Clinic Ins and Outs- MA’s, Scribes, APP’s
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What people say here in the forum is sometimes what they think is right/ideal but not the reality of their practices.
So, safe to assume this wasn’t discussing (and AI documenting) oxy 5 bid, but rx is 7.5 tid?
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That’s not remotely close to what I’m doing
I only do one short acting and everyone is less than 50 OME. No full mu with BZ meds
guilty conscience? was never talking about you.
That’s very reasonable. It’s crap like this that is not reasonable. This is the hardest I’ve ever rejected a referral. On this for mild lumbar degenerative change.
That’s insane…
Despite my restrictions, I am the most lax doc in area. I always get patients who have cushingoid syndrome from steroids, SCS, 5 back surgeries and sent to me. Sent to me as they don’t want further interventions
They are able to get my with less than 30 OME
this looks like something my ex-partner would prescribe for mechanical low back pain; what a rough time getting rid of his patients
Steve Lobel always assumes all pain docs are drug dealers. I raaarely exceed 120 MME’s and I have an absolute hard cap of 200 MME’s. I never prescribe 2 IR opiates concurrently. Only time I will rx an opiate to a patient who is on a benzo from outside provider is if I have a concurrent Rx form filled out by said provider for coordination of care. Rarely fill early for specific situations. Never fill across state lines. If I go over 10mg Oxy or hydrocodone QID then I’ll add a ER med for baseline pain control. I dont prescribe benzos or Soma.
Does any of that sound unreasonable?
Does any of that sound unreasonable?
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I do practice by coming down on anything >90 OME to below 60 OME
Where you drawing your practice patterns from?
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I'm a pain doc and not a drug dealer.
The oxy/meth/mso4 guy above is.
Whoever posted feel free to PM me contact info.
When not in office, I consult for the government. My work allows you guys to continue prescribing by removing drug dealers from dealing and allowing opiates to remain a WHO "necessary" medication.
Well, can you share what makes a “drug dealer” in the governments eyes, as far as pain docs go? Any guiding principals or pointers?
@lobelsteve
Can you post you quarterly PMP report in the private forum? Mine looks worse than it is due to the single oral diazepam pills I prescribe for procedural anxiolysis.
Can you post you quarterly PMP report in the private forum? Mine looks worse than it is due to the single oral diazepam pills I prescribe for procedural anxiolysis.
How do you get PMP reports?
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log in to your state database and click around. We have quarterly prescriber reports that compare you to others in your specialty.
New one comes out this week.
You’ll be fine because the qty is low, the sig is clearly for a procedure, it is non escalating, and it is not a chronic medication.
Oh, I know. It does show I have like 250 patients receiving sedatives per quarter. Pregabalin and I assume the single dose diazepams.
Getting back to the topic, does anybody have any other pointers for how to be successful in a HOPD setting? I keep hearing burnout rates are higher in this setting, with less supports and difficulty in dealing with managerial staff etc. What has everyone else' experience been?
I don’t see how burn out could be higher. I am way more burned out self employed. You just have to accept that you are an employee and behave as such.
My ASC won’t allow me to give Preop anxiolytics to age over 70, but I’ve discovered tizanidine 4-6 mg chills them out too. Enough that they wanted to ban that next 😂
HOPD should have less burnout depending on what practice.
You’re usually paid wRVU and everything like billing, staffing, marketing is done for you.
You also likely have hospital support for referrals
My mind keeps going back to the documentation burden, with all thats required these days...
Get with the AI.
Game changer. You just have to spend some time initially learning it and programming it but it should do everything much quicker. It’s changed my life
Which AI do you use? Even with all the LCD requirements and the opiate compliance crap?
If you are going to the hospital, they will probably have epic. You can just use the .texts and blow in all of the nonsense. The referrals from the hospital practices are all filled with templates.
HOPD is for the most part great and likely the easiest and most hands off relative to other practice settings. The only downsides are lack of control and autonomy and they like to cut wRVUs every few yrs as new grads are happy to join the practice for pellets (<60 wRVU). Endlessly wondering when the rvu train will run dry
Honestly it doesn’t matter. I use Heidi but I’m sure your hospital has AI that can be incorporated into it (most likely EPIC)
Ask them/ some that incorporate directly into it
Yea they have epic and use suki AI.
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We got it for a flat 115 per month per provider
I've been using and AI scribe, and the HPI it generates is pretty solid after I gave it some instructions.
But how does your AI scribe do with PE and A/P?
Mine is mediocre with PE as it cannot seem to organize things decently and just gives lines of findings I call out.
And the A/P it generates is awful. It includes so much extraneous crap in there and creates new headings to repeating thing over and over
Are you using yours to do your whole note? I'm still trying to find a balance of using AI with dragon and template/dot phrases.
I've been trying AI and it's hard to believe it would do things like LCD requirements without you verbalizing them during the visit while it was listening. Dot phrases still great for that.
You’ll be burned out if you think you could change it to the way you want it. If you just realize that it’s a hospital run practice and they will run it the way they want to. You’ll be completely fine.
Shadow urology and see how they do things.
yes i rarely start opiates, i rarely take over. i think i have started 1 new patient in the past 6 months. she is over 85 years old and failed PT and injections.
otoh, i took over a practice during the heavy-handed opiate days and have maintained approximately 30 people who are on 60 MED and a roughly 3 that are on 90. i tapered down or discontinued a large number.
leaning on opiates is an easy escape solution that can have horrendous ramifications downstream. like riding a motorcycle without a helmet - feels great until one gets injured...
Same could be said for literally anything we do. I would argue that chances of serious permanent harm are greater with some of the interventions we offer than with reasonable opiate rx’ing.
all of our procedures have the potential for harm.
but please name me one other that has the potential for as much long term destruction of physical, mental and social capacity as opioid use. i have never seen a patient die of an SCS overdose or get admitted with RFA withdrawal syndrome or get a divorce over SIJ paucity disorder.
finally, if there is a procedure out there that you think has potential for greater serious harm than opioids then that is a procedure you should not be offering to patients.
but please name me one other that has the potential for as much long term destruction of physical, mental and social capacity as opioid use. i have never seen a patient die of an SCS overdose or get admitted with RFA withdrawal syndrome or get a divorce over SIJ paucity disorder.
finally, if there is a procedure out there that you think has potential for greater serious harm than opioids then that is a procedure you should not be offering to patients.
SIJ fusion
Steve could you please explain? I’d honestly like to hear your thoughts on this.
Procedure without merit. Not based on science or need.
true but you could be hard pressed to say it does more long-term harm than opioids.
Patient specific for all of this.
Irony is that this could describe either of these two options
New England compounding says hi
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I am HOPD. The things that have made the most difference for burnout is saying "No" to stuff I don't want to do. Talks, committees, meetings, teaching, etc. There is always desire for physician input and it is easy to become the person to ask if you always say yes. If you feel passionate about something than by all means say yes, but be very choosy. Rarely do you ever get paid for that time.
Working less (im down to 4 days a week) made the biggest difference by far for my burnout. I am hoping to go down to 3 days a week in the next 3-5 years.
I have a human scribe that makes my busy clinic day much better. He currently is better than my AI scribe but compared to all my other previous scribes the AI is better.
Having my financial ducks in a row also makes a big difference. I am able to walk away right now and live a minimal/modest lifestyle. I will keep working so that I can do more when I retire and currently I don't feel like quitting, but knowing I could or can in a few years makes all the difference. The pressure to have to be at a job and work because of lifestyle creep/never ending financial obligations will considerably compound your burnout. If you havent yet, get your finances in order. Same with any spouse/significant other. If stuff is hard at home, work will be much more challenging. Often it is hardwired personality stuff that gets triggered when something happens at work (or home, or wherever). If you find you are overreacting to things or the same button is getting pushed you might consider working with a therapist. A good therapist is some of the best money people spend to improve their lives. I get that it isn't for everyone but if you find yourself struggling at least consider it. Usually HOPD have lots of support and resources for people for free to address this.
Also why I dont do them.
I mean, a cervical epidural has the potential for causing harm worse than death- quadriplegia.
I know a very good and respected pain doctor who inadvertently killed an elderly patient via complications of a lumbar epidural. Hospital settled on it recently for a million bucks.
Factually, I hear more about complications from procedures causing a lot more near misses and harmful outcomes than I do from opiates.
Don’t get me wrong though. I very well recognize the dangers of opiate prescribing. I am very careful. I do not play around and the patients know this. If there is any sign of deviation from the rules, its game over.
that is not the procedure that is the problem. that is the interventionalist cutting corners and costs.
so not quite applicable.
same thing as NECC. focusing on 1 injection does not equate to treatment that affects society as a whole.
for every 1 person that you talk about, there are 100 more people who have horrible side effects including death from opioids and even more friends and family who are affected.
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factually, you will not hear about complications from opioids - because people will not willingly discuss their adverse effects or their social difficulties with regards to these meds. you have to ask, and then you will get denial after denial.
why? because people dont want to stop their narcotics.
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go ahead and focus on a specific complication with 1 specific injection on 1 specific person, but you are comparing a grape to a vineyard.
and again:
finally, if there is a procedure out there that you think has potential for greater serious harm than opioids then that is a procedure you should not be offering to patients.
If you really think its just focusing on one injection you need a reality check. Are you a pain management physician?
How about the blood patch which resulted in seizures in a new mother and she collapsed on top of and suffocated baby.
My colleague had a high spinal after a cervical facet. Patient coded and had to be intubated and ventilated until it wore off. Luckily that one survived.
I know numerous pain docs who have caused serious permanent disabling neurological injuries doing epidurals and SCS’s.
I know of far fewer deaths from opiates prescribed in a responsible and lawful manner.
C’mon. Surely you are not so naive.
