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General Outpatient Medicine, Anyone?

Discussion in 'Internal Medicine and IM Subspecialties' started by MyNameIsOtto, Jul 21, 2011.

  1. MyNameIsOtto

    5+ Year Member

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    Is ANYONE in medicine planning on general outpatient practice after residency? I've been giving this thought but not finding much in the form of support from anyone.

    One ongoing issue is RESIDENT RUN CLINIC! Please tell me the real-world isn't like this. We don't actually manage anything in our primary care clinic. As an intern I typically saw "hospital discharge follow-ups that don't have PCP's." So, I would spend >30 mins doing a pretty thorough H and P on a patient I would never see again (non-compliant, but decided to show up after hospitalization for 1 appt.)

    There is poor outpatient training in our program, and I'm hoping my program isn't atypical with regards to this. We are trained pretty well how to be hospitalists and admitting specialists but I couldn't tell you how to manage a stable asthma patient or diabetic.
     
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  3. jdh71

    jdh71 epiphany at nine thousand six hundred feet
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    I thought new rules required a stable patient panel?

    Anyway, I had the same (I think it was 100 or so) patients for 3 years during residency, and by the middle of the second year it wasn't too bad. I got to know all of them really pretty well. I already miss a few of them.

    I think out patient primary care wouldn't be horrible gig on many different levels, if you could find the right practice set-up. 9-5ish, no weekends, no call. Though all of the stuff that frustrates all too many of us about primary care would still be there, but some people like it inspite of all of that. So if you're one of those people, then it would probably be pretty good, provided you've found the right market and the right practice set-up.
     
  4. IMdocT

    IMdocT Retired
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    i think every resident clinic in general has many problems that can make residents shy away from outpatient work. the resident clinic usually serves indigent patients. there are socioeconomic barriers, and poor healthcare contact in the past. they have a million problems that have not been properly addressed, there are a lot of compliance issues. it's hard to see them again in clinic because you have only one half-day a week. there are a few that show up for ER follow up and don't come back. the primary care attendings tell me, though, that the real-world practice is not typically like this. don't forget that just like hospital contracts, you can also usually build your own outpatient practice to your liking. i've had good patients too. if you're and intern, give it time, and your panel will start to build and you'll get to know some of your patients better
     
  5. DIce3

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    Outpatient general internal medicine is great. I have been a solo traditional internist for over ten years and am very satisfied with my work. I recommend seeing your own patients in the hospital as this is rewarding and your patients will be most appreciative. The demand for traditional internists is incredible. Prepare to be a real doctor from day one as you will solve problems from every corner of medicine daily. Starting a solo practice is very doable and hearing the continual groaning from my friends about meeting RVU quotas and MBA enforced rules makes me love my boss more and more.
     
  6. w1ll

    w1ll Junior Member
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    I know there is a great deal of variability depending on your practice, but I was always under the impression that a traditional internist makes a lot less $ than their hospitalist counterparts or big private practice groups. Is this true? If so, I'm guessing the lasting patient relationships are what compensates for the less $.
     
  7. DIce3

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    When I was in training, a cardiology fellow bragged to me about how he would make as much doing one diagnostic cardiac catheterization as I would make all day seeing patients in the office. At the time this was true. After January 1st 2010, cardiologists started begging hospitals to buy them out because "they can't afford to practice medicine." (read: Medicare is leveling the field)

    Big groups have more ancillaries than the solo person. I have an INR machine, EKG, nebulizer, and a few other tools. I do not have a lab or a bone densitometer. Five+ years ago the larger groups in town were making good money on the bone densitometry unit. Currently it is almost a wash to have one and soon it may be a slight loss. (read: Medicare is leveling the field)

    Reimbursement will change and will not stay adjusted for inflation. (read: you are going to take home less and less over time)

    It saddens me that so few people want to be solo traditional internists any more. Solo practice means you control your life. Yes, I do buy toilet paper for the office. Yes, I do payroll and pay quarterly estimated taxes. BUT I have no MBA or other silly administrator telling me what I have to do. And... it is going to be really hard for my boss to fire me or get upset with me when I want to cut out at 4 PM.

    As for the hospitalist question: watch what happens over the next six months. All of a sudden a few commercial contracts for hospitalists changed. They have no say about which patients show up in the ER. So, if insurance A decides they are not paying for subday codes, they can stop paying for all subday codes. It does appear to be legal. (read: this is going to be really interesting really fast)
     
  8. bronx43

    bronx43 Word.
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    Your post is truly insightful, and I agree 100%.

    Also, I never understood it when people have superiority complexes about their specialty, especially when it's about money in the current reimbursement model. You don't make more money, because of some intrinsic quality of your service. You make more money, because of entirely artificial value assignments by multiple third parties. I mean, is getting paid a lot for a heart cath really something to brag about? So... you basically just spent 8 years to train for something that can essentially be taught in half that time to perform a service that is only currently well reimbursed, but will inevitably be cut down by the almighty CMO.
     
  9. MyNameIsOtto

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    Thanks for the responses everyone.

    Back to the original post. Can anyone in general medicine provide some insight. Do you get to actually manage conditions or is the majority of everything referred out? Are you finding yourself dealing with increasing number of patients that want referrals for everything they have?

    With the depth and breadth of internal medicine, how were you prepared day 1 out of residency, which doesn't even train you for outpatient medicine?
     
  10. DIce3

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    You can manage everything yourself. I only refer out procedures and disease states above my ability. I frequently have patients that come for a first visit that have ten specialists. We usually decrease that to zero to two.

    I was scared and poorly prepared on the first day out and remain scared that I will miss something all the time. You will need the rest of your life to figure out how to really practice medicine. I am 16 years out of medical school and am finally learning how to diagnose and treat diseases daily.
     
  11. witchbaby

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    I'm a recent US IM grad who is currently working abroad, but planning to come back to the US and become a primary care doc. I think most American IM residency programs are doing a real disservice to their residents who might be interested in primary care. I started medical school and residency wanting to be a PCP in a clinic somewhere. By the end of intern year I felt like I needed to be figuring out what fellowship I would be applying to.

    Why? You spend almost all your time in the hospital. You and your colleagues may often grumble about why "The PCP didn't take care of this" simple problem (IE, why is this patient bothering me?), or how badly the PCP messed up the management when a really sick patient comes your way. Your clinic probably feels like it's dragging you away from your sick, hospitalized patients, to see well patients, who are often not sure why they're there. You're rushing to finish your critical patient care duties, get to clinic, only to try and see a bunch of healthy(ish) patients and document stuff as quickly as you can and get back to the inpatients. And to top it off, maybe your patients frequently no show (nice schedule wise, not good for the self esteem.) Maybe you wait longer for your preceptor than the time you get with your patients.

    It wasn't until my third year of residency when I had to start saying goodbye to my clinic patients that I realized that clinic really was where I belonged. (Even though few of my fellow residents even considered practicing general internal medicine in a clinic.) Yeah, clinic feels like an interruption of more time-sensitive work, but assuming you have enough continuity in your clinic to see some patients regularly, you will come to appreciate the work you do for them as well.

    In this era of specialization, it takes some bravery to join a general IM outpatient practice, but if it's what you want to do, it will be much more rewarding than succumbing to the pressure to specialized you are probably feeling now. My few colleagues who have done it seem very happy, and have gained lots of confidence over the past year. You will not be prepared by residency clinic (or even you 3 month outpatient rotation) for solo primary care practice. But you will have the tools and critical thinking skills to figure it out, and if you find the right practice, support from your more experienced colleagues for the common things we see very little of in residency. (MSK complaints, rashes, etc)

    General internists make less than specialists, it's true. Many of us hope that that will change as health care reform recognizes that talking to a patient and thinking critically about how to best manage their multiple chronic diseases may be as valuable as procedurizing them. But it might not. Either way, you'll still be earning a living wage, so you should do what you are happiest doing.

    In the meanwhile, if your residency program has multiple continuity clinic options available, you need to find out from your colleagues who actually has the most continuity and transfer there. Most of your colleagues probably could care less, and if you express and interest in primary care, your program should be willing to work with you. I'm sure they're proud of their fellowship match rate, but they will probably also acknowledge the increasing rarity of the true general internist and support you, because sooner or later people are going to start asking what it is about internal medicine residency that makes everyone specialize.
     
  12. gutonc

    gutonc No Meat, No Treat
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    Although I never had an interest in primary care, I completely agree with this assessment of the outpatient training most people get in IM. If I had been interested in it though, I'm pretty sure I would have had the same response you did.

    I will be curious to see if the way some programs (including the one I attended) are handling the new work hour and RRC outpatient rules will make this better. The 3+1 schedule (which has numerous implementations...I'll describe the one at my former program) has 3 weeks of regular rotations (wards, ICU, subspecialty consults, ambulatory or subspecialty clinic, etc) but with no continuity clinic. This is followed by a week of nothing but clinic, generally 5-6 half days of continuity clinic with some other clinic experiences thrown in.

    There are plenty of potential downsides to this but I think the biggest plus is that you don't have the time pressure of racing to and from clinic when you're on wards/ICU and you can just focus on your clinic patients. Secondly it will allow residents to get a slightly more realistic experience with what outpatient medicine is really like.
     
    #11 gutonc, Jul 24, 2011
    Last edited: Jul 26, 2011
  13. MyNameIsOtto

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    Thank you for the replies.

    Any current attendings, particularly in group private practices, have any insight into residents decisions to pursue primary care in the era now of super specialization? Where do you see general medicine in 5 to 10 years?
     
  14. NRAI2001

    NRAI2001 3K Member
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    When it comes to primary care how do FP vs IM fare?? The hospital I m workin at currently seems like fp residents can really maximize their residency training and electives and learn a lot of outpatient procedures and skills that to me sound very valuable. Speaking with a few of the FP residents they said that they ve done many electives in pain medicine, dermatology, GI, cards... Allowing them to do many outpatient procedures in all these fields (some were said they would incorporate much of derm, pain management into their practices; one fp attending even said that some of his grads were doing flex sigs and colonoscopies, stress tests, echos..etc in their practices....)?
     
  15. Sneezing

    Sneezing Even Bears do it!
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    -The government is taking over health care directly and indirectly. As a result medicine is going to be split into two tiers.

    -Tier 1: The free thinking, true medicine practicing physician who is paid for their time and advocates for their patient in a true patient-physician relationship. Only a hand full of specialties will be able to do this. Those with lower overhead and minimal equipment costs. IM, FM, Psych, Peds, and a hand full of IM subspecialists and maybe a smaller amount of plastics/derm/general surgery. These are the people who will function outside of the ACOS, the HMOs, and the over restrictive insurance companies. This is freedom. This is rationing based on the patients wallet and not the government's.

    Tier 2: Is the larger domain where the bottom line matters most and patient care is a secondary goal. The government will be spear heading this as they are already doing so. Physicians will be sparse, as it is easier to control the prescribing habits of a midlevel with check box medicine. There will be a physician-government-patient relationship. Treatments will be rationed by the government as they are the ones paying. However, the government doesn't want to pay because that means a larger bill for tax payers. They don't want new technology or new drugs because those are more expensive. They don't want super sub specialists because they treat less for more cost, when they could have more generalists treating more people. Effeciency will be talked about but as with all government agencies the bureaucracy protects the lazy and timeliness will be a dream. There will be pressure for people to try and be in tier 1.

    -Now is a good time to be going into general internal medicine. Cash only practices can and are flourishing. They are the original way to practice medicine. They are also called direct practice, direct access, concierge, retainer style, and other terms.
     
  16. drrockstar140

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  17. docmandingo

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    I'm glad someone else brought up this topic. I just got off a very rewarding month of general outpatient internal medicine. I've decided to seriously consider primary care as a carreer instead of specializing. I worked with a physician who had been working for 50+ years and it seemed like an incredibly rewarding field.
     
  18. bronx43

    bronx43 Word.
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    Whether or not GIM is rewarding was never really the issue. Like any field, there are people who find it rewarding and others who don't. The main road block to general medicine is the comically low pay compared with pretty much every other field out there. The question is, are you willing to take a gigantic pay cut (assuming you had the option of high paying fields) in exchange for a more fulfilling career.
     
  19. anthroguy

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    If you are considering gen oupt IM, you should strongly consider FM. You have more procedural training along wiht more gyn+ob which really helps in assessing pts. Rotations in urology, sx, derm also only help in outpt practice.
     
  20. ShyRem

    ShyRem I need more coffee.
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    It depends on where you practice. I know someone who just signed a contract for outpatient IM practice for a salary not that much less than a hospitalist salary, nice signing bonus, and monthly stipend throughout her remaining year and a half of residency. Now this isn't in a huge city but rather a small city. Nice area. But definitely not in the middle of nowhere either.
     
  21. kikoBG

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    Private practice general docs can earn VERY good living. It all depends on your personality, competency, and business skills. Build a huge patient base, open up several offices, have other docs/ NPs work for you and watch your income outgrow the cards guy at the local hospital :)
    I know one doc who practices integrative medicine (general IM + alternative medicine certifications) and he recently opened his 4'th clinic in Chicagoland. He has MDs, NPs, chiropractors, massage therapists, secretaries, and medical scribes working for him. He's 39. His practice truly helps patients get and stay well, so the word of mouth is ridiculous.
     
  22. dragonfly99

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    In the private world (or if you become employed in outpatient primary care), as mentioned above by some others, you will likely have "better" patients and a better run clinic. You won't have so many no shows, probably, and you'll have less "socially bad" patients. Resident clinics tend to be filled with more indigent patients and those with social problems. Also, as an intern you don't yet have a stable patient panel. Some resident clinics are better run than others. Some residencies in general are better run than others.

    One plus of doing either hospital medicine, traditional IM (admit own patients and do outpatient clinic) or an outpatient clinic-only primary care job is that your services will be in demand when you graduate. You'll have more choices about where to live and practice than we specialists. It's a numbers game and there are always more jobs for primary care. Also, I'll bet there is a high burnout rate as well...if you're in a big integrated system, there tends to be a lot of "dump on the PCP" where all the patient labs, phone calls, etc. get triaged to you even if it was a stupid question like "where is the lab for my blood draw" or some question for one of the specialists they saw, or a lab a specialist ordered. So that would be one drawback.

    In terms of the cardiologist bragging about his pay, please don't tar a whole specialty based on one individual's comment. Also, I think that primary care is important but I also think I should be paid a little more for my extra 5 years of training (where someone who went straight to IM has been making a "real" salary for the past 5 years), particularly since I'll be doing procedures where if not done correctly a patient could bleed to death or have a heart attack or be otherwise harmed. I can say based on recent job interviews that cardiology still makes >> primary care IM, but it does depend on the job and the physician. There are general internists with good business sense, and/or who work a lot of hours, and do quite well financially (ditto for hospitalists).
     
  23. dragonfly99

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    It's not actually as easy to do a cardiac cath, (and especially not to stent people) as some of you probably think. I totally didn't realize all the complexities of the decision making and the "doing" of these types of procedures until I did fellowship. Diagnostic cath on a relatively healthy patient isn't too bad, but there is still risk of severe patient harm...so the stress is considerable. Doing complex PCI/stenting is a major deal...and there are more and more obese and geriatric and vasculopathic patients now than ever, which makes doing the procedures harder. I'm not an interventionalist but I respect the h*ll out of those guys and I now kind of understand why they get paid the big bucks. And don't forget they have chosen a life where they'll be getting out of bed in the middle of the night for emergent caths for ST elevation MI's for the rest of their professional lives...
     
  24. Paddington

    Paddington SDN Lifetime Donor
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    I've always thought that Family Medicine should try to distinguish themselves from IM by focusing more on outpatient practice during residency. I could be wrong though.
     
  25. smq123

    smq123 John William Waterhouse
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    We do.

    As 3rd year FM residents (in my program, at least), we do two full days of clinic a week, unless we're on the inpatient service that particular month. You see the same patients over and over again, so you get a very stable panel. We get very close with our patients because we see them in the outpatient setting so much; some residents have even gotten invited to funerals/weddings/baptisms. It sounds very Marcus Welby-ish, I know. :laugh:

    We're also expected to keep up with messages/refills/phone calls even if we're not in the clinic. So, if you're on another rotation, skimming over your messages in the EMR is an expectation. It doesn't have to be every day, but with a reasonable frequency. So you keep up with your patients and their issues that way, too.

    I'm comfortable in a pretty good range of procedures - wart removal (i.e. cryo), skin biopsies (shave/punch/curette/excision), paps, IUDs, colposcopy, I&Ds, suturing, anoscopy, toenail removals (surprisingly fun if you're not squeamish). Joint injections aren't my favorite, but I can do them. We do a fair number of splints, too. This isn't even a rural program; we're 10 miles outside a major city.

    One of my fellow residents will be doing flex sigs and colonoscopies when he graduates. He's the exception; I would really rather not do them. (Watching an asleep patient fart out the insufflated gas, and spray the gastroenterologist with liquid stool decided that for me.) One of our attendings does nasopharyngoscopy as well.

    As interns we are mostly inpatient based; as 2nd and 3rd years, we start doing more outpatient rotations. For example, our cardiology rotation involves seeing patients with the outpatient cardiologists, not in the CCU.

    Some residents have gone on to become hospitalists, despite all this - they just made sure that all their electives were inpatient based ones.
     

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