New attending - exhausted from complex patients

[increscence]

I recently finished fellowship and started private practice. In this medium-sized town, there's only one other person in my subspecialty.

All my patients are fairly complex and are challenging for multiple reasons - the diagnoses themselves, the patients' cognitive limitations (making it more difficult to explain to them what's going on and why I'm recommending this or that treatment), the patients' logistical considerations, etc. Almost every single patient has more than one of these issues. Even though I'm still building up my practice and have a fairly light patient load (20-22 patients/day), I come home totally wiped out. From what people have been telling me, it sounds like everyone in the community heard that I was coming and are now sending me their complex anterior segment patients all at once.

I will say that, since the patients are so complex and are often collaborative with other specialists, I write thorough notes. I also send letters to PCP and referring docs religiously, partly to maintain the lines of communication, and also to establish a good reputation.

I'm not complaining - I knew full well that this would be the case, and I'm very happy to be in a place where I'm needed and can actually do some good work. I just didn't expect it to be this draining.

The practice itself is great, very warm and welcoming. Personal life is okay - without going into details, I have some minor stuff going on but no more than the average person. I have a good support structure.

Does anyone have any advice to offer? Strategies to cut down on the burnout? Do you split up your visits for complex patients - one to discuss the diagnosis and hand the patient an informational brochure, and the next to actually discuss surgery? Were you in a similar position at the start of your career, and did it get better over time? Did your schedule become more balanced (routines vs complex patients)?

One thing I know I need to get better at is breaking up the visits. For example, instead of addressing all five of their major eye problems at once, discuss the top 2-3 now, and bringing them back to discuss the next 2-3. Otherwise, it gets too overwhelming and time-consuming both for the patient and for me.

Thank you for the advice everyone, I really appreciate it.

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[LightBox]

You are on the right path. Just address 1 or 2 of the most pressing complaints/issues first. The longer you get to know these complex patients, the less work it will be since you won't be re-inventing the wheel with every visit.

One thing you might want to ask your referring doctors, is whether they would be okay with just getting a copy of your exam note (i.e. instead of a full-blown letter). That will save you oodles of time if you can just fax over your last exam note instead of writing a long-winded letter. Most of my referring eye doctors (e.g. optometrists, retinal specialists) don't care about having personalized letters written out. But primary care doctors (who cannot decipher eye vocabulary) might still want a clear/concise letter.

 

[dantt]

I recently finished fellowship and started private practice. In this medium-sized town, there's only one other person in my subspecialty.

All my patients are fairly complex and are challenging for multiple reasons - the diagnoses themselves, the patients' cognitive limitations (making it more difficult to explain to them what's going on and why I'm recommending this or that treatment), the patients' logistical considerations, etc. Almost every single patient has more than one of these issues. Even though I'm still building up my practice and have a fairly light patient load (20-22 patients/day), I come home totally wiped out. From what people have been telling me, it sounds like everyone in the community heard that I was coming and are now sending me their complex anterior segment patients all at once.

I will say that, since the patients are so complex and are often collaborative with other specialists, I write thorough notes. I also send letters to PCP and referring docs religiously, partly to maintain the lines of communication, and also to establish a good reputation.

I'm not complaining - I knew full well that this would be the case, and I'm very happy to be in a place where I'm needed and can actually do some good work. I just didn't expect it to be this draining.

The practice itself is great, very warm and welcoming. Personal life is okay - without going into details, I have some minor stuff going on but no more than the average person. I have a good support structure.

Does anyone have any advice to offer? Strategies to cut down on the burnout? Do you split up your visits for complex patients - one to discuss the diagnosis and hand the patient an informational brochure, and the next to actually discuss surgery? Were you in a similar position at the start of your career, and did it get better over time? Did your schedule become more balanced (routines vs complex patients)?

One thing I know I need to get better at is breaking up the visits. For example, instead of addressing all five of their major eye problems at once, discuss the top 2-3 now, and bringing them back to discuss the next 2-3. Otherwise, it gets too overwhelming and time-consuming both for the patient and for me.

Thank you for the advice everyone, I really appreciate it.

Address the reason the patient is being referred to you and defer management of their other eye problems to their referring doctor unless urgent.

 

[Slide]

For referral letters, template as much of it as possible. That way you only have to fill in relevant sections for a good letter. Your EMR may have an option to do this; if not, just saving some templates in a Word/Pages doc works. With this, writing in depth letters takes less than a minute.

As you get more comfortable with your patients, you can start to judge how much you need to tell them. Some want to hear everything, others only want to know what they should do and no more. Being in a state where at least 15% of the population is illiterate, sometimes less is more, and that helps cut down on the length.

If you’re seeing patients as a referral for a complex issue, stick to just that. Have patients address their other issues with the referral source. For instance, I don’t do routine refractions in my practice, and it saves a ton of time.

last, as your reputation grows, you’ll get easier patients. In addition, your complex patients may no longer be as complex as you get to know them. That will help save time.

 

[MstaKing10]

Also as you transition from training to attending status there is another layer of stress in that you are responsible now for the patient. No longer can you defer to your attendings as you did in training. Also community docs look to you for guidance with these complex patients. These issues will of course get easier to manage as you become more comfortable practicing. Above advice is helpful. I would only add the importance of personal time to decompress. Super important. Used to feel guilty taking time off in residency/fellowship. Now I really relish my time off and disconnect. I know you just started but don’t be afraid to take a long weekend or two here and there. Makes a major difference.