patient volume

[KHE]

I wouldn't call it an "entitlement." Most people who graduate residency expect there to be a "demand" for their skills. That has historically been the case for the past century, and it is the case with the large majority of specialties available to medical students. New ophthalmologists have the expectation that they will be able to find a decent job as easily as their peers who did residencies in different areas.

That's precisely why I said "not really" entitlement.

I understand that people expect there to be a demand for their skills but what residents need to understand is that there skill set alone is not nearly enough to make them effective as an employee or partner.

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[cme2c]

People with serious problems walking in can happen within any practice setting. So again, does one really need to always be current with the latest IM treatment protocols to be effective in a walk in clinic?

Hence his statement about missing something serious, it's not about treatment.

 

[KHE]

Hence his statement about missing something serious, it's not about treatment.

Let me ask it a different way then....

What percentage of doctors currently working in the walk in clinics of America are actually up on the latest IM treatment guidelines?

 

[cme2c]

Let me ask it a different way then....

What percentage of doctors currently working in the walk in clinics of America are actually up on the latest IM treatment guidelines?

AGAIN, its not about TREATMENT. Its about misdiagnosing a patient. The fact that you don't get the difference is plain SCARY.

 

[KHE]

AGAIN, its not about TREATMENT. Its about misdiagnosing a patient. The fact that you don't get the difference is plain SCARY.

*sigh*

Ok....fine....

How many doctors working in the walk in clinics of America are up on the latest IM DIAGNOSIS protocols?

How many presentations that are unusual enough walk into the walk in clinics of America every day such that it would be ideal to have an IM doctor who is up on the latest IM DIAGNOSIS protocols?

 

[bungo]

*sigh*

Ok....fine....

How many doctors working in the walk in clinics of America are up on the latest IM DIAGNOSIS protocols?

How many presentations that are unusual enough walk into the walk in clinics of America every day such that it would be ideal to have an IM doctor who is up on the latest IM DIAGNOSIS protocols?

Well to put it in perspective, I just bought the latest set of IM diagnosis protocols last year, and they already seem out of date. Hope this helps.

Also, the ratio is usually 1-2 out of 100 diagnosis cannot be made without the latest versions of the protocols for each specialty.

knowledge base, training, and experience have all been rendered obsolete by the protocols.

 

[KHE]

Well to put it in perspective, I just bought the latest set of IM diagnosis protocols last year, and they already seem out of date. Hope this helps.

Also, the ratio is usually 1-2 out of 100 diagnosis cannot be made without the latest versions of the protocols for each specialty.

knowledge base, training, and experience have all been rendered obsolete by the protocols.

The reason I'm asking is not to be argumentative or contrarian. There is discussion in this thread about a new graduate concerned about not being able to make any money for a bunch of months until they get credentialled onto third party plans. A suggestion was made that they work in an urgent care facility for those 6 months though it might be "shady" because as a new ophthalmology resident they would not be up to date on the latest IM protocols.

My question is......are the vast majority of doctors who work in urgent care centers up to date on these protocols?

Does one need to be up to date on these protocols to be effective to deal with the vast majority of urgent care center encounters? Would the poster in this thread be incompetent/ineffective for 6 months in an urgent care center?

 

[guttata]

The reason I'm asking is not to be argumentative or contrarian. There is discussion in this thread about a new graduate concerned about not being able to make any money for a bunch of months until they get credentialled onto third party plans. A suggestion was made that they work in an urgent care facility for those 6 months though it might be "shady" because as a new ophthalmology resident they would not be up to date on the latest IM protocols.

My question is......are the vast majority of doctors who work in urgent care centers up to date on these protocols?

Does one need to be up to date on these protocols to be effective to deal with the vast majority of urgent care center encounters? Would the poster in this thread be incompetent/ineffective for 6 months in an urgent care center?

For liability reasons, a clinic manager would probably never consider hiring a subspecialist to do primary care work. The competency question will depend on the individual. But I think most would agree that, as residents, we do not keep up to date on many primary care protocols/algorithms (which can change fairly often). Depending on the clinic, it can be like a mini-ER.

To Bitterwife - it's fine to be frustrated. You both have sacrificed a lot to get where you are now. We all have to vent, but your negativity will accomplish nothing. Many practices across the nation are suffering - but, what do you expect when you have the worse recession in 80 years? The medical field is not immune to the economy (as previously thought). Actually, I am not surprised many people do not seek care - many eye diseases are painless.

I could be as bitter as hell. I have joined a practice without a future. My partner has never had an associate (partly my fault for not doing my due diligence). My clinic volume has dropped 2/3rd (yes, 66-67%) compared to residency. Yes, some days, I bitch and moan at home - but in the end, it does nothing.

You have options, but your husband really needs to get licensed in a state (credentialing is another matter)

1. military jobs - you can often apply for out-of-state military jobs. They will accept a medical license from any state.

2. locums tenens - you did not mention having any kids, so this may be an option. No, it is not ideal, but it will pay the bills.

3. fellowship - if the market is really terrible in your area, this can 'buy' you some time. some fellowships are in high demand, even in an area saturated with general guys

4. solo practice - you said he was already a coding expert and that he was hard working. You can work (not many people have that option) while he is building his practice. We receive no training in business or marketing (and fiscally and personally conservative as a group - ie, anti-risk takers) , so this really scares a lot of us from going solo.

5. temporary (2-3 years) job in the middle of nowhere. You can save money to fund a solo practice in a few years.

6. part-time job - in some practices, you can bill under another physician's medicare number while waiting to be credentialed.

7. VAs - some VAs will pay very well for C&P exams. You do not need medicare credentialing.

Good luck.

 

[cme2c]

*sigh*

Ok....fine....

How many doctors working in the walk in clinics of America are up on the latest IM DIAGNOSIS protocols?

How many presentations that are unusual enough walk into the walk in clinics of America every day such that it would be ideal to have an IM doctor who is up on the latest IM DIAGNOSIS protocols?

All it takes is one. Those of us with real medical degrees actually care about patients enough that we don't want to put someone at risk, even if there is a low chance.

 

[VA Hopeful Dr]

The reason I'm asking is not to be argumentative or contrarian. There is discussion in this thread about a new graduate concerned about not being able to make any money for a bunch of months until they get credentialled onto third party plans. A suggestion was made that they work in an urgent care facility for those 6 months though it might be "shady" because as a new ophthalmology resident they would not be up to date on the latest IM protocols.

My question is......are the vast majority of doctors who work in urgent care centers up to date on these protocols?

Does one need to be up to date on these protocols to be effective to deal with the vast majority of urgent care center encounters? Would the poster in this thread be incompetent/ineffective for 6 months in an urgent care center?

Its not always about being up to date on the latest protocols and algorithms. Its about comfort level and I would suspect that ophthalmology residents, and, since they no longer see acute care general medicine patients anymore, they're less likely to have ready access to the knowledge they would need to be comfortable practicing primary care medicine.

 

[VA Hopeful Dr]

All it takes is one. Those of us with real medical degrees actually care about patients enough that we don't want to put someone at risk, even if there is a low chance.

That's a bit uncalled for.

 

[Visionary]

I could be as bitter as hell. I have joined a practice without a future. My partner has never had an associate (partly my fault for not doing my due diligence). My clinic volume has dropped 2/3rd (yes, 66-67%) compared to residency. Yes, some days, I bitch and moan at home - but in the end, it does nothing.

I'm repeating myself, but how far out of residency are you? If this is your first year out, such a drop is not unexpected. In residency, you're seeing patients in a well-established and usually overloaded practice. Once you start your own practice, it can take 3+ years to build up volume. The exception is when you are taking over for a retiring doc. You may not keep all of that doc's patients, but you aren't starting from scratch, as you are when you go out on your own or even join an existing practice. When you are added to an existing practice, building a steady volume will take time, even if there is initially volume to spare. This is not something that is really discussed in residency or fellowship.

 

[guttata]

I'm repeating myself, but how far out of residency are you? If this is your first year out, such a drop is not unexpected. In residency, you're seeing patients in a well-established and usually overloaded practice. Once you start your own practice, it can take 3+ years to build up volume. The exception is when you are taking over for a retiring doc. You may not keep all of that doc's patients, but you aren't starting from scratch, as you are when you go out on your own or even join an existing practice. When you are added to an existing practice, building a steady volume will take time, even if there is initially volume to spare. This is not something that is really discussed in residency or fellowship.

Two years out, I average 12-13 patients a full day. I understand most say you need 3-5 years to build a busy practice; but compared to my colleagues, I think I am building incredibly slowly - at this rate, it's going to take 5-8 years. There were existing docs here as well, so there should be some built-in volume. Done all the PCP handshakes, nursing talks, community talks. I don't want to get into all the details, but there is too much inertia here (long time employees, antiquated thinking, and inefficiency).

Ie, new patient will call in for an annual exam - they will schedule two weeks out even though I can see the patient today. My pleas for seeing more patients everyday go unheard.
Ie, new patients still split between the doctors even though the other doctor is booked for six weeks and wants to 'retire' soon.
Ie, constant turnover of front-desk and techs.
Ie, time to process check-in is longer than the entire examination

Honestly, I do not know how they stay in business and I'm afraid to even buy in (if ever offered partnership).

Who knows - maybe they are trying to frustrate me to the point of leaving. Maybe, I am not partnership material.

But, it's my fault for believing the false promises of partnership/volume/surgeries and for not doing my due diligence.

I can complain on and on, but it's useless. Hopefully my experience will be an eye-opener for new grads.

Again, too much inertia. I can't move it, so if I secure a loan, I'm going solo. I'm sure the first few years of solo will be very challenging (and probably tougher than my current situation). But, at least, if I fail, I will have no one to blame but myself. If I can't secure a loan, I'm still moving on.

 

[odieoh]

Two years out, I average 12-13 patients a full day. I understand most say you need 3-5 years to build a busy practice; but compared to my colleagues, I think I am building incredibly slowly - at this rate, it's going to take 5-8 years. There were existing docs here as well, so there should be some built-in volume. Done all the PCP handshakes, nursing talks, community talks. I don't want to get into all the details, but there is too much inertia here (long time employees, antiquated thinking, and inefficiency).

Ie, new patient will call in for an annual exam - they will schedule two weeks out even though I can see the patient today. My pleas for seeing more patients everyday go unheard.
Ie, new patients still split between the doctors even though the other doctor is booked for six weeks and wants to 'retire' soon.
Ie, constant turnover of front-desk and techs.
Ie, time to process check-in is longer than the entire examination

Honestly, I do not know how they stay in business and I'm afraid to even buy in (if ever offered partnership).

Who knows - maybe they are trying to frustrate me to the point of leaving. Maybe, I am not partnership material.

But, it's my fault for believing the false promises of partnership/volume/surgeries and for not doing my due diligence.

I can complain on and on, but it's useless. Hopefully my experience will be an eye-opener for new grads.

Again, too much inertia. I can't move it, so if I secure a loan, I'm going solo. I'm sure the first few years of solo will be very challenging (and probably tougher than my current situation). But, at least, if I fail, I will have no one to blame but myself. If I can't secure a loan, I'm still moving on.

Out of curiosity are you paid on salary or by productivity, or some combination? That does sound frustrating with the old doc still taking a lot of the new patients, especially if he's wanting to retire. How good is your communication with him and your relationship in general with him? I would try to bring it up.

Dealing with front desk issues can be a huge pain, especially in the role of recent associate, they all know who is signing the checks and it isn't you so they have every reason in the world to go out of their way to do things for the boss and no real reason to do anything for you. I hate being a schmoozer but I've had to force myself to do a bit with the front office people and it does help some I've found. Then again, the doctor I work with, also looking to retire in the next few years, has instructed them to put all new patients in with me unless they kick and scream and insist to see him. That is really nice, I have to admit.

Looking at it from the other side of the coin, its probably a really scary time to bring on a new associate, with the economy and healthcare being in such limbo.

 

[orbitsurgMD]

Two years out, I average 12-13 patients a full day. I understand most say you need 3-5 years to build a busy practice; but compared to my colleagues, I think I am building incredibly slowly - at this rate, it's going to take 5-8 years. There were existing docs here as well, so there should be some built-in volume. Done all the PCP handshakes, nursing talks, community talks. I don't want to get into all the details, but there is too much inertia here (long time employees, antiquated thinking, and inefficiency).

Ie, new patient will call in for an annual exam - they will schedule two weeks out even though I can see the patient today. My pleas for seeing more patients everyday go unheard.
Ie, new patients still split between the doctors even though the other doctor is booked for six weeks and wants to 'retire' soon.
Ie, constant turnover of front-desk and techs.
Ie, time to process check-in is longer than the entire examination

Honestly, I do not know how they stay in business and I'm afraid to even buy in (if ever offered partnership).

Who knows - maybe they are trying to frustrate me to the point of leaving. Maybe, I am not partnership material.

But, it's my fault for believing the false promises of partnership/volume/surgeries and for not doing my due diligence.

I can complain on and on, but it's useless. Hopefully my experience will be an eye-opener for new grads.

Again, too much inertia. I can't move it, so if I secure a loan, I'm going solo. I'm sure the first few years of solo will be very challenging (and probably tougher than my current situation). But, at least, if I fail, I will have no one to blame but myself. If I can't secure a loan, I'm still moving on.

If this is true, then your practice's policies are at odds with your interests. They are even at odds with their interests.

You wouldn't be the first to find yourself in the position you are in.

If they control where patients are being scheduled, and they are not active in reducing backlogs for appointments by filling out your schedule and reducing the older doctor's bookings to reasonable length of time, then they are thwarting your efforts to grow and ******ing the overall growth of the practice. That hurts everyone.

Everybody wants to retire. What are the alternatives short of working until your practice dwindles (not pretty) or going out with your boots on (usually is accompanied by dwindling, decline of reputation and other not-so-pretty things?)

You need to meet with your principals in an un-distracting setting with no other practice personnel around and lay out your concerns. Get the data together so you can show them--schedules and whatnot--and tell them exactly what you want them to do to fix the scheduling problem (e.g. you see all new referrals and all new patients and anyone "lost" to followup until the seniors get their backlog under control.)

Really, a practice like yours that has senior doctors frustrating patients with long back bookings is just asking for a competitor to move next door and open up. This is a "move in and eat your lunch" scenario in the making. If your practice can't or won't provide timely service, someone else soon will. Someone else with the credit to open a second office and enough time to staff it or a new associate that isn't being held back by a management suffering sloth, stupidity and fear will grow his practice in exactly the place you would like to grow yours.

If after being told what you think needs to be done and the partners do nothing, then you should work on your exit plan.

 

[Visionary]

If this is true, then your practice's policies are at odds with your interests. They are even at odds with their interests.

You wouldn't be the first to find yourself in the position you are in.

If they control where patients are being scheduled, and they are not active in reducing backlogs for appointments by filling out your schedule and reducing the older doctor's bookings to reasonable length of time, then they are thwarting your efforts to grow and ******ing the overall growth of the practice. That hurts everyone.

Everybody wants to retire. What are the alternatives short of working until your practice dwindles (not pretty) or going out with your boots on (usually is accompanied by dwindling, decline of reputation and other not-so-pretty things?)

You need to meet with your principals in an un-distracting setting with no other practice personnel around and lay out your concerns. Get the data together so you can show them--schedules and whatnot--and tell them exactly what you want them to do to fix the scheduling problem (e.g. you see all new referrals and all new patients and anyone "lost" to followup until the seniors get their backlog under control.)

Really, a practice like yours that has senior doctors frustrating patients with long back bookings is just asking for a competitor to move next door and open up. This is a "move in and eat your lunch" scenario in the making. If your practice can't or won't provide timely service, someone else soon will. Someone else with the credit to open a second office and enough time to staff it or a new associate that isn't being held back by a management suffering sloth, stupidity and fear will grow his practice in exactly the place you would like to grow yours.

If after being told what you think needs to be done and the partners do nothing, then you should work on your exit plan.

orbitsurgMD beat me to the punch and, as usual, provides excellent advice. Your scenario is one that's changeable, if appropriate steps are taken. If not, it would be worth looking elsewhere (even if it means starting over), rather than just hanging on until a senior doc retires.

 

[guttata]

I appreciate the advice.

I have approached the practice manager and senior doctor on many occasions, starting in my first year. I am basically told to be patient and the practice will build. At this rate, I may be dead by the time my practice is thriving. Reading between the lines, they imply that I should be grateful for what I do have. Previous associates have plateaued patient volume - and it's not the typical ceiling (500-600/month) you would imagine. It's more like 250-300 encounters a month.

Frankly, it makes no sense to me. I am salaried (+unattainable bonus), so you would think they would want to build me up as quickly as possible. Changes over the last two years have been done in order to minimize expenses rather than to grow the practice. I think the practice is dying.

I cannot think of why they would do this except (1) the senior doctor is content with 'living off' his current patients, so he has no incentive to re-build another practice. Therefore, he is trying to maximize profits now before retiring and relying on me for a golden parachute (2) senior doc doesn't want me billing/collecting more than he does - giving me leverage in contract negotiations (3) they want me to leave (multiple sources confirm that he has never had a partner).

At least I have favorable non-compete terms (really, none). Will keep everyone updated.

 

[orbitsurgMD]

I appreciate the advice.

I have approached the practice manager and senior doctor on many occasions, starting in my first year. I am basically told to be patient and the practice will build. At this rate, I may be dead by the time my practice is thriving. Reading between the lines, they imply that I should be grateful for what I do have. Previous associates have plateaued patient volume - and it's not the typical ceiling (500-600/month) you would imagine. It's more like 250-300 encounters a month.

Frankly, it makes no sense to me. I am salaried (+unattainable bonus), so you would think they would want to build me up as quickly as possible. Changes over the last two years have been done in order to minimize expenses rather than to grow the practice. I think the practice is dying.

I cannot think of why they would do this except (1) the senior doctor is content with 'living off' his current patients, so he has no incentive to re-build another practice. Therefore, he is trying to maximize profits now before retiring and relying on me for a golden parachute (2) senior doc doesn't want me billing/collecting more than he does - giving me leverage in contract negotiations (3) they want me to leave (multiple sources confirm that he has never had a partner).

At least I have favorable non-compete terms (really, none). Will keep everyone updated.

An unattainable bonus is reason enough to exit. If you can't ever see the benefits of the extra patient seen and the extra hour worked, you are being cheated. If the scheduling practices are what are causing this to be the case, then those are what have to change. If they can't understand that, how keeping you from attaining better production will rob you (and them) of the funds needed for you to buy your share of the practice and ultimately of their wished-for "golden parachute," then they are foolish, or they have some other undisclosed plan that doesn't involve you.

As the lawyers like to say, "time is of the essence." They have to get things changed in a timely way. It is not reasonable to string you along while under-supporting you until they feel good and ready to do something else. Every year you live with that is a working year you aren't working under better and more productive circumstances, with them or somewhere else.


Now that I think of it, if you aren't too spendy in lifestyle, you can make it with your present volume on your own. You should write up a business plan and meet with some of the local banks commercial lending departments. Despite all the recent changes, local doctors are good business and good risk. I can tell you for a fact that 12 to 13 patients a day is enough to meet repayment on a modest startup capital equipment loan and a line of credit, pay current expenses on a small office with minimum staff and leave enough to pay yourself and have some money for extra expenses like office lasers. If you bail, maintain good relationships with your former employers if you can; cover their call, don't badmouth them no matter how much you might want to. If their practice is in fact dwindling, you will be around to take patients looking for an alternative. Don't steal their employees, though, that can work against you.

 

[Visionary]

At least I have favorable non-compete terms (really, none). Will keep everyone updated.

Really, a practice like yours that has senior doctors frustrating patients with long back bookings is just asking for a competitor to move next door and open up. This is a "move in and eat your lunch" scenario in the making. If your practice can't or won't provide timely service, someone else soon will. Someone else with the credit to open a second office and enough time to staff it or a new associate that isn't being held back by a management suffering sloth, stupidity and fear will grow his practice in exactly the place you would like to grow yours.

If you have no non-compete, you might consider what orbitsurgMD mentioned. It will take front-end investment, but could pay off in the long term. You've likely accumulated enough business experience and made enough connections in the community that you could pull it off.

 

[odieoh]

If you have no non-compete, you might consider what orbitsurgMD mentioned. It will take front-end investment, but could pay off in the long term. You've likely accumulated enough business experience and made enough connections in the community that you could pull it off.

If he were to pull out and start up on his own, does he have any rights to the patient charts from the old practice? Seems like they would belong to the practice.

An unattainable bonus is reason enough to exit.

I wouldn't say this is always the case, although with the other things going on for Guttata it probably is. I have a bonus written into my contract that I will probably never hit. But, 1. My salary is pretty reasonable and 2. We talked about it while writing the contract and basically I sacrificed a good bonus for very favorable buy in conditions after 2 years of salary. And most importantly I completely trust the senior doc.

 

[Visionary]

If he were to pull out and start up on his own, does he have any rights to the patient charts from the old practice? Seems like they would belong to the practice.

No, but given the way the current practice is being run, Guttata may be able to develop a lot of business quickly with a solo start-up. That was the point orbitsurgMD seemed to be making. There is obviously some risk, but the upside is potentially huge.

 

[WhatNEyeTem]

I have absolutely NO sense of entitlement. Yes, hubby has worked HARD...scholarships, loans, you name it. I worked three jobs to get him through medical school. It's just very disappointing to find that even though he is very business-minded (he's a coding WIZARD) and willing to work VERY hard (he offered to see Saturday clinics 3 weekends a month for one practice), no one is willing to give him a chance. There were jobs that were offered and then fell through at the last minute, all at the end of recruiting season, when there is nothing else available. Everyone's February collections were at an all-time low, and NO ONE that I've met has a job this year. 1 practice we looked at hired an OD instead, so they wouldn't have to share any surgeries. I don't think it's too much to ask that after ALOT of hard work, we would like to live somewhere semi-desirable and make an "okay" salary that allows us to save for retirement, and maybe pay back the student loans before it's time to send the kids to college.

Broaden your search -- there are definitely jobs out there!

 

[eyesupply]

Mrs. Bitter Wife isn't getting much support here but she does have a point.

Ophthalmologists, particularly residents, tend to think they are in a great specialty and make a lot. However, they don't know that there are other specialties where the money is greater. If one is in private practice, the expenses to have a busy practice are high. Equipment and techs are very expensive. If you don't have many techs, you can't see too many patients. An internist can see a patient with a cold in 8 minutes (4 minutes talk, 4 minutes exam) Try refraction and doing all the points of an eye exam. There are too many things to measure in 4 minutes by yourself.

Established ophthalmologists tend to be good businessmen so the offerings to new residents are not very high paying for the workload.

All doctors are hostage to Medicare and politicians. In other professions, your pay is not dictated to you. Private insurance companies based reimbursement on Medicare.

cme2c has the right attitude (I presume). Do eye work because he has some interest and expertise in it and enjoy life earning frequent flyer miles

 

[KHE]

Mrs. Bitter Wife isn't getting much support here but she does have a point.

Ophthalmologists, particularly residents, tend to think they are in a great specialty and make a lot. However, they don't know that there are other specialties where the money is greater. If one is in private practice, the expenses to have a busy practice are high. Equipment and techs are very expensive. If you don't have many techs, you can't see too many patients. An internist can see a patient with a cold in 8 minutes (4 minutes talk, 4 minutes exam) Try refraction and doing all the points of an eye exam. There are too many things to measure in 4 minutes by yourself.

Established ophthalmologists tend to be good businessmen so the offerings to new residents are not very high paying for the workload.

All doctors are hostage to Medicare and politicians. In other professions, your pay is not dictated to you. Private insurance companies based reimbursement on Medicare.

cme2c has the right attitude (I presume). Do eye work because he has some interest and expertise in it and enjoy life earning frequent flyer miles

Within the context of a medial practice, what do you all think makes someone a "good" business person vs a "bad" one?

What attributes do you think the good ones have that the bad ones don't?

 

[DOCTORSAIB]

Within the context of a medial practice, what do you all think makes someone a "good" business person vs a "bad" one?

What attributes do you think the good ones have that the bad ones don't?

I'll bite.

Adaptiblity.

 

[KHE]

I'll bite.

Adaptiblity.

That's probably a good one.

Anyone else want to chime in?

 

[cme2c]

I'll bite.

Adaptiblity.

Spelling aptitude?