheumatologic issue. “So…do any of your joints hurt?”

This happens at least several times a week.

PCPs: pull your pants up and do better. It’s not that hard.

You dont glance over the referrals beforehand? When I get one of those I tell my office to reach out to them and ask why the pt was referred before scheduling

 

[MD46]

We get these all the time as well, I have to constantly tell the office to make sure we know the reason for consult and pertinent /relevant labs for the referral.

I have yet to turn back a patient back but to be honest it is such a waste of time.

Even after all the back and forth, routinely few people a week are like this……

 

[mulberry]

There's stupid flexibility in nocturnist medicine. Anyone working less than 10 shifts a month at my shop only has to work one weekend a month and one winter/summer holiday.
If you like nights but looking for a better work-life balance (i.e less holidays and weekends), why not go part time and moonlight only the shifts that suit your lifestyle on top of that? Or better yet, go locums and cherry pick your exact dream schedule?

lets say I wanted to only do locums and get paid to my s-corp/llc. that means i have to provide health/dental/retirement/etc except malpractice which the locum agencies usually provide. Working nights 7 on 14 off, for example, will I get paid more through my s-corp or by being employed (factoring in everything i have to pay out of pocket)? I have no student loans. Any advice is appreciated.

 

[VA Hopeful Dr]

You dont glance over the referrals beforehand? When I get one of those I tell my office to reach out to them and ask why the pt was referred before scheduling

Epic doesn't allow me to send a referral without at least one diagnosis attached.

 

[chessknt]

lets say I wanted to only do locums and get paid to my s-corp/llc. that means i have to provide health/dental/retirement/etc except malpractice which the locum agencies usually provide. Working nights 7 on 14 off, for example, will I get paid more through my s-corp or by being employed (factoring in everything i have to pay out of pocket)? I have no student loans. Any advice is appreciated.

The fact that you are asking this question means you need a CPA (at least when you are starting) who can explain this.

But to answer the question--it depends on the theoretical difference between the w2 vs 1099 rate however you don't get to pick 1099 vs w2--it is determined by your relationship with the employer. Also you frequently don't need to form an s corp due to tax law changes.

 

[chessknt]

Epic doesn't allow me to send a referral without at least one diagnosis attached.

I know of exactly one private practice that uses epic in my area, the rest of us are on some variation of Microsoft word or Twitter that couldn't give less of a **** if I sent a picture of a banana for a consult.

 

[NewYorkDoctors]

Epic doesn't allow me to send a referral without at least one diagnosis attached.

honestly that's all I would need... and i dont even get that

If I saw reason for referral OSA or dyspnea or something, i would know exactly how to get things rolling from the moment a patient steps into the room. naturally that may not be the only thing evaluated.

its when nothing is present , i would do a classic full H&P like any other Internist. because patient's are hard to focus with their history, this tends to burn extra time that I willl never get back... alas

 

[dozitgetchahi]

You dont glance over the referrals beforehand? When I get one of those I tell my office to reach out to them and ask why the pt was referred before scheduling

We do. And sometimes we get information and sometimes we don’t. We intercept a lot of these before they get to us.

 

[mulberry]

The fact that you are asking this question means you need a CPA (at least when you are starting) who can explain this.

But to answer the question--it depends on the theoretical difference between the w2 vs 1099 rate however you don't get to pick 1099 vs w2--it is determined by your relationship with the employer. Also you frequently don't need to form an s corp due to tax law changes.

How sure are you about that last sentence? Attendings in person and legit "financial advisors/CPAs" on YT give excellent break down showing how you can benefit from tax reductions. The top .0001% definitely do it in similar fashion. But I will take your advice and speak with a CPA before my first big boy job.

 

[Splenda88]

Epic doesn't allow me to send a referral without at least one diagnosis attached.

I find it hard to believe that a referral from a physician not associated w/ a reason for the referral. This is unacceptable.

 

[VA Hopeful Dr]

I find it hard to believe that a referral from a physician not associated w/ a reason for the referral. This is unacceptable.

Give it time, you'll soon realize just how many of your colleagues are worthless in every sense of the word.

 

[Osteoth]

I know of exactly one private practice that uses epic in my area, the rest of us are on some variation of Microsoft word or Twitter that couldn't give less of a **** if I sent a picture of a banana for a consult.

Lmao too real.

 

[aafisahar]

Give it time, you'll soon realize just how many of your colleagues are worthless in every sense of the word.

there are so many bad doctors out there

like how do you put your shoes on in the morning bad

 

[chessknt]

How sure are you about that last sentence? Attendings in person and legit "financial advisors/CPAs" on YT give excellent break down showing how you can benefit from tax reductions. The top .0001% definitely do it in similar fashion. But I will take your advice and speak with a CPA before my first big boy job.

It depends on your income but the reality is that you save some SE taxes and gain access to some extra pre-tax savings in exchange for taxes that can become too complicated to manage on your own and incur increased costs. You arent going to get access to .0001% tax loops because those people own the government and write laws that exempt their wealth from taxation. You are a rich doctor routinely exempted from any laws designed to lessen the tax burden.

 

[greatnt249]

I find it hard to believe that a referral from a physician not associated w/ a reason for the referral. This is unacceptable.

Even worse...sometimes the associated order for the referral just happens to be the first diagnosis in the patient's problem list that they click on. You don't find out about that until they're in your office; if you're lucky enough, the patient has some semblance of insight as to why they're there. More often than should be acceptable, you get a response from the patient resembling something along the lines of "I don't know why I'm here, should be all in my chart."

 

[Splenda88]

Even worse...sometimes the associated order for the referral just happens to be the first diagnosis in the patient's problem list that they click on. You don't find out about that until they're in your office; if you're lucky enough, the patient has some semblance of insight as to why they're there. More often than should be acceptable, you get a response from the patient resembling something along the lines of "I don't know why I'm here, should be all in my chart."

I would have called these docs and tell them it's unacceptable. They will keep doing it if you don't do that.

 

[greatnt249]

I would have called these docs and tell them it's unacceptable. They will keep doing it if you don't do that.

They're in our network...I'd just get told to play nice in the sandbox. Usually physicians are not the guilty party if you catch my drift.

 

[dozitgetchahi]

Epic doesn't allow me to send a referral without at least one diagnosis attached.

Epic doesn’t, I agree, but I’ve used a number of **** EMRs in the past that did. Also a lot of these types of referrals seem to come from dinosaurs scribbling out a referral order on a script pad…but a fair number are from younger, fresh MD/DOs (and midlevels, often midlevels) who really should know better.

 

[NewYorkDoctors]

Epic doesn’t, I agree, but I’ve used a number of **** EMRs in the past that did. Also a lot of these types of referrals seem to come from dinosaurs scribbling out a referral order on a script pad…but a fair number are from younger, fresh MD/DOs (and midlevels, often midlevels) who really should know better.

while I do not blame the dinos for doing this (though I personally will be the first to get used to the holodeck once it is created, iPads and keyboards will be left in the dust lol), I blame them for not taking "15 seconds" to tell their secretaries "I am referring this patient to Dr so/so. Please fax the reason is XYZ and fax the latest blood work and imaging over."

 

[rokshana]

I would have called these docs and tell them it's unacceptable. They will keep doing it if you don't do that.

They keep doing it regardless if you call…and frankly that would take up too much time in the day.

 

[dozitgetchahi]

They keep doing it regardless if you call…and frankly that would take up too much time in the day.

And I think some of the thinking from these referring docs goes like “well I sent you a patient, I sent you business…why do you care”. I’ve noticed that a lot of referring docs who do this are the type who value volume over quality. Who cares if you did anything productive for this patient, or if it was an appropriate referral…you saw another patient!

 

[NewYorkDoctors]

And I think some of the thinking from these referring docs goes like “well I sent you a patient, I sent you business…why do you care”. I’ve noticed that a lot of referring docs who do this are the type who value volume over quality. Who cares if you did anything productive for this patient, or if it was an appropriate referral…you saw another patient!

reasonable take from a business perspective i guess...

but i cannot do a proper consult sometimes if I have a blank slate. im just lucky i can obtain most of the local patients workup

PMD sends nothing

so hell othere. how can i help you today?
check the computer
I did. its blank you PCP didn't send anything
I do CC and HPI and evaluation
ugh i already did the breathing test! you did a spirometry with your PCP which honestly is just way for your PCP to make some more money without any real use to the patient. I am doing the real deal today.
ugh i already had a CXR and CT scan. do you have the report?
isnt it in your computer??

i cannot deal with this kind of disaster.


Addendum: hospital clinics for certain specialists (like thoracic surgery and others) will not schedule an appointment unless all workup is sent in.
i trie that one time then crazy people threatened my office staff they would review bomb my google profile and website with 1 stars. NYC is full of crazies.
someone tried that then I "community-noted" that response with (no PHI) details that the patient never was seen and is nuts. I have multiple burner accounts. I counter-review the bad reviews if the bad reviews were for patients that were NEVER EVEN SEEN BEFORE.

 

[smq123]

Epic doesn’t, I agree, but I’ve used a number of **** EMRs in the past that did. Also a lot of these types of referrals seem to come from dinosaurs scribbling out a referral order on a script pad…but a fair number are from younger, fresh MD/DOs (and midlevels, often midlevels) who really should know better.

The truth of the matter is is that there are crappy lazy doctors everywhere. You guys see it from the PCPs, because that's the nature of the workflow.

As a PCP, we see it from the specialists too. From the specialists who can't be bothered to finish their notes, making reasonable follow up impossible (my favorite was from a neurologist who told my patient "you've had a stroke," couldn't be bothered to elaborate on that, and whose note was "note dictated, job # <blank>," and had no plan or orders in their note), to the specialists who tell the patients "tell your PCP to order the CT scan, I don't have time for the prior auth (because clearly the PCP does), to the GI who once told the patient that the PCP should order the pre-colonoscopy prep, there are plenty of crappy doctors in all specialties to go around.

 

[NewYorkDoctors]

The truth of the matter is is that there are crappy lazy doctors everywhere. You guys see it from the PCPs, because that's the nature of the workflow.

As a PCP, we see it from the specialists too. From the specialists who can't be bothered to finish their notes, making reasonable follow up impossible (my favorite was from a neurologist who told my patient "you've had a stroke," couldn't be bothered to elaborate on that, and whose note was "note dictated, job # <blank>," and had no plan or orders in their note), to the specialists who tell the patients "tell your PCP to order the CT scan, I don't have time for the prior auth (because clearly the PCP does), to the GI who once told the patient that the PCP should order the pre-colonoscopy prep, there are plenty of crappy doctors in all specialties to go around.

I make it a point to declare in my notes that My staff will take care of all subsequent PAs and scheduling for CT chests and LDCT. This is a practical point as when another doctor plays hero ball and fails the PA (due to insufficient documentation ) , I am unable to use the PA portal for an instant approval and have to have my staff call the PA company (rather than use a quick click click on the portal ) to do a peer to peer and waste time out of life

 

[DrMetal]

Even worse...

Worse than the Bruins losing in the first round after winning the President's Trophy? (sorry, too soon).

 

[greatnt249]

Worse than the Bruins losing in the first round after winning the President's Trophy? (sorry, too soon).

I'm used to heartbreak...was lucky enough to watch them win one Stanley Cup during my lifetime. Honestly watching them lose in the finals twice was probably worse than watching them get knocked out early; at least when that happens I can move on with my life. Figured they would have learned from Tampa Bay when they got blanked by Columbus, but I guess that lesson didn't sink in. Mostly sad that Bergeron couldn't get another Cup under his belt; never would have thought he would have had the career he had with all those concussions early on.

 

[rokshana]

And I think some of the thinking from these referring docs goes like “well I sent you a patient, I sent you business…why do you care”. I’ve noticed that a lot of referring docs who do this are the type who value volume over quality. Who cares if you did anything productive for this patient, or if it was an appropriate referral…you saw another patient!

Keeps me from seeing a pt that actually needs my help.
Luckily, most of the places I’ve worked at will review the referral and if not adequate information, the pt won’t be scheduled until the appropriate information is sent… ot the referral is declined.
I do 60 min new pts and 30 min follow ups… volume is not my goal.

 

[Splenda88]

Keeps me from seeing a pt that actually needs my help.
Luckily, most of the places I’ve worked at will review the referral and if not adequate information, the pt won’t be scheduled until the appropriate information is sent… ot the referral is declined.
I do 60 min new pts and 30 min follow ups… volume is not my goal.

How do you make money then?

 

[rokshana]

How do you make money then?

I’m paid by the hour…5 pts or 10 pts… I get paid the same

 

[Osteoth]

I’m paid by the hour…5 pts or 10 pts… I get paid the same

How does the system make money then

 

[rokshana]

How does the system make money then

I bill by time, so usually level 4 and level 5s
But generally I’m at places that are desperate for help… so making money off of me isn’t the goal either.
Generally service lines like endocrinology are at best break even, but are many times revenue losing… but the services are needed. And we do a lot of labs and imaging…generating revenue for other service lines.

 

[NewYorkDoctors]

How does the system make money then

I’m sure a health system will quickly lose its employees by turning things into an assembly line and not giving the doctors more pay and they will quickly lose reviews if they led to an assembly line approach.

It seems most logical that a hospital system will put up with an essential service like endocrine and neph as long as it’s not a money loser as long as it complements their really money makers (ortho and cards )

Smaller in private practices have no such penalties for doing this. Plus if the small business owner doctor is making more (for lesser quality ) , most don’t happen to mind the extra work time .

 

[dozitgetchahi]

The truth of the matter is is that there are crappy lazy doctors everywhere. You guys see it from the PCPs, because that's the nature of the workflow.

As a PCP, we see it from the specialists too. From the specialists who can't be bothered to finish their notes, making reasonable follow up impossible (my favorite was from a neurologist who told my patient "you've had a stroke," couldn't be bothered to elaborate on that, and whose note was "note dictated, job # <blank>," and had no plan or orders in their note), to the specialists who tell the patients "tell your PCP to order the CT scan, I don't have time for the prior auth (because clearly the PCP does), to the GI who once told the patient that the PCP should order the pre-colonoscopy prep, there are plenty of crappy doctors in all specialties to go around.

Oh I know it. I clean up enough bizarre messes from nearby rheumatologists too, and there are a ton of other specialists I won’t refer patients to because the quality their care is atrocious.

I order all relevant studies and handle all the prior auths myself. Part of this is that as a PP doc at a big multispecialty group, I get ancillaries on these studies - so I’m happy to do it - but even when I worked at a hospital system I did it too. The only time I pass it to someone else is if I’ve tried to get the prior auth and it gets denied repeatedly. (Which doesn’t happen often.)

 

[PikminOC]

I’m sure a health system will quickly lose its employees by turning things into an assembly line and not giving the doctors more pay and they will quickly lose reviews if they led to an assembly line approach.

It seems most logical that a hospital system will put up with an essential service like endocrine and neph as long as it’s not a money loser as long as it complements their really money makers (ortho and cards )

Smaller in private practices have no such penalties for doing this. Plus if the small business owner doctor is making more (for lesser quality ) , most don’t happen to mind the extra work time .

Explain making more for less quality pls

 

[rokshana]

Explain making more for less quality pls

Eat what you kill…the more pts you see, the more rvus, the more money you make on a production model…at some point seeing 40-50 pts a day means you really can’t give quality care.

 

[PikminOC]

Eat what you kill…the more pts you see, the more rvus, the more money you make on a production model…at some point seeing 40-50 pts a day means you really can’t give quality care.

No different from at the hospital

 

[VA Hopeful Dr]

No different from at the hospital

I've steadily cut down my patient load for the last 2 years. Have received exactly zero pushback from the hospital about it.

 

[PikminOC]

I've steadily cut down my patient load for the last 2 years. Have received exactly zero pushback from the hospital about it.

Once again your situation is very different from what I see. Hospitals have increased overheard and decreased reimbursement. They are pushing the physicians I know for more production for the same pay

 

[rokshana]

No different from at the hospital

You’re right… the hospitalist seeing 20-25 pts a day isn’t giving quality care either.
When I did hospitalist work… those assessments where I was getting that many pts consistently were not assignments I stayed at for very long.

 

[NewYorkDoctors]

Explain making more for less quality pls

99213-mill

some PP physicians will spend only 5 minutes per patient and bill 99213. this is plausible as one can justify "i spent chart review time, orders time, prscription time, and documenting in the chart time becacuse im a slow dinosaur and spend 20-29 minutes".

spend less time per patient and bill the usual 99213. see more get paid more.
quality invariably suffers

many PP PCP officse are like this

 

[VA Hopeful Dr]

Once again your situation is very different from what I see. Hospitals have increased overheard and decreased reimbursement. They are pushing the physicians I know for more production for the same pay

Completely agree, there are definitely more predatory hospitals out there.

Also plenty that aren't. Our main local competitor mandates 20 minute appointments. Our standard is 15, so those doctors get more time per patient with fewer appointments. They also make more per RVU so money ends up being similar.

 

[dozitgetchahi]

Eat what you kill…the more pts you see, the more rvus, the more money you make on a production model…at some point seeing 40-50 pts a day means you really can’t give quality care.

In rheum, I think that “upper limit of quality” is around about 25 pts/day at most. The rheums nearby who see 30/day are not people I would send my family members to see. (I average maybe 16-20 and don’t plan to go beyond that unless I hire a scribe in the near future.)

Near one of my previous jobs, there was a “high volume” rheum who did 15 minute visits for everyone. New pt, followup, it didn’t matter - you’re getting 15 minutes of her time. She apparently never ran behind, but she would show pts the door at exactly 15 minutes. I cleaned up a lot of messes coming out of that office.

 

[NewYorkDoctors]

In rheum, I think that “upper limit of quality” is around about 25 pts/day at most. The rheums nearby who see 30/day are not people I would send my family members to see.

Near one of my previous jobs, there was a “high volume” rheum who did 15 minute visits for everyone. New pt, followup, it didn’t matter - you’re getting 15 minutes of her time. She apparently never ran behind, but she would show pts the door at exactly 15 minutes. I cleaned up a lot of messes coming out of that office.

I will say that is a "great business model" but quality kind of suffers for a specialist INITIAL evaluation.
This works fine for PCP in which it's basically - well the differential is X,Y,Z. it's not something i can fix with meds alone. I will refer you now. that's understandable
Addendum: this is not a PCP bashing line. As you read in other threads, I do PCP also so I know what its like.
Plus I know the academic internists are doing their SBIRTs, PHQ2/9s, Tug and GO tests, risk assessment scores, calculating ASCVD risk via the ACC/AHA calculator , going through the social determinants of care, doing the whole D.E.I in healthcare thing as well, etc..... and doing some real hard work. but most PP PCPs are not doing those things.

with the use of 99358, 99487, 99491 codes to pay doctors for work OUTSIDE of the office visit (hence to better preparation for a complex patient), i'm not sure why more prep work isnt done more often! I do this all the time ! (within reason of course)

I think I know... you can't eat RVUs lol. having an employed doctor use these codes does not lead to extra money in the pocket

 

[Splenda88]

In rheum, I think that “upper limit of quality” is around about 25 pts/day at most. The rheums nearby who see 30/day are not people I would send my family members to see. (I average maybe 16-20 and don’t plan to go beyond that unless I hire a scribe in the near future.)

Near one of my previous jobs, there was a “high volume” rheum who did 15 minute visits for everyone. New pt, followup, it didn’t matter - you’re getting 15 minutes of her time. She apparently never ran behind, but she would show pts the door at exactly 15 minutes. I cleaned up a lot of messes coming out of that office.

I am not a rheumatologist obviously, but it's hard to quantify/qualify these things.

When I was in residency, one of my co-residents who is also a good friend could finish seeing 9 patients and did everything correctly (per our attendings) by 11am while I was still working until 3-4pm. He was also arguably among the top 2 residents of a class of 30.

The guy was a working machine. FMG graduated IM residency at the age of 25 and is fellow at a top 10 cardiology program now.

 

[sloh]

I am not a rheumatologist obviously, but it's hard to quantify/qualify these things.

When I was in residency, one of my co-residents who is also a good friend could finish seeing 9 patients and did everything correctly (per our attendings) by 11am while I was still working until 3-4pm. He was also arguably among the top 2 residents of a class of 30.

The guy was a working machine. FMG graduated IM residency at the age of 25 and is fellow at a top 10 cardiology program now.

Inpatient and outpatient are different though. Inpatient lends itself more to higher volume and efficiency without sacrificing quality of care.

 

[dozitgetchahi]

I am not a rheumatologist obviously, but it's hard to quantify/qualify these things.

When I was in residency, one of my co-residents who is also a good friend could finish seeing 9 patients and did everything correctly (per our attendings) by 11am while I was still working until 3-4pm. He was also arguably among the top 2 residents of a class of 30.

The guy was a working machine. FMG graduated IM residency at the age of 25 and is fellow at a top 10 cardiology program now.

I have trained and worked as a rheumatologist in 4 different states at this point. Everywhere that I’ve worked, there’s always been a “30/day” rheumatology practice nearby - and they have always been horrible.

This is a specialty which requires fairly extensive and detailed H&Ps, with patients who are often complex - and even “stable” rheum patients have a way of having random things happen that complicate visits and make them take longer. In fact, one of the things that I (and most good rheumatologists) like about the specialty is that you can take the time to really listen to the patient and try to figure out what the hell is going on.

You can try to cut corners and speed it up, but much beyond 25/day and I promise that you’re not cutting fat anymore. It’s muscle. The 30/day rheums rarely have their patients under control and doing well. Plus, who do you want to send your mother to? The doctor who’s going to sit down and take the time to make sure everything gets sorted out, or the guy with his foot on the gas nonstop who’s going to hurry out of the room?

And I don’t think PCPs should be doing this either. I’ve posted at length around here about PCPs not getting the job done because they’re packing in 40/day and doing a crap job of it.