artvandale

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I was wondering if any practicing FPs or residents would comment on any downsides of out-patient medicine esp in an urban setting. With less and less grads going into primary care I was wondering what the negatives/regrets are esp from those actually in the field. Appreciate your help. Thank you.
 

Doctor Grim

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Good thing about FM is that you can tailor your own practice. I chose it because I like outpatient, can design my own practice, and won't have to stay all day in the hospital. It's just me.

Quite a few people whom I have trained with love outpatient services. I'm in a metro area and my friends are doing well seeing on the avg 12-15 patients per day, 4 1/2 day of work, 8A-4P, making $165K plus bonus. These are geriatrics patients by the way. The key to higher pay relies on the way you code, but that's a different story for another day.

So the work is fun and lifestyle is great!
 

andwhat

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Good thing about FM is that you can tailor your own practice. I chose it because I like outpatient, can design my own practice, and won't have to stay all day in the hospital. It's just me.

Quite a few people whom I have trained with love outpatient services. I'm in a metro area and my friends are doing well seeing on the avg 12-15 patients per day, 4 1/2 day of work, 8A-4P, making $165K plus bonus. These are geriatrics patients by the way. The key to higher pay relies on the way you code, but that's a different story for another day.

So the work is fun and lifestyle is great!

I know people doing that schedule, loving it -- and making over $200 K (not straight salary, this is with the incentives, and coding) doing strictly outpatient. Coding properly is not all that complicated. It is time consuming to pick up -- but not that bad honestly.
 
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andwhat

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I was wondering if any practicing FPs or residents would comment on any downsides of out-patient medicine esp in an urban setting. With less and less grads going into primary care I was wondering what the negatives/regrets are esp from those actually in the field. Appreciate your help. Thank you.
I think that it gets way way way way too much bad rep.... its an amazing field honestly.... Primary Care / Intensivist work as a Hospitalist, etc... out patient medicine is challenging and fun at times also.. Hospitalist life is fun..
I will tell you, that the compensation in Outpatient Medicine, and Primary Care in general, doesn't match up with its counterparts.
Compensation should improve. However it is a lifestyle issue... as a Specialist, yes you will make more money.......
However you will be on call ... and one dimensional, which is fine if you love what you do.. example Anesthesia, Derm, etc... Great lifesyles also, however one dimensional...
 

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speaking of coding, there should be a whole subforum dedicated to that on SDN,
don't you think??

all you wise folk can be our teachers
 

racerx

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speaking of coding, there should be a whole subforum dedicated to that on SDN,
don't you think??

all you wise folk can be our teachers
IMHO, a very good idea. +1
 

Doctor Grim

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I'll see where and how far this integrative medicine takes me. I'd really want to start an outpatient IM consult service at my medical school so I don't have to do any primary care.
 

Doctor Grim

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^ I don't get it...what would people be referring to you for? :confused:
A bunch of things-

From addiction, acne to dm, htn, hyperlipidemia to dementia, MS, osteoporosis, PD, pain, fibromyalgia.

The key is the integrative holistic approach to treatment involivng patients in their decision making.

I was told you could make recom to the patients' PCPs on optimizing conventional med treatment plus suggestions on Comp & Alt Med modalities. You'd never change tx because you're not taking the pts away from their PCP.

You'd then code for the reason(s) why the patient is seen by you.

In 1996 alone, more money in healthcare were spent on CAM than primary care. I'd imagine that it is even more today.

I'm starting my fellowship training next week so I'll know more. But really looking forward to it because NCAAM does have a lot of money for educational program development and research in CAM.

My guess is that we'll see more Integrative Family Medicine Residency Programs within the next decade. A lot of the medical schools have already jumped on it. Long Beach VAMC has an Integrative Medicine Clinic. Our VA established an accupucture clinic..etc. Gov knows that veterans would prefer it nowadays and few studies have demonstrated that veterans would want this service if offered.

We'll see. It'll just be nice to be able to do consults than the actual primary care.
 

Blue Dog

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The key is the integrative holistic approach to treatment involivng patients in their decision making.
I wouldn't need to refer a patient to somebody else for that.

You may be overestimating the potential for a consult-based practice, IMO, but good luck, nonetheless.
 

Doctor Grim

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I wouldn't need to refer a patient to somebody else for that.

You may be overestimating the potential for a consult-based practice, IMO, but good luck, nonetheless.
As a PCP myself, true, there are lots of things I can do to educate my patients w/o a formal training. But as a former FM resident, I was, well, my attendings and I were overwhelmed at times with questions from zealous patients like red yeast rice, COQ-10, accai berries, green tea extracts, st. john's worts, ginko, ginseng, garlic..etc and whether we perform acupuncture or acupressure (which we had to refer them out).

It is all about giving patients choices within the boundary of evidence based medical care.

In my geriatric practice, I see lots of patients as consults. These patients sometimes travel 2-3 hours and quite a few are from bordering states who just want second opinion from a "specialist" because their PCPs, according to the patients, are no longer capable of meeting their needs or interested in their myriads of medications and problems. We're a reputable academic center so we spend an hour with our patients, run tests, make appropriate referrals, and unless it is something urgent that needed to be done, we don't change medical regimens at the first or second visits and we only make recom to their PCPs. Most of our patients said they still want to keep their PCPs BUT would like to return 1-2x per year just for f/u's-which is fine with us.

So do FM docs see a lot geriatric patients? Sure. Can FM docs handle geriatric patients? Yes, in most cases. Are they geriatricians? No. And there are certain things that fellowship trained doctors just do better, IMHO.

And eventually, like geriatrics years ago (in the 80s and early 90s), there will be a push for specialization and board certification in Integrative Medicine.

So I think overall patients would just do what is "right" for them based on their "comfort" level about certain treatments. It's about choices.
 
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Doowai

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Coding needn't be a big mystery. Family Practice Management has lots of great articles on coding in every issue, and the full content is available online here: http://www.aafp.org/online/en/home/publications/journals/fpm.html
I agree. As a chiropractor I used wayyyyy more codes than the average chiro - I had in office EKG, Vascular Doppler ultrasound, spirometry, blood lab and had an LPN hired who did my draws (or I frequently drew blood) - and I never found coding all that difficult.

yet the MD practice management people I read of or know make this a big part of their offerings. Chiro coding is something everyone does with a one day seminar once a year and buying a new code book.

On the other hand, chiro practice consultants are usually about making more money (more of it cash) , with less work (not necessarily hours, but less difficulty) : how to train front desk staff affectively - how to have less cancellations and more control of your scheduling (scripts for staff etc), how to increase collections, how to leverage time, how to "retire in practice" etc - etc. Its much harder to learn that in some ways, as you have to change the way you think about things : "screw the patients insurance, they have the money to buy a refrigerator so they have the money to pay for such-and-such" versus "well, their co-pay went up $10 if they see me out of network, so understandably they are quitting me and going to a new doctor in network".
 

Doowai

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My opinion, as a chiropractor (which is outpatient), is it depends on what you consider a pro and a con. Seeing the same people over and over for years can be a negative or a plus (hey missuz jones.....how is your IBS?).

Building a practice can be either also - if you are confident , and knoweldgeable it is soooo much fun as you watch your numbers soar. Once you plateau in terms of numbers tweaking other variables is fun - I enjoyed knowing my "hopper time (the time someone spent sitting in a chair in the waiting room, priot to going back to a treatment room)" was less than 5 minutes average per year, or seeing your collections in the mid 90% without using a collection agency. If you are unconfident in business , building a business is a daily unpleasant roller coaster.

As mentioned previously, being able to direct your practice towards more derm or more endocrine is a huge plus in my opinion. I had done just about everything that could be done as a chiropractor and my only next move if I wanted to change things up was going into medicine. I had several years where I did the plain old run of the mill chiropractic back cracking, then several years where my practice was primarily acupuncture (after seeing a case of Guillion Barre which had a recent EMG get better in 5 visits I started to lose interest), several years in which I did alot of diagnostics since few to none were available in the small town, I did a practice that was younger YUPPIES and a practice that was 90% Medicare. I like being able to change things up to avoid boredom.
 

Drawing Dead

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I agree. As a chiropractor I used wayyyyy more codes than the average chiro - I had in office EKG, Vascular Doppler ultrasound, spirometry, blood lab and had an LPN hired who did my draws (or I frequently drew blood) - and I never found coding all that difficult. /quote]


Before I say this, Doowai, this is not a personal attack on you, so please don't take it that way.

But I find it disturbing that chiropractors can do this stuff. Now, I don't know how encompassing chiropractor school is, but I can only imagine since I have lost count on how many of my patients come in with abnormal lab values from their chiropractor and says "They wanted you to see this". Why are you ordering this stuff when all you can give them is chromium piccolinate or garlic?

I had one guy the other day tell me that he's convince that the niacin he's on is the cause of all his life's problems. He wanted to stop taking it. At the same time, he had, and I kid you not, a BRIEFCASE full of "natural" supplements his chiropractor convinced him to take (oh yeah, and he wanted a B-12 shot and a B-6 "shot"). I told him that he could get B-6 pills where he got his other stuff, and to ask for B-3 as well if he didn't want to take his Niacin. Oh, and lastly, I had to renew his script for Androgel. He's 85 and worried about taking "medication" but topical roids are ok.

Another lady came in because she was warm all the time, sweating, lost weight, was losing hair, and felt a lump in her throat. She called her chiropractor, who said "It's cancer, go to your doctor." Then, after she made the appointment, called her and said "Oh, it could be your thyroid." And guess who gets to see Ms. Panicky It's all your fault because my chiropractor said its cancer McGhee? That was a fun hour in clinic.
 

andwhat

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I agree. As a chiropractor I used wayyyyy more codes than the average chiro - I had in office EKG, Vascular Doppler ultrasound, spirometry, blood lab and had an LPN hired who did my draws (or I frequently drew blood) - and I never found coding all that difficult. /quote]


Before I say this, Doowai, this is not a personal attack on you, so please don't take it that way.

But I find it disturbing that chiropractors can do this stuff. Now, I don't know how encompassing chiropractor school is, but I can only imagine since I have lost count on how many of my patients come in with abnormal lab values from their chiropractor and says "They wanted you to see this". Why are you ordering this stuff when all you can give them is chromium piccolinate or garlic?

I had one guy the other day tell me that he's convince that the niacin he's on is the cause of all his life's problems. He wanted to stop taking it. At the same time, he had, and I kid you not, a BRIEFCASE full of "natural" supplements his chiropractor convinced him to take (oh yeah, and he wanted a B-12 shot and a B-6 "shot"). I told him that he could get B-6 pills where he got his other stuff, and to ask for B-3 as well if he didn't want to take his Niacin. Oh, and lastly, I had to renew his script for Androgel. He's 85 and worried about taking "medication" but topical roids are ok.

Another lady came in because she was warm all the time, sweating, lost weight, was losing hair, and felt a lump in her throat. She called her chiropractor, who said "It's cancer, go to your doctor." Then, after she made the appointment, called her and said "Oh, it could be your thyroid." And guess who gets to see Ms. Panicky It's all your fault because my chiropractor said its cancer McGhee? That was a fun hour in clinic.

I will say that chiro students were a very hard working and smart group. That being said, sometimes there should be some limitations... I once heard of a lady that died of a ruptured aneurysm in her neck -- she presented with neck pain, and obtained a high grade adjustment (aggressive one? I am not sure what that means)
The aneurysm ruptured, and she died.
Doctoring is for doctors. Sure it may seem fun, and interesting, but there is a scope of limitations in place for each and every profession.
That is a litigation landmine.
 

Drawing Dead

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I will say that chiro students were a very hard working and smart group. That being said, sometimes there should be some limitations... I once heard of a lady that died of a ruptured aneurysm in her neck -- she presented with neck pain, and obtained a high grade adjustment (aggressive one? I am not sure what that means)
The aneurysm ruptured, and she died.
Doctoring is for doctors. Sure it may seem fun, and interesting, but there is a scope of limitations in place for each and every profession.
That is a litigation landmine.
Probably the one we osteopaths know as Cervical HVLA, the same one chiropractors are pushing for to be the sole providers for instead of osteopaths. Talk about forgetting your roots (and forgetting to check for vertebrobasilar insufficiency )

Sorry, I hi-jacked this thread. Back to your regularly scheduled programming.
 
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lowbudget

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Before I say this, Doowai, this is not a personal attack on you, so please don't take it that way.

But I find it disturbing that chiropractors can do this stuff. Now, I don't know how encompassing chiropractor school is, but I can only imagine since I have lost count on how many of my patients come in with abnormal lab values from their chiropractor and says "They wanted you to see this". Why are you ordering this stuff when all you can give them is chromium piccolinate or garlic?

I had one guy the other day tell me that he's convince that the niacin he's on is the cause of all his life's problems. He wanted to stop taking it. At the same time, he had, and I kid you not, a BRIEFCASE full of "natural" supplements his chiropractor convinced him to take (oh yeah, and he wanted a B-12 shot and a B-6 "shot"). I told him that he could get B-6 pills where he got his other stuff, and to ask for B-3 as well if he didn't want to take his Niacin. Oh, and lastly, I had to renew his script for Androgel. He's 85 and worried about taking "medication" but topical roids are ok.

Another lady came in because she was warm all the time, sweating, lost weight, was losing hair, and felt a lump in her throat. She called her chiropractor, who said "It's cancer, go to your doctor." Then, after she made the appointment, called her and said "Oh, it could be your thyroid." And guess who gets to see Ms. Panicky It's all your fault because my chiropractor said its cancer McGhee? That was a fun hour in clinic.
Hmmmm... I read this post twice. First, as written. And the second time, I replaced "family doctor" every time the word chiropractor was mentioned.

I'm just saying.

I actually find it gratifying when patients are sent to me after being seen by another provider. It makes me feel smart, especially when the problem to be sorted out is quite simple to me. And, there's almost always an eager attentiveness in the patient's face... like they were listening, intently, as if they really valued what I had to say.

I guess it's annoying during residency when patients are sent to you, but once everything is said and done and it's build-your-own-practice time... it goes from annoying June 30... to sending Thank You cards July 1st.
 

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Hmmmm... I read this post twice. First, as written. And the second time, I replaced "family doctor" every time the word chiropractor was mentioned.

I'm just saying.

I actually find it gratifying when patients are sent to me after being seen by another provider. It makes me feel smart, especially when the problem to be sorted out is quite simple to me. And, there's almost always an eager attentiveness in the patient's face... like they were listening, intently, as if they really valued what I had to say.

I guess it's annoying during residency when patients are sent to you, but once everything is said and done and it's build-your-own-practice time... it goes from annoying June 30... to sending Thank You cards July 1st.
flip side of that, unfortunately, in outpatient and inpatient medicine... the patients that are looking for you to make "mistakes"... that aspect is horrible.. they will criticize each and every single thing..
 

Drawing Dead

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Hmmmm... I read this post twice. First, as written. And the second time, I replaced "family doctor" every time the word chiropractor was mentioned.

I'm just saying.

I actually find it gratifying when patients are sent to me after being seen by another provider. It makes me feel smart, especially when the problem to be sorted out is quite simple to me. And, there's almost always an eager attentiveness in the patient's face... like they were listening, intently, as if they really valued what I had to say.

I guess it's annoying during residency when patients are sent to you, but once everything is said and done and it's build-your-own-practice time... it goes from annoying June 30... to sending Thank You cards July 1st.
Yeah, I had to read your post twice as well. First to see where I said I was annoyed that these patients were sent to me, and secondly see if you misunderstood my post

Both of these patients are established patients in the clinic I work in. My point about the first patient was that chiropractors should not be ordering tests if they can't do anything but send you to the PCP when they get an abnormal value. What annoys me about this, and should annoy you too, is that the chiropractor is making the money from the diagnostic portion of patient care, even though they have limited means by which to treat. Kind of like them saying "Hey, I found this problem, I need you to fix it for me." As good and warm inside as it makes you feel, he's the smart one, since he just turned you into his assistant while he makes the most money he can.

The point of my second patient was that he scared the patient to death telling her it was cancer, then (and this is judging from the way she described the phone conversation with her chiropractor, and how the events panned out) must have punched her symptoms into WebMD and called back saying "or it could be your thyroid" Then I had to spend a great deal of time with her, falling behind my clinic schedule, assuring her that it most likely wasnt cancer, and in the worst case scenario, usually is very treatable. If physicians took a phone call from a patient, listened to a bunch of symptoms, and then made a concrete diagnosis right there, we would all be out of jobs. He created this crapstorm of hysteria, and I had to deal with it, and my other patients had to lose valuable time out of their day.

Andwhat summarized it almost perfectly, but I would say leave doctoring to physicians. And, as you stated in another post on this forum, everyone should know the limitations of their practice. That includes ordering/performing tests you can't do anything about, or diagnosing conditions of which you have not even seen.
 

lowbudget

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Andwhat summarized it almost perfectly, but I would say leave doctoring to physicians. And, as you stated in another post on this forum, everyone should know the limitations of their practice. That includes ordering/performing tests you can't do anything about, or diagnosing conditions of which you have not even seen.
Hmm... I may have sounded like an @ss. Certainly wasn't my point.

My point is/was that there's no way from keeping non-doctors from doctoring, be it chiropractor, nurses, co-workers, Mystery Diagnosis enthusiasts, the internet, the TV, Men's Health & Cosmo, or mother-in-laws. The reality of it is that doctors don't have a monopoly on information. I think you'll lose your mind when you start competing head on against these forces. I'm still working on how to flip this to my advantage.

And some times, we, as PCP's, do the same thing and ask our specialist colleagues to clean up after us too. Sometimes, it's appropriate; other times, it's not.

Fundamental issue here is trust and communication. Both of which are hard to establish when you're running around clinic like a mad man. When patients don't trust you, they go elsewhere for information. And... to Andwhat's point, when they don't trust you, they are vigilante and are looking for you to make mistakes.

When they do trust you, they come to you... and listen. Some may trust you because you "know more". Others are persuaded with evidence, logic, and explanation. Many times, it's an issue of familiarity and access. Patients can access the internet easily, or know their mother-in-law has all the answers.

The challenge for us is to be just as accessible and familiar to the patient... and unfortunately, I just don't know how to be more available to my patients or get to know them and gain their trust without losing my mind.

I was once told from an old FP once that when patients start going to chiropractors for primary care, we, as FP, have failed our end of the bargain. I thought it was a bit harsh all around. But sometimes, when I think about it, there's some truth to it.
 
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Drawing Dead

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Hmm... I may have sounded like an @ss. Certainly wasn't my point.

My point is/was that there's no way from keeping non-doctors from doctoring, be it chiropractor, nurses, co-workers, Mystery Diagnosis enthusiasts, the internet, the TV, Men's Health & Cosmo, or mother-in-laws. The reality of it is that doctors don't have a monopoly on information. I think you'll lose your mind when you start competing head on against these forces. I'm still working on how to flip this to my advantage.

And some times, we, as PCP's, do the same thing and ask our specialist colleagues to clean up after us too. Sometimes, it's appropriate; other times, it's not.

Fundamental issue here is trust and communication. Both of which are hard to establish when you're running around clinic like a mad man. When patients don't trust you, they go elsewhere for information. And... to Andwhat's point, when they don't trust you, they are vigilante and are looking for you to make mistakes.

When they do trust you, they come to you... and listen. Some may trust you because you "know more". Others are persuaded with evidence, logic, and explanation. Many times, it's an issue of familiarity and access. Patients can access the internet easily, or know their mother-in-law has all the answers.

The challenge for us is to be just as accessible and familiar to the patient... and unfortunately, I just don't know how to be more available to my patients or get to know them and gain their trust without losing my mind.

I was once told from an old FP once that when patients start going to chiropractors for primary care, we, as FP, have failed our end of the bargain. I thought it was a bit harsh all around. But sometimes, when I think about it, there's some truth to it.

It's all good, just a healthy debate. And don't worry about being more accessable, eventually they will get your cell/home phone number from a nurse like I've already have happen.
 

piggie

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downside is, by the way i have an itch here, here, here
i had chest pain for 20000 years already

if you are a specliast you can say... oh well, go to see your FP
as an FP , you can't
 

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I don't agree. You can send them to a cardiologist who must work it up and give a definitive treatment plan whether nothing at this time, exercise stress, cath or medical therapy.
 
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