Re: CA license, but no board cert. How to get life back on track with a baby?

[tofoo]

First of all, two things.

1. There will be haters who will challenge me and call me a liar. I don't care. I'm not writing this for them anyways.
2. Please refrain from sending me PMs for the time being. I would like to keep the discussion public for benefit of people who will be reading this in the future.

For context, please read the following post first:

CA license, but no board cert. How to get life back on track with a baby?

Pertinent info: Graduated from UNC-Chapel Hill back in 2009 with decent USMLE scores (230-240s). Matched into gen surg residency but suffered a spine fracture during PGY2. Have California MD license since 2011. Been living in S. Korea from 2012 til now. With wonderful spouse and a beautiful 2...

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If you look at the date of my last last entry in that post, you'll see January 7th, 2018. I remember exactly where I was when I last wrote that. I was standing alone in this cafe I had remodeled all on my own. I sold that cafe in February or March.

My wife, 6 month old son, and I went for a short vacation to Bali in April and moved to California last June. I didn’t know it that time, but that same month, some wound doctor in town got arrested for something he did years ago and it finally caught up with him. His face and name was all over the town news. There was a sudden vacuum, and I ended up filling in that position and only found out about what happened long after I signed the contract which was binding for at least 90 days.

None of that mattered anyways. Turns out, I had a knack for taking care of wounds. In about 3 months, I was the busiest wound care physician in town and was rounding at up to 17 nursing homes per week, seeing about a 80-100 patients a week. Lots of procedures.

Within a few months, I started to close up some “impossible” wounds. Here is a picture that I have permission to share.

Picture of wound, NSFW
View attachment 271907

On the left is a failed muscular flap on a stage 4 pressure wound down to the ischial bone in a relatively young quadriplegic patient. His mom is with him in the room everyday. She had been watching these gaping holes in her son’s body deteriorate over the course of two years. Everyone was waiting for the patient to die when I took over his care late last year. On the right is the wound 5 months later. It’s even better now but I am too lazy to update this picture. On a side note, he's got a suprapubic catheter, and I recently caught an episode of urosepsis early before the primary care team did. His wound bled more than normal, and I worked him up because the NP wouldn't do anything about it. My plan is to see him off vent and watching him move in a powered wheelchair controlled by mouth, before election day next year. We'll go together to vote, but he will vote for the other party. LOL.

Anyways, I was doing well so soon after I got back to the US and to clinical work. January of this year, I made 25k (pretax). Not only that, during that month, I was offered half a million dollar contract (as 1099 contractor, within 6 months of moving to California). Two months later in March, I was offered a partnership elsewhere in a lesser desirable location. I turned both down to start my own company.

There's more to this. Tomorrow, I will write about the time between January and now. The day after, I will reflect on that experience.

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[Raryn]

Good for you for carving out a niche in a field (wound care) that doesn't necessarily need board certification. I absolutely believe your story - it's a field with significant need and most of the people most qualified to do it (surgeons) often don't want to. I don't know if I necessarily believe the $500k contract, but the rest is absolutely believable.

Our posts in your original thread were not meant to be saying you had no chance at all - just that the odds were poor for getting back into formal training and we didn't recommend general medicine work without training.

 

[tofoo]

Good for you for carving out a niche in a field (wound care) that doesn't necessarily need board certification. I absolutely believe your story - it's a field with significant need and most of the people most qualified to do it (surgeons) often don't want to. I don't know if I necessarily believe the $500k contract, but the rest is absolutely believable.

Our posts in your original thread were not meant to be saying you had no chance at all - just that the odds were poor for getting back into formal training and we didn't recommend general medicine work without training.

Yeah I recognize that. Were I in your shoes, I would have to given the same advice you had given. Except I guess the only difference would be that I now know that wound care is a viable option for someone like me.

At the time, I did take the advice to heart. I really thought the only way forward was to go into anesthesiology residency and had an anesthesiologist in San Diego who reached out to me and was helping me with the application.

Somewhere along the way, though, I began to realize that residency was not the only path.

I’ll write more later after my evening errands.

 

[tofoo]

For the last year, I worked extremely hard to build a solid reputation, and now I am my own boss. I do education rounds with NPs and we generally have a good pace. Some days do get hectic.

Yesterday, I started at 7AM and finished at 9PM. I had a patient with nec fasciitis. I had just debrided her sacral wound just yesterday from black to red yesterday, but I asked the nurses to keep a close eye on that wound because the wound shouldn’t have been that necrotic after last week’s debridement. I did mention nec fasc as a remote possibility to nurses and patient’s daughter. Well I was rounding at the same facility for another patient who had a feeding tube issue. The nurse told me the patient with the necrotic wound had a fever of 102 and a white count. When we uncovered the dressing, the wound was necrotic again and fetid. I told them to call 911 and debrided the wound as fast as I can. Then I painted the whole surface with silver nitrate before the EMT arrived. I wrote a quick note for the ED and gen surgeon to read and attached my business card to the note so they could call me if they had any questions. She was off within 10 minutes. I quickly counseled the daughter on what I thought was going on, the grim prognosis, and that she can always call me for questions but she should let the surgeon at the hospital do what he needs to do without much hesitation on her part. Then they were off. I wiped my brow and then went back to the patient with feeding tube problem.

For the most part, I block all ED transfers for surgical issues unless it is life threatening (i.e. nec fasc and peritonitis). Over the last year, I found 2 nec fasc in patients and 1 peritonitis for a g tube. In all three patients, the primary care team had missed the diagnosis, and I was the one to recognize them upon physical exam. The first nec fasc patient lived for another month, but passed away later in hospice as patient had CLL. The second nec fasc patient from yesterday, we will see. The patient with peritonitis is still alive. I still manage his g tube on a routine basis.

My practice is going so well that there is now a waitlist for nursing homes to bring our company in. This is virtually unheard of in this industry.

Needless to say, I don’t worry about what I am going to do when I grow up any more. Now I just daydream about what I am going to do when my practice is mature (and it will mature when we have cornered the market in 2 years time).

Since January of last year when I last wrote that post, my family moved three times. Across the ocean, to tiny room in a friend’s house, to a two bedroom apartment, to this 2000+ sqft house in the center of this city.

Our son grew up to be a wonderful toddler without any major illnesses. My wife recently gave birth to our second child - a daughter. I named her something that means “answers to prayers”. Our house has a pool in the backyard. For the past two weekends,I held parties for nurses and others who have worked together with me to take care of all of the patients.

Difficult to believe, I know. I might have left some details out. All I have said is factual and true as far as I can remember, including the rough number figures about January.

Yesterday, that nec fasc debridement had RVU of 17. I did two more procedures each with RVU higher than that. I saw a total of 12 patients and performed 6 additional procedures on top of that. My RVU for yesterday was probably close to 100, if not more. You don't have to believe me, but this is what Medicare wants. I keep all these surgical issues at bay. I&D by bedside in nursing home. I do that all the time. IR procedures. Yeah I carry gastrografin in my car. In fact, I carry a whole instrument tray thing in my merc wagon.

Medicare recognizes that 1) there is a significant cost of transporting these patients to hospitals who are bed bound, 2) they have to pay out so much more for ancillary things at the hospital (medical supplies, labs, etc), and 3) outcomes are better if the doctors go routinely and manage issues instead of the issues getting so bad that patients are shipped out to hospital. You are probably aware of this but Medicare is actively changing the post acute and rehab scenery with financial incentives and penalties to decrease bounce backs. For every dollar Medicare spends on me, they are probably saving two to five because the patients stayed out of hospital and discharged from nursing home early. I routinely close dehisced amputation stump incision within a month.

I know it's hard to believe. I know I'm a unicorn, yet I exist. I’m just put this out for the good people who struggled the same things as I have and wanted to let them know that the nursing home scenery welcomes talented caring people.

Okay, tomorrow or whenever I get around to it, I am going to share my meditation on what all this experience has taught me and what I want to do next.

 

[hamstergang]

1. There will be haters who will challenge me and call me a liar. I don't care.

You don't have to believe me
...
Difficult to believe, I know. I might have left some details out. All I have said is factual and true as far as I can remember
...
I know it's hard to believe. I know I'm a unicorn

The only reason I at all doubt your story is because of how much you're preemptively trying to convince us it's true. You expect us to not believe you before anyone's given any feedback.

 

[tofoo]

The only reason I at all doubt your story is because of how much you're preemptively trying to convince us it's true. You expect us to not believe you before anyone's given any feedback.

You dont have to believe me.

 

[calvnandhobbs68]

I know it's hard to believe. I know I'm a unicorn, yet I exist. I’m just put this out for the good people who struggled the same things as I have and wanted to let them know that the nursing home scenery welcomes talented caring people.

The nursing home scenery welcomes a warm body with an active medical license.

Luckily you happen to be a caring person who actually seems to like the care you provide in nursing homes (which most people hate...thus the looking for warm bodies with medical licenses). This isn't actually terribly hard to believe. The only places where people don't care about board certification/board eligibility are places where they can't find a doctor who's actually board eligible in the specialty they need. Thus why we typically tell people who haven't completed a whole residency to look for jobs in these types of places (rural urgent cares, nursing homes, occupational med clinics, etc).

 

[dpmd]

The nursing home scenery welcomes a warm body with an active medical license.

Luckily you happen to be a caring person who actually seems to like the care you provide in nursing homes (which most people hate...thus the looking for warm bodies with medical licenses). This isn't actually terribly hard to believe. The only places where people don't care about board certification/board eligibility are places where they can't find a doctor who's actually board eligible in the specialty they need. Thus why we typically tell people who haven't completed a whole residency to look for jobs in these types of places (rural urgent cares, nursing homes, occupational med clinics, etc).

This. You definitely couldn't pay me enough to do that job.

 

[Groove]

Damn, you got lucky. Incredible story, and I'm glad your back healed up after your fall. To be quite honest, the decision to forego residency and travel internationally was IMO incredibly irresponsible but that's me. I would have written you off as having zero chance at re-establishing your medical career. I truly hope no-one else reading your post becomes inspired to make a similar decision because you literally dodged a terminal bullet.

That being said, it sounds like you've had an incredibly fortuitous turn of events and carved out your own niche. Congratulations. That's remarkable. I think I would have given up hope.

 

[tofoo]

Damn, you got lucky. Incredible story, and I'm glad your back healed up after your fall. To be quite honest, the decision to forego residency and travel internationally was IMO incredibly irresponsible but that's me. I would have written you off as having zero chance at re-establishing your medical career. I truly hope no-one else reading your post becomes inspired to make a similar decision because you literally dodged a terminal bullet.

That being said, it sounds like you've had an incredibly fortuitous turn of events and carved out your own niche. Congratulations. That's remarkable. I think I would have given up hope.

I think you've hit the nail on the head. I am planning to delve into this with more detail in my next reply.

Hope I have time sometime later this week to do this.

 

[Dr.LeoSpaceman]

Okay, tomorrow or whenever I get around to it, I am going to share my meditation on what all this experience has taught me and what I want to do next.

First off, I think everyone here would be happy for you that things have worked out in such a positive way. So congratulations are certainly in order. Perhaps it's just me, but the tone of your posting is somewhat unseemly. If you want to share a reflection on what your doing and how you got there, I think we'd all be happy to hear it. Knowing that you're doing something fulfilling is certainly important for people who may be in your position to hear. But the focus of your posts on how much you're billing and how much everyone loves you is a bit over the top.

For the most part, I block all ED transfers for surgical issues unless it is life threatening

I'd also caution you on this. I think it's great you're trying to temporize the things you can to avoid having patients bounce back. I certainly find it draining to have a patient come back to the ED from a SNF for something minor that just needed a physician to evaluate it. But the flipside is that it's frustrating to get a transfer into the hospital where someone has been nibbling around the edges of the problem, yet it's progressed or failed to improve and now I have to take over. You also reference closing a dehisced amputation stump. One would hope you're contacting the original surgeon to talk about the issue, and make sure they are ok with you taking care of it.

 

[tofoo]

Thank you for your kind words, everyone. It's been a busy couple of weeks.

But the focus of your posts on how much you're billing and how much everyone loves you is a bit over the top.

I haven't made a single dime since I started my practice almost two months ago. Having said that, I know most doctors do not know how much Medicare reimburses for the things I do. My current theory on why nursing home wound care market can't attract talented surgeons is that the young graduates simply are not exposed to the work and the reimbursement structure. No midnight calls, little stress, and better pay than private practice in hospital settings.

I don't know where I said everyone loves me but I understand that I sound like a guy with ego problems, which I most certainly do. The point I wanted to convey was that I feel appreciated by the people I interact with on a weekly basis. It's a truly rewarding experience to see a chronic wound close. Patients appreciate you when you mend their wounds.

I'd also caution you on this. I think it's great you're trying to temporize the things you can to avoid having patients bounce back. I certainly find it draining to have a patient come back to the ED from a SNF for something minor that just needed a physician to evaluate it. But the flipside is that it's frustrating to get a transfer into the hospital where someone has been nibbling around the edges of the problem, yet it's progressed or failed to improve and now I have to take over. You also reference closing a dehisced amputation stump. One would hope you're contacting the original surgeon to talk about the issue, and make sure they are ok with you taking care of it.

I agree with you on the triage aspect of this. In nursing homes, 95% of surgical ED transfers are for dislodged/clogged G tubes, abscess, lacerations, and periwound cellulitis with systemic signs. These are the ones you find draining, and I manage them by bedside.

I think I mentioned above that I send patients out for suspected nec fasc and peritonitis after pulled g tube, but these are rare. The recent nec fasc patient from few weeks ago has since passed away.

The other surgical ED transfer are the ones that really should have been managed via clinic visit at an earlier time. These issues, I coordinate with PCP to get a clinic appointment.

Earlier on, I had taken care of a patient with crushed finger injury that resulted in dry gangrene. Unlike gangrenous toes, the fingers should have been amputated but the hospital he came from didn't get a hand surgery consult. I asked for weeks to have the patient be seen at the local hand surgery clinic, but this didn't happen. Instead, they sent the patient to the ED several times where the patient was just given abx and sent back. Out of frustration, I called the hand clinic myself and arranged for an appointment, explaining the situation. The patient was seen in clinic the next week, from where he was admitted to the hospital and underwent amputation. That was the first time I learned to be proactive about getting the PCP onboard and coordinating care as much as I need to. This is more of a problem at certain nursing homes than others.

There was a time when I was making lots of calls to 3rd party clinics, but these days, I have cellphone numbers to most PCPs who ask for consult. I usually let them know and they make the arrangements for patients to be seen in clinics, so I haven't been needing to do it so much the past 3 months.

Hope that clarifies any misunderstanding.

 

[tofoo]

So this is my reflection.

A lot of people were urging me not to enter the clinical arena without some kind of re-integration program or a residency. I really took that to my heart, and I only applied for the wound care job because I have a family to take care of, with plans to apply for anesthesiology residency down the road. It was 3 months into that job that I realized that I was making enough to afford a living for my family without having to put them thru residency with the minimal pay and the long hours away from home. It was a difficult decision not to pursue residency anymore.

I am triumphant now, but that was a long struggle since the day I fell from that cliff 8 years ago. Like someone above said, it was a terrible move not to complete a residency but to move overseas, from a career standpoint. But it's something I needed to do, to find meaning and purpose in life after those 20 hours at the base of the cliff.

I thought a lot about what everyone had written in the original post and in this thread. I considered most of the concerns with some weight, and I know these concerns arise from having seen incompetence in people who come with the gaps in training. So why was it that I was any different?

1. Unrecognized knowledge base: This is something I had left out in the original post. During the time I was overseas, I was on the editorial board of the plastic surgery journal in the country I was in and reviewed more than 300 papers and co-authored a handful of papers. Translated 2 books into English. By the time I was ready to come back to the states, I had learned a lot about wound healing and reconstructive principles. I just didn't recognize that I knew a lot. It also helped immensely that I was exposed to a certain wound textbook from the pre-free flap era that translated extremely well for the nursing home wound care model. This was luck masquerading as opportunity.

2. Preparation: I wake up at 4:30 and leave home around 7AM. Around 5AM, I sit at the desk and review the rounding list from the previous week. If there was a problem that I needed to address, there was usually a comment I left to remind myself. I read up on the issue. Sometimes, I might order an instrument from my supplier. Most wound care doctors don't bother with stuff like ordering their own syringes and needles, but I had spent a lot of time figuring out what works (25G needle, 2% lidocaine) and what doesnt (27G). Now I am always ready to do minor blocks if the benzocaine spray isn't going to be enough. This preparation has allowed me to be more capable and more efficient. The wound doctors who show up with a handful of disposable curettes and a benzocaine spray cannot debride a sensate wound to the n-th degree. So they do the bare minimum each day.

3. Team building: This is something that I also learned over the course of the past year. There is a lot of variability in the nurses who take care of wounds - the treatment nurses. Currently, the extent of the conversation that most wound doctors have with tx nurses is what is required for documentation (e.g. wound measurements) and the dressing order for the week. For me, I make it a point to introduce new tx nurses to the idea of wound bed preparation (T.I.M.E. assessment) and the basic mechanism of wound healing. It's a long didactic process that takes about 2-3 months to acclimate to, and it's mentally taxing when I have a thousand things to do. But I know that education component really improves my own practice. My outcomes are better when the nurses are able to assess the states of a wound and communicate this better. Another thing I try to instill in nurses is that they are to never apologize to me for txting me or calling me in evenings, nights, or weekends. I find it that the more comfortable the nurses feel about txting me, the more I can keep tabs on the patients throughout the week while I am not there. It is as if I look at a hundred wounds everyday without physically being everywhere. I trust my nurses to tell me when things aren't going right, and they almost always do when they have been working with me for a little while.

It was an extraordinary set of fortunate circumstance under which I came back to clinical practice - without any board certification - that I was able to start my own practice without capital and take market share away from several multimillion dollar corporations. I am not sure this can be replicated elsewhere by a non-board certified doctor. If it happens, that person must have something he/she cannot articulate for oneself or be extremely lucky. And that's why I think everyone wants re-entrants to be cautious because of the critical nature of our work.

I definitely do think my story is possible for a young general surgeon or a plastic surgeon with the entrepreneurial attitude and grit. I am currently helping a HMO general surgeon to build his nursing home practice in another city. He was the person who recommended that I look into wound care in the first place and became privy to all of what I had written here since the beginning. I suspect he will fly past me once he gets going, what with all the training and years of OR experience he has on me.

That is all that I have to say for now. I will try to post another update in maybe 6 months time.

 

[Snoopy2006]

@tofoo Congratulations, that's a remarkable story. I don't think you could have written a better ending to that. I respect the hell out of physicians with that entrepreneurial spirit, which is rare among us.

You found a narrow field that most doctors don't want to go into, found a market ripe for the taking, and created a hell of a business. Major respect.

 

[MechEDoc]

Would love an update!

 

[tofoo]

2nd update to "CA license, but no board cert. How to get life back on track with a baby?"

To recap: Back in November 2017, I was a new father and was desperate to get back into medicine. I thought my best bet would be to get back into residency (I was hoping to get into anesthesiology back then). In September 2018, I began what I thought was going to be a temporary work taking care...

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