Acting as your own PCP

[Pain Applicant1]

---

Members don't see this ad.

I don't like relying on referrals for my patients and want to be more independent. I'm in private practice on my own, opened for almost 15 months and the vast majority of patients come from PCPs. The local orthopods don't want me around as their surgery rate has dropped (not sure if I'm the variable) since I've been here and their spine guy is doing LESIs on everyone, regardless of etiology so I'm cutting into his business. The hospital owns all of the PCP groups in town and of course they're not happy about the surgery rate dropping. The PCP group, on the other hand, owns the building that the hospital who owns their group rents from so they all, in one way or another, have a vested interest in each other. Blah blah blah.

I'm thinking of doing my own PCP work (HTN, HLD, BP, DM) mgmt in order to help maintain an inflo of patients. I'm still at about 3-4 new patients per day but this has decreased from about 6 or more per day since I began. Considering that I lose a good amount of patients as I don't typically write for opioids, I am concerned that my referral rate will eventually dry up. I still remember how to manage most PCP issues since internship and residency and after reviewing a few articles I'm sure I'll be up to par. Anyone every consider this?

 

[101N]

I don't like relying on referrals for my patients and want to be more independent. I'm in private practice on my own, opened for almost 15 months and the vast majority of patients come from PCPs. The local orthopods don't want me around as their surgery rate has dropped (not sure if I'm the variable) since I've been here and their spine guy is doing LESIs on everyone, regardless of etiology so I'm cutting into his business. The hospital owns all of the PCP groups in town and of course they're not happy about the surgery rate dropping. The PCP group, on the other hand, owns the building that the hospital who owns their group rents from so they all, in one way or another, have a vested interest in each other. Blah blah blah.

I'm thinking of doing my own PCP work (HTN, HLD, BP, DM) mgmt in order to help maintain an inflo of patients. I'm still at about 3-4 new patients per day but this has decreased from about 6 or more per day since I began. Considering that I lose a good amount of patients as I don't typically write for opioids, I am concerned that my referral rate will eventually dry up. I still remember how to manage most PCP issues since internship and residency and after reviewing a few articles I'm sure I'll be up to par. Anyone every consider this?

The definition of a dilettante. Bad idea, don't do it.

 

[TX PAIN DOC]

Don't complicate your life by going outside your scope of practice. It would be better to start writing opiods than to do that.

 

[Ducttape]

i know a few docs that are dual board certified in internal medicine and pain.

the only one of them who still does primary care medicine does so because he has to.

 

[emd123]

Bad idea, 2 reasons:

1-Unless your primary specialty is IM or FP, it's out of scope. The breadth of knowledge you need to be a generalist is huge. It's not just BP refills and URIs. It is its own specialty. There's no way you could do it properly. You'd be begging for a lawsuit-a-minute. Being a generalist is complex and much harder than sticking a needle.

2-Plus, what else do PCPs do tons of?

Opioids.

Who are you going to send opiod patients to then? Pain? Primary care?


This plan would backfire. See if you can hold out and get through the rough patch. If not, just start prescribing, but do it:

Right, and YOUR WAY.

That's what I do. Don't sign on to asinine opiod regimens that are failing or dangerous. Regimens that you disagree with taper, or stop. Don't be afraid to say "no" or "this plan is going nowhere long term" if its true. Don't be afraid to tell people "you need detox, not more opioids" if that's what they truly need. Trust me, the PCPs won't care if these patients go find new doctors.

But also, some people do great on opioids, ie, little old lady started on butrans or something else low dose and tells you "I never felt better before" and never fails a UDS or asks for a dose increase when not truly needed.

You don't have to sign on to a legacy of insanity.

You can help some people by prescribing.

You can help others (perhaps more) by saying: "No."

Trust me, the PCPs won't care what you prescribe or how much of it, as long as they can wash their hands of it. You'll get way more referrals by doing even minimal prescribing.

Plus, what happens when a new fellowship trained Pain guy sets up shop down the street and does all the procedures you do, plus prescribes?

But hey, on the other hand, if you can keep convincing them to send you the fun stuff that pays a lot of $ and keep the "pain," more power to you.

 

[SSdoc33]

id sooner quit medicine than be a PCP

 

[Jcm800]

id sooner quit medicine than be a PCP

i used to think that, but in many ways being a PCP would be fine, if the money didnt suck...

could you imagine an entire day where you have the vast majority of "legitimate" patients...
i use legitimate carefully, they may be hypochondriacs, but at least the vast majority wouldnt be drug seekers, or the typical pain patient. Some would...
grass is greener.

I think if we made the same money, and i didnt need to work as crazy as they do, i could do it... maybe. probably not.

i take it back

it probably does suck.

 

[smq123]

I'm thinking of doing my own PCP work (HTN, HLD, BP, DM) mgmt in order to help maintain an inflo of patients. I'm still at about 3-4 new patients per day but this has decreased from about 6 or more per day since I began. Considering that I lose a good amount of patients as I don't typically write for opioids, I am concerned that my referral rate will eventually dry up. I still remember how to manage most PCP issues since internship and residency and after reviewing a few articles I'm sure I'll be up to par. Anyone every consider this?

As a PCP (Family Med), I don't think this is a good idea. I can see how it could easily swallow your entire practice and be the only thing you do (if you do it correctly).

Managing STABLE HTN, hyperlipidemia, and diabetes is easy. But the problem is is that most patients are not stable. So that means bringing them back in every month, sometimes every two weeks, to titrate their medications and adjust. Which is fine if it's just one or two patients, but if you're doing a lot of them (to build your pain management panel), that can get overwhelming fast. That also means checking labs often, and following up on those. All those labs, in addition to the labs you do with your pain practice, can be a lot.

Primary care is a lot more than HTN and hyperlipidemia, though, too. So the amount you'd have to read would be a lot - probably more than you want. Today I saw a newly dx'ed Hepatitis C, menorrhagia, possible MS, hypogonadism, hypothyroidism, chronic pancreatitis, and poorly controlled epilepsy/seizures. There's also a lot of depression, anxiety, schizophrenia, etc.

Finally, I can see how this would backfire and dry up your referrals completely. I know that it isn't meant as an insult, but some of your referring PCPs may take it that way ("He thinks he knows how to do my job as well as I do?!"). They may also question your clinical judgement if you decide to go that route. You're already running a risk of not getting a lot of referrals because you don't prescribe opioids; this could just make it worse.

i take it back

it probably does suck.

It doesn't suck. 🙂 I don't have any loans (thank you, federal primary care scholarships), I work 40 hours a week, rarely work weekends, home call only. It could definitely be worse.

 

[SSdoc33]

The good thing about being a PCP would be that you do get to see a ton of different stuff. The bad thing would be that you wouldn't be qualified to treat most of it.

 

[hyperalgesia]

I would sooner invent a diagnosis. Like "Fatigue-algosis"... This is the thing people have when they have back pain and are tired all the time and no one else can help them. Since I discovered the disease, I am the best person to treat it. I use a special herbal recipe, prepared with lasers and radiofrequency. I am also one of the few people board certified by the World Board of Medical Specialties.

This is the art of direct-to-pt-marketing. It seems like all the years of training are irrelevant compared to your sales pitch.

 

[101N]

The good thing about being a PCP would be that you do get to see a ton of different stuff. The bad thing would be that you wouldn't be qualified to treat most of it.

Unless you are rural. Then you get to do everything, and they do it pretty darn good too.

 

[joshmir]

Have you thought about bringing in an NP or PA with extensive primary care experience to do the primary care for you?

I agree with other posters, better to write opiates the right way

 

[Ducttape]

Have you thought about bringing in an NP or PA with extensive primary care experience to do the primary care for you?

I agree with other posters, better to write opiates the right way

im not sure this is a good idea either, as the physician has to "supervise" the midlevel, and is "responsible" for the actions of the midlevel. that will bring up issues of competence in that particular field of medicine by any lawyer.

 

[SeniorWrangler]

This seems like a good time to re-introduce yourself to your referral base. Meeting other docs and being a helpful resource and a nice guy instead of just a name on a consult note can really help get referrals. Your patients can be a great source of referrals, too, if you can get the word-of-mouth going.

Being a PCP is a noble aspiration, but unfortunately it doesn't make economic sense unless you've got some kind of awesome boutique practice where people pay wellto get their blood pressure neds refilled. Also, if a patient goes sour on you, you've got no one to refer them back to.

 

[Ducttape]

have you considered a satellite office?

locate an area close but not too close to you, one that does not have a local pain doc.

set up a satellite office to see patients there, once maybe twice a week. market to that area.

you might need to hire a midlevel provider to man the office while you are at the satellite, and vice versa, and to help with seeing new patients...