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How Are PCP's Making Money?

Discussion in 'Pre-Medical Osteopathic [ DO ]' started by Ibn Alnafis MD, 12.28.11.

  1. Ibn Alnafis MD

    Ibn Alnafis MD

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    I have been shadowing an FP who runs a family clinic and noticed that he only sees 22-26 patients/day of which only 2-3 are new patients. Almost half of his patients are insured via Medicare while the other half either have private insurance or pay cash. For those who pay in cash, the clinic charges $50 per established or follow-up patient and $100 for the new ones. The doctor occasionally performs pap smears and other little procedures.

    So, I made a quick calculation in my head and figured out that clinic generates a gross income of 900-1200/day. If the doctor works 5 days/week, 48 weeks/ year, he will collect $216k-288k/year of gross income, which translates into roughly 110-$150k of net income (assuming only 45% of the gross income goes toward overhead costs).

    Am I missing anything, or this is how little PCP's make?

    Are there additional ways through which PCP's could generate more income without compromising the quality of care they deliver or working 80 hours/weeks?
  2. MedPR

    MedPR

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    $130k sounds about right for a FP who works in a clinic. I don't think you're missing anything.
  3. willen101383

    willen101383

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    Before med school for a period of time before I moved to Philly I worked in the clinical lab in a massive GPs office. Over time I got to know the docs pretty well and still keep in touch with them...so I have a bit of inside info on their business practices.

    First up, these dudes each see almost 40 patients a day. They have a ton of midlevels to rake in extra cash for all of those low complexity visits. They have XR in house, they have a lab RAKING IN THE CASH...like MOUNTAINS. I always talk about my lab background here so I wont get into that, but CBCs cost like 2 cents a pop to run, but you can bill out 30 or 40 bucks for one and make maybe 15 or 20. That goes for most of the lab tests...you make a KILLING if you have a well run lab with people who know what they are doing and little waste.

    Run a U/A on every patient and make it a practice rule that every patient also gets a microscopy even if the dip is negative = an extra few bucks per UA because a poor soul like me has to sit there and read it under the scope.

    Throw in lots of little other tests, audiology, spirometry, XRs on every little musculoskeletal complaint with an acute onset.

    Have a diabetes counselor on site.

    One of the docs does colposcopies, vasectomies, LEEP procedures. All of those are money makers. And dont forget that each vasectomy patient gets no less than 3 post vasectomy semen analyses...again that some poor chap like me has to deal with.

    If you are a good businessman you can figure out the stuff that insurance will pay for under the guise of "screening" even though you have zero clinical suspicion of anything.

    Pt has no BPH or any urinary sx to speak of...yet everyone over 40 gets a PSA because thats whats recommended....sure just send em down to your in house lab.

    The best part of this practice is: the original 6 docs bought the building. For 10 years they rented our other office space in the building to a cardiologist, a neurologist, an optician/optometrist, a rehab facility....all of them paying thousands and thousands in rent a month. Last summer they sold the building to a private management company and made something like 30+ million split 6 ways. Each one of those docs is a FP doc...and all are multimillionaires before 50.

    You need to be a savvy businessman, and a good doc and the money will come. The problem is that most docs are financial morons.
  4. Prncssbuttercup

    Prncssbuttercup Established Member -- OMSIII

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    The doc I shadowed is a clinician, he's making 180-200/yr seeing about that many pts/day... Other friend is a hospitalist, making 220
  5. ManBroDude

    ManBroDude Half man, half bearpig

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    It's interesting that JUST NOW in 2011 medical schools are starting to implement business practice classes and/or joint MBA programs. The double edged sword is this: if physicians are sworn to do no harm, does that mean it's right to force people to pay for extraneous lab UA's and x-rays even though everyone in the office and in the profession knows it's not needed? Where do you cross the line between actually taking care of them (I mean, literally, caring for a person) and making a living? Or becoming a multi-millionaire? I understand that some people will always have their best interests in mind, even under the guise of "I'm a doctor that helps poor sick people".

    But it's sad that the American medical-industrial complex is turning physicians into vendors and scam artists, especially at the FP level we DO's hold so dear.
  6. willen101383

    willen101383

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    :thumbup:

    Sadly we get zero business classes. We get plenty of worthless ethics type stuff, but nothing on how to actually make money in your profession. Wouldnt want anyone to think doctors arent just in it purely to help people. :rolleyes: I have no issue saying that if docs didnt get compensated the way they did, I wouldnt be a med student.
  7. DrWily

    DrWily

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    Everything is a business; medicine is not excluded. That being said, I think the hippocratic oath of "Do No Harm" is really to protect against malicious intent. Even if a "screen" isn't really needed, it's still a screen and may possibly catch something. Line excerpt from Modern Day Hippocratic Oath:

    "I will prevent disease whenever I can, for prevention is preferable to cure."

    I guess you could lump those in with this? :)
  8. DocEspana

    DocEspana my troubles will have trouble with me

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    It was stated much more specifically and with better articulation above but... if you want to make a simple FP practice turn into a lucrative one there are two easy steps (and this applies to all business).

    1) Own the means of production. By that I mean, own the lab. Nice profit
    2) Appeal to women. which of course means if you're FP and you do obstetrics and gynecology you'll be greatly augmenting your income (and malpractice, but i understand the offest it worth it)
  9. Prncssbuttercup

    Prncssbuttercup Established Member -- OMSIII

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    And this thought process is EXACTLY what is wrong with US medicine
  10. Wolverines83

    Wolverines83 ASA Member

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    I think it was more of an honest mathematical question. How does A + B actually equal C?

    To go a step further, the OP might even be trying to figure out if PC is financially (woops, I said the f-word) worth it to pay off loans and or justify long hours. Nothing wrong with that. Medicine doesn't = martyrdom.
  11. Prncssbuttercup

    Prncssbuttercup Established Member -- OMSIII

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    I'm referring to the idea of upcharging people to get more money
  12. Druggernaut

    Druggernaut Lifetime Donor

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    I 100% agree. But when you get to the point that you run a UA on everyone and then further test it even if the results were negative (as in Willen's example), it seems pretty unethical. When you're x-raying every acute injury, you've gotten to the point that you'll do harm to your patients for financial gain. That's grounds for revoking a license. They can justify it to protect themselves from that, but in reality, it's criminal.
  13. munchymanRX

    munchymanRX Purveyor of Fine Nomz

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    At the risk of sounding cliche, "don't hate the player, hate the game".

    Medicine is a high overhead business, and the way the billing and insurance systems are structured mean that physicians get paid for volume rather than quality of care. Throw in the litigiousness-favoring nature of our malpractice system and you have a recipe for a healthcare industry that forces doctors to adopt money-chasing habits in order to stay afloat.
  14. Prncssbuttercup

    Prncssbuttercup Established Member -- OMSIII

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    Way to defend something that's wrong... two wrongs don't make a right... Only 3 lefts do
  15. jinobi

    jinobi

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    ....eh? :confused:

    You can stick to your principles to not upcharge people or bill more for unnecessary services - but under the current system, that'll mean you'll have to take on more volume to stay afloat. There's currently a shift from bundled payments back to a fee-for-service system, though the type of payments you receive will be influenced by the type of practice you're in (HMO, academic, private...)

    Nothing wrong with trying to make more money, but there's a grey area between overtreatment for reimbursement's sake and overtreatment for completeness's sake. If you're going for the latter, you gotta have some business savvy.
  16. absolutdokta

    absolutdokta Get some!

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    While I agree that it seems a little fishy to run tests just to run tests and rake in the money, the malpractice issues are so ridiculous these days that docs almost have to practice medical-legal medicine rather than medicine according to signs/symptoms/history. It not longer simply, "I really dont think you have (insert disease) because the history and presentation do not suggest it....BUT.....we better do this (insert test) even though its expensive just to cover our ass...er....all the bases. Docs almost can't think for themselves with all these damn lawyers chomping at the bit.
  17. DocEspana

    DocEspana my troubles will have trouble with me

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    I agree with the above. :thumbup:
  18. Prncssbuttercup

    Prncssbuttercup Established Member -- OMSIII

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    That is a huge issue I agree...

    As for the rest, how do we fix a broken system if no one is willing to take a stand?? If no one breaks the status quo it will just keep getting worse....
  19. DocEspana

    DocEspana my troubles will have trouble with me

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    if i understand you, what youre suggesting is that someone break the status quo by not practicing defensive medicine (a combination of overtesting and ruling out obscure diseases)? Studies show those people do in fact exist and do in fact get sued more than the "average" physician in their field. I have not personally seen it, but I have been told many times by my direct superiors that it exists and is one of the documents used by physician advocates to fight for tort reform.

    The people standing up are the ones who are fighting the battle for stuff like tort reform, malpractice reform, and physician amnesty. Things that we sort of tune out as soon as we hear because they are conversations held entirely in legal-ese and "that cant ever apply to us, right?". Thinking that a physician can ever be a non-political occupation is laughable. Medicine and healthcare are political bargaining chips and its repeated losses in the government and court room that led to us having to do all these extra tests. Whether the physician embraces the reality and makes extra money off of tests he's going to be running anyway is simply a sign of industriousness, since the choice is either do those tests or be buried under frivolous (and they almost always are frivolous) lawsuits that slowly chip away at your money and sanity.
  20. Mbeas

    Mbeas Hi I'm Kate

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    charge for OMM
  21. Prncssbuttercup

    Prncssbuttercup Established Member -- OMSIII

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    DocE, I'm not disputing some of what you're saying, but I think that a great deal of the waste in our system is caused by this very issue. It is, at its core, greed. So, you are advocating putting greed ahead of your patient, and using their insurance company to do so. What if this person doesn't have insurance? Would you still do it? I find the idea of that absolutely disgusting, and yet it happens all the time. A friend of mine just had a CT run because of swelling in her face, if they would have done a FNA they would have just as easily found the fluid was filled with bacteria, thus cellulitis. Instead, they charged her (she has no insurance) for a CT scan that really wasn't necessary. Again, disgusting... Our system is corrupt, and if physicians are helping, right along with the insurance companies, it is wrong. Plain and simple. Healthcare costs are out of control, and this kind of mentality is pouring gas on the fire...
  22. Skinceutical

    Skinceutical

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    Actually, the problem here is that as a pre-med, you simply don't have a clue as to how little you actually know about medical decision making.

    First of all, FNA is not particularly useful in diagnosing cellulitis, and would be unnecessarily invasive in this case. As for the CT scan, there are some forms of facial cellulitis that invade deeper structures and are considered medical emergencies. As a result, a CT is considered standard of care for many presentations of facial cellulitis. If your friend had lost her vision due to a delayed diagnosis, you'd probably be on here ranting about how evil doctors didn't treat her the same way they would an insured patient.

    Save the self-righteous anger for something else.
    Last edited: 12.31.11
  23. Prncssbuttercup

    Prncssbuttercup Established Member -- OMSIII

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    Well, when your cheeks are full of fluid and they drain it off, why not just run a ****ing microscopy on it and say "oh yep, bacteria"?? She was already sent from urgent care to the ER, so I'm assuming they were pretty sure it was beyond their abilities... So why not give her a dose of IV abx, some meds, and do the CT scan if it hasn't improved in 24-48hrs? Or, does it really just come down to, we have a CT and we get lots of money if we use it? And you're right, I am a pre-med, but I am certainly not naive, nor stupid. So lets have a civil discussion instead of coming out with the 'tude
  24. ToldYouSo

    ToldYouSo Student

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    Kinda ironic considering urgent care in itself is a good money maker and that most of the issues handled there are self limiting and usually minor, but when something serious does turn up the de-facto medico-legal step is to send the patient to an ER to protect themselves, NOT because of a lack of "abilities."

    Not qualified to recommend any type of treatment and I'm also not sure why you're arguing with a resident :confused:
  25. willen101383

    willen101383

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    In their defense, you can miss things by simply relying on the dip and not doing a micro. Ive seen plenty of negative dips, and when I put em under the scope see plenty of X. Doesnt happen often, but it does happen. You can get so much mucus in a sample that RBC/WBCs dont come into good contact with the pad on the strip and you might miss it. Hell, there are things like trich/yeast/non nitrite forming bacteria that UA strips wont even pick up. Ive seen it all happen before. All tests have shortcomings, which is why it is important to have well trained, well educated people running these tests that know what to look for. Sadly this isnt always the case. There is a saying in lab medicine "good MDs need good MTs." UAs arent perfect, and its always important to trust your clinical judgement vs relying fully on a test. Obviously these guys are doing this to make a buck however...but figured id put that out there for your own knowledge.
  26. Skinceutical

    Skinceutical

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    I repeat, a pre-med, you simply don't have a clue as to how little you actually know about medical decision making.

    1. If she had "cellulitis" as you claimed earlier, her cheeks would be edematous and swollen, but likely would not have a pocket "full of fluid" for someone to drain.
    2. While a gram stain and wound culture may help tailor antibiotic coverage later on, they WOULD NOT change acute management.
    3. What part of "medical emergency" did you not understand? If your friend actually had a form of cellulitis with vision or life-threatening sequelae, then letting her sit on IV antibiotics for 2 days without any diagnostic imaging would be considered malpractice.
    4. Lastly, physicians in the ED do not get a kickback for every CT they request.
  27. willen101383

    willen101383

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    For my own clinical knowledge advancement; we are referring to cavernous sinus invasion correct?
  28. Prncssbuttercup

    Prncssbuttercup Established Member -- OMSIII

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    I think most urgent care centers I have been to are pretty limited in their abilities... they can stitch, splint a sprain, and other similar things, but they can't cast a fracture, or run an IV (this is the urgent care facilities I am familiar with), she was hoping to get away with a lower bill, and went to the urgent care, which referred her on. If the course of treatment is going to be a dose of IV abx, with an oral follow up (my mother in law gets cellulitis frequently from being home bound), why not just do the meds, and wait to do the CT scan if there's no improvement? It is a legitimate question, not an argument.

    The argument comes from the comment "Actually, the problem here is that as a pre-med, you simply don't have a clue as to how little you actually know about medical decision making"

    Personally, I see people with insurance get WAY more unnecessary tests because the insurance company won't complain *as much* they will just raise the rates of the person...
  29. Skinceutical

    Skinceutical

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    That and orbital cellulitis were the two big complications I had in mind.
  30. willen101383

    willen101383

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    Its the nature of the game sadly. Sure, always trust your clinical judgement, but what happens when that rare complication arises, your miss a diagnosis, a patient suffers significant morbidity or even dies...and you end up sued. Sure, nobody is denying this exists, but would you rather miss a diagnosis that ultimately may end up with your patient dying and you getting sued (as rare as it may be), or bill someone's insurance for a test that is probably not needed, but a good test to get?

    As far as as the clinical management goes, while I am sure skin will elaborate more (and correct me if I am wrong), facial cellulitis can easily spread to the cavernous sinus and then cause meningitis or cavernous sinus thrombosis=potential death. Empiric tx wouldnt be the wisest option here, because you want to actually visualize the depth of invasion and the structures involved. When death is very possible outcome, you want to get that CT vs empiric tx. Sure it sucks your friend got billed without insurance, but its better off than him/her being dead or up in the unit with complications and being stuck with that MASSIVE bill.
  31. Prncssbuttercup

    Prncssbuttercup Established Member -- OMSIII

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    No, it wasn't, it actually was lower jaw/cheek, that started from (possibly, although patient & physician are unsure) a 'stabbed' gum...

    I should add, the reason she went to urgent care is because she thought she was having some sort of allergic reaction to ??? and figured they'd give her some kind of allergy meds or epi... But the doc, clearly, didn't see it as that and sent her on...

    Skin: For the record, constructive criticism comes with constructive comments, or comments to help improve, your comments seem to only be for the purpose of being insulting. So thanks for that... In the future, when you deal with students and residents, maybe learn from someone who has taught: when you tell someone they're wrong, show them how to be better, otherwise it's destructive criticism...
    Last edited: 12.31.11
  32. jinobi

    jinobi

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    SBB, just restrain yourself when you're over your head in something rather than finding another way to attack someone who is trying to correct what you're saying...
  33. Prncssbuttercup

    Prncssbuttercup Established Member -- OMSIII

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    All I'm saying is people don't have to be asshats on this forum. If you disagree, say so, we're adults, be an adult and be respectful. Assumptions were made about the situation which were incorrect, on both sides, which is why I asked for clarification.
  34. Skinceutical

    Skinceutical

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    Maintaining a healthy appreciation for the limits of your own knowledge base is a vital part of medical training and practice. I'm halfway through residency and freely admit that my own clinical judgement isn't up to the level of those ahead of me in training and experience.

    When you come on here without a single day of medical training and dismiss the actions of other physicians as "absolutely disgusting" and "putting greed ahead of your patient" (those are your exact words, mind you), I find that frankly offensive. The fact of the matter is that your assessment of the situation was (not surprisingly) incorrect. When I pointed out that at this point you don't have the knowledge base to assess the validity of their decisions, you lashed out and assumed I was calling you stupid and naive.

    You have a lot to work on, and I hope medical school teaches you a little bit of humility. There's nothing more dangerous in the hospital than someone who thinks they know more than they actually do.
  35. DocEspana

    DocEspana my troubles will have trouble with me

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    A relevant fact to this whole thing: most ERs are volume revenue units. Which mean they dont see a cent of profit from running tests. This is done on purpose. They get paid per patient and get paid the same amount if they see them and send them home with directions for a cold compress as they do if they nuke them from space with every medical gun in the arsenal. Its to encourage them to both run every test necessary to make sure the patient is properly diagnosed and managed as well as to prevent them from running tests that serve no real utility just to earn profit.

    This fact is ER specific, so it wont apply to other fields, but since we were discussing ER I figured I'd add that.
  36. DrMediterranean

    DrMediterranean

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    .
    Last edited: 01.01.12
  37. Bacchus

    Bacchus PGY Too-many-expectations Moderator

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    The above business plan and all is great, except as we try to control healthcare costs there will need to be considerably more justification for said tests. Medicare rules all. I also feel that the mantra of unnecessary testing needs to be looked at.
  38. willen101383

    willen101383

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    I wouldnt really say they are doing too many tests unnecessarily. Clinically, with a negative DRE and what not, do you REALLY need to be running PSAs? Probably not. But as a patient how would you feel if your doctor told you there was a test out there that could just add one more "piece to the puzzle" in ascertaining you dont have prostate cancer.....but they werent going to do it to save costs. I know id be a bit upset.

    The UA thing is the only thing those guys do that is sort of suspect...but like I said above, it may be justified based on my experiences.

    At any rate, tort reform needs to happen before we can rein in these out of control testing costs. I dont really understand why legislatures dont get this fact. In states like PA (as you know all too well bacchus) where there are no caps on suits....coupled with the likely to sue patient population here in philly, things are especially bad. Id rather run every test in the book to minimize chances I miss a dx and get sued....
  39. MedPR

    MedPR

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    I work in a hospital microbiology/virology lab and a lot of the time physicians order PCR testing for multiple viruses. Maybe it's possible for the pt to have all of them, or have symptoms indicative of all of them, but I doubt it. Here's an example of one list of orders that made me think the physician either had no idea what was going on with the pt, or there was somehow money involved.

    The tests ordered were for:
    hsv
    vzv
    cmv
    adenovirus
    enterovirus
    ehrlichia
    leptospira

    Really doctor? You can't rule out any of those without an expensive test?
  40. DocEspana

    DocEspana my troubles will have trouble with me

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    Ehrlichosis? Well that one is an outlier here. Unless there is a tick on them. But then why no Luke disease?
  41. Skinceutical

    Skinceutical

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    Not sure what the rationale was for the last two, but the rest sound like reasonable orders for a patient presenting with meningeal signs. CMV is a little borderline, but entirely understandable if the patient was immunosuppressed.

    And again, your hospital lab is not paying the hospitalists and/or residents to order lab work. That said, a positive viral PCR could decrease duration of hospitalization and decrease the amount of empiric IV antibiotics administered, potentially offsetting the cost of the tests.

    I'm not going to try to claim that no one ever orders unnecessary testing, but it is kind of ridiculous to see people with little to no understanding of medical decision making (or physician billing/compensation for that matter) try to argue that this is all being done out of greed.
  42. willen101383

    willen101383

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    If you are a clinical lab technologist (I am guessing you are not) you should know that docs dont get kickbacks for ordering labs in hospitals. Yeah maybe in the private office example I cited above docs have financial incentives to order labs but not in the hospital. In your example, with so many viruses causing so many overlapping symptoms you do need to have a shotgun apprach like this sometimes to figure out what was going on. Just in your example alone a few of those can cause similar clinical syndromes. Do you know the patients hx/sx? Did you see the patient? Unless you did and possess the same clinical knowledge as the doc that saw the patient, you are in no place to state the testing he ordered was excessive. Furthermore in a situation where a patient may be decompensating rapidly a shotgun approach like this is necessary to r/i or r/o a whole bunch of things rapidly vs waiting for the results of a PCR screen, which we all know isnt going to come back in 20 minutes.
  43. absolutdokta

    absolutdokta Get some!

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    lots of armchair docs up in here:rolleyes:
  44. willen101383

    willen101383

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    While I fully agree with you, I am sure you remember what it was like to be a premed.

    Skin said it perfectly "you dont know how little you know."

    Sadly, some of my classmates refuse to acknowledge what they dont know, and still think they know everything, which is fing dangerous!
  45. xXIDaShizIXx

    xXIDaShizIXx Clinical Psychology Psy.D. Candidate

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    I have no idea. I shadowed a PCP and they saw maybe 10-15 patients all day and probably ~12 just wanted pills. :thumbdown:
  46. willen101383

    willen101383

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    How dare you unhijack this thread.
  47. xXIDaShizIXx

    xXIDaShizIXx Clinical Psychology Psy.D. Candidate

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    :confused: Sorry if I said something offensive..
  48. willen101383

    willen101383

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    It was a joke!!!!

    I would tell you an airplane joke but it would go over your head! :D
  49. tkim

    tkim D-d-d-dilaudid

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    Dude, you go to the only for-profit med school in america.
  50. tkim

    tkim D-d-d-dilaudid

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    In our Lyme-heavy area, our infectious dz docs recommend we test for ehrlichosis as well as Lyme.

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