FP Brethren help a Pedi brother out...

Discussion in 'Family Medicine' started by J-Rad, May 12, 2008.

  1. J-Rad

    Physician Moderator Emeritus

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    A few questions for you (directed at attendings and those in residency):

    How long are your well child visits? Has the new recommendation for autism screening at 18 and 24 months changed the time on those WCC's. And for residents, how many patients do you have in a 1/2 day continuity clinic (per resident year)

    I'm asking these questions to get some outside background on a local system issue. Thanks.
     
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  3. EdibleEgg

    EdibleEgg Member

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    well child= 30 min, that hasn't changed

    intern 4-5
    PGY2 7-8
    PGY3 8-10

    give or take, depending on the resident
     
  4. J-Rad

    Physician Moderator Emeritus

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    Thanks.
     
  5. sophiejane

    sophiejane Exhausted
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    At my program, which is heavy on clinic:

    Intern: 7-9 (I've seen 10 on a half day on several occasions)
    2nd year: 10-15
    3rd year: 12-18

    30 minutes for a well child would be great. I do them in 15-20 min but only because the nurses do a lot of the questionaires (Denver, lead, TB) and the vision and hearing screen and of course the vax's. Basically I do the physical exam and cram as much education as possible into the time I have.

    We haven't changed anything with autism screening yet, but I am sure it is in the works.
     
  6. lowbudget

    lowbudget Senior Member

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    15 min visits. I screen with the 2 questions and 3 exam items which I get when I'm playing with the kids, which from what I've read are pretty sensitive single items for pick up. I use and play with the otoscope light before I exam their ears. It's pretty fast.

    That said, I haven't had an abnormal screen that would necessitate more questions.
     
  7. EdibleEgg

    EdibleEgg Member

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    At my program, which is heavy on clinic:

    Intern: 7-9 (I've seen 10 on a half day on several occasions)
    2nd year: 10-15
    3rd year: 12-18

    So you guys are averaging 25-35 patients a day as a 3rd year? What's your interaction with attendings like when you are seeing those numbers? I'm not being critical, just curious. I average around 30 a day in the real world, and that's much easier than the 20 a day I saw during residency.
     
  8. sophiejane

    sophiejane Exhausted
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    What are they? Do share!!
     
  9. sophiejane

    sophiejane Exhausted
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    Interaction with attendings when you are that busy is limited, there is no doubt. It's something we are working on--a lot of us feel overwhelmed in clinic. However, there is a lot to be said for volume--it doesn't replace careful teaching, but it certainly helps build confidence. On one end of the spectrum are programs where all residents check out all patients to an attending, even 3rd years. On the other end, there's us. We can check out to an attending, but don't have to. First years are required to have their charts co-signed by an attending, but after that, co-signing is not required.

    The encouraging thing is that even though it's a bit of a trial by fire at first (though certainly a lot more time to check out to attendings is available as a first year than a third year), what I am seeing in our 3rd years is very solid docs who can handle most of what they see in clinic by themselves. They ask attendings for help with the very difficult or complex patients, the weird rashes, another pair of eyes on Xrays, to get another idea about a treatment plan, etc. They are ready for solo practice and can handle high volumes with confidence from the day they leave the program.
     
  10. secretwave101

    secretwave101 Senior Member

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    20 min for a WCC

    1st - 6-8
    2nd - 8-10
    3rd - 10-12

    Can't see how I could do more than that in a 1/2 day and still precept. Saw 9 today with an IUD placement and a keloid injection, two routine OB's and other FM stuff. Barely had time to precept the IUD and didn't touch a single note. I'll catch up by Christmas.
     
  11. sophiejane

    sophiejane Exhausted
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    Notes while in clinic? I think I've had time to complete a note once or twice....
     
  12. secretwave101

    secretwave101 Senior Member

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    Not a fair comparison, but I watched an orthopod conduct clinic with an efficiency I can only dream about. He dictates the old fashioned way. No computers. He walks out of an exam room, talks into his mini-recorder for less than 120 seconds and completes the note right there. He then walks into the next room. Hours are 7-3. Sees 50 patients a day. Following his 3pm appointment, he signs some stuff for less than 20 minutes and he is DONE. That's it. Done.

    I asked him if he's ever going to crank up an EMR, and his response was, "Why? Then I'd have to sit down between each patient."

    Until I can spend more time with the patient than I do with their chart...AND still have a life outside my job, I'm going to keep believing there is a better way to get it done.
     
  13. lowbudget

    lowbudget Senior Member

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    Yea, I don't think that's a fair comparison. Ortho's have different standards when it comes to coding (and therefore charting). Their bullet points are different than Gen Med.

    I'd also be interested to see how high this doc is coding for his office visits. The less extensive your charting, the less you can code. He may not care so much because he makes his money doing operations. But as family docs, our office visit coding is key. The other difference is his post-op visits. Post-op visits are considered global with the procedure (i.e. it's included). So it may not matter how extensive his post-op notes are so long as everything is okay because he won't get more money for charting more. Just a thought
     
  14. lowbudget

    lowbudget Senior Member

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    3rd years: 8-14, depending on the clinic session. Our AM clinic lasts longer than PM clinic, but basically 15 minute slots per visit. Only >65 physicals and procedures are allowed to be 30 mins.

    18 is too much for residency. I couldn't imagine clinic ending on time if we had that much. All you need is a procedure, a pelvic, or a non-English speaker to throw a monkey wrench in that business. It takes some patience with kids too if you want to get a good exam. Even adolescents, who give crappy or imaginative histories.

    At our program, a large number of patients have private insurance and have a choice, so service, satisfaction, and being on time is important. I've rotated through the county-cattle-call (which was like lining up to get into a club), but our clinic doesn't work like that. We're independent for practice by 3rd year and we can get by not precepting if they're privately insured or self-pay so long as patients aren't super complicated or have some issue that potentially could result in resident liability. But we also have a large Medicaid and Medicare population also and every of these cases must be verbally checked out in these patients and attending must see the patient if we code high on Medicare patients (99203 or higher, 99214 or higher). I think Conroe got in trouble with the government few years ago because of this, was hit with a huge penalty that threatened to close the residency down. Rumor has it the PD lost his job over it.

    Our nursing staff is pretty good, but I trust our nursing staff up to a certain level. They're only as good as their level of training/experience; and I don't trust them to do my job.

    Our residents are pretty good at knowing when to shift liability to faculty. As cowboy/girl as some of us are, no one is interested in going to law school. So it takes time to present patients and get faculty see some of them to take us off the hook.

    The idea in going fast is so that you can use that time for your complicated patients. But if they stack you that hard, you don't have that wiggle room.

    With some of the managed care plans we're a part of, we have performance/quality indicators that we have to hit and we get dinged if we ignore them (by review as residents, and by clinic revenue as a practice). I'm one of those want-to-figure-it-out types and try to keep my referrals to a minimum (which requires some artful dance sometimes with some patients). So to address all these complicated issues all take time.

    I'd be interested to see how others do it.
     
  15. ramonaquimby

    ramonaquimby I'm a PGY3?! WHAT?!

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    i've been trying to get a thread like this going for some time. interesting how it took a peds residnet to get it going on an FM board :(

    welcome, J-rad! :)

    anyway, our residency is clinic heavy too. ours sounds more inefficient and poorly-run than you guys' though. nurses don't do anything but vital signs. it makes a WCC visit absolutely insane to do in 15 minutes. good lord.

    PGY1 - 1 clinic per week - 7-8 patients booked
    PGY2 - 3 clinic per week - 10-11 patients booked
    PGY3 - 4 clinic per week - 13-14 patients booked

    pure insanity. i can't do this in "real life"...i didn't sign up for this. i think it would be more doable/enjoyable if well-child exams and yearly physicals, 'new patient' appointments, and deaf or mentally ******ed patients' appointments got the 30 minutes they deserved, but they don't, so i get easily frustrated and disappointed.
     
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  17. J-Rad

    Physician Moderator Emeritus

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    And to continue the irony, I posted a similar (but sufficiently different question to avoid the "cross-post hammer", hopefully ;)) in the Peds forum and got an overwhelming one response...

    ...Thanks
     
  18. labruy69

    labruy69 Member

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    wcc - 20 minutes and includes precepting with an attending...haven't added official autism screen at 18-24 months, but working on implementing into our wcc template on the EMR.

    1st yr 45 min appts til Jan, then 30 min appts til March, then 20 min appts.
    2nd and 3rd yrs 20 min appt
    3rd yrs do 1 month at end of 3rd yr with 15 min appts...but still have to precept.
    30 min for procedure appts
    AM office has 7-9 pts btwn 9-11:20am
    PM office has 10-12 pts btwn 1-4
    evening hrs 5-6 pts btwn 5-7
    all pts must be precepted at some point b.c most are medicare/medicaid and it's easier to precept all then find the 1 or 2 with regular insurance. as you feel comfortable you can send pts home and precept later in the day.
    do wcc notes while in room with pt, also do other easy templates in the exam room, but many notes done after clinic is over.
     
  19. sophiejane

    sophiejane Exhausted
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    How do you do that? So, if there are 2 no-shows for a first year, there's one patient to see and that's clinic for the day?

    I should clarify that we have about a 25-30% clinic-wide no show rate, though mine is more like 15-20%. So in actuality, I end up seeing about 6-7 per half day clinic. The majority of first year visits are well child and OB, with the more complicated pts being added later. I have a few complicated ones on my panel, and they do take more time, but I normally will only have 1-2 complicated pts in a half day, the rest are more acute visits or ob or wcc.
     
  20. EdibleEgg

    EdibleEgg Member

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    We had a pretty high no show rate as well, more so for interns. The numbers I posted were patients seen, not scheduled.
     

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