Advice on gen peds jobs

[zeppelinpage4]

Hey guys, just posting because I could use some advice for my first attending job.

I just graduated from residency and have two job options but wanted some second thoughts from other pediatriciana.

Job 1: Great location in my current city, just a few minutes from where I live now. Pay is great, 200-250k/year (possibly more) depending on productivity, but I will be seeing 35-50 patients/day, 4 days/week with 1-2 weekends a month. The doctors seemed very nice and said they’d start me at a volume I was comfortable with and build me up. I liked the staff, the office, and obviously love the location. The pay is also great. Only concern for me is the volume and hours. I want to take my pediatric boards next year in 2021 and am worried I may not be able to dedicate time to studying (my in service scores were very low and I need to put the time in to pass). It’s also my first job out of residency and I’m wondering if the high volume would make it difficult for me to read up on my patients and get comfortable as an attending. I don’t mind working hard or being busy since the compensation and location are great but I want things to be manageable.

2) Job 2: Very rural, closest Walmart is an hour away, old houses and few ammenities. Would be a big adjustment for my spouse and I. But 4 days/week, no weekend call. 1 week a month you cover a relaxed low acuity inpatient unit by phone (mid levels do all the work and rarely call you). 18-22 patients a day, very relaxed schedule and also 240k/year. So very good pay and schedule. I’d have more time to dedicate to boards and adjusting to being an attending but I don’t see myself staying here more than 2-3 years due to the location.

Is 35-50 patients a day overwhelming, especially for a fresh grad? Or can I adjust to it? I tend to be slower in clinic now but I’m sure with practice, good note templates, and repetition the speed would come. I like the first job in every way except for the volume, so I’m leaning toward that. But I don’t want to overwhelm myself and fail my boards either.

---

Members don't see this ad.

 

[Goneril]

Yes 35-50 patients per day is way too much, even for an experienced doctor. Hopefully you can find a better job offer in what seems like your preferred location.

I also think you should start asking about malpractice tail coverage. The ideal job covers the tail.

 

[zeppelinpage4]

Yes 35-50 patients per day is way too much, even for an experienced doctor. Hopefully you can find a better job offer in what seems like your preferred location.

I also think you should start asking about malpractice tail coverage. The ideal job covers the tail.

Thanks, yes I do hope something pops up. I’ll likely take this job for now since I need some income, but I’ll keep looking in the area.
And I appreciate the tip, will ask about tail in my contract.

Is there anything I can read or do to prep for a gen peds jobs these next few weeks? I mean I know residency we do a fair amount of clinic but I feel like my training was very inpatient focused. I’m terrible at rashes for instance, but can’t find a good overall review. Had a weird rash the other day on a kid and even my attending seemed to not know exactly what it was.

 

[mvenus929]

Is 35-50 patients a day overwhelming, especially for a fresh grad? Or can I adjust to it? I tend to be slower in clinic now but I’m sure with practice, good note templates, and repetition the speed would come. I like the first job in every way except for the volume, so I’m leaning toward that. But I don’t want to overwhelm myself and fail my boards either.

35 patients per day is 13 minutes per patient without a lunch break, or a day that's longer than 8 hours. If you don't know the system and aren't super comfortable with gen peds topics, you're not going to be able to do well and it's a recipe for burnout (even for an experienced doc). You can't do a decent WCC in 10 minutes--the counseling alone takes that long.

Most outpatient peds jobs do somewhere around 20 patients per day with a mix of well (longer visits) and sick visits (shorter visits). You get faster as you get to know the system and your patients, but I can't imagine anyone doing 10 minute visits consistently if they're going to provide any sort of good care.

The only way I can see that being manageable is by having two NPs seeing patients and you staffing them. But I wouldn't recommend that to a new grad either.

 

[zeppelinpage4]

35 patients per day is 13 minutes per patient without a lunch break, or a day that's longer than 8 hours. If you don't know the system and aren't super comfortable with gen peds topics, you're not going to be able to do well and it's a recipe for burnout (even for an experienced doc). You can't do a decent WCC in 10 minutes--the counseling alone takes that long.

Most outpatient peds jobs do somewhere around 20 patients per day with a mix of well (longer visits) and sick visits (shorter visits). You get faster as you get to know the system and your patients, but I can't imagine anyone doing 10 minute visits consistently if they're going to provide any sort of good care.

The only way I can see that being manageable is by having two NPs seeing patients and you staffing them. But I wouldn't recommend that to a new grad either.

Okay, that's helpful to know. Maybe I misunderstood the doctors at the practice. I know they've seen up to 50 on a busy day, but perhaps that's not typical. The minimum I need to see for my base income is ~15 patients/day. So perhaps, it's not always so busy. I'll definitely double check though. None of the doctors at the practice seemed burned out (most have been there for many years) and they said they were busy but left on time most days and kept up. I also know a private practice doc who also see that volume. So I figured maybe it could be doable. But when you actually break it down minute by minute like you did, I do agree burnout is a real risk.

That's too bad. The location is perfect, and I do know the system well because the clinic is under the same hospital system as my residency, so EMR and basic workflow is essentially the same. However, I don't want to take on a stressful job, the past 3 years was enough. But moving rural also doesn't seem too appealing, that'll come with it's own adjustment and stress.

 

[calvnandhobbs68]

35 patients per day is 13 minutes per patient without a lunch break, or a day that's longer than 8 hours. If you don't know the system and aren't super comfortable with gen peds topics, you're not going to be able to do well and it's a recipe for burnout (even for an experienced doc). You can't do a decent WCC in 10 minutes--the counseling alone takes that long.

Most outpatient peds jobs do somewhere around 20 patients per day with a mix of well (longer visits) and sick visits (shorter visits). You get faster as you get to know the system and your patients, but I can't imagine anyone doing 10 minute visits consistently if they're going to provide any sort of good care.

The only way I can see that being manageable is by having two NPs seeing patients and you staffing them. But I wouldn't recommend that to a new grad either.

If it's only 4 days a week though, I'm betting they're expecting OP to do 4x 10 hour days a week. So little bit more time to spread those out on (still pretty brutal though).

If you're seeing 35 patients a day consistently you should be making >250K. You're seeing a mix of 99213/99214 followups with new intakes thrown in there probably throughout the day. Even if it averages out to only $60 a visit, 60x35= 2100x 4 days a week x 48 weeks a year (4 weeks off for vacay and stuff)-> $403K. Probably will average out to be more. Yeah some of that should be going to overhead for the other partners but not 150K a year considering you add probably little/no incremental cost to them.

Here's AAP survey on Medcaid reimbursement for reference, as you can see in most states a pure mix of 99213/99214 will still average out to the $50-60 range. And that's if your panel was 100% Medicaid (most aren't seeing anywhere near that much Medicaid unless you're working in an FQHC or something).

https://www.aap.org/en-us/professional-resources/Research/Medicaid%20Reimbursement%20Reports/medicaid_reports_national_all.pdf

 

[Tribeca]

The rural job seems to offer work-life balance and low cost of living for a relatively high pay. Is it possible to live closer to a suburb or the city and drive in instead of living in the rural area? I have seen others do this.

 

[Goneril]

The rural job seems to offer work-life balance and low cost of living for a relatively high pay. Is it possible to live closer to a suburb or the city and drive in instead of living in the rural area? I have seen others do this.

I think this is probably the best solution. The first job sounds like a recipe for burnout and frustration.

 

[Cuthbert]

I’ve been working in a community setting for ten years. So I’d like to think that I have hit my stride. We get paid on an RVU basis. My RVUs are consistently over the 95th percentile or higher. I do gen peds and some light NICU coverage down to 34 weeks. But I still only average around 25 clinic patients per day (usually 4 days per week). And even then, I typically have to come in early to get my charts done.


I have no idea how you would get charts done well when seeing 35-50 patients per day! Or give good medicine for that matter. How many nurses will you have?


Is this a private clinic? Can you make partner? What do the other docs make? If they are seeing that many patients, it should be very much north of $400,000 per year.

 

[mvenus929]

Okay, that's helpful to know. Maybe I misunderstood the doctors at the practice. I know they've seen up to 50 on a busy day, but perhaps that's not typical. The minimum I need to see for my base income is ~15 patients/day. So perhaps, it's not always so busy. I'll definitely double check though. None of the doctors at the practice seemed burned out (most have been there for many years) and they said they were busy but left on time most days and kept up. I also know a private practice doc who also see that volume. So I figured maybe it could be doable. But when you actually break it down minute by minute like you did, I do agree burnout is a real risk.

That's too bad. The location is perfect, and I do know the system well because the clinic is under the same hospital system as my residency, so EMR and basic workflow is essentially the same. However, I don't want to take on a stressful job, the past 3 years was enough. But moving rural also doesn't seem too appealing, that'll come with it's own adjustment and stress.

I think you need to ask more information. It sounds like they're ballparking their numbers, and you should ask more structured questions. Things like...

1) How many minutes are WCC visits scheduled for? Sick visits? Other follow-ups (e.g. asthma, ADHD, etc)
2) Are patients routinely overbooked? What's the no-show rate?
3) Are sick appointments blocked off until the day of, or overbooked? Is there one person who sees the sick kids in a given day? Are sick kids worked in with whoever is available or are attempts made to keep the patients with their primary physician?
4) How are weekend appointments arranged? Are they walk-in, sick visits only, a mix? Only in the morning or all day? Saturday and Sunday?
5) How does practice call work? Is there a nurse triage overnight?
6) Do you have a dedicated nurse/MA? Will they triage the phone calls/paperwork/etc that comes with being a PCP? Will they call the family with results?

I've seen all variations of these questions, so it's a good idea to get a sense of what their day-to-day schedule actually looks like.

Also, this is one of the reasons I didn't do gen peds. Seeing 20-25 patients per day (let alone double that) sounds awful. I'll be sitting back on my 15-18 patients per day

Since you're planning on taking boards next year, you should also figure out when they would want you to start (can you have 1-2 months of dedicated study time), and time off the week of boards.

 

[zeppelinpage4]

Sorry for the delayed response guys, in the process of moving and didn't get to log in.

If it's only 4 days a week though, I'm betting they're expecting OP to do 4x 10 hour days a week. So little bit more time to spread those out on (still pretty brutal though).

If you're seeing 35 patients a day consistently you should be making >250K. You're seeing a mix of 99213/99214 followups with new intakes thrown in there probably throughout the day. Even if it averages out to only $60 a visit, 60x35= 2100x 4 days a week x 48 weeks a year (4 weeks off for vacay and stuff)-> $403K. Probably will average out to be more. Yeah some of that should be going to overhead for the other partners but not 150K a year considering you add probably little/no incremental cost to them.

Here's AAP survey on Medcaid reimbursement for reference, as you can see in most states a pure mix of 99213/99214 will still average out to the $50-60 range. And that's if your panel was 100% Medicaid (most aren't seeing anywhere near that much Medicaid unless you're working in an FQHC or something).

https://www.aap.org/en-us/professional-resources/Research/Medicaid%20Reimbursement%20Reports/medicaid_reports_national_all.pdf

Wow, thank you so much for this breakdown. I really had no idea how much I could generate per patient or what the billing actually worked out. That pdf is really informative.

That really puts the workload into perspective. The 200k income seemed good for the area, but seeing how much revenue I'm generating for the group that makes the salary seem less appealing.

Is this why owning a private practice is so lucrative? I know someone who owns a private practice seeing 30-40 patients/day and minus the cost of running the practice, the rest of the revenue is going right to them.

The rural job seems to offer work-life balance and low cost of living for a relatively high pay. Is it possible to live closer to a suburb or the city and drive in instead of living in the rural area? I have seen others do this.

Yeah this was my original hope/plan.

The rural job requires covering a small hospital (it's very low acuity and not too stressful), so I have to live within 20-30 minutes of the clinic/hospital for call and the nearest small suburb/city is 50-60 minutes way so I can't live too far. The other downside to this is that that immediate area within 30 minutes of the hospital actually has relatively high cost of living (popular vacation spot in the summer), as much as a major city despite being very rural.

I’ve been working in a community setting for ten years. So I’d like to think that I have hit my stride. We get paid on an RVU basis. My RVUs are consistently over the 95th percentile or higher. I do gen peds and some light NICU coverage down to 34 weeks. But I still only average around 25 clinic patients per day (usually 4 days per week). And even then, I typically have to come in early to get my charts done.


I have no idea how you would get charts done well when seeing 35-50 patients per day! Or give good medicine for that matter. How many nurses will you have?


Is this a private clinic? Can you make partner? What do the other docs make? If they are seeing that many patients, it should be very much north of $400,000 per year.

I believe each doctor has their own nurse and nursing assistant to do pre-charting and vaccines etc. So that should help a little. But I don't know if it will be enough to make up for the volume.

So to my surprise, it's not private practice but part of a larger healthcare network. I don't know what the other doctors are earning but being under a larger healthcare network, I assumed they don't make too much more than what I was offered. Since they have more experience, probably 230-300k if I had to guess. But based on the breakdown from calvnandhobbs68, I think you're right that north of 400k/year should be expected. Either the healthcare network is generating a lot of revenue off of the doctors, or the doctors are earning more than I expected. I'm going to touch base again and clarify exactly how many patients they are typically seeing, because the numbers don't add up right now.

I think you need to ask more information. It sounds like they're ballparking their numbers, and you should ask more structured questions. Things like...

1) How many minutes are WCC visits scheduled for? Sick visits? Other follow-ups (e.g. asthma, ADHD, etc)
2) Are patients routinely overbooked? What's the no-show rate?
3) Are sick appointments blocked off until the day of, or overbooked? Is there one person who sees the sick kids in a given day? Are sick kids worked in with whoever is available or are attempts made to keep the patients with their primary physician?
4) How are weekend appointments arranged? Are they walk-in, sick visits only, a mix? Only in the morning or all day? Saturday and Sunday?
5) How does practice call work? Is there a nurse triage overnight?
6) Do you have a dedicated nurse/MA? Will they triage the phone calls/paperwork/etc that comes with being a PCP? Will they call the family with results?

I've seen all variations of these questions, so it's a good idea to get a sense of what their day-to-day schedule actually looks like.

Also, this is one of the reasons I didn't do gen peds. Seeing 20-25 patients per day (let alone double that) sounds awful. I'll be sitting back on my 15-18 patients per day

Since you're planning on taking boards next year, you should also figure out when they would want you to start (can you have 1-2 months of dedicated study time), and time off the week of boards.

Thanks so much, this helps a lot. Those questions will definitely help me get a better idea versus just knowing average patients/day. I'm going to try and go back for a second look and shadow them in clinic if I can. And I will definitely clarify with the questions you listed. I don't think I can make an informed decision without knowing the above.

Wow, 15-18 sounds great. Can I ask what specialty you're in?

I will ask that too, my boards are top priority this year.

 

[mvenus929]

Thanks so much, this helps a lot. Those questions will definitely help me get a better idea versus just knowing average patients/day. I'm going to try and go back for a second look and shadow them in clinic if I can. And I will definitely clarify with the questions you listed. I don't think I can make an informed decision without knowing the above.

Wow, 15-18 sounds great. Can I ask what specialty you're in?

I will ask that too, my boards are top priority this year.

I'm Endo (finishing up fellowship). Our diabetes patients (the ones on insulin, anyway) are currently 45 minutes, our endocrine follow-ups are 25 minutes, and our endocrine new patients are 45 minutes. Most places (that aren't exclusively private practice) have new patients scheduled for between 45 and 60 minutes, and follow-ups between 15 and 30 minutes. It's harder when you start out, as you don't know the patients and every patient is 'new' even if they're established with the practice. The patients I've been following for 2 years I can generally see and staff in 20 minutes, but the patients who are follow-ups but I've never seen before take closer to 25-30 minutes (not including chart prep time) because I have to ask clarifying questions that weren't previously documented.