wRVU

[DrSwede]

Hey there -

I feel like I have somewhat of a grasp of wRVU, but what I don't understand is what the total number of hourse reflect.

For example, if someone says 4000 wRVU's, I'm assuming that is for the year? And if so, what does that look like for a typical week (ie number of patients, procedures).

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[deleted472101]

Not very busy but busier than academic

 

[BobBarker]

The busy guys on here do 10,000 plus a year.

 

[bronchospasm]

Off topic but can you throw some light on the inspiration behind your handle bedpan commando

 

[studentologist]

About how many RVUs does the typical Pain Physician achieve the first year out of fellowship?

 

[BobBarker]

Just depends on the situation, how hard a worker you are, and how quickly you can get on insurance panels. It should be easy to do 6000. My second month I did 500 and it was like a 25- 30 hour a week job at that point.

 

[lobelsteve]

6000 wrvu should be 40 hr equivalent with light mix of procedures.
12000 is procedure heavy, 30-40 per week.
15000 is needle monkey, no time to talk to patients.


This is all shooting from the hip./

 

[gdub25]

Attending at my fellowship did 1200 wRVU the month I was in his particular clinic. I kept notes on the volume as a baseline for my own knowledge when it came time to look for jobs. That clinic had 32-34 patients scheduled per day and did 13-16 procedures per day. There were two midlevels who saw the patients and attending did all the procedures as well as saw a few patients to keep things moving. Attending an not got wRVU for the procedures he did or patients he saw, not getting RVU from patents the midlevels were seeing. Clinic started at 8am and we scheduled last patient at 3pm. We were always done by 4pm, finished notes and put the door by 5pm at the latest, almost always had a 30-45 minute break for lunch.

 

[DrSwede]

Thanks for all of the replies, they've been helpful as I try to wrap my head around the intricacies of job offers.

Off topic but can you throw some light on the inspiration behind your handle bedpan commando

I was a medic in the Air Force and this is what people, who were Air Force but not in the medical field, would call us. I think there's a book written by a WWII nurse called bedpan commando. I have always embraced it

 

[freddydpt]

Attending at my fellowship did 1200 wRVU the month I was in his particular clinic. I kept notes on the volume as a baseline for my own knowledge when it came time to look for jobs. That clinic had 32-34 patients scheduled per day and did 13-16 procedures per day. There were two midlevels who saw the patients and attending did all the procedures as well as saw a few patients to keep things moving. Attending an not got wRVU for the procedures he did or patients he saw, not getting RVU from patents the midlevels were seeing. Clinic started at 8am and we scheduled last patient at 3pm. We were always done by 4pm, finished notes and put the door by 5pm at the latest, almost always had a 30-45 minute break for lunch.

I wish I could observe how this clinic runs because that's the exact volume I'd like to achieve.

 

[SSdoc33]

Thanks for all of the replies, they've been helpful as I try to wrap my head around the intricacies of job offers.



I was a medic in the Air Force and this is what people, who were Air Force but not in the medical field, would call us. I think there's a book written by a WWII nurse called bedpan commando. I have always embraced it

Amazon product

not on the top on my list, but anything with WWII, cant be all bad

 

[SSdoc33]

I wish I could observe how this clinic runs because that's the exact volume I'd like to achieve.

judging by your previous posts, i think you do a little bit "too" good of a job. very through. most likely with very good outcomes. however, that is not valued in our fee for service model. you MUST sacrifice quality for $$$ if that is your goal. no way around it.

 

[freddydpt]

judging by your previous posts, i think you to a little bit "too" good of a job. very through. most likely with very good outcomes. however, that is not valued in our fee for service model. you MUST sacrifice quality for $$$ if that is your goal. no way around it.

I PM'd you... and thank you

 

[clubdeac]

Attending at my fellowship did 1200 wRVU the month I was in his particular clinic. I kept notes on the volume as a baseline for my own knowledge when it came time to look for jobs. That clinic had 32-34 patients scheduled per day and did 13-16 procedures per day. There were two midlevels who saw the patients and attending did all the procedures as well as saw a few patients to keep things moving. Attending an not got wRVU for the procedures he did or patients he saw, not getting RVU from patents the midlevels were seeing. Clinic started at 8am and we scheduled last patient at 3pm. We were always done by 4pm, finished notes and put the door by 5pm at the latest, almost always had a 30-45 minute break for lunch.

So just to clarify, the clinic sees a total of 32-43 patients per day (13-16 of which are procedures) and there is one doctor and two midlevels that see those patients. So each midlevel sees about 6-8 patients and the doc did 16 procedures and saw a few patients

 

[BobBarker]

and who got the RVU's from the fellow?

 

[gdub25]

The clinic schedules a total of 32-34 per day. Of those 32-34, about half get same day procedures. Typically the midlevels see all the patients (15-17 each) and the MD does procedures. MD will step in to visit with patients if they have questions, to say hi, or to see patient himself if the midlevels are getting backed up. He will also see all new patients. The month I was there they did not change the volume of the clinic to account for me so there were no additional RVU generated from me being there (however some of the clinics do increase number of patients on the schedule the month they have a fellow). I did every procedure under the supervision of the attending and saw all the new consults. It's my understanding the attending does not get any RVU from patients seen by the midlevels, he only benefits from them by way of them feeding him injections. We have 5 pain clinics associated with the institution where I'm a fellow and they are all operate this way. In general, for every attending there is 1-2 midlevels and every clinic has 2-3 procedure rooms. All clinics do same day, in office procedures with no sedation.

 

[bedrock]

judging by your previous posts, i think you do a little bit "too" good of a job. very through. most likely with very good outcomes. however, that is not valued in our fee for service model. you MUST sacrifice quality for $$$ if that is your goal. no way around it.

agree.

Freddy,

Everything you've posted suggests you are a great pain physician. The benefit of your unique educational background is to improve your skills at diagnosis and treatment with multiple modalities, not just poking them with a needle.

Midlevels evaluating pain patients leads to incorrect procedures being performed, however this is itself is lucrative as the patient has to keep coming back for more procedures, but it is not good medicine.

 

[freddydpt]

agree.

Freddy,

Everything you've posted suggests you are a great pain physician. The benefit of your unique educational background is to improve your skills at diagnosis and treatment with multiple modalities, not just poking them with a needle.

Midlevels evaluating pain patients leads to incorrect procedures being performed, however this is itself is lucrative as the patient has to keep coming back for more procedures, but it is not good medicine.

My thought is if I train the midlevels to practice at the same level as me, briefly confirm physical exam, the volume would still be there including clinic patients and procedures (needles and OMT). I couldn't allow for incorrect procedures, or at least ones I don't believe are indicated. My professor used to say, "What do you call performing a procedure you know won't work or be of value to the patient?... Assault." That always resonated with me.

For those who think midlevels can't be trained well... shockingly, my current MA/scribe (sees almost all patients with me) doesn't even have an associates degree yet presents to me and nails the dx (or part of the dx's) about 80% of the time (before I enter the room)... as a fresh out of school medical assistant! It's quite impressive. I offered to pay for her to go to PA school if she continued with me afterwards.

 

[gdub25]

I disagree with the thought that midlevels seeing patients leads to incorrect procedures being done. I completely understand the thought/concern, but having worked in 3 separate clinics in three different towns I have seen this model in action. The midlevels and physician are in the same clinic at the same time. The midlevels are well trained by the pain physician and are intelligent people who are capable of seeing these patients and making some decisions. In the case that they see a patient and have any questions at all the physician is right there to step in and evaluate the patient personally. Every patient is checked out with the attending before a procedure is performed and the attending meets and talks with the patient as they are heading into the procedure room, confirming the symptoms and HPI.

I'm just a fellow and obviously haven't seen it all yet. I still have a lot to learn. I would like to know opinions of others regarding the practice model I've described. I don't see anything about this that says "bad medicine" but maybe it's because this is the environment I've trained in and all I know.

 

[freddydpt]

Gdub, I think when you get out and start looking into private practice jobs, you'll notice something... there are a lot of "cookie cutter" treatment algorithms out there that some PAs follow based on either prior experience or lack of training. They do need to be trained. What upsets me a little are these algorithms setup that are "clinic policies" of required injections. For example, I have a friend leaving his practice soon because all patients are required to go through 3 sets of 2-level TFESI prior to any other procedure being performed... whether or not it is a clear example of SIJ pain or facet pathology... and that's just one example. So, if a PA is trained to believe that this is the correct thing to do... it might propagate. In general, I think midlevels can be taught to practice great medicine.

 

[SSdoc33]

In general, I think midlevels can be taught to practice great medicine.

i dont.

i dont want to be seen by a midlevel as a patient, nor do i want to work with one. they have uniformly, in my experience, made poor clinical decisions and decreased my productivity. the same can be said for my fellows. after a year of training, 3 years of residency, a year of intership and 4 years of med school, i still have a tough time getting them to make the right decisions.

what we do is very nuanced. or at least it should be. i just dont believe that a midlevel can perform the job of a pain doc. this is essentially what you are asking them to do. unless you have a very clear plan in place (if A then B. If C then D), midlevels are virtually useless to me at least. even when you think you have all of the bases covered, something else ops up that requires your attention that you hadnt even thought of. all of this hand-holding, correcting, rescheduling, fixing documentation to get prior auths, etc takes time and decreased your efficiency.

this is the same reason that templated notes and algorithms are useless. you want something done right, you have to do it yourself.

 

[drusso]

I keep hearing about how payors wants us to practice as a "team." Doesn't this involve working with mid-levels?

"According to AMA policy on point, physicians must retain authority for patient care in any team care arrangement (e.g., integrated practice) to assure patient safety and quality of care. In these care delivery systems, the personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients.21 The physician is ultimately responsible for coordinating and managing the care of patients and, with the appropriate input of other members of the health care team, ensuring the quality of health care provided to patients.22 In these settings, there should be a professional and courteous relationship between all members of the health care team, with mutual acknowledgement of and respect for each other’s contributions to care."

http://www.isahq.org/LinkClick.aspx?fileticket=o4BIBsMbyMg=&tabid=36

I also understand that policy-makers wants MD's/DO's, PA's, and NP's to "practice at the top their license." As a Board Certified, ACGME-fellowship trained Pain Specialist, what is the "top of my license?" If a lower cost provider can do something I can do, then shouldn't I focus my efforts on things only I can do?

http://www.acpinternist.org/archives/2006/04/teamwork.htm

 

[jonnylingo]

after a year of training, 3 years of residency, a year of intership and 4 years of med school, i still have a tough time getting them to make the right decisions.

what we do is very nuanced. or at least it should be. i just dont believe that a midlevel can perform the job of a pain doc.

yes and yes.

If our exam and diagnostic skill set is simple enough for a midlevel, or even freddydpt's MA to master, what does that say about us and our training? Who then needs a physician? For what? The injection? 8-9 years post grad training to be told by a midlevel where to put a needle?

I think our biggest contribution to the patient's pain treatment is to get the diagnosis right, and focus on a comprehensive plan. Not midlevel work IMHO.

 

[jonnylingo]

The clinic schedules a total of 32-34 per day. Of those 32-34, about half get same day procedures. Typically the midlevels see all the patients (15-17 each) and the MD does procedures. MD will step in to visit with patients if they have questions, to say hi, or to see patient himself if the midlevels are getting backed up. He will also see all new patients. The month I was there they did not change the volume of the clinic to account for me so there were no additional RVU generated from me being there (however some of the clinics do increase number of patients on the schedule the month they have a fellow). I did every procedure under the supervision of the attending and saw all the new consults. It's my understanding the attending does not get any RVU from patients seen by the midlevels, he only benefits from them by way of them feeding him injections. We have 5 pain clinics associated with the institution where I'm a fellow and they are all operate this way. In general, for every attending there is 1-2 midlevels and every clinic has 2-3 procedure rooms. All clinics do same day, in office procedures with no sedation.

Completely bass-ackwards.

The meat of pain/MSK/spine medicine is first and foremost - get a proper diagnosis. I think this is the most difficult step. Not midlevel work. If you disagree, then we are screwed. Why pay for and go through our training if this is midlevel work?

The treatment is distant second as far as critical thinking. We have limited tools in the shed as far as treatment goes. Getting the patient to the RIGHT tool shed is, in my opinion, the most difficult part.

What has been described is, in my opinion, an injection mill.

 

[drusso]

yes and yes. Who then needs a physician? For what? The injection? 8-9 years post grad training to be told by a midlevel where to put a needle? I think our biggest contribution to the patient's pain treatment is to get the diagnosis right, and focus on a comprehensive plan. Not midlevel work IMHO.

Payors and insurance companies want us to work as a team. They want us to function at the "top of our license." What is the "top of the license" for a specialist's PA? What is the top of the license for a Board-Certified/Fellowship Trained Pain Specialist? If the economic incentives don't differentiate between the two is it because no value has been demonstrated between the levels of training?

In my community, the ortho PA's first assist all surgeries, do new patient evals, go to the ED and "tee-up" the fractures when their supervising MD is clinic or the OR, they even completely manage the simple fractures. The best pain PM&R/PA I ever worked with was a former ortho PA and paramedic. He was gunner and eventually went back to med school.

Even the psychiatrists are using mid-levels and just more or less just "staff" patients with their psych NP's and LCSW's. Try to get a MD/DO psychiatrist to sit with a patient for 60 mins of psychotherapy. Outside of a cash-based private practice, that model does not exist.

Why do we coddle the pain PA's so much? Shouldn't the pain PA's be doing some more heavy lifting like their primary care, surgical, and even psychiatric analogues?

What should be the scope of practice for a well-trained physiatric or pain PA?

 

[lonelobo]

Slippery Slope before the midlevels are granted the ability to practice independently.
They will work for much cheaper than us.

Not a pretty picture...hope my Brewery takes off

 

[deleted472101]

Would having a bunch of MAs and a scribe be cheaper?

 

[drusso]

Would having a bunch of MAs and a scribe be cheaper?

Seems that is what Medicaid would prefer.

 

[Ducttape]

i think you non-midlevel guys are thinking and doing this all wrong.

the way it should work is that the midlevel assists you, and the physician makes the decision. there is no reason in gods green earth that a board certified doc needs to get family history, history of prior non-applicable surgeries, delve into reasons why the patient doesnt want gabapentin/elavil/etc, go over intimate details (unless appropriate) regarding psychological traumas in the past (esp if patient is previously abused female and doctor is male), etc.

these nuggets of info are crucial, but they dont require a physician to obtain, and a nurse or MA does not have the qualifications or knowledge of the questions and nuances to ask. also, the doctor doesnt have to be a dumb office recorder/typist - that info is put in by the midlevel.

the physician then uses this information, does a thorough and complete exam, can succinctly review all the info, and come up with a plan.


A supervisory role - if you feel that using midlevels is completely wrong.... how do you justify the way we work with/as medical residents and fellows? the process should be the same. i see all the patients the midlevel sees on the same day. its not the most efficient, but it is a lot more efficient than being completely on my own (esp since im not a primary interventionalist).

 

[lobelsteve]

i think you non-midlevel guys are thinking and doing this all wrong.

the way it should work is that the midlevel assists you, and the physician makes the decision. there is no reason in gods green earth that a board certified doc needs to get family history, history of prior non-applicable surgeries, delve into reasons why the patient doesnt want gabapentin/elavil/etc, go over intimate details (unless appropriate) regarding psychological traumas in the past (esp if patient is previously abused female and doctor is male), etc.

these nuggets of info are crucial, but they dont require a physician to obtain, and a nurse or MA does not have the qualifications or knowledge of the questions and nuances to ask. also, the doctor doesnt have to be a dumb office recorder/typist - that info is put in by the midlevel.

the physician then uses this information, does a thorough and complete exam, can succinctly review all the info, and come up with a plan.


A supervisory role - if you feel that using midlevels is completely wrong.... how do you justify the way we work with/as medical residents and fellows? the process should be the same. i see all the patients the midlevel sees on the same day. its not the most efficient, but it is a lot more efficient than being completely on my own (esp since im not a primary interventionalist).

Patients can do all you say based on a T-system in a portal. The problem is that it takes our training to get the HPI and ask the next question in a line of questions based on prior answers.

 

[specepic]

Maybe I'm a Luddite here but a clinic running 2-3 midlevels to one doc who is the main procedure person is not the care I want to deliver. What is our training worth? Why did we do what we did in residency and fellowship?

I work in an ortho group that has PAs. They work with the ortho docs. They do all the stuff drusso describes above and do it fairly well, especially the senior PA, pretty independent, BUT there is a big difference b/t "bone broke must fix" and chronic pain.

I'm not saying I would never use a PA but I would also be realistic why I am using them and what their limits are.

 

[drusso]

Maybe I'm a Luddite here but a clinic running 2-3 midlevels to one doc who is the main procedure person is not the care I want to deliver. What is our training worth? Why did we do what we did in residency and fellowship?

I work in an ortho group that has PAs. They work with the ortho docs. They do all the stuff drusso describes above and do it fairly well, especially the senior PA, pretty independent, BUT there is a big difference b/t "bone broke must fix" and chronic pain.

I'm not saying I would never use a PA but I would also be realistic why I am using them and what their limits are.

"What is our training worth?" Well, are your payers recognizing your added in training and expertise? Have we, as a profession, lobbied for a separate fee schedule for ACGME-trained & ABMS-certified specialists?

Again, why do we coddle pain mid-levels when other specialists work them to the bone?

 

[specepic]

"What is our training worth?" Well, are your payers recognizing your added in training and expertise? Have we, as a profession, lobbied for a separate fee schedule for ACGME-trained & ABMS-certified specialists?

Again, why do we coddle pain mid-levels when other specialists work them to the bone?

Well, now new questions are being introduced. I was raising the point of quality of care and whether PAs/NPs are up to work independently in chronic pain (meds, evals, and/or procedures?), and you note the frustration that hosp, health systems, and insurance companies dont much care who does the work and would really prefer less MD/DO and more PA/NP to save $ (or think they are saving money that remains to be seen over time).

Maybe I have it all wrong, but when I see practices that have a whole lot of midlevels, those tend to be mills, with protocols rather than individualized care. Maybe I just havent seen the right groups. Dont get me wrong, I have been considering a PA for a while, I'm just not sure how I would make it work.

 

[drusso]

Maybe I have it all wrong, but when I see practices that have a whole lot of midlevels, those tend to be mills, with protocols rather than individualized care. Maybe I just havent seen the right groups. Dont get me wrong, I have been considering a PA for a while, I'm just not sure how I would make it work.

Hospital-based practices? The absolutely number of midlevels matters less than the ratio. Our state limits supervision to 4 PA-C per MD/DO. NP's are independently licensed and you can employee them by the dozens.

 

[ampaphb]

Get over yourselves. What we do isn't rocket-science. Not all PA's are created equal. I have met some that are very good, and others who aren't.

My first PA was straight out of training. She spent 2 months shadowing me, and read the SIS guidelines cover to cover. We had a retired PM&R inpatient doc on staff at the time, and he taught her how to take a detailed H&P. Then she saw patients. Sure, she made mistakes, but she didn't make them twice.

She just left, and we hired the local spine surgeon's PA, who has been in practice for more than a decade. He spent a month with the prior PA. It's like having a surgeon in the practice. He brings a different perspective, and is a resource I can draw on.

PA's can be very useful. The devil is in the details. You have to put in the time to train them. And anytime they have a question, you have to take the time to explain your thought process. They have to be smart enough to understand, and retain the information. They also have to be willing to learn, and humble enough to ask when they don't know. Clearly, they can handle the straight forward cases. They have to recognize when to ask for help.

I don't know everything. Even about pain. I have a group I go to when I need insight. I find admitting I don't know the answer wasn't my strong suit, and has only come as I matured. (insert insult/joke/wise ass snarky comment here)

There are pain docs I wouldn't let touch my pets. There are others (albeit just a few) who I would ask to to a C/S TF-ESI if I needed one. Mid-level are exactly the same. Some are terrific. Others are terrible. Anyone who makes an overarching statement about an entire class of people (all surgeons are overly aggressive, all pain docs do the right thing, all mid-level are incapable of assessing pain paitients) is being unfair.

 

[Ducttape]

no, they are not up to working independently. even as one that supports use of midlevels, they need to be supervised and monitored closely. all major decisions have to come through the physician. give them leeway to discuss HEP, CBT, review whether last injection worked or not, stay the course when patients (invariably) request opioids, want doses increased, want benzos, soma, etc.

the major decisions - which injections to perform, whether to consider COT, etc. have to come through you.

 

[SSdoc33]

the major decisions - which injections to perform, whether to consider COT, etc. have to come through you.

isnt that 90% of what we do?

so, you let them see injection f/u patients? then they have to decide if another shot is needed.

or the medication f/u? is the med working, do i increase or not? is the side affect real or not?

what happens when the PA misses something? infection, maybe a AAA on an MRI, blood thinner, or a cancer history that may be missed. i am an admitted control freak, but i just cant trust someone else to do it (especially someone with inadequate training)

yes, there are good and bad physician extenders. but if you have to "check their work" on virtually every patient, it neither saves time, increases revenue, nor improves care.

 

[ampaphb]

I am not a control freak. I have faith in my ability to hire good people, and train them well.

Btw, what happens when you make a mistake? ;-)

 

[SSdoc33]

I am not a control freak. I have faith in my ability to hire good people, and train them well.

Btw, what happens when you make a mistake?

Sent from my SAMSUNG-SM-G920A using SDN mobile

i own it. and i accept it. but i dont want the onus and punishment of taking responsibility for someone else's mistake.

 

[freddydpt]

Get over yourselves. What we do isn't rocket-science. Not all PA's are created equal. I have met some that are very good, and others who aren't.

My first PA was straight out of training. She spent 2 months shadowing me, and read the SIS guidelines cover to cover. We had a retired PM&R inpatient doc on staff at the time, and he taught her how to take a detailed H&P. Then she saw patients. Sure, she made mistakes, but she didn't make them twice.

She just left, and we hired the local spine surgeon's PA, who has been in practice for more than a decade. He spent a month with the prior PA. It's like having a surgeon in the practice. He brings a different perspective, and is a resource I can draw on.

PA's can be very useful. The devil is in the details. You have to put in the time to train them. And anytime they have a question, you have to take the time to explain your thought process. They have to be smart enough to understand, and retain the information. They also have to be willing to learn, and humble enough to ask when they don't know. Clearly, they can handle the straight forward cases. They have to recognize when to ask for help.

I don't know everything. Even about pain. I have a group I go to when I need insight. I find admitting I don't know the answer wasn't my strong suit, and has only come as I matured. (insert insult/joke/wise ass snarky comment here)

There are pain docs I wouldn't let touch my pets. There are others (albeit just a few) who I would ask to to a C/S TF-ESI if I needed one. Mid-level are exactly the same. Some are terrific. Others are terrible. Anyone who makes an overarching statement about an entire class of people (all surgeons are overly aggressive, all pain docs do the right thing, all mid-level are incapable of assessing pain paitients) is being unfair.

I don't think I could have said it better myself.

 

[Ducttape]

isnt that 90% of what we do?

so, you let them see injection f/u patients? then they have to decide if another shot is needed.

or the medication f/u? is the med working, do i increase or not? is the side affect real or not?

what happens when the PA misses something? infection, maybe a AAA on an MRI, blood thinner, or a cancer history that may be missed. i am an admitted control freak, but i just cant trust someone else to do it (especially someone with inadequate training)

yes, there are good and bad physician extenders. but if you have to "check their work" on virtually every patient, it neither saves time, increases revenue, nor improves care.

90% of what i/we do is to encourage patients to be more active, be more functional, that opioids are not indicated for chronic nonmalignant pain. i dont run a needle shop.

patients are told when to expect that they might need another injection by me, so they take the initiative and ask about injections. if they come in unexpectedly, then the midlevel texts me.


fyi some of these midlevels have experience that goes beyond your pain experience. if so inclined, hire one that has had experience doing other fields, like radiology, or oncology...

their ultimate expertise is a combination of their prior experience and what you teach them.