Midlevel supervision

[miacomet]

Ugh I'm so sorry you're going through this. I hope it goes in your favor.

The idea that we're responsible for all PA and NP care when most of us have absolutely no power to provide said oversight over them is insane (SDGs being an exception). The likelihood of us being roped into a PA/NP lawsuit will only become more common as PA/NPs see more and more patients to make our corporate overloads fatter.

Anybody have ideas to meaningfully shift the risk from a doc up the chain to the CMG or hospital or whoever employs the PA/NP? A lawsuit from a doc roped into a PA case that loses? Something else? Yeah I know I'm probably dreaming.

It's really hard to shift the burden to nonclinicians even though they control our world and our care. But I don't understand why we can't shift the burden to NPs (and potentially PAs as they are angling to practice independently) since they practice under their own license.

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[namethatsmell]

It's really hard to shift the burden to nonclinicians even though they control our world and our care. But I don't understand why we can't shift the burden to NPs (and potentially PAs as they are angling to practice independently) since they practice under their own license.

Fair points.

 

[thegenius]

It's really hard to shift the burden to nonclinicians even though they control our world and our care. But I don't understand why we can't shift the burden to NPs (and potentially PAs as they are angling to practice independently) since they practice under their own license.

You have the right to do what you want with them. You can treat them like residents. You can write notes on all their patients. There is nothing preventing you from doing this. It's inefficient and a waste of time, and defeats the purpose of having them. But if you are in a group with 15-20 other doctors and you can't change the politics of the group yourself, then do something to protect yourself.

This is what I do...the MLP will present cases like this

1) "14 yo with ankle pain after falling off his skateboard, I'm getting an xray". I don't need anymore information.
2) "25 yo woman with dental pain for 3 days, she wants Norco". I'll ask is she drooling, can she open her mouth wide open, and does she have significant facial swelling. If no to those...then I'm done.
3) "28 yo man with PMH of Type1DM, gastroparesis, p/w vomiting and epigastric pain for 1 day. 15th visit in 2 years for this complaint. I'm going to do x, y, and z." They know what labs to run and how to treat. I might say "do not give him narcotics under any circumstance, and if there is a problem let me know." I don't really care if he gets imaging or not, maybe the labs will dictate it as such. Dispo is based on whether we can make him better or not.
4) The computer says "44 yo woman with dizziness." I notice that the patient has never been here before. PA comes back and says "44 yo woman with Alports Syndrome, ESRD on dialysis, p/w feeling dizzy during dialysis and couldn't finish her session. BP is 105/45." I will go in and see that patient, and depending on which PA I'm working with, I will take over the case. That is not an easy case. IV access will be hard. The differential is broad. She could have anything.

 

[GeneralVeers]

I'm still on good terms with the PA. She is very good clinically and fast, just made an error. I understand their limitations, and try to proactively look at all cases they pick up in order to head off any potential problems in workup.

This was with a CMG, so the PA is not my employee and I have no choice to work with them. On the plus side, midlevels are pretty much the only way we can see >$300/hr salaries. If I can only get RVUs for pts I see, then I'm stuck at around 2.5 pts/hour which would equate to around $225/hr.

 

[sunshinefl]

Just a med student here, following the thread...but, if I would be held responsible for everything the mid level working with/around me did/didn’t do, I would want full authority for hiring, firing, training, and working with specific PAs.

 

[GeneralVeers]

Just a med student here, following the thread...but, if I would be held responsible for everything the mid level working with/around me did/didn’t do, I would want full authority for hiring, firing, training, and working with specific PAs.

Welcome to the world of CMGs where you get none of those things.

 

[deleted859535]

Just a med student here, following the thread...but, if I would be held responsible for everything the mid level working with/around me did/didn’t do, I would want full authority for hiring, firing, training, and working with specific PAs.

As a counterpoint to GV above: I'm a newer partner with an SDG where we get this, as the PAs work with us. But any position in which you have full authority over such issues will come with pros/cons. It isn't all rainbows and ponies and may not be worth it depending on your point of view in practice versus what a CMG is like.

 

[JAFERD]

Welcome to the world of CMGs where you get none of those things.

Alternatively, don’t work for a CMG!


Sent from my iPhone using Tapatalk

 

[W19]

I'm still on good terms with the PA. She is very good clinically and fast, just made an error. I understand their limitations, and try to proactively look at all cases they pick up in order to head off any potential problems in workup.

This was with a CMG, so the PA is not my employee and I have no choice to work with them. On the plus side, midlevels are pretty much the only way we can see >$300/hr salaries. If I can only get RVUs for pts I see, then I'm stuck at around 2.5 pts/hour which would equate to around $225/hr.

$225/hr is not good enough!

 

[GeneralVeers]

$225/hr is not good enough!

No it's not.....at least if I'm seeing 2 pts/hr.

 

[GeneralVeers]

Alternatively, don’t work for a CMG!


Sent from my iPhone using Tapatalk

Not possible these days in most areas.

 

[thegenius]

$225/hr is not good enough!

$225 for 2.5 pts/hr would mean I would look for a new job. That's terrible. It is hard to see 2.5/hr and not burn out after several years. especially if the ER is like most where you can't get patients good follow-up, etc.

 

[AlmostAnMD]

Are all of you laughing at 225/hr factoring in total compensation or just the hourly wage? I mean, for example, Columbus, Ohio isn't a "hot" or in demand city, but I know for a fact there isn't a single SDG, CMG or academic gig in town or close to town that pays over 200. Now, once you say factor in profit sharing / benefits etc it's possible to get north of 300, but as a base salary it's not possible and columbus isn't even the most in demand place....otherwise, what city in montana are we talking about here

 

[namethatsmell]

I know for a fact there isn't a single SDG, CMG or academic gig in town or close to town that pays over 200. Now, once you say factor in profit sharing / benefits etc it's possible to get north of 300

If total remuneration (excluding benefits) works out to be 300/hr I wouldn't care if it was paid hourly or via profit sharing. That would be better than pretty much any CMG aside from their travel gigs/locums.

But to echo the above, pph matters. Generally, if you're not getting at least 100/pt somebody's likely making a ton of cash off your work. 300/hr for 2pph is great. Similarly, if you're getting 180 for 0.5pph that's great too.

 

[GeneralVeers]

Are all of you laughing at 225/hr factoring in total compensation or just the hourly wage? I mean, for example, Columbus, Ohio isn't a "hot" or in demand city, but I know for a fact there isn't a single SDG, CMG or academic gig in town or close to town that pays over 200. Now, once you say factor in profit sharing / benefits etc it's possible to get north of 300, but as a base salary it's not possible and columbus isn't even the most in demand place....otherwise, what city in montana are we talking about here

I always break down every possible job into total $/hour as it's the only fair way to compare sites equally. For places which have a heavy RVU component, I always ask what the MEDIAN hourly is for the group so I can an idea of what to expect. $225 + benefits is okay......$225 total compensation is not great.

 

[miacomet]

I work with someone who trained in Ohio, and the persistently poor salaries in what is generally considered an undesirable part of the country are an ongoing mystery to many.

For comparison (and I do think we may be bought out in the next year or two), I earn well over $100 pph plus benefits and live in a super desirable mountain town. Frankly, when my unicorn gig dries up (and they all do), my guess is I will be out of the EM game. The marginally higher hourly for EM vs Urgent Care and its better hours and lower liability just isn't worth it to me. Except for my unicorn gig (and similar unicorns), EM just isn't worth the pain unless you are making over $250/hr with a tolerable patient load, regardless of benefits.

Also, "total compensation" is generally complete crap and something recruiters use to lowball docs. A 10k match and health insurance don't really make much difference vs the major tax and retirement benefits of being self-employed. I avoid all discussion of "total compensation" with any and all jobs/recruiters etc.

 

[BoardingDoc]

Also, "total compensation" is generally complete crap and something recruiters use to lowball docs. A 10k match and health insurance don't really make much difference vs the major tax and retirement benefits of being self-employed. I avoid all discussion of "total compensation" with any and all jobs/recruiters etc.

The total comp numbers you get from recruiters generally is garbage, agreed. That said, when comparing two jobs, I completely agree with Veers. Take all the benefits you get, assign a dollar value and calculate your hourly rate that way. Your statement makes it sound like a 1099 job is inherently superior, which is obviously situation dependent.

 

[miacomet]

The total comp numbers you get from recruiters generally is garbage, agreed. That said, when comparing two jobs, I completely agree with Veers. Take all the benefits you get, assign a dollar value and calculate your hourly rate that way. Your statement makes it sound like a 1099 job is inherently superior, which is obviously situation dependent.

Of course not. My point was more that EVERY job comes with some kind of benefit, whether it's health insurance or a more beneficial tax situation, and that it's easy to get sucked in by the "total compensation package" unless you rigorously compare the actual vs perceived benefits.

 

[BoardingDoc]

Of course not. My point was more that EVERY job comes with some kind of benefit, whether it's health insurance or a more beneficial tax situation, and that it's easy to get sucked in by the "total compensation package" unless you rigorously compare the actual vs perceived benefits.

So you're saying the 100k in USACS I was offered in "equity" as a "physician owner" isn't as good as I was led to believe?

 

[miacomet]

So you're saying the 100k in USACS I was offered in "equity" as a "physician owner" isn't as good as I was led to believe?

Now that's a headscratcher . I consider myself fortunate to never have been offered such a "benefit" along with other "benefits" such as a signing bonus paid out over 5 years.

 

[deleted109597]

So you're saying the 100k in USACS I was offered in "equity" as a "physician owner" isn't as good as I was led to believe?

Can you sell it? Are you paying taxes on it?

 

[namethatsmell]

Can you sell it? Are you paying taxes on it?

I still don't understand how people fall for this crap.

People have to pay taxes on the USACS "equity." From what I understand, there's no clear path to valuing or selling these shares when you want to cash out since it's a closed process within the company. Oh, and you still get zero control over your job even though you're now an "owner."

I almost have to give kudos to these guys for finding a way to dupe docs into voluntarily putting on handcuffs and shackling themselves to a dumpster fire while they wait to hopefully get their money back.

 

[BoardingDoc]

Can you sell it? Are you paying taxes on it?

No idea. I know that USACS offers this BS "equity" to people they sucker in. I interviewed with them a couple of years ago and they didn't really have any response when I asked what "physician ownership" meant exactly, as they had mentioned it several times. They mentioned the equity and how the upper mgmt was docs, then just sort of trailed off. I do not, nor will I ever work for that POS company.

 

[miacomet]

I still don't understand how people fall for this crap.

People have to pay taxes on the USACS "equity." From what I understand, there's no clear path to valuing or selling these shares when you want to cash out since it's a closed process within the company. Oh, and you still get zero control over your job even though you're now an "owner."

I almost have to give kudos to these guys for finding a way to dupe docs into voluntarily putting on handcuffs and shackling themselves to a dumpster fire while they wait to hopefully get their money back.

I still don't understand how people fall for this crap.

People have to pay taxes on the USACS "equity." From what I understand, there's no clear path to valuing or selling these shares when you want to cash out since it's a closed process within the company. Oh, and you still get zero control over your job even though you're now an "owner."

I almost have to give kudos to these guys for finding a way to dupe docs into voluntarily putting on handcuffs and shackling themselves to a dumpster fire while they wait to hopefully get their money back.

We received absolutely no counseling or advice on the contractual EM issues in residency or, more importantly, prior to choosing EM as a field. This should, frankly, be mandatory at all levels of training, although it looks like CMGs are moving into every part of medicine except certain surgical subspecialties.

I did interview with a job for a private group that was misrepresented to me as democratic that also so generously allowed docs to buy shares in the company but was owned by two corrupt individuals. I asked politely why I would ever want to buy shares in a company that didn't have open books and in which I had no voting rights. They lost one of their contracts shortly after.

EM is a great field for those who don't mind the corporate game (or want to be a part of the corruption) but it really presents challenges for many other folks. My suggestion to students would be to run from CMS-heavy specialties as this is the future. But I think many of today's students don't mind having corporate overlords. I think if you want to do EM, much like primary care, it's really hard to argue against training as a midlevel instead.

 

[Modanq]

I will never work in an ED that forces the physician to sign off on an NP or PA chart. The idea of that is so horrendous to me that it makes me physically ill. Essentially, what your group is telling you is that "We want to bill higher for physician level of care, but we want to see as many patients as possible. You are here to help us bill for more money, even if it means that you assume higher risk for yourself by signing off on a chart from a provider who has less than half the amount of training that you do".

It's an absolute joke.

Physicians are hands down to blame for unproliferated midlevel expansion without any regulation or oversight. Everyone wants the big bucks, but we are ultimately selling out our own careers and the future of our specialty by partaking in this nonsense. EM is going down the road of anesthesia with the CRNAs. Everyone is sitting on cloud nine right now since our specialty is booming, but in 20 years time, EM residency slots will go unfilled (like anesthesia) given the lack of demand for our specialty and the unregulated growth of midlevel providers. And that's only secondary to the fact that we are providing care to patients by people who have less training. It's bad patient care, period.

Are some midlevels "good"? Sure. They can put together a laceration, reduce a fracture and splint etc. But why you would trust someone who has a fraction of your training, sign off their chart, and assume medical responsibility for someone's health is beyond me. Forget the fact that you open yourself up to medicolegal nightmares, but you are ultimately allowing someone with less experience than you to take care of an actual patient's health and make a mistake.

This is not because they are "dumb" or "stupid", it's because their training simply does not prepare them for managing patients with serious medical issues when they present to the ED. This is not to sleight them in any way. It's the same reason why I'm not adequately trained to operate on a femur. Sure, I could spend the next several months, do an orthopedic rotation and see some surgeons hammer pins and nails into a bone, but does that mean that I am qualified to do this on my own? Absolutely not.

You don't know what you don't know. The false equivalency of PA/NP training to MD/DO training needs to stop, and EM physicians need to get vocal about it instead of sitting happy with their huge paychecks they are getting right now, not thinking about the future of the specialty.

Midlevel encroahment is the downfall of physicians and medicine. Why do we need doctors when all you need is uptodate and an experienced PA/NP? Admins know it, lazy physicians know it, Midlevels knows it, and patients don’t care.

 

[Millennial ER Doc]

"I think if you want to do EM, much like primary care, it's really hard to argue against training as a midlevel instead."

Interesting comment I think. A mid level has how many post-undergrad years worth of training... 2? And in the ER they make what? 75-150K?

Speaking w/ the scribes I work w/, the majority are pursing nursing or PA school. Not sure if it's because they're not competitive (likely not lol; not that they're not smart, just that I don't believe anyone is truly competitive until they score > 75-80th percentile on the MCAT) for med school or because they've thought through the pros/cons of going through all the competition, schooling, training and debt required to become an ER attending.

My approach to managing mid-levels is much like the "thegenius" described.

I don't see us being as replaceable as Family Docs, purely because mid-levels aren't credentialed/trained for the truly emergent pathology (rapidly progressing airway compromise, orbital compartment syndrome, emergent deliveries, etc).

"Midlevel encroachment is the downfall of physicians and medicine." Maybe. I think the corporatization of medicine more so. Everyone looks out for their own self interest ($$$)... Until their loved one becomes truly sick, then they demand to see the doctor or blame the doctor if things go wrong.

I feel for all the med students/residents forced into primary care because of poor step scores or a mis-step along the way. America has lost it's appreciation and respect for the very difficult jobs Family Docs (and Pediatricians) have... which is a damn shame.

The baby boomers are about to suffer the brunt of the mismanagement as you know NPs/PAs are gonna be the ones staffing nursing homes and seeing Medicare patients. And the glut of admin/C-suite/private equity will line their pockets, fleecing the government and the public by keeping costs opaque and politicians on their pay roll. Not to mention big pharma, insurance and medical equipment companies.

As an attending 3 months in, would I do this all over again? Absolutely. But only because I managed to make it into ER, trained at a good residency and am in a position to pick my job, save money for the next 10 years and shelter myself should salaries drop... assuming I don't get sued, divorced or otherwise bamboozled. Practicing medicine is nice too

And besides, what else would I do? Be a mid-level? spending my career as a (well paid) de-facto resident... no thank you. A lawyer --> no jobs. An engineer --> very difficult work for the salary of a mid-level. Finance --> aka scum, lol. I can't think of many things as fulfilling as being in a position to truly help someone when their sick and in need AND receive an attending sized pay cheque for it... even if it wasn't as big as it used to be.

 

[miacomet]

"I think if you want to do EM, much like primary care, it's really hard to argue against training as a midlevel instead."

Interesting comment I think. A mid level has how many post-undergrad years worth of training... 2? And in the ER they make what? 75-150K?

Speaking w/ the scribes I work w/, the majority are pursing nursing or PA school. Not sure if it's because they're not competitive (likely not lol; not that they're not smart, just that I don't believe anyone is truly competitive until they score > 75-80th percentile on the MCAT) for med school or because they've thought through the pros/cons of going through all the competition, schooling, training and debt required to become an ER attending.

My approach to managing mid-levels is much like the "thegenius" described.

I don't see us being as replaceable as Family Docs, purely because mid-levels aren't credentialed/trained for the truly emergent pathology (rapidly progressing airway compromise, orbital compartment syndrome, emergent deliveries, etc).

"Midlevel encroachment is the downfall of physicians and medicine." Maybe. I think the corporatization of medicine more so. Everyone looks out for their own self interest ($$$)... Until their loved one becomes truly sick, then they demand to see the doctor or blame the doctor if things go wrong.

I feel for all the med students/residents forced into primary care because of poor step scores or a mis-step along the way. America has lost it's appreciation and respect for the very difficult jobs Family Docs (and Pediatricians) have... which is a damn shame.

The baby boomers are about to suffer the brunt of the mismanagement as you know NPs/PAs are gonna be the ones staffing nursing homes and seeing Medicare patients. And the glut of admin/C-suite/private equity will line their pockets, fleecing the government and the public by keeping costs opaque and politicians on their pay roll. Not to mention big pharma, insurance and medical equipment companies.

As an attending 3 months in, would I do this all over again? Absolutely. But only because I managed to make it into ER, trained at a good residency and am in a position to pick my job, save money for the next 10 years and shelter myself should salaries drop... assuming I don't get sued, divorced or otherwise bamboozled. Practicing medicine is nice too

And besides, what else would I do? Be a mid-level? spending my career as a (well paid) de-facto resident... no thank you. A lawyer --> no jobs. An engineer --> very difficult work for the salary of a mid-level. Finance --> aka scum, lol. I can't think of many things as fulfilling as being in a position to truly help someone when their sick and in need AND receive an attending sized pay cheque for it... even if it wasn't as big as it used to be.

I still think the ROI for two years of PA school with maybe a one year residency is way better than on medical school plus residency. Conceivably, a 25 year old PA can start socking away cash with a six-figure salary while medical students are still accruing debt and applying for residency. Compounding will work for them and against the poor beleaguered resident with three more years of training ahead. After ten years in the ED, said PA can move on over into plastics, derm, whatever floats their boat. And I don't see a ton of PAs staffing the graveyards- they all seem to clock out at midnight.

As to getting into medical school, with schools opening every year and DO schools seemingly opening every month, it's not that hard- we are up to a 45% admit rate for allopathic schools, I believe.

You do make some great points, and I fully appreciate hearing WHY so many students want to go into EM with the obvious and increasing problems in the field. We don't know where medicine will be in ten years, and maybe a short residency with immediate payoff is the way to go. But I'm curious- what do you plan on doing after ten years? Are you going to be a pit doc into your sixties? EM, as I have previously posted, is a great way to make good coin for a decade or so. But there aren't a ton of appealing exit strategies aside from UC (and that really is midlevel city) and admin. Ask docs out in the community how they feel about drunks, malingerers, corporate medicine, nights, holidays, and weekends a decade out, and they will tell you for the most part they are pretty beat. EM is great for ten years, but what's the exit plan?

 

[Millennial ER Doc]

Not sure on a exit strategy, too many variables: am I married? Does my spouse work? Kids? How many? What part of the country are we living? Are the parents still healthy?

The only thing I can control at the moment is how much I save, so I'll try to max out the 401K or SEP IRA (I'm have a meeting w/ an accountant in the next couple weeks) and hopefully save a total of 90-150K a year for the next 10 years.

In residency there were a few attendings I had who were nocturnists in their mid to late 40s w/ kids big and small; they'd been doing it for years. Plus they had the residents do all the work

Ultimately I like what emergent said; if you don't need BIG bucks, then working at a cush ER or FSED would still net you a great salary ($230/hr @ 12 hr shifts x 5 shifts/month = gross $165K)

* the circadian rhythm disturbance is a B, I try to minimize the pain by stacking my shifts as a nocturnist (but I'm young and single and recognize I may not be able to do this long term).

** I still believe getting into med school is absurdly competitive. Any GOOD med school that is (allopathic schools have like what? a 5% acceptance rate each). Sure there are less competitive DO schools & the Caribbean, but undergrads need to think long and hard before going into MASSIVE debt to attend these places. Residency spots are limited, and these schools from I what I hear, fudge their numbers on their actual match rates. If I were a DO student who didn't have astronomical board scores, I would focus on psych or physiatry and avoid family medicine like the plague

 

[Millennial ER Doc]

I don't fault PAs and NPs for fighting for their own self interests ($$$ & work life balance), that's kind of the American way.

It is disappointing that some bad apples (some DNPs, some NPs, some PAs, most chiropractors and most naturopaths) world try to deceive patients into believing their training is on par w/a physicians... but isn't imitation the highest form of praise? Fraud in this case, but still.

 

[hundreddaysoff]

"I think if you want to do EM, much like primary care, it's really hard to argue against training as a midlevel instead."

Interesting comment I think. A mid level has how many post-undergrad years worth of training... 2? And in the ER they make what? 75-150K?

Speaking w/ the scribes I work w/, the majority are pursing nursing or PA school. Not sure if it's because they're not competitive (likely not lol; not that they're not smart, just that I don't believe anyone is truly competitive until they score > 75-80th percentile on the MCAT) for med school or because they've thought through the pros/cons of going through all the competition, schooling, training and debt required to become an ER attending.

My approach to managing mid-levels is much like the "thegenius" described.

I don't see us being as replaceable as Family Docs, purely because mid-levels aren't credentialed/trained for the truly emergent pathology (rapidly progressing airway compromise, orbital compartment syndrome, emergent deliveries, etc).

"Midlevel encroachment is the downfall of physicians and medicine." Maybe. I think the corporatization of medicine more so. Everyone looks out for their own self interest ($$$)... Until their loved one becomes truly sick, then they demand to see the doctor or blame the doctor if things go wrong.

I feel for all the med students/residents forced into primary care because of poor step scores or a mis-step along the way. America has lost it's appreciation and respect for the very difficult jobs Family Docs (and Pediatricians) have... which is a damn shame.

The baby boomers are about to suffer the brunt of the mismanagement as you know NPs/PAs are gonna be the ones staffing nursing homes and seeing Medicare patients. And the glut of admin/C-suite/private equity will line their pockets, fleecing the government and the public by keeping costs opaque and politicians on their pay roll. Not to mention big pharma, insurance and medical equipment companies.

As an attending 3 months in, would I do this all over again? Absolutely. But only because I managed to make it into ER, trained at a good residency and am in a position to pick my job, save money for the next 10 years and shelter myself should salaries drop... assuming I don't get sued, divorced or otherwise bamboozled. Practicing medicine is nice too

And besides, what else would I do? Be a mid-level? spending my career as a (well paid) de-facto resident... no thank you. A lawyer --> no jobs. An engineer --> very difficult work for the salary of a mid-level. Finance --> aka scum, lol. I can't think of many things as fulfilling as being in a position to truly help someone when their sick and in need AND receive an attending sized pay cheque for it... even if it wasn't as big as it used to be.

HVAC repair maybe?

 

[hundreddaysoff]

But I'm curious- what do you plan on doing after ten years?

1. $300K/y * 10y = $3M in the bank
2. buy house free and clear
3. $2M * 2.5% = $50K/y = average income of a US family
4. teach my kids, drink beer, run around the woods (in that order?)
5. +/- buy a pony

 

[namethatsmell]

1. $300K/y * 10y = $3M in the bank
2. buy house free and clear
3. $2M * 2.5% = $50K/y = average income of a US family
4. teach my kids, drink beer, run around the woods (in that order?)
5. +/- buy a pony

Eh?

I'm no WCI and certainly no math whiz, but I don't follow...

After taxes your 3M is closer to 2M.

How about money to subsist on day to day during those 10 years? And if you want to possibly live a little and go on a trip etc?

Then figure another chunk of change going to things you didn't anticipate: your roof fails, your pony bites somebody's hand off and sues you, etc.

Depending on interest rates and your local market and cash flow, buying a house free/clear could be a great move. Or the wrong move.

I'm all for option 4 though, and good for you for starting to think about the long term early on.

 

[deleted497653]

Eh?

I'm no WCI and certainly no math whiz, but I don't follow...

After taxes your 3M is closer to 2M.

How about money to subsist on day to day during those 10 years? And if you want to possibly live a little and go on a trip etc?

Then figure another chunk of change going to things you didn't anticipate: your roof fails, your pony bites somebody's hand off and sues you, etc.

Depending on interest rates and your local market and cash flow, buying a house free/clear could be a great move. Or the wrong move.

I'm all for option 4 though, and good for you for starting to think about the long term early on.

Yeah-> the math is off. 300K will be taxed at 35% rate or higher so that will definitely be much less. Also if you quit after 10 years, you may not have made enough retirement savings. Can someone more knowledgeable than me answer this; Can you collect social security at 65 if you only made contribution for 10 years of employment?

 

[miacomet]

Yeah-> the math is off. 300K will be taxed at 35% rate or higher so that will definitely be much less. Also if you quit after 10 years, you may not have made enough retirement savings. Can someone more knowledgeable than me answer this; Can you collect social security at 65 if you only made contribution for 10 years of employment?

You can collect SS at normal retirement age (which varies on when you were born) or normal early or late SS retirement age as long as you have made your ten years times four quarters of contributions. Doesn't matter if you never worked a day again- once you are vested, you are treated like anyone else. For now.

So, let's say you earn 300k a year and take home 200k (if you are employed and single without a bunch of dependents, it will be much less, say 150k), but let's say 200k. If you live frugally and buy a cheap house and get a 401k match, let's say you can sock away 120k a year in a nice mix of index funds. This will be much harder if you have loans, but let's say 120k. I think it's pretty hard for most docs to save more than that off of a 300k salaried income. So I'm being generous here- no loans, enough deductions, a fairly high savings rate, but an average EM salary.

Starting at zero NW (not even negative, which is the case for most grads) and assuming a 7.5% rate of return (we are far into a bull market, so that's fairly optimistic for the next decade) and adding 120k a year for 10 years, you would end up with a nest egg of $2,072,298. I don't see how you get to $3 mm unless you buy a house that appreciates massively and that you pay down aggressively. This doesn't count college savings, either. That would throw off 80k a year at 4% withdrawal rate. Would a doc retire on that? Maybe. But not a ton of wiggle room for kid expenses, college etc. But a $3 mm nest egg sounds unlikely without counting one's primary residence.

Any other thoughts?

 

[hundreddaysoff]

Eh?

I'm no WCI and certainly no math whiz, but I don't follow...

After taxes your 3M is closer to 2M.

How about money to subsist on day to day during those 10 years? And if you want to possibly live a little and go on a trip etc?

Then figure another chunk of change going to things you didn't anticipate: your roof fails, your pony bites somebody's hand off and sues you, etc.

Depending on interest rates and your local market and cash flow, buying a house free/clear could be a great move. Or the wrong move.

I'm all for option 4 though, and good for you for starting to think about the long term early on.

300K/y savings is all either after-tax or tax-deferred, and I'm assuming 50K/y before tax for living expenses s/p FIRE. So ~40K/y after-tax s/p FIRE, which I can still easily live on especially if my wife is still working. All my current living expenses are already figured in ($50K/y fo life). I'm renting so roof stuff isn't an issue. I have $2M umbrella insurance so the pony stuff isn't an issue. (Assuming I had a pony yet... *sigh*)

My biggest uninsured risk is that my compensation goes down as an emergency doctor, for any of the several reasons we've covered on this forum, and I thus fail to save $300K/y. If I can't control this by moving, then you're right, I fail and it's time to suck it up and work for more years. Not the end of the world.

 

[Groove]

Reviving this thread for some clarification. Does anyone actually know if the actual cosignature on an APC chart is REQUIRED for billing and/or supervisory requirements of the state?

CMG's always try to muscle you into signing these things, but what if you are sent a chart and you simply refuse to sign it. What then? Can you actually do that and keep your job? I am sitting on a chart that I refuse to sign and sent it to the medical director. Yes, I was on shift that day but I never saw the pt and there were other docs on shift but I luckily got sent the chart. In my opinion, if a doc is uncomfortable with signing it, he/she should be able to send it to the medical director for signature. After all, it's the medical director that is facilitating all the credentialing paperwork for the APC and attesting as their "supervising physician". I know this because they have tried to trick me into signing the paperwork before for new hires and I refused. Anyway, in this case the director declined to sign it either and said "I wasn't there in the department, so I can't sign it"

I thought you didn't have to be physically in the department to "supervise" APC management, you simply had to be available by phone or in person. Am I wrong on this?

What do you guys do when you get a chart that you simply don't want to sign?

 

[EctopicFetus]

Billing depends on what insurance they have and state law. Also most hospitals (like everyone I ever worked in) requires MLP charts to be cosigned by a physician. you do not need to be physically present to sign for the charts. Think urgent cares etc. I also know this for Neurosurgery, GI, Cards etc MLPs.

 

[Rekt]

Reviving this thread for some clarification. Does anyone actually know if the actual cosignature on an APC chart is REQUIRED for billing and/or supervisory requirements of the state?

CMG's always try to muscle you into signing these things, but what if you are sent a chart and you simply refuse to sign it. What then? Can you actually do that and keep your job? I am sitting on a chart that I refuse to sign and sent it to the medical director. Yes, I was on shift that day but I never saw the pt and there were other docs on shift but I luckily got sent the chart. In my opinion, if a doc is uncomfortable with signing it, he/she should be able to send it to the medical director for signature. After all, it's the medical director that is facilitating all the credentialing paperwork for the APC and attesting as their "supervising physician". I know this because they have tried to trick me into signing the paperwork before for new hires and I refused. Anyway, in this case the director declined to sign it either and said "I wasn't there in the department, so I can't sign it"

I thought you didn't have to be physically in the department to "supervise" APC management, you simply had to be available by phone or in person. Am I wrong on this?

What do you guys do when you get a chart that you simply don't want to sign?

APC? There's nothing advanced about them. You won't even sign the chart. Call them what they are.

 

[Groove]

Billing depends on what insurance they have and state law. Also most hospitals (like everyone I ever worked in) requires MLP charts to be cosigned by a physician. you do not need to be physically present to sign for the charts. Think urgent cares etc. I also know this for Neurosurgery, GI, Cards etc MLPs.

That's exactly what I thought. The director can totally sign these, he just doesn't want to either.

 

[MechEDoc]

That's exactly what I thought. The director can totally sign these, he just doesn't want to either.

My fear is if that I refuse to sign charts and forward them to the medical director I will be taken off the schedule. Has anyone had any luck agreed to only sign charts for patients that have been presented and/or seen by themselves with the remainder of the charts being forwarded to the medical director?

My view with regards to "supervision" is that for patients that I am unaware of I am unable to supervise the mid-level's work. I do not hire these people, evaluate them, promote them, or fire them. I have no "supervisory" role aside from potentially being involved in a given the patient's care while I am on shift.

 

[GonnaBeADoc2222]

You will be fired if you refuse to sign and that's the policy at the shop you are at. Make no mistake about it.

At one CMG site I was at we (mostly) collectively refused to sign (worst group of midlevels I've ever worked with), thus we changed the culture and I THINK the director signed. I say I think because the midlevels stopped sending charts to those that refused to sign and I never got bothered about it.

At one non CMG site I was at, the expectation was still to sign. So don't think this is just a CMG thing.

If you're gonna get sued, you're gonna get sued. you'll get snagged for something despite your best efforts. Best you can do is sign sign away without further discussion and keep working to move to a non-cmg / tyrannical large hospital system with better leadership.


Sent from my Pixel 3 using SDN mobile

 

[MechEDoc]

If you're gonna get sued, you're gonna get sued. you'll get snagged for something despite your best efforts. Best you can do is sign sign away without further discussion and keep working to move to a non-cmg / tyrannical large hospital system with better leadership.

I agree, but the grass isn't always greener on the SDG side. Money talks everywhere. Fast, good, and cheap - most groups chose fast and cheap. Profits are maximized with faster throughput (fast) combined with decreasing expense (cheap). "Good" is sacrificed.

 

[thegenius]

I agree, but the grass isn't always greener on the SDG side. Money talks everywhere. Fast, good, and cheap - most groups chose fast and cheap. Profits are maximized with faster throughput (fast) combined with decreasing expense (cheap). "Good" is sacrificed.

+100

This defines the behavior of everyone in our society (even physicians)

 

[Hercules]

I agree, but the grass isn't always greener on the SDG side. Money talks everywhere. Fast, good, and cheap - most groups chose fast and cheap. Profits are maximized with faster throughput (fast) combined with decreasing expense (cheap). "Good" is sacrificed.

True but at least in an SDG you’ll be the ones hiring/firing midlevels. You’ll also be the ones deciding what your group’s midlevel policies are. And you’ll be the one profiting off the work they do.

 

[EctopicFetus]

True but at least in an SDG you’ll be the ones hiring/firing midlevels. You’ll also be the ones deciding what your group’s midlevel policies are. And you’ll be the one profiting off the work they do.

This is exactly right. My sdg we got rid of the bad ones. We sign the notes and are compensated for it. if you want to not sign thats ok someone else will. we also only use them to work low acuity cases. for those of you working for a CMG you are getting suckered into signing those charts for nothing.

 

[GeneralVeers]

Anybody have ideas to meaningfully shift the risk from a doc up the chain to the CMG or hospital or whoever employs the PA/NP? A lawsuit from a doc roped into a PA case that loses? Something else? Yeah I know I'm probably dreaming.

Make the "supervising physician" be one of the C-suite executives who no longer works clinically but has to sign all their charts and take all the responsibility.

 

[MedicineZ0Z]

You have the right to do what you want with them. You can treat them like residents. You can write notes on all their patients. There is nothing preventing you from doing this. It's inefficient and a waste of time, and defeats the purpose of having them. But if you are in a group with 15-20 other doctors and you can't change the politics of the group yourself, then do something to protect yourself.

This is what I do...the MLP will present cases like this

1) "14 yo with ankle pain after falling off his skateboard, I'm getting an xray". I don't need anymore information.
2) "25 yo woman with dental pain for 3 days, she wants Norco". I'll ask is she drooling, can she open her mouth wide open, and does she have significant facial swelling. If no to those...then I'm done.


3) "28 yo man with PMH of Type1DM, gastroparesis, p/w vomiting and epigastric pain for 1 day. 15th visit in 2 years for this complaint. I'm going to do x, y, and z." They know what labs to run and how to treat. I might say "do not give him narcotics under any circumstance, and if there is a problem let me know." I don't really care if he gets imaging or not, maybe the labs will dictate it as such. Dispo is based on whether we can make him better or not.
4) The computer says "44 yo woman with dizziness." I notice that the patient has never been here before. PA comes back and says "44 yo woman with Alports Syndrome, ESRD on dialysis, p/w feeling dizzy during dialysis and couldn't finish her session. BP is 105/45." I will go in and see that patient, and depending on which PA I'm working with, I will take over the case. That is not an easy case. IV access will be hard. The differential is broad. She could have anything.

Or you can make a point and actually see the patient (at least briefly) aka doing your job as the ED doctor and not entrusting people's lives with someone who has 1/3 of med school education and nothing more.

APC? There's nothing advanced about them. You won't even sign the chart. Call them what they are.

Lol said this a million times. Like what exactly is "advanced" about these folks?

 

[GonnaBeADoc2222]

Or you can make a point and actually see the patient (at least briefly) aka doing your job as the ED doctor and not entrusting people's lives with someone who has 1/3 of med school education and nothing more.



Lol said this a million times. Like what exactly is "advanced" about these folks?

Sometimes easier said than done my friend

Sent from my Pixel 3 using SDN mobile

 

[cyanide12345678]

Reviving this thread for some clarification. Does anyone actually know if the actual cosignature on an APC chart is REQUIRED for billing and/or supervisory requirements of the state?

CMG's always try to muscle you into signing these things, but what if you are sent a chart and you simply refuse to sign it. What then? Can you actually do that and keep your job? I am sitting on a chart that I refuse to sign and sent it to the medical director. Yes, I was on shift that day but I never saw the pt and there were other docs on shift but I luckily got sent the chart. In my opinion, if a doc is uncomfortable with signing it, he/she should be able to send it to the medical director for signature. After all, it's the medical director that is facilitating all the credentialing paperwork for the APC and attesting as their "supervising physician". I know this because they have tried to trick me into signing the paperwork before for new hires and I refused. Anyway, in this case the director declined to sign it either and said "I wasn't there in the department, so I can't sign it"

I thought you didn't have to be physically in the department to "supervise" APC management, you simply had to be available by phone or in person. Am I wrong on this?

What do you guys do when you get a chart that you simply don't want to sign?

My first shift as attending, i got home after my shift and reviewed the charts from the mlp. I really didn't like one discharge they made. Called up the patient, told the patient to return to ER. Put in a note saying i told the patient to return to ER as an attestation of the mlp note as i disagreed with the disposition.

Now i ask my MLPs to tell me about most of what they see and i follow their workup and labs.

 

[deleted497653]

It’s better to atleast eyeball all midlevel patients even if it’s just to say hi to the patient. Tell the midlevel working with you to present to you a quick summary as soon as they see three or four patients so you can keep up. You don’t want them telling you about the patient right before they plan to discharge because the patient wants to leave at that point and probably won’t want any more testing and you might not be at a point where you can stop. Really I’ve found sometimes midlevels are good but doesn’t hurt to just eyeball for yourself.
Really it takes 2 minutes and you just say, “I’m dr so and so and I’m working with np so and so. Hope you feel better soon. Np so and so will come talk to you about the plan”.