Job issue

[Wayner]

Hello,

Need advice on job situation. I did an advanced endo fellowship and joined hospital employed position to build basic advanced endoscopy practice. Referral base is from 6 general GIs and some surgery groups around.

Last year did close to 250 EUSs and 150 ERCPs. Few stenting, 10 Axios, lots of EMRs and almost no Barrett's.

Other partners do ERCPs and place plastic stents but do not know how to do Spy, remove larger stones or deal with complex stricture. They do most of their ERCPs when covering the inpatient hospital week. I'm the only one who is doing EUS, Spy and luminal stents. I was hoping to do more ERCPs as sometimes they do cases which I feel need an EUS or SpyGlass but they end placing plastic stent and refer as outpatient. I'm usually at the hospital and available to do these cases but they just proceed and do them. On some months, they seem to even do more ERCPs than me as the volume of ERCPs come from inpatient not outpatient cases and it depends on the week. On my inpatient week last time, I did 2 ERCPs only. Other colleagues can do up to 10 as it all varies depending on the week. I'm dissatisfied with the ERCP volume and don't want to just do the re-do and stent pull. It also feels odd someone who did not do advanced endoscopy to do more ERCPs in a week than an advanced endoscopist. I complained about this and about my ERCP volume but essentially nothing changed as everyone wants to do them and keep up with their skills. Initially they used to refer all non-stone cases to me when there is concern for malignanbcy but now they just do the ERCP, place a stent and refer as outpatient even for cancer patient. We are RVU based model and we are all meeting our targets. Any help appreciated.

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[1Cor1557]

Hmmm 🤔 this is a peculiar position for sure, with that kind of setup I'm shocked not more of the ercp hobbyists would just completely relinquish the practice all together with a pro like you around, if anything in that setup usually expect to be tough for the opposite reason with one advanced person occasionally getting disgruntled from being the only one dealing with pancreaticobiliary cases and the rest giving it up

 

[Elixir6]

You need to get the head partner to do something about it. Otherwise can always say you'll leave because you'll lose your own skills this way

 

[Wayner]

Thanks for the input. I clearly feel I'm not doing enough and I should be doing more. When I was hired for the position, the plan was that I do most if not all of ERCPs in the hospital which is around 400 cases a year. Once I started, I figured this was not the case and whoever is covering the inpatient week will just go ahead and do it despite me being available most of the time to do it. I did work with surgery and practices around to build my referral base which helped me get some outpatient cases but the bulk go cases come during the inpatient week. They kept saying I'm not available during my outpatient week but this is not true as I can be at the hospital almost all days except Fridays. I talked to them and the senior partner is willing to give up some of his ERCPs whenever I'm available but the newly hired person who is general and not advanced trained is not willing to give his cases. The only reason I can think he wants to do it is to generate more RVUs during his inpatient week.

 

[Suprep]

Thanks for the input. I clearly feel I'm not doing enough and I should be doing more. When I was hired for the position, the plan was that I do most if not all of ERCPs in the hospital which is around 400 cases a year. Once I started, I figured this was not the case and whoever is covering the inpatient week will just go ahead and do it despite me being available most of the time to do it. I did work with surgery and practices around to build my referral base which helped me get some outpatient cases but the bulk go cases come during the inpatient week. They kept saying I'm not available during my outpatient week but this is not true as I can be at the hospital almost all days except Fridays. I talked to them and the senior partner is willing to give up some of his ERCPs whenever I'm available but the newly hired person who is general and not advanced trained is not willing to give his cases. The only reason I can think he wants to do it is to generate more RVUs during his inpatient week.

Fair point but what is the issue with the doing the follow up ERCP as outpatient along with other things like EUS
? You are pulling the stent out but still completing all the other therapies that are needed - like spy, lithotripsy, complex stricture management. How does it matter you are not doing the initial ERCP? You should be fairly confident of your cannulation technique and so a repeat ERCP shouldn't affect that.

If your partners cases are ending up with more complications, there may be a case point to bring up. In the absence of that, I do not see this pattern changing. Your bargaining chip is you leaving but asking others to give up something they want to keep doing, if that was not initially clarified with them ahed, is wrong(not saying you are wrong. whoever proposed that you do bulk of ercp did not tell the other existing guys nor the new guy who joined that you will be doing most of the ercp)

 

[Suprep]

Hello,

Need advice on job situation. I did an advanced endo fellowship and joined hospital employed position to build basic advanced endoscopy practice. Referral base is from 6 general GIs and some surgery groups around.

Last year did close to 250 EUSs and 150 ERCPs. Few stenting, 10 Axios, lots of EMRs and almost no Barrett's.

Other partners do ERCPs and place plastic stents but do not know how to do Spy, remove larger stones or deal with complex stricture. They do most of their ERCPs when covering the inpatient hospital week. I'm the only one who is doing EUS, Spy and luminal stents. I was hoping to do more ERCPs as sometimes they do cases which I feel need an EUS or SpyGlass but they end placing plastic stent and refer as outpatient. I'm usually at the hospital and available to do these cases but they just proceed and do them. On some months, they seem to even do more ERCPs than me as the volume of ERCPs come from inpatient not outpatient cases and it depends on the week. On my inpatient week last time, I did 2 ERCPs only. Other colleagues can do up to 10 as it all varies depending on the week. I'm dissatisfied with the ERCP volume and don't want to just do the re-do and stent pull. It also feels odd someone who did not do advanced endoscopy to do more ERCPs in a week than an advanced endoscopist. I complained about this and about my ERCP volume but essentially nothing changed as everyone wants to do them and keep up with their skills. Initially they used to refer all non-stone cases to me when there is concern for malignanbcy but now they just do the ERCP, place a stent and refer as outpatient even for cancer patient. We are RVU based model and we are all meeting our targets. Any help appreciated.

also imagine this - you are a solo advanced endoscopist practicing in a community based center, most of your referring docs work outside your system who refer you EUS, EMR and follow up of ERCPs that were doing by the referring doctor. will you refuse to do those cases in that situation? will you see this situation differently since those docs work outside the system?

 

[Wayner]

I'm comfortable with my cannulation and this is not the problem. When I joined the practice the model was I do the bulk of ERCPs and others focus on general GI. I did advanced because I wanted to do mostly advanced and not do an EGD with biopsy when next door there is an ERCP happening. This was clearly agreed among everyone in the practice before I joined. I'm not exactly sure I understand the scenario you are describing. The outside docs do not do any advanced work and only scope at the ASC. I'm talking about the physicians within my own group.

 

[Suprep]

I'm comfortable with my cannulation and this is not the problem. When I joined the practice the model was I do the bulk of ERCPs and others focus on general GI. I did advanced because I wanted to do mostly advanced and not do an EGD with biopsy when next door there is an ERCP happening. This was clearly agreed among everyone in the practice before I joined. I'm not exactly sure I understand the scenario you are describing. The outside docs do not do any advanced work and only scope at the ASC. I'm talking about the physicians within my own group.

ok that part was missing in original post. if it was already discussed and agreed upon to take over most advanced cases, all the more reason to feel disgruntled when things dont happen the way it should.

perhaps, discuss in ur next physician meeting and have an open discussion. u can at least know if things are likely to change or remain the same. then u can decide to stay or leave