Getting paneled by insurance companiee

[Freedoc]

I am going to be opening a private practice in fall 2014 after residency. I have been looking into office sharing, offsite secretarial services, ipad based EMR - these all seem to be coming together.

I have decided I am going to get paneled with insurance starting out rather than going cash only though I will be open to doing cash with patients outside of those insurance companies.

I am not sure where to start however with paneling and whether there are pitfalls or things to look out for or consider when negotiating with these companies.

Any input would be much appreciated.

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[F0nzie]

Call a handful of insurance companies and start negotiating. Then ask yourself "am I willing to be on call 24/7 for every patient on my caseload for that rate".

 

[whopper]

It's going to highly vary per insurance company. Some are relatively easy. Others will be a pain in the butt. Others, even when paneled, will be a pain in the butt in getting reimbursements.

If you work at someone's office, they might be able to do all the work for you. You simply give them your CV and then they'll just have you sign everything you need to sign and they'll do the rest. Otherwise, expect to go through a mountain of paperwork as if you're applying to several colleges.

To give you an example of what I mean by pain in the butt, there's another attending in my state with my name that's a cardiologist. One insurance company asked me why I, a cardiologist, wanted to go into psychiatry and the office and I told them repeatedly they were getting me confused with someone else and they wouldn't take the 30 seconds it took to simply look up that there were more than one person with the same name. That issue took a few hours of our office having to call their office and them putting our secretary through a roller-coaster of BS wasted time.

My recommendation is if you can't start out cash-only and need a foundation, get the foundation with insured patients, but once there, start transitioning out of it unless the insurance company is very easy in business dealings. Some are better than others.

Then ask yourself "am I willing to be on call 24/7 for every patient on my caseload for that rate".

True, and mountain of other BS too.

 

[vistaril]

Call a handful of insurance companies and start negotiating. Then ask yourself "am I willing to be on call 24/7 for every patient on my caseload for that rate".

I don't quite look at it that way...I don't think agreeing to see a pt as an outpt means you are 'on call 24/7'........I do think it means you have a duty to provide an office number(and check your messages once a day), but being 'on call 24/7'? Gosh no.......a lot of outpt psychiatrists don't even have admitting priv anywhere, which would mean you can't go in and see them anyways.

 

[whopper]

When you see an insurance patient, you get paid for the visit. The only thing that usually pays is the visit, but you are beholden under doctor-patient relationship guidelines and insurance contracts to still provide for things that can't necessarily be done with an office visit. So if that patient calls your office to the point of annoyance, you don't get paid for it. If they call you 3AM and you have to call emergency services, and stay up until the police or ambulance pick them up, you don't get paid for it. You call the patient's other doctors to touch base and the phone call is 30 minutes you don't get paid.

That said, the vast majority of patients usually aren't this high maintenance. The ones that are high maintenance you can do some behavioral interventions to reduce their dependent traits. Some patients, however, are still very intrusive and annoying. A guy I terminated (or more like he terminated me) called my office several times a day, asking to talk to me, and all he wanted to do was do guy-talk as if I was his best buddy. I told him several times that this is not the way treatment works. He became irate. So did his wife that was very upset with me because I wouldn't reveal everything the patient told me to her despite that he wanted his treatment private from her. I was about to terminate him, but hey, he beat me to it. The guy called me incompentent for not spending about 3-5 hours a day for him--and him alone.

A few months later I saw him in the bank making a new account. Wow was that awkward.

 

[vistaril]

When you see an insurance patient, you get paid for the visit. The only thing that usually pays is the visit, but you are beholden under doctor-patient relationship guidelines and insurance contracts to still provide for things that can't necessarily be done with an office visit. So if that patient calls your office to the point of annoyance, you don't get paid for it. If they call you 3AM and you have to call emergency services, and stay up until the police or ambulance pick them up, you don't get paid for it. You call the patient's other doctors to touch base and the phone call is 30 minutes you don't get paid.

That said, the vast majority of patients usually aren't this high maintenance. The ones that are high maintenance you can do some behavioral interventions to reduce their dependent traits. Some patients, however, are still very intrusive and annoying. A guy I terminated (or more like he terminated me) called my office several times a day, asking to talk to me, and all he wanted to do was do guy-talk as if I was his best buddy. I told him several times that this is not the way treatment works. He became irate. So did his wife that was very upset with me because I wouldn't reveal everything the patient told me to her despite that he wanted his treatment private from her. I was about to terminate him, but hey, he beat me to it. The guy called me incompentent for not spending about 3-5 hours a day for him--and him alone.

A few months later I saw him in the bank making a new account. Wow was that awkward.

1) at 3am many psychiatrists aren't going to be talking to their patients because the pts don't know the psychs personal number.
2) my understanding of things is that you can charge for long phone calls cash pay, if the pt so desires to engage in such long calls and pay for them. If they don't want to pay, well that will stop the phone calls🙂.....by accepting a commercial insurance, I don't think you are
relinquishing your right to ever recieve any money for other services from that pt. Rather, you are relinqishing your right to recieve cash pay money for the service you provided under insurance. I don't see how it's any different than a dermatologist who bills blue cross to remove a pt's malignant looking mole but then the pt pays cash for botox

 

[whopper]

1) at 3am many psychiatrists aren't going to be talking to their patients because the pts don't know the psychs personal number.

Several standards suggest that office based practices need 24/7 coverage for emergencies. A patient of yours calls your number saying it's an emergency, you'll likely need to talk to them unless you have someone covering your service that can do this for you.

2) my understanding of things is that you can charge for long phone calls cash pay, if the pt so desires to engage in such long calls and pay for them. If they don't want to pay, well that will stop the phone calls🙂.....by accepting a commercial insurance, I don't think you are
relinquishing your right to ever recieve any money for other services from that pt. Rather, you are relinqishing your right to recieve cash pay money for the service you provided under insurance. I don't see how it's any different than a dermatologist who bills blue cross to remove a pt's malignant looking mole but then the pt pays cash for botox

With some insurance companies, they make you not accept payment outside of insurance. A lot of this depends on the insurance because each one will have their fine print. Now if you violate this rule, yes, I don't see much happening to the clinician though I'm of the sort that wants to follow my contract. For example, I knew a doc that had a patient also call him to the point of annoyance and he set up a behavioral treatment that unless he thought the call was important, she had to pay the office $5 per minute of the call. I believe he was possibly violating the insurance guidelines, but I don't think his patient was going to report it, and he didn't either so it just went on.

 

[Freedoc]

Thank you all for the responses.

Anyone have any idea were I could find a resource informing of what going regional insurance reimbursement rates are ?
If not, anyone willing to give a few ball park or specific figures from personal or second hand knowledge?

 

[vistaril]

Several standards suggest that office based practices need 24/7 coverage for emergencies. A patient of yours calls your number saying it's an emergency, you'll likely need to talk to them unless you have someone covering your service that can do this for you.

the model I've always used and seen others use is an office voice message after hours just telling them to go to the ER in the case of an emergency and if it's not an emergency then leave a message and it can be addressed during business hours(like they need a PA or something). Being on call for outpatients(who arent cash pay VIPs) would seem truly unpleasant and something I wouldn't ever be interested in participating in. If there are some standards that suggest that they will certainly be standards I have little interest in following 🙂 None of the major insurers in this area require any such thing(24/7 coverage)

 

[digitlnoize]

the model I've always used and seen others use is an office voice message after hours just telling them to go to the ER in the case of an emergency and if it's not an emergency then leave a message and it can be addressed during business hours(like they need a PA or something). Being on call for outpatients(who arent cash pay VIPs) would seem truly unpleasant and something I wouldn't ever be interested in participating in. If there are some standards that suggest that they will certainly be standards I have little interest in following 🙂 None of the major insurers in this area require any such thing(24/7 coverage)

This is often debated around here, and is something I've often wondered about myself. Most private practice people in this area do the same. They just have a voicemail at night telling them to go to the ER, especially if they are having SI or a med side effect that concerns them.

Most people tend to say that you *should* provide 24 hour coverage, but few actually do.

I'm on the fence. On the one hand, it'd be nice. On the other hand, I can't evaluate them over the phone and I'm certainly not going to meet them at my office at 3am to see if they're having NMS or talk them down from the ledge. In nearly every case I can think of, I'm going to send them to the ER, so why not just tell them that up front and get my sleep so I'm a more functional doctor during day hours?

It's a tough call and one I'm glad I don't have to make for a few more years. Regardless, if you call around your community at night and see what other people are doing, you'll find your local standard of care. I'll probably just go with that...whatever it is.

I would like to see some data (although I'm fairly certain none exists) that compares outcomes in the two. I would almost bet that there are LOWER rates of poor outcomes with the "go to the ER" model, simply because you are sending them to the ER in a more over-protective fashion than if you talk with them on the phone and tell them to see you in the morning and hope they make it. Data though, would be helpful.

Edit: Not data, but an interesting article with some references: http://www.currentpsychiatry.com/th...patient/2ee64c4166e1457098dfd8d24948b8bd.html

 

[whopper]

Most people tend to say that you *should* provide 24 hour coverage, but few actually do.

The big question, do you HAVE TO PROVIDE 24/7 coverage?

I can't give a simple yes or no.

Would it lead to better care? Of course. So would only having one patient and attending to that patient's needs every single moment. Of course there's a cut off where we are allowed to not do that.

Let's look at it from a malpractice standpoint and assume you want to practice in a manner that affords you the most profit while giving the standard of care and not wanting to be called excessively. Do you have to provide 24/7 coverage for outpatient?

Yes if -->
1) Your state laws require it. This is something you'll have to look up on your own.
2) The insurance company you're paneled on requires it. You don't follow this, expect to be grilled in court while the lawyer on the other side cross-examines you while showing the print saying you were supposed to provide 24/7 coverage on a big projection screen, make you read it aloud while the judge and jury can hear and pointing the laser pointer on a huge screen asking you to recite the "YOU ARE REQUIRED TO PROVIDE 24/7 COVERAGE."

Then expect the lawyer to repeat it again louder.

Then again louder.

Then again louder.

Then ask, "Sir, can you read? Do you understand English?" (Yes). "Then why sir did you violate your contract?"

If you have half a brain, don't expect this to go well in court for you. It will, however, go very very very well for the plaintiff. Also, if the lawyer is especially nasty, (or just depending on your viewpoint), expect to possibly be on the local news when this happens, and when you leave the courtroom, we'll get a nice video of you with your suit jacket covering your face. "Dr. Shmoe refused to comment. This is a video of the doctor leaving the courtroom today."

3) The standard of care requires it. That standard is geographic....but here's the big exception....

Malpractice cases, and this is not taught in residency or medical school, but is taught in forensic psychiatry, are going away from the geographic standard. The reason why is the argument has been successfully brought up several times that if only a few doctors practice in the specific area, it creates too much of a risk for poor practice to be the standard.

Instead of the "standard of care" the new standard being used in many courts is the "reasonable" or "prudent" practitioner standard. So, for example, let's pretend you're the only psychiatrist in the entire county. You could argue that you ARE THE STANDARD. A judge will likely rightfully think that this puts too much power in your hands and will go with the reasonable practitioner standard instead of the standard of care for that local area.

The reasonable or prudent practitioner standard is one where they get an expert witness, and regardless of the geographic standard, state what a reasonable doctor would do. If the defendant didn't do what the reasonable doctor would've done they'll lose the case. I can tell you this. Many doctors will argue that 24/7 coverage is reasonable.

Further, national experts have recommended 24/7 coverage. Another aspect of the reasonable or prudent practitioner model is that professional organizations considered legitimate such as the APA, if they endorse a specific practice standard, you bet the court will likely accept it as the model to rely upon.

Did the APA recommend a 24/7 coverage model? That I do not know and we've argued that before. For me, I decided not to look it up (though anyone of you can. Simply call the APA or look for it on their website) because for me, the geographic standard does require 24/7 coverage so I already know what I have to do. Even if I didn't practice in this area, I'd likely want 24/7 coverage anyways.

My recommendation is get 24/7 coverage but hire some psychologists or counselors to do it for you and they filter out the BS calls. That's what I did when I was doing private practice. I ended up getting called every several weeks to months for an emergency while the other person got called every few days and he just handled it for me.

 

[PistolPete]

What counselor or psychologist or NP or PA wants to take 3am calls for emergencies? And even if they do, how much would a psychiatrist have to pay them?

 

[michaelrack]

What counselor or psychologist or NP or PA wants to take 3am calls for emergencies? And even if they do, how much would a psychiatrist have to pay them?

Some large systems (psych clinic associated with a large hospital or mental health center) do in fact have such coverage, with a psychiatrist providing backup. The requirement for 24/7 coverage is part of the corporatization of medicine- The government and hospitals want to make doctors employees rather than independent professionals.

 

[whopper]

What counselor or psychologist or NP or PA wants to take 3am calls for emergencies? And even if they do, how much would a psychiatrist have to pay them?

One on your payroll that you can be paid a heck of a lot less than another psychiatrist.

 

[vistaril]

One on your payroll that you can be paid a heck of a lot less than another psychiatrist.

but that is still a significant expense, and with the margins in insurance based med mgt what they are now, extra significant expenses just aren't feasible......especially when they don't generate clear cut collections(as this wouldn't)

I'll concede that I am not familiar with a lot of different regions.....but in the few areas I'm familiar with the idea of a commercial insurance based outpt psych providing true 24/7 coverage is laughable. It's beyond laughable actually.

A more reasonable question for the group is as follows: is business hours c0verage for outpt psych mandatory? I actually know of some insurance based practices that will not see walkins under any circumstances. If an outpt calls the office at 11am and says he is having a serious med se or is suicidal or whatever, he is told by staff(if he doesn't have an appt scheduled that day) to go to the er. in the middle of the day. It happens out there...and it is fairly common.

 

[whopper]

but that is still a significant expense, and with the margins in insurance based med mgt what they are now, extra significant expenses just aren't feasible......especially when they don't generate clear cut collections(as this wouldn't)

I'll concede that I am not familiar with a lot of different regions.....but in the few areas I'm familiar with the idea of a commercial insurance based outpt psych providing true 24/7 coverage is laughable. It's beyond laughable actually.

You could have the "filterer" as I'll call him or her get paid per call. E.g. $25 per call. IMHO that's relatively cheap. You could also start incorporating BS calls into the therapy as a marker of improvement. Less BS calls the better. If insurance allowed it, I would bill the patient for a BS call. The money goes to the filterer. If insurance doesn't allow it, have the filterer or you undergo therapy where BS calls are part of a treatment contract that they be decreased over time with part of the therapy as defining what is BS and what isn't.

Some insurance plans I do believe do allow you to bill for calls but from what I understand they are the extreme minority. Someone let me know if I'm wrong. I do know that the private practice I worked for were quite savvy with this type of thing and they told me billing phone time was usually not possible.

Also bear in mind you could terminate patients that abuse their use of calls to the office and that the ones that do are the minority of patients. As long as your practice has at least a few dozen patients, and it will to be viable unless you're just doing a day in the office in a larger practice that you don't own or manage, you will get some patients with personality traits where they call the office all the time.

From personal experience the most amount of abuser-callers tend to be ones that are entitled (e.g. they got money and were born into it with parents that never truly raised them well), or patients on the opposite side of the spectrum that are also entitled. Another type is the dependent PD or lonely type that complains often, they usually have a somatic complaint. Yet another demographic is a patient that believes you are supposed to be their friend and start getting mad at you because you don't want to have beers together.

The majority of patients, when they do call, are very appropriate. Another faction of patients will not call, fearing that they will be wasting your time even when they should be calling you.

As for regions, as far as I know insurance doesn't vary in reimbursement. There are, however, some insurance companies that only operate and have clienteles in specific areas.

 

[Freedoc]

How much do garden variety insurance companies vs medicare reimburse on avg for psychotherapy w/EM, med mngmt, intakes?

 

[SteinUmStein]

With regard to the 24/7 coverage issue, several psychiatrists in private practice in my area refer to our local university's psych ER after hours despite no affiliation with said university. Is this "coverage"? Does this change if you are known to the university staff or could any random person theoretically piggyback off of a local psych ER or medical ER for their 24/7 coverage? I don't believe these providers are paying anything into the university system for this coverage but I could be wrong.

 

[whopper]

several psychiatrists in private practice in my area refer to our local university's psych ER after hours despite no affiliation with said university. Is this "coverage"?

Yes, but the psychiatrist is supposed to be answerable. E.g., if they show up the ER, the ER might call the doctor up asking them to give them a sit-rep.

24-hour coverage truly is a pain in the butt, but if you don't do it, you are taking a serious risk because several argue it should be the standard. I don't now if the APA really has made that into one of their professional guidelines, but if they did, and there was a lawsuit, expect to lose it if the APA endorsed it. Even if they didn't, it's likely the standard of care in the area, and even if not, courts are walking away from the geographic standard and are starting to embrace the "prudent physician" or national standards now.

The prudent physician standard differs from the standard of care in the sense that there could be, for example, just 1-2 doctors in the area and they could both be bad. To argue that they're the standard is monopolistic thinking that a court will likely not accept. The prudent physician standard asks the question, would a reasonable doctor have done this action? It doesn't allow bad doctors that are the only ones in the area to get away with bad practice that a geographic standard of care could allow.

The national standard? Several professional organizations such as the AMA or APA will put down practice guidelines. Again if the geographic standard is lower than the national standard, the court may adopt that one instead, especially if what the doctor did was outrageous but done by others in the area.

Besides, if you do a good practice you should have something 24-7. I've always argued that doctors deserve to make money, but I will state that I would've liked to have seen people argue for or against a 24-7 coverage based on good practice instead of it simply being a pain in the butt.

 

[softballtennis]

My outpatient psych also works in a psychiatric hospital but when I call her outpatient practice. The message for the practice says to call 911 or go to the ER if it is a emergency. I also know that you can leave a message and they will get back to you. My psych also has a pager so anytime she is needed she will know. I'm not sure what times she is on call but never at night or anytime she leaves the hospital , but if one of her patients is having an emergency and there is another doctor on call. She will be paged because since she knows that patient she can then asess them and tell them what to do.

 

[michaelrack]

Yes, but the psychiatrist is supposed to be answerable. E.g., if they show up the ER, the ER might call the doctor up asking them to give them a sit-rep.

.

So how about this as a theoretical 24/7 plan for a psychiatrist: all after hour calls to his office get a message to go to the local ER for an emergency, with the option to talk to a live person (there are relatively cheap services in which a secretary will take messages after hours). If a ER/hospital talks to the secretary, the secretary gives them the psychiatrist's cell/home phone or otherwise connects the ER to the psychiatrist. If a patient talks to the secretary, the patient will be quickly told that he needs to call the office during routine hours for non-urgent problems, otherwise go to the ER. If the patient says something like "I am going to kill myself unless I can talk to the psychiatrist right now", a protocol is followed in which a 24 hour/72 hour hold is filed (after the secretary notifies the psychiatrist).

Disclaimer: I am not personally currently practicing outpatient psychiatry

 

[Freedoc]

Does any one know how much insurance companies (Aetna, Blue Cross etc) reimburse on avg for psychotherapy w/EM, med mngmt, psychotherapy alone, intakes?

 

[dl2dp2]

Does any one know how much insurance companies (Aetna, Blue Cross etc) reimburse on avg for psychotherapy w/EM, med mngmt, psychotherapy alone, intakes?

This is variable depending on the geography and plans. Your best option is to have a list of billing codes and call each of the companies to find out on your own.

 

[Freedoc]

Thing is, rates must be negotiated with these companies. Before I even go there I was hoping to get some ball park figures from those who may have already done this. True, rates vary with plan and location. If one were to incorporate location into their response this would be welcome. Just lookin for some figures from anyone with experience. Anyone got any?

 

[whopper]

I haven't read the APA guidelines yet, but found them on their website.

You have to be a member to login and see it.
http://www.psychiatry.org/practice/...ce-handbook?CookieExpires=1/8/2014 5:37:53 PM

 

[W19]

Does one need to be BC/BE to be paneled by insurance companies? I am contemplating of doing only 1-year residency after med school, which will make me eligible to get a physician license in some states... Will I be able to get paneled by insurance companies with just a GP license?

 

[Shikima]

Does one need to be BC/BE to be paneled by insurance companies? I am contemplating of doing only 1-year residency after med school, which will make me eligible to get a physician in some states... Will I be able to get paneled by insurance companies with just a GP license?

You want the short answer or the long answer?

They both wind up with No.

 

[OldPsychDoc]

Does one need to be BC/BE to be paneled by insurance companies? I am contemplating of doing only 1-year residency after med school, which will make me eligible to get a physician license in some states... Will I be able to get paneled by insurance companies with just a GP license?

What makes you think that this is a good idea?

 

[FlowRate]

This thread was necro'd in the worst of ways. As I reached the end of the thread, I was hoping to hear someone give a definitive "Turns out you don't need to take home call for the rest of your life in outpatient psych."

 

[W19]

What makes you think that this is a good idea?

I don't know whether it's a good idea or not... I think if I can get paneled by insurance companies with a GP license, it won't be hard to do outpatient medicine in my community, which has a lot of immigrants.

 

[W19]

Or you could swing two more years of a family residency and give immigrants less than sub-standard care.


Sent from my iPhone using Tapatalk

You are making the assumption that patients who see GP or NP/PA receive sub-standard care...

 

[notdeadyet]

You are making a big assumption that patients who get their care from GP and NP/PA receive sub-standard care...

No, not an assumption. Residency training is considered the standard physician-level of care in this country. A long time ago that was not the case, and there are likely some good old-school GPs who gave good care. But doing an internship and planning on targeting communities where there are "lots of immigrants" because you reckon they'll be happy to see someone without residency training is bad strategy and more than a little exploitive.

The NP/PA thing is a red herring. NPs and PAs finished their training. They would not be providing below the standard of care. A newly graduated intern who did not complete residency would be below the standard of care. And that's now. Give it a few years and this will be even more true.

 

[hamstergang]

You are making the assumption that patients who see GP or NP/PA receive sub-standard care...

Yes, sort of. As someone who's been through intern year and then more, I (like others, like who you quoted) am making the assessment that after one year nearly no one is capable of delivering care that isn't substandard.

 

[W19]

No, not an assumption. Residency training is considered the standard physician-level of care in this country. A long time ago that was not the case, and there are likely some good old GPs who gave good care, but doing an internship and planning on targeting communities where there are "lots of immigrants" because you reckon they'll be happy to see someone without residency training is bad strategy and more than a little exploitive.

The NP/PA thing is a red herring. NPs and PAs finished their training. They would not be providing below the standard of care. A newly graduated intern who did not complete residency would be below the standard of care.

I am not going to respond to your personal attack... But I happen to think after 5,000+ hours of formal training (clerkship and 1 year residency) I will be more qualified than an individual who complete only 700-1,000 hrs (NP) or 2,000 hrs (PA)..

 

[downwithDTB]

No, not an assumption. Residency training is considered the standard physician-level of care in this country.

Actually, it is an assumption. There is no evidence evidence that residency training improves physician performance, or *very importantly*, that all residency training programs improves physician performance. Remember, blood letting used to be a "standard of care." Lots of things were standards of care before randomized, controlled trials were done. I always find it amusing the duality of people saying how "important residency training was" with "how important moonlighting during residency was." How is it fair to suggest that a moonlighter is OK but someone with similar training practicing as a GP isn't? The great problem with medical education: no one is actually willing to test any real hypotheses about how important anything at all is... and when we do, it's usually with questionable outcome measures and never with randomization. That said, I'm sure there are physicians who would be better with one year of residency than others would be after 10.

 

[notdeadyet]

I am not going to respond to your personal attack... But I happen to think after 5,000+ hours of formal training (clerkship and 1 year residency) I will be more qualified than an individual who complete only 700-1,000 hrs (NP) or 2,000 hrs (PA)..

No attack intended. I didn't make mention of your character, just your professional strategy.

Most docs and other folks who know something about the healthcare field would drive great distances to avoid sending their friends and family to a doctor who dropped out after residency. This is because most docs remember how little they actually knew as interns, despite what the cocky of us thought at the time. You don't know what you don't know.

You're caught up on the NP and PA thing. The difference between them and and a privately practicing intern is that they finished their training.

 

[notdeadyet]

Actually, it is an assumption. There is no evidence evidence that residency training improves physician performance, or *very importantly*, that all residency training programs improves physician performance. Remember, blood letting used to be a "standard of care."

Yep. Blood letting was the standard of care once upon a time. It is not the standard of care now.

Much like practicing independently with intern-level training.

 

[W19]

No attack intended. I didn't make mention of your character, just your professional strategy.

Most docs and other folks who know something about the healthcare field would drive great distances to avoid sending their friends and family to a doctor who dropped out after residency. This is because most docs remember how little they actually knew as interns, despite what the cocky of us thought at the time. You don't know what you don't know.

You're caught up on the NP and PA thing. The difference between them and and a privately practicing intern is that they finished their training.

Oh I see... It's not about sub-standard of care. It's about finishing what one started!

 

[notdeadyet]

Oh I see... It's not about sub-standard of care. It's about finishing what one started!

Yes, training to completion is important because it ensures that you have had all the necessary exposure and training that the field feels is relevant.

There are a slew of things you will not have had exposure to as an intern. Internship is not designed as a boot camp or crash course, because the vast majority of docs do not drop out.

 

[notdeadyet]

Anyway W19, I'm not sure if you're worried about matching into residency or are burned out or what the situation is. But your professional opportunities and your clinical abilities will be many, many times greater if you stick out and complete a residency in almost any field. With the speed at which opportunities for intern-only trained physicians have rapidly dried up over the past decade, there is a good chance that by the time you finish Med school and try to practice, you could find yourself painted into a dim corner very very soon. Give it some thought before doing that to yourself. Best of luck to you....

 

[hamstergang]

Actually, it is an assumption. There is no evidence evidence that residency training improves physician performance, or *very importantly*, that all residency training programs improves physician performance.

There's no RCT that shows that preschoolers are worse than doctors either, but we don't need an RCT for everything. I'm just a PGY-5 (2nd year C/A fellow), and when I see the work of PGY-1s or even 1st year fellows, I certainly see substandard care. It's generally minor mistakes, but it's not optimal treatment and I very strongly suspect will lead to worse outcomes in the long run based on what we do know. Additionally, I see that I myself suggest treatment plans that aren't so great, and my attendings' actually do know enough more than me to provide better care to patients.

Maybe when you finally make it out of med school you'll see that this really isn't an assumption, but it is based on evidence gathered every day in actual practice.

 

[downwithDTB]

Maybe when you finally make it out of med school you'll see that this really isn't an assumption, but it is based on evidence gathered every day in actual practice.

I don't doubt that people at every level of training and experience many better decisions. Absolutely. However, the two questions of 1) whether a motivated, independent learner practicing outside of a formal residency would progress along side his residency trained partners (e.g. not comparing a PGY-2 or GP to an attending, but rather comparing a GP with 4 years of post residency group practice to a first year attending s/p residency) and 2) whether *all* residency training programs actually provide benefit over GP + time. Perhaps some (but not all/most) really are just cheap, cheap labor with worthless supervision.

We're up in arms over worthless board exam repeats without evidence, but god forbid someone suggest that residencies of arbitrary length (why do I need 5 years to chop out a gall bladder but only 4 to practice the most important specialty! But if I also do peds and child psych, I really only need 1.5 years of adult psych to practice it, and if I do basic science research I can cut my clinical time in most non-surgical specialties in ~half, because that makes sense) are to be defended to the death.

And what about all the GPs in the military? Are you implying that they provide substandard care?

 

[clausewitz2]

I don't doubt that people at every level of training and experience many better decisions. Absolutely. However, the two questions of 1) whether a motivated, independent learner practicing outside of a formal residency would progress along side his residency trained partners (e.g. not comparing a PGY-2 or GP to an attending, but rather comparing a GP with 4 years of post residency group practice to a first year attending s/p residency) and 2) whether *all* residency training programs actually provide benefit over GP + time. Perhaps some (but not all/most) really are just cheap, cheap labor with worthless supervision.

We're up in arms over worthless board exam repeats without evidence, but god forbid someone suggest that residencies of arbitrary length (why do I need 5 years to chop out a gall bladder but only 4 to practice the most important specialty! But if I also do peds and child psych, I really only need 1.5 years of adult psych to practice it, and if I do basic science research I can cut my clinical time in most non-surgical specialties in ~half, because that makes sense) are to be defended to the death.

And what about all the GPs in the military? Are you implying that they provide substandard care?

N of 1, but a radiology resident I am friendly with who did a few years as an Army GP in Afghanistan prior to rads said that he felt constantly terrified that he was going to kill someone and didn't know how to cope with many of the cases brought to him. So...maybe the military GP model is more about providing some care rather than standard care. I suspect if the military had the trained manpower to do away with the system it would be gone tomorrow.

 

[clausewitz2]

I don't know whether it's a good idea or not... I think if I can get paneled by insurance companies with a GP license, it won't be hard to do outpatient medicine in my community, which has a lot of immigrants.

W19, you know how you have a lot of anxiety about matching intona residency that you have expert many times across multiple SDN forums somewhat out of proportion to your actual risk of going unmatched? Consider what your life will be like professionally if your employment options are limited entirely to "whoever is desperate enough for an MD of any description to take a huge gamble on my non-standard qualifications."

Why would you do that to yourself?

 

[OldPsychDoc]

....Consider what your life will be like professionally if your employment options are limited entirely to "whoever is desperate enough for an MD of any description to take a huge gamble on my non-standard qualifications."

Why would you do that to yourself?

My point also. The downside of this proposed path is huge, compared to any potential upside.

 

[Shikima]

So, in the current era where Physicians are lumped in with mid-levels all described fondly as 'Providers'.... why wouldn't we want to go back to the days of GPs? Effectively that's what mid-levels are, right?

 

[notdeadyet]

So, in the current era where Physicians are lumped in with mid-levels all described fondly as 'Providers'.... why wouldn't we want to go back to the days of GPs? Effectively that's what mid-levels are, right?

"Provider" is not a dirty word. It's a term that needed to be coined to encapsulate the fact that healthcare services are delivered by a wide range of people and skill sets. Inventing a pseudo-physician or physician-lite role and creating a new one-year residency is possible but it would be bad juju. It would water down what it means to be a physician.

If we want to separate psychiatrists from mid-level providers we need to play to our strengths and training and do things they can not. Anything an NP or PA can do 85% as well for 50% of the cost is going to shift from physicians to mid-levels as they ramp up (and given healthcare costs in this country, that ain't a bad thing).

What individuals need to ask themselves is: what do I do that NP/PAs can do 85% as well, can I do it better, or should I do different?

 

[W19]

W19, you know how you have a lot of anxiety about matching intona residency that you have expert many times across multiple SDN forums somewhat out of proportion to your actual risk of going unmatched? Consider what your life will be like professionally if your employment options are limited entirely to "whoever is desperate enough for an MD of any description to take a huge gamble on my non-standard qualifications."

Why would you do that to yourself?

I feel like the match is getting crazier by the year... I am a MS2 with no red flags so far and I probably rank in the 3rd quartile in my class and trying to get in the 2nd quartile by the end of the academic year. I go to a low tier US MD and I am worried any step 1 score <220 might severely limit my chance to match FM or psych. I am the kind of person who is always prepared for the worse. Thus, I am trying to gather all the info necessary so when I am facing with the worse, so I know what to do to go forward...

 

[notdeadyet]

I feel like the match is getting crazier by the year... I am a MS2 with no red flags so far and I probably rank in the 3rd quartile in my class and trying to get in the 2nd quartile by the end of the academic year. I go to a low tier US MD and I am worried any step 1 score <220 might severely limit my chance to match FM or psych. I am the kind of person who always prepared for the worse. Thus, I am trying to gather all the info necessary so when I am facing with the worse, so I know what to do to go forward...

If you are low tier USMD with low step scores and ho-hum letters of recommendation with no big failures and no big red flags, you will still match somewhere in Family or Psych. These are two of the least competitive specialties out there and there is no indication that they won't continue to be (for all the talk of psychiatry getting more competitive, there aren't any indications that it is on path to become more competitive than anything other than Peds, Family, and bottom rung-IM).

Apply early and apply broadly and you will match. It might not be at Acme University and it might not be in NY or LA, but you'll find a home.

 

[FlowRate]

I feel like the match is getting crazier by the year... I am a MS2 with no red flags so far and I probably rank in the 3rd quartile in my class and trying to get in the 2nd quartile by the end of the academic year. I go to a low tier US MD and I am worried any step 1 score <220 might severely limit my chance to match FM or psych. I am the kind of person who is always prepared for the worse. Thus, I am trying to gather all the info necessary so when I am facing with the worse, so I know what to do to go forward...

You'll be able to match FM or Psych with virtually any CV, provided you don't fail anything. You won't get your top pre-interviews choice with low stats, but you'll match somewhere.