Getting tired of doing primary care

[thegenius]

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<rant>
Getting increasingly tired of doing so much primary care in the ED. The worst are the increasing number of patients being sent by "doctors", "nurses", "friends" and other people to get checked out.

Every symptom can be an emergency. A nurse over the phone told my patient yesterday that "If you have a sinus infection it can go to your brain. You should go to the ER." While true, the communication is stripped of context and probability, which is the essence of clinical reasoning. What’s being lost is not just efficiency, it’s the skill gradient itself. The probability of that event is somewhere on the order of 1 in 10,000 or lower.

I know this isn't new. And I know this happens everywhere. Just ranting.

It's the worst with patients who are poorly educated, poorly insured, those with language barriers, and others features that somehow incorporates about 90% of all people in the US. They all come to the ER for everything. EVERY SINGLE SYMPTOM NEEDS EMERGENCY EVALUATION.

The end result is a feedback loop that hollows out the whole system. Outpatient doctors, stripped of opportunities to practice real clinical judgment, become increasingly reliant on the ED to rule out emergencies. Their diagnostic instincts dull, their threshold for referral drops, and confidence erodes across the board. What’s left is a health ecosystem where only the ED still practices undifferentiated medicine, while everyone else handles stable chronic disease. And there is no incentive to fix it.

It's such a terrible system, and it's never going to change unfortunately.

The ED has become the backstop for a health care system that no longer knows how to triage risk.
</rant>

 

[JacobMcCandles]

To be fair, I find that for about 80% of people who said Dr. So and So told me to come to the ED never actually spoke with the doctor and only spoke with whatever random person that picked up the phone in clinic.

 

[prolene60]

I never really understood why the nurse or whoever answers the patient consult phone line doesn’t ever have some sort of middle ground to tell patients to come into the office the next day. Why is the algorithm always either “stay home” or “ Go directly to the ER.”
However despite all of the primary care we do, typically I feel overjoyed to tell people I have excluded all their emergent conditions and simply refer them back to their PCP. Also, since COVID I have been more tolerant of these things and somewhat appreciative because I don’t think I would have a job if only true emergencies came in.

 

[Porfirio]

I am cool with seeing the primary care drop ins. I am not cool with the understaffing to make more profit.

 

[Pinner Doc]

<rant>

The end result is a feedback loop that hollows out the whole system. Outpatient doctors, stripped of opportunities to practice real clinical judgment, become increasingly reliant on the ED to rule out emergencies. Their diagnostic instincts dull, their threshold for referral drops, and confidence erodes across the board. What’s left is a health ecosystem where only the ED still practices undifferentiated medicine, while everyone else handles stable chronic disease. And there is no incentive to fix it.
.
</rant>

While this is true, I’m still grateful for the fact we can say “we’ve ruled out an emergency; please follow up with your PCP.”

 

[southerndoc]

Thanks for the RVUs. Follow-up with your PCP.

 

[WhatJobDoIPick]

The thing is...CMS compensation has been so gutted and the private insurers are downcoding everything and refusing to pay IDR disputes they lose...that we have to make it up on volume.

The system is so trash and there is zero political will to fix it.

I am very happy to tell a grateful patient that the asymptomatic hypertension the dingus at the urgent care sent them in for is nothing to worry about acutely.

I'm less happy to deal with the complaints of some CMS loser upset that the nurses didn't wait on them fast enough.

I'm thankful that I only have to do this for another 5 years.

 

[emergentmd]

An obvious rule non cardiac rule out chest pain from a PCP who is insured pays much better than a clearly crashing cardiac pt from a nursing home on medicare.

TBH, I have always loved these pts. Educated, takes care of their health, insured, low risk. I get paid 3-4x as much as said medicare pt with 1/4 of the work. All they really care about is reassurance and I am happy to reassure anyone with an EKG/Labs/CXR.

I am so happy I am out of the hospital game and now my shift is 90% insured most wanting reassurance.

 

[thegenius]

There is some satisfaction to a certain degree.
But most of the time these patients don't even have anything that is treatable in our setting. It's not like they HAVE cystitis and they are sent to "R/O Pyelonephritis." and we give them antibiotics.

People don't understand what the ER is for. Laypersons thought process: If I am SENT THERE, then I MUST HAVE AN EMERGENCY and hence I will get a diagnosis and treatment.

If I were a multi-multi millionaire I would run an ad campaign across the US for 6 months to tell people not to go to the ER unless you have a f'ing knife sticking out of your neck.

It's just a waste of time. A waste of everyone's time and one of the many reasons why every single state runs a deficit for health care spending. it just steadily sucks the life out a job. Not everyday is bad. It's like a stock market in steady decline. There are good weeks, and good days, but the trend is DOWN.

thank you for rant #2

 

[bravotwozero]

I don't care when this happens on day shift. But when this happens at 3am, where I could have gotten a little shuteye, that's when I have to suppress the rage.

 

[bravotwozero]

Thanks for the RVUs. Follow-up with your PCP.

The next day, southern doc gets a screen shot of his press ganey comments from his medical director:

'Dr Southerndoc didn't address my complaints. He doesn't care about my chronic toenail discoloration that's been there FOR TWO WHOLE YEARS. Dr Southerndoc is an a-hole. He is the worst doctor I have ever seen in my life'

P.S. Your turkey sammiches are soggy

P.P.S. The tv remote control was NOT working. Lame!

 

[DocEspana]

The next day, southern doc gets a screen shot of his press ganey comments from his medical director:

'Dr Southerndoc didn't address my complaints. He doesn't care about my chronic toenail discoloration that's been there FOR TWO WHOLE YEARS. Dr Southerndoc is an a-hole. He is the worst doctor I have ever seen in my life'

P.S. Your turkey sammiches are soggy

P.P.S. The tv remote control was NOT working. Lame!

Literally had a patient complaint come in just on friday from a patient clearly unaware that they were talking to the person who handles the patient complaints. So complaint says "this doctor is horribly arrogant and acts like he knows everything but needs to be reminded he DOES NOT. Please make sure he gets disciplined for how he treated me."

my contemporaneously written note (condensed because i write very long HPIs as a bad-but-useful habit I picked up along the way): "Patient presents to the ED openly admitting that she feels like she's having a panic attack and afraid 'i might have ****ed myself over' because she 'accidentally' drove from [major city] to [minor city 4 hours away]. Reports she is 'incredibly high risk for clots' because she has a history of a-fib treated with both a watchman procedure and currently on eliquis. Reports she called her cardiologist who told her to 'get my ass to an ER and demand an ultrasound of my legs and not leave until I get it.' Patient has no leg pain, swelling, redness. Patient has no known history of LE coagulopathy OR pulmonary embolism, she is anticoagulated and s/p watchman despite no history of coagulation complications. Attempts to reassure patient that she can definitely have an ultrasound, but that she is not actually high risk for leg DVT lead to patient telling me to 'just do the job my cardiologist told you to do' and suggest that I 'know your place' and 'stop trying to act like you know anything about this'."

Obviously, u/s negative.

I am still annoyed that the cardiologist even played into her paranoia, but I guess when the patient is so foul of a person the best thing that you can do is just say 'yes' to then and direct them somewhere else rapidly.

 

[WhatJobDoIPick]

Literally had a patient complaint come in just on friday from a patient clearly unaware that they were talking to the person who handles the patient complaints. So complaint says "this doctor is horribly arrogant and acts like he knows everything but needs to be reminded he DOES NOT. Please make sure he gets disciplined for how he treated me."

my contemporaneously written note (condensed because i write very long HPIs as a bad-but-useful habit I picked up along the way): "Patient presents to the ED openly admitting that she feels like she's having a panic attack and afraid 'i might have ****ed myself over' because she 'accidentally' drove from [major city] to [minor city 4 hours away]. Reports she is 'incredibly high risk for clots' because she has a history of a-fib treated with both a watchman procedure and currently on eliquis. Reports she called her cardiologist who told her to 'get my ass to an ER and demand an ultrasound of my legs and not leave until I get it.' Patient has no leg pain, swelling, redness. Patient has no known history of LE coagulopathy OR pulmonary embolism, she is anticoagulated and s/p watchman despite no history of coagulation complications. Attempts to reassure patient that she can definitely have an ultrasound, but that she is not actually high risk for leg DVT lead to patient telling me to 'just do the job my cardiologist told you to do' and suggest that I 'know your place' and 'stop trying to act like I know anything about this'."

Obviously, u/s negative.

I am still annoyed that the cardiologist even played into her paranoia, but I guess when the patient is so foul of a person the best thing that you can do is just say 'yes' to then and direct them somewhere else rapidly.

The more my NW rises, the less I care about "patient experience." You gonna fire me? Don't think so.

You were too nice, I would have kicked out without ultrasound.

 

[WhatJobDoIPick]

There is some satisfaction to a certain degree.
But most of the time these patients don't even have anything that is treatable in our setting. It's not like they HAVE cystitis and they are sent to "R/O Pyelonephritis." and we give them antibiotics.

People don't understand what the ER is for. Laypersons thought process: If I am SENT THERE, then I MUST HAVE AN EMERGENCY and hence I will get a diagnosis and treatment.

If I were a multi-multi millionaire I would run an ad campaign across the US for 6 months to tell people not to go to the ER unless you have a f'ing knife sticking out of your neck.

It's just a waste of time. A waste of everyone's time and one of the many reasons why every single state runs a deficit for health care spending. it just steadily sucks the life out a job. Not everyday is bad. It's like a stock market in steady decline. There are good weeks, and good days, but the trend is DOWN.

thank you for rant #2

The ER is truly the convenience department.

Symptoms for 2 seconds...go to the ER

Resolved symptoms...go.to the ER "just in case"

Specialist appointment in 4 weeks or less but "can't wait"...go to the single coverage ER that has no consultants

Chronic symptoms and seen by 67 specialists with no diagnosis...ER

Emtala has ruined this specialty. There's not anywhere close to the necessary volume of real emergencies to justify the number of ERs open and ER docs. Medicaid pays basically nothing. So we need to make it up on volume. You need maybe 10% of the current ER docs and ERs open to actually run this specialty the way it was intended.

 

[AlmostAnMD]

A part of me sort of gets it

I had a back issue that went on for a few months. I basically just wanted a ct to rule out cancer and other rare **** so I can just admit I'm 40 and move on without thinking about it.


I asked my pcp for a ct. He said to get insurance to cover it I'd need to start with an xray, do 6 weeks of supportive care/nsaids/etc then apply for auth.

I was like

I just want the ct. Order the CT pls

He said he could order it but I'd have to pay out of pocket. I said whatever. So I paid $700 (60% self pay discount!) And got it done 2 days later.

A part of me was like, honestly I could have just gone to the ER

Lol


EDIT: the most annoying part about this is my pcp charged me $25 for the secure chat interaction. Never actually saw him and probably should have just ordered it myself

 

[southerndoc]

The next day, southern doc gets a screen shot of his press ganey comments from his medical director:

'Dr Southerndoc didn't address my complaints. He doesn't care about my chronic toenail discoloration that's been there FOR TWO WHOLE YEARS. Dr Southerndoc is an a-hole. He is the worst doctor I have ever seen in my life'

P.S. Your turkey sammiches are soggy

P.P.S. The tv remote control was NOT working. Lame!

As an administrator, I get everyone's PGs (NRC is what we use). Things like that are common for all of us. I think people complain more about not getting a blanket than they do about not addressing chronic problems.

 

[WhatJobDoIPick]

A part of me sort of gets it

I had a back issue that went on for a few months. I basically just wanted a ct to rule out cancer and other rare **** so I can just admit I'm 40 and move on without thinking about it.


I asked my pcp for a ct. He said to get insurance to cover it I'd need to start with an xray, do 6 weeks of supportive care/nsaids/etc then apply for auth.

I was like

I just want the ct. Order the CT pls

He said he could order it but I'd have to pay out of pocket. I said whatever. So I paid $700 (60% self pay discount!) And got it done 2 days later.

A part of me was like, honestly I could have just gone to the ER

Lol


EDIT: the most annoying part about this is my pcp charged me $25 for the secure chat interaction. Never actually saw him and probably should have just ordered it myself

You're out of the game too long so you don't really understand anymore.

The reason why conservative measures are done first is because 99% of back pain is benign. So no, it doesn't belong in an ER.

But, as you did, if you want to expedite imaging for peace of mind, you are totally within your rights to pay cash out of pocket.

The system shouldn't bear the burden of every Karen or Bob who is 300lb and has back pain.

 

[bravotwozero]

But, as you did, if you want to expedite imaging for peace of mind, you are totally within your rights to pay cash out of pocket.

Which I'm pretty sure would still end up being way cheaper than an ED visit.

 

[WhatJobDoIPick]

Which I'm pretty sure would still end up being way cheaper than an ED visit.

For all of us here, yes.

For the state "insurance" patients, they have absolutely no skin in the game, and usually nothing to do, so they want their's right now.

 

[Emapp20177]

You're out of the game too long so you don't really understand anymore.

The reason why conservative measures are done first is because 99% of back pain is benign. So no, it doesn't belong in an ER.

But, as you did, if you want to expedite imaging for peace of mind, you are totally within your rights to pay cash out of pocket.

The system shouldn't bear the burden of every Karen or Bob who is 300lb and has back pain.

The problem w/ EM is that 1%.

Well patients are great, discharge them ASAP
Sick patients are great, admit them ASAP

The middling unknown - the worst.

 

[AlmostAnMD]

For all of us here, yes.

For the state "insurance" patients, they have absolutely no skin in the game, and usually nothing to do, so they want their's right now.

Yeah that's really what I was alluding to. If there's no cost difference, why not just go to the ed? It's whatever you want, whenever you want. So, of course they just show up and demand x y z

 

[emergentmd]

I think of my EM shift like a sport like golf. If I am going into a golf tournament, do I want my round to be full of 20ft puts, blasting out of the bunker, hitting out of the rough with a tree in front of me or would I rather hit the fairway off the tee every time, hit my 9 iron onto the greens, 1 foot puts for birdie all day.

Being woken up at 2am to take care of a 20 yr old chest pain sucks, we have all been there/done that.

But love me a shift of no critical care, no procedure, no crashing pts, no potential lawsuit pts all day long. I am one of the EM docs on here who liked their job when I was in the hospital, like my EM workplace now, and like the lifestyle. But at the end of the day, it is still a job to pay the bills. I prefer being fresh when I come home to the family rather than feeling beaten up walking through the door.

 

[WhatJobDoIPick]

I think of my EM shift like a sport like golf. If I am going into a golf tournament, do I want my round to be full of 20ft puts, blasting out of the bunker, hitting out of the rough with a tree in front of me or would I rather hit the fairway off the tee every time, hit my 9 iron onto the greens, 1 foot puts for birdie all day.

Being woken up at 2am to take care of a 20 yr old chest pain sucks, we have all been there/done that.

But love me a shift of no critical care, no procedure, no crashing pts, no potential lawsuit pts all day long. I am one of the EM docs on here who liked their job when I was in the hospital, like my EM workplace now, and like the lifestyle. But at the end of the day, it is still a job to pay the bills. I prefer being fresh when I come home to the family rather than feeling beaten up walking through the door.

The patients who present as critical care at their outset are not the patients you're gonna get sued over.

 

[emergentmd]

The patients who present as critical care at their outset are not the patients you're gonna get sued over.

Tell that to the family of the young ICU pt that I responded to during a code and sued me when she didn't make it.

I get your point, but 6 inch puts over a 10 footer any day.

 

[RustedFox]

The patients who present as critical care at their outset are not the patients you're gonna get sued over.

Yeah.
I love you bro.
But you're dead wrong .

 

[RustedFox]

Tell that to the family of the young ICU pt that I responded to during a code and sued me when she didn't make it.

I get your point, but 6 inch puts over a 10 footer any day.

Can't say I agree with this statement, either.

You can bench 225 for single reps all day every day, and you'll never sniff 315. You can say: "I played single-A baseball", but you never had a MLB plate appearance. Didn't do it. Don't wanna hear the "I coulda..." speech. Can it.

Theres something to be said for greatness. You need to be in the fight to be great. That only comes by being in the ring.

 

[emergentmd]

Can't say I agree with this statement, either.

You can bench 225 for single reps all day every day, and you'll never sniff 315. You can say: "I played single-A baseball", but you never had a MLB plate appearance. Didn't do it. Don't wanna hear the "I coulda..." speech. Can it.

Theres something to be said for greatness. You need to be in the fight to be great. That only comes by being in the ring.

Bro, I am like Ali. I have been in the biggest fights for many years. Even Ali knew it was time to call quits. I rather go out a champion rather than trying to be in the biggest fight knowing my legacy would get creamed.

To think about it, I feel more like Jon Jones with just one "loss-suit"

 

[RustedFox]

Bro, I am like Ali. I have been in the biggest fights for many years. Even Ali knew it was time to call quits. I rather go out a champion rather than trying to be in the biggest fight knowing my legacy would get creamed.

To think about it, I feel more like Jon Jones with just one "loss-suit"

If true, then nobody wants to hear you talk about being in the ring anymore. You're not in it. You're not even on the card. Nobody wants to hear you talk about six-inch putts. We can all do that.

 

[emergentmd]

If true, then nobody wants to hear you talk about being in the ring anymore. You're not in it. You're not even on the card. Nobody wants to hear you talk about six-inch putts. We can all do that.

Got it chief. I must have missed the sign that "only Pit docs allowed". Let me step aside while you continue to whine.

 

[thegenius]

Emtala has ruined this specialty. There's not anywhere close to the necessary volume of real emergencies to justify the number of ERs open and ER docs. Medicaid pays basically nothing. So we need to make it up on volume. You need maybe 10% of the current ER docs and ERs open to actually run this specialty the way it was intended.

Yup I agree in general. EMTALA is not bad per se, but the system that pays based on volume, and not bulk, makes ER care untenable.

We are allowed to say no. But the hospital doesn't want to deal with the bad PR.

If our hospitals got $X/person/year in their catchment area, things would be a LOT different. I suspect so at least.

 

[thegenius]

Yeah that's really what I was alluding to. If there's no cost difference, why not just go to the ed? It's whatever you want, whenever you want. So, of course they just show up and demand x y z

This has to be fixed. It's just nuts. Politicians are so afraid of losing a vote that they can't vote in sensible health care access policy.

Primary care should be free (but only under appointment only) for Medicaid folks. ER should be paid. Free access 24/7/365 is completely folly.

 

[thegenius]

But love me a shift of no critical care, no procedure, no crashing pts, no potential lawsuit pts all day long. I am one of the EM docs on here who liked their job when I was in the hospital, like my EM workplace now, and like the lifestyle. But at the end of the day, it is still a job to pay the bills. I prefer being fresh when I come home to the family rather than feeling beaten up walking through the door.

These shifts are rare though. If these were the norm 80-90% of the time, then this would be a much more satisfying job.

The system makes it very hard for us to "just say no."

 

[EctopicFetus]

Serious question for you guys. My main site is a very busy spot. When people come in for a stupid test as long as it is an adult I’ll order this. This is in reference to the patient sent by cardiology on eliquis and with a watchman with LE pain (or whatever the symptoms were).

I feel 0 burn out. I enjoy my job, I am very heavily paid based on RVUs. The options in my mind are:

1) Spend a bunch of time talking the patient out of it. Leaving them unhappy and perhaps filing a complaint. Some of these energy vampires may even impact my mood depending on the interaction. Bill at a lower level than #2

2) spend 10 seconds in the room, order the US, get the negative result leave the patient feeling like I heard them and listening to their doctor ordering this dumb test. My repeat visit with them lasts another 10 seconds. No complaint, patient believing they are heard and I can potentially bill a higher code. Meanwhile I use that time and effort to see another patient and get paid for those other patients.

Outside of MRI and CTs for Peds this is my move. If people want a discussion we can have it. I am one of the lowest admitters in my group, my LOS is very low and my system cares incredibly little about patient satisfaction though my scores tend to run barely above average since I refuse to sit outside of breaking bad news. I want an honest opinion from you folks.

Arguing with a crazy patient about a test with no downside (US) seems like it would be a lose lose when dealing with a crazy person. I think this has allowed me to keep my sanity, make work enjoyable and fatten my wallet. What am I missing?

 

[Pinner Doc]

Got it chief. I must have missed the sign that "only Pit docs allowed". Let me step aside while you continue to whine.

I’m out of the ring (well, only about 8 months) but I still come here to mostly lurk, process latent trauma, and thank heavens for good life decisions.

 

[WhatJobDoIPick]

Serious question for you guys. My main site is a very busy spot. When people come in for a stupid test as long as it is an adult I’ll order this. This is in reference to the patient sent by cardiology on eliquis and with a watchman with LE pain (or whatever the symptoms were).

I feel 0 burn out. I enjoy my job, I am very heavily paid based on RVUs. The options in my mind are:

1) Spend a bunch of time talking the patient out of it. Leaving them unhappy and perhaps filing a complaint. Some of these energy vampires may even impact my mood depending on the interaction. Bill at a lower level than #2

2) spend 10 seconds in the room, order the US, get the negative result leave the patient feeling like I heard them and listening to their doctor ordering this dumb test. My repeat visit with them lasts another 10 seconds. No complaint, patient believing they are heard and I can potentially bill a higher code. Meanwhile I use that time and effort to see another patient and get paid for those other patients.

Outside of MRI and CTs for Peds this is my move. If people want a discussion we can have it. I am one of the lowest admitters in my group, my LOS is very low and my system cares incredibly little about patient satisfaction though my scores tend to run barely above average since I refuse to sit outside of breaking bad news. I want an honest opinion from you folks.

Arguing with a crazy patient about a test with no downside (US) seems like it would be a lose lose when dealing with a crazy person. I think this has allowed me to keep my sanity, make work enjoyable and fatten my wallet. What am I missing?

I agree w this. I spend very little time in the room as well and tend to "just order the test" outside of peds stuff. It's the people who are still dissatisfied after negative unnecessary testing that grind my gears. My system cares very much about patient satisfaction, although I care very little.

 

[BoardingDoc]

Serious question for you guys. My main site is a very busy spot. When people come in for a stupid test as long as it is an adult I’ll order this. This is in reference to the patient sent by cardiology on eliquis and with a watchman with LE pain (or whatever the symptoms were).

I feel 0 burn out. I enjoy my job, I am very heavily paid based on RVUs. The options in my mind are:

1) Spend a bunch of time talking the patient out of it. Leaving them unhappy and perhaps filing a complaint. Some of these energy vampires may even impact my mood depending on the interaction. Bill at a lower level than #2

2) spend 10 seconds in the room, order the US, get the negative result leave the patient feeling like I heard them and listening to their doctor ordering this dumb test. My repeat visit with them lasts another 10 seconds. No complaint, patient believing they are heard and I can potentially bill a higher code. Meanwhile I use that time and effort to see another patient and get paid for those other patients.

Outside of MRI and CTs for Peds this is my move. If people want a discussion we can have it. I am one of the lowest admitters in my group, my LOS is very low and my system cares incredibly little about patient satisfaction though my scores tend to run barely above average since I refuse to sit outside of breaking bad news. I want an honest opinion from you folks.

Arguing with a crazy patient about a test with no downside (US) seems like it would be a lose lose when dealing with a crazy person. I think this has allowed me to keep my sanity, make work enjoyable and fatten my wallet. What am I missing?

This was always my mentality as well with the exception of the not uncommon case where a young person would be sent in to get a CTA chest to R/O the PE that they very obviously didn't have.

Those annoyed the hell out of me because the frictionless approach (and more profitable approach) is to just do the scan. That said, I generally prefer not to subject young nice people to a bucketload of ionizing radiation at the behest of jenny McJennyson who has fewer clinical hours under her belt than a dog groomer does at PetSmart. I'd invariably try to talk them out of it, but I'd certainly keep the offer on the table.

 

[emergentmd]

I’m out of the ring (well, only about 8 months) but I still come here to mostly lurk, process latent trauma, and thank heavens for good life decisions.

Great fighters can only last so long in the ring. Same for EM docs, everyone has a time when they should hang it up. So glad I hung it up 7 yrs ago. Life is so much better, happier, more time with the kids. Although I have always loved PIT EM and always thought I was in a good mood when I came home; my wife tells a different story. She is absolutely right looking back and I always need an hr to decompress but hard to see when you are still in the fight.

 

[emergentmd]

Serious question for you guys. My main site is a very busy spot. When people come in for a stupid test as long as it is an adult I’ll order this. This is in reference to the patient sent by cardiology on eliquis and with a watchman with LE pain (or whatever the symptoms were).

I feel 0 burn out. I enjoy my job, I am very heavily paid based on RVUs. The options in my mind are:

1) Spend a bunch of time talking the patient out of it. Leaving them unhappy and perhaps filing a complaint. Some of these energy vampires may even impact my mood depending on the interaction. Bill at a lower level than #2

2) spend 10 seconds in the room, order the US, get the negative result leave the patient feeling like I heard them and listening to their doctor ordering this dumb test. My repeat visit with them lasts another 10 seconds. No complaint, patient believing they are heard and I can potentially bill a higher code. Meanwhile I use that time and effort to see another patient and get paid for those other patients.

Outside of MRI and CTs for Peds this is my move. If people want a discussion we can have it. I am one of the lowest admitters in my group, my LOS is very low and my system cares incredibly little about patient satisfaction though my scores tend to run barely above average since I refuse to sit outside of breaking bad news. I want an honest opinion from you folks.

Arguing with a crazy patient about a test with no downside (US) seems like it would be a lose lose when dealing with a crazy person. I think this has allowed me to keep my sanity, make work enjoyable and fatten my wallet. What am I missing?

Bottom line is, it is still a Job. A very high paying job. You/I will never change the system. If my mindset was to do what is always medically correct, I would be hated by specialists/patients/admin. If I do what makes pts happy (to an extent), then my life is better. TBH, doing test reassures pts and this alone helps them mentally.

 

[emergentmd]

These shifts are rare though. If these were the norm 80-90% of the time, then this would be a much more satisfying job.

The system makes it very hard for us to "just say no."

Yeah man. I hear you. The job get harder and harder when you have more work placed on you plus having constant Admin overlording. Best to look through rose colored glasses. Its $100 in your pocket for 10 minutes of work. Block out all of the other unnecessary noise.

 

[AlmostAnMD]

Bottom line is, it is still a Job. A very high paying job. You/I will never change the system.

Sort of? Depends on the job, I guess. I rallied really hard with our system and attorney general to kick a medicaid payor out of our state. Took lots of work/lobbying/executive alignment.

Then, after a year of work/close documentation/constant complaints that payor has not had their contract renewed and will exit the state. It was a massive team effort to stamp out fraudulent ciphering of federal dollars by this payor.

Digging a moat to protect hospitals IS possible. Requires insane dedication and yes, won't be done from the pit.

I've got one more I need to kick out and I'll have stamped out most inpatient medicaid fraud we experience!

MA plans, on the other hand, are another beast. But I'm not giving up and taking those ****ers to ALJ hearings until they pay us what they owe/filing CMS complaints for star rating hits until the new final rule barring complaints affecting star rating hits.

It's VERY possible to go on the offensive against "the system", just requires much work/support. And getting out of the pit. Yes in the pit you are a cog, you stfu and do what you're told. Strongly encourage anyone who isn't happy with medicine to do at least a little admin work.

 

[Janders]

This was always my mentality as well with the exception of the not uncommon case where a young person would be sent in to get a CTA chest to R/O the PE that they very obviously didn't have.

…at the behest of jenny McJennyson who has fewer clinical hours under her belt than a dog groomer does at PetSmart.

It will make you happy that “Jenny” sent us some stupid things from UC my last shift, and our long time PA was audibly whining about it to the newest PA without naming “Jenny”.

I heard the vignette and ridiculous referral for CTA+US despite negative ddimer and clear zoster as the source of chest pain… and I said “wait is this a referral from Jenny??”

Our PA laughed and said of course, and the new PA said “do you all know Jenny?”

I started to explain the ridiculous referrals I’ve gotten for r/o dissection, PE, renal colic, epidural abscess, and septic shock on the same patient, topping it off for the ultimate referral for r/o dissection r/o ovarian torsion r/o testicular torsion (same patient!) and the other MD walked up, overheard, and said “oh that sounds like Jenny?!”

(Her name isn’t Jenny, but this is a real local UC PA that has such a ridiculous referral pattern, for the past decade, that (1) her name strikes fear in the heart of triage nurses (2) my second child’s college fund is purely from her referrals and (3) radiology may name the second CT scanner in her honor.)

 

[Janders]

And yeah I agree with people uptread.

If someone wants a reasonable safe test like blood work, US, X-ray I spend all of 1 minute exploring their reasons and the potential they just want a doctor to look at something and reassure them (some only need that!). Then I pretty much order what they want, unless it’s absolutely bat **** insane. This isn’t where the system is going bankrupt or our wait times are failing.

 

[battie]

Vet med ER doc here. I get plenty of these "easy case and revenue for the GP cases" (vomiting/diarrhea work-up, UTIs, non-fracture lameness, etc.). These are 70-80% of my cases moreso because GPs simply don't have the time in their day. Between seeing 35 cases plus some drop offs from same day sick appts, they simply don't have the time (and sometimes the knowledge).

When I was looking for a GP job last fall and tried to market myself as an UC doc that can see sick appointments all day. Only one clinic was interested.

Is human GP just too busy/lacking in knowledge, or is it the client education like some of y'all have mentioned?

 

[WhatJobDoIPick]

Vet med ER doc here. I get plenty of these "easy case and revenue for the GP cases" (vomiting/diarrhea work-up, UTIs, non-fracture lameness, etc.). These are 70-80% of my cases moreso because GPs simply don't have the time in their day. Between seeing 35 cases plus some drop offs from same day sick appts, they simply don't have the time (and sometimes the knowledge).

When I was looking for a GP job last fall and tried to market myself as an UC doc that can see sick appointments all day. Only one clinic was interested.

Is human GP just too busy/lacking in knowledge, or is it the client education like some of y'all have mentioned?

Nah, the GP definitely has the time. Or, better rephrased, they have the same time restrictions are you do, they just don't care.

You have the ability to quote a price and if the owner doesn't want to spend the coin, can say good day. We in human land are obligated to work up every single patient regardless of ability to pay, or else face the consequences.

 

[RustedFox]

Serious question for you guys. My main site is a very busy spot. When people come in for a stupid test as long as it is an adult I’ll order this. This is in reference to the patient sent by cardiology on eliquis and with a watchman with LE pain (or whatever the symptoms were).

I feel 0 burn out. I enjoy my job, I am very heavily paid based on RVUs. The options in my mind are:

1) Spend a bunch of time talking the patient out of it. Leaving them unhappy and perhaps filing a complaint. Some of these energy vampires may even impact my mood depending on the interaction. Bill at a lower level than #2

2) spend 10 seconds in the room, order the US, get the negative result leave the patient feeling like I heard them and listening to their doctor ordering this dumb test. My repeat visit with them lasts another 10 seconds. No complaint, patient believing they are heard and I can potentially bill a higher code. Meanwhile I use that time and effort to see another patient and get paid for those other patients.

Outside of MRI and CTs for Peds this is my move. If people want a discussion we can have it. I am one of the lowest admitters in my group, my LOS is very low and my system cares incredibly little about patient satisfaction though my scores tend to run barely above average since I refuse to sit outside of breaking bad news. I want an honest opinion from you folks.

Arguing with a crazy patient about a test with no downside (US) seems like it would be a lose lose when dealing with a crazy person. I think this has allowed me to keep my sanity, make work enjoyable and fatten my wallet. What am I missing?

I had a whole thread on this one a few years back. Order the ultrasound. The [RPG] jokes that followed were golden.

 

[RustedFox]

Got it chief. I must have missed the sign that "only Pit docs allowed". Let me step aside while you continue to whine.

I hear you man, and I'm happy for you that you're out. But I don't think you understand how condescending your posts come off when there are guys like @CajunMedic out there double-defibrillating people with a stiff upper lip. That guy is GOAT'ed.

 

[watermanMD]

Their diagnostic instincts dull, their threshold for referral drops, and confidence erodes across the board.

Thissssss

This place is cooked.

 

[DocEspana]

As an administrator, I get everyone's PGs (NRC is what we use). Things like that are common for all of us. I think people complain more about not getting a blanket than they do about not addressing chronic problems.

Just saw one today where the patient had two complaints

1. they received oral cipro instead of iv cipro and they are 'used to' receiving iv cipro for this and

2. the ER entrance is hard to find and we should make structural changes to the hospital to fix that.

 

[WhatJobDoIPick]

Just saw one today where the patient had two complaints

1. they received oral cipro instead of iv cipro and they are 'used to' receiving iv cipro for this and

2. the ER entrance is hard to find and we should make structural changes to the hospital to fix that.

People with low IQ are unable to recognize people w expertise.

If my fan belt needs replacing, I don't criticize my mechanic for the method of replacing. I pay my money, say thank you, and are on my way.

 

[DocEspana]

The patients who present as critical care at their outset are not the patients you're gonna get sued over.

I find the ones that become problems (thankfully ive avoided lawsuits entirely so far) are the ones that you expect it from the least. The dumpster fire and the vocally angry patient both get some impressive defensive documentation. Its the "that was NOT a part of the visit, they were here for headache" who has an ischemic limb.

So by the rules of ones you least expect: it'll be the ones that are already perimortem before you even got involved - because I agree that I wouldnt expect it from them