How to grow without being overwhelmed

[Pain Applicant1]

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I've opened my own practice just shy of a year ago and have been lucky to where my practice has grown very fast. I'm currently at about 26-29 patients per day and am scheduling >5 new patients per day on average. It's been a blessing and a curse. I've recently changed my office hours to M-Th from 8-6 to try and accommodate and free up some time but am still finding myself working all of the time. I'm doing a lot paperwork and notes and taking care of business related issues in my "free" time. Don't get me wrong, it's better than the alternative of struggling for patients and I'm very thankful for where I am but it's kind of becoming overwhelming. I of course would like to spend more time with my wife and family and get back to my hobbies. I have one front desk girl, one MA full time, one MA part time, and I outsource my billing.

Has anyone been in this situation? Anyone want to chime in on how to make things more efficient or how to handle the volume? Should I stop accepting new patients? Look to hire more help? Cut back on hours? Heeeelp! 😱

 

[mille125]

I've opened my own practice just shy of a year ago and have been lucky to where my practice has grown very fast. I'm currently at about 26-29 patients per day and am scheduling >5 new patients per day on average. It's been a blessing and a curse. I've recently changed my office hours to M-Th from 8-6 to try and accommodate and free up some time but am still finding myself working all of the time. I'm doing a lot paperwork and notes and taking care of business related issues in my "free" time. Don't get me wrong, it's better than the alternative of struggling for patients and I'm very thankful for where I am but it's kind of becoming overwhelming. I of course would like to spend more time with my wife and family and get back to my hobbies. I have one front desk girl, one MA full time, one MA part time, and I outsource my billing.

Has anyone been in this situation? Anyone want to chime in on how to make things more efficient or how to handle the volume? Should I stop accepting new patients? Look to hire more help? Cut back on hours? Heeeelp! 😱

Currently you are only working 4 days a week if I read this correctly. A three day weekend every weekend is much more "free time" than most of us have. Easiest solution in to open up friday. Maybe change hours to 8-5. I dont see how more office workers could help you.

 

[bedrock]

Currently you are only working 4 days a week if I read this correctly. A three day weekend every weekend is much more "free time" than most of us have. Easiest solution in to open up friday. Maybe change hours to 8-5. I dont see how more office workers could help you.

Agree with mille125. It's hard to feel bad for you when you're only working 4 days a week. Most of us on the forum don't have the luxury of doing that....

Besides that, the solution is quite simple. Look at your contracts and payments and drop your worst payors. Generally best to start with the smaller companies when doing this.

If you drop your worst insurances, not only do you have more free time, you also get paid more per hour for the time you are working.

 

[Pain Applicant1]

I was working 5 days/week 40 hours but worked well into the late evening on most days. I'm now open 4 days per week but still at 40 hours as I increased my hours per day. I figured I could have Friday to catch up on business and paperwork. I don't see patients on Friday but am still working doing business related issues which tends to trickle deep into the weekend. It's not anywhere close to a 3 day weekend as I would like it to be.

How many hours do you guys work per week? Do most on here work >60 hours per week still? I want to increase efficiency and don't want to work >60 hours/week for the rest of my life. At 40 hours per week, 110-120 pts/week, how many and what type of employees do you think are necessary? If on average, seeing 110-120 pts/week requires 60 hours/week of work for most people, then I'll most likely accept that I just need to see less patients by dropping my lower payers, as mentioned above. If that's average then I'll accept that, but if anyone feels that I should be more inefficient and 110-120 pts/wk should not require 60 hrs/wk of work, please let me know.

 

[mille125]

I was working 5 days/week 40 hours but worked well into the late evening on most days. I'm now open 4 days per week but still at 40 hours as I increased my hours per day. I figured I could have Friday to catch up on business and paperwork. I don't see patients on Friday but am still working doing business related issues which tends to trickle deep into the weekend. It's not anywhere close to a 3 day weekend as I would like it to be.

How many hours do you guys work per week? Do most on here work >60 hours per week still? I want to increase efficiency and don't want to work >60 hours/week for the rest of my life. At 40 hours per week, 110-120 pts/week, how many and what type of employees do you think are necessary? If on average, seeing 110-120 pts/week requires 60 hours/week of work for most people, then I'll most likely accept that I just need to see less patients by dropping my lower payers, as mentioned above. If that's average then I'll accept that, but if anyone feels that I should be more inefficient and 110-120 pts/wk should not require 60 hrs/wk of work, please let me know.

We all have admin work which is unfortunately a part of private practice. However, if you are working every friday into the weekend every week on admin that seems with a lot. I do all of the admin for a practice about three times the size of yours and I dont spend 1/4 of the time that you have mentioned and my weekends are untouched. What exactly are you doing on the admin fridays?

 

[mille125]

I was working 5 days/week 40 hours but worked well into the late evening on most days. I'm now open 4 days per week but still at 40 hours as I increased my hours per day. I figured I could have Friday to catch up on business and paperwork. I don't see patients on Friday but am still working doing business related issues which tends to trickle deep into the weekend. It's not anywhere close to a 3 day weekend as I would like it to be.

How many hours do you guys work per week? Do most on here work >60 hours per week still? I want to increase efficiency and don't want to work >60 hours/week for the rest of my life. At 40 hours per week, 110-120 pts/week, how many and what type of employees do you think are necessary? If on average, seeing 110-120 pts/week requires 60 hours/week of work for most people, then I'll most likely accept that I just need to see less patients by dropping my lower payers, as mentioned above. If that's average then I'll accept that, but if anyone feels that I should be more inefficient and 110-120 pts/wk should not require 60 hrs/wk of work, please let me know.

And to answer your question my average work day is 8:30-5:30 including admin. I see average 23 patients per day (sometimes 15, sometimes 30)

 

[emd123]

Look at your contracts and payments and drop your worst payors.

Agree, big time. This is the biggest force we have in the fight for fair reimbursement. Drop the worst payers. Plus it accomplishes your goal of keeping your practice growth under reasonable control. Not all doctors have this luxury. It truly is a luxury to be able to pick and choose what insurances you accept or don't accept.

Plus, if you just expand endlessly to meet "demand" you could find yourself needing to be open 24/7. You have to draw the line somewhere. Make those who don't pay you fair market value go elsewhere.

 

[Ligament]

After opening my solo private practice 2.5 years ago I am in the same boat, but working 5 days per week and seeing around 20 per day. I could see many more if i followed up in person with patients all patients but have needed to make less complicated followups done by phone with my staff to free me up. Not complaining, feel lucky, but it is an interesting issue when your business grows like this...feels like it is getting out of my control...

 

[facets]

Why do you need to grow it further? Is your family being supported on 4 days a week? Really, your kids are only small once, spend time with your family. I disagree with the others on this board, people get by on much less. You don't want to be a success at work and a failure at life. If you all are living on 4 days a week, spend that time with loved ones, they might not be there tomorrow

 

[mille125]

Why do you need to grow it further? Is your family being supported on 4 days a week? Really, your kids are only small once, spend time with your family. I disagree with the others on this board, people get by on much less. You don't want to be a success at work and a failure at life. If you all are living on 4 days a week, spend that time with loved ones, they might not be there tomorrow

So you are saying that he should turn all new patients away or just have unacceptable wait times to get in? I dont know if I agree with that. Your referring providers would stop referring at some point if it takes 4-6-8 weeks to get in new patients or if you stop taking new patients. In my opinion, if you are out hanging a shingle, you are not going to be able to keep a 4 day per week schedule without damaging your business somewhere down the road. You could work for someone else or work in academics and do this but this is the tradeoff for having your practice. This is true of other small successful business. I think the key is maximizing your time. That is why I have said that 1 whole day plus per week is too much for admin in a solo practice.

 

[hyperalgesia]

I would definitely do something different if you are unhappy with the situation. I agree with others, the easiest thing to do would be to stop bending over for the insurance companies.

Are these mostly medication pts or interventional pts? If you are getting dumped on by PCPs, like "I'm here because Dr. Whats-his-name said you'd take over my Dillies", then that's a place to drop the hammer.

 

[PMR2008]

Why would you not consider hiring a PA/NP or even consider expanding your practice by hiring another physician?

 

[Jcm800]

I am impressed you have done this one year outta the gate. Good job!

I was working 5 days/week 40 hours but worked well into the late evening on most days. I'm now open 4 days per week but still at 40 hours as I increased my hours per day. I figured I could have Friday to catch up on business and paperwork. I don't see patients on Friday but am still working doing business related issues which tends to trickle deep into the weekend. It's not anywhere close to a 3 day weekend as I would like it to be.

How many hours do you guys work per week? Do most on here work >60 hours per week still? I want to increase efficiency and don't want to work >60 hours/week for the rest of my life. At 40 hours per week, 110-120 pts/week, how many and what type of employees do you think are necessary? If on average, seeing 110-120 pts/week requires 60 hours/week of work for most people, then I'll most likely accept that I just need to see less patients by dropping my lower payers, as mentioned above. If that's average then I'll accept that, but if anyone feels that I should be more inefficient and 110-120 pts/wk should not require 60 hrs/wk of work, please let me know.

 

[facets]

I have not worked Fridays in over 13 years. Reduce the problem patients, drop the bad payers, the crazy (medicaid) patients and those just on medications. Then you will have time for new patients who really need help, not drugs (medication management and almost all medicaid ) You can do this, I stopped seeing medicaid patients when I realized that they were making me crazier than they are.
My point is that to be healthy you need balance. I don't want him to wake up some day and find that he has a great practice, millions of dollars, but his kids are grown up and gone and his wife divorcing him and taking half the money anyway. I've seen it, they die miserable but rich

So you are saying that he should turn all new patients away or just have unacceptable wait times to get in? I dont know if I agree with that. Your referring providers would stop referring at some point if it takes 4-6-8 weeks to get in new patients or if you stop taking new patients. In my opinion, if you are out hanging a shingle, you are not going to be able to keep a 4 day per week schedule without damaging your business somewhere down the road. You could work for someone else or work in academics and do this but this is the tradeoff for having your practice. This is true of other small successful business. I think the key is maximizing your time. That is why I have said that 1 whole day plus per week is too much for admin in a solo practice.

 

[101N]

I have not worked Fridays in over 13 years. Reduce the problem patients, drop the bad payers, the crazy (medicaid) patients and those just on medications. Then you will have time for new patients who really need help, not drugs (medication management and almost all medicaid ) You can do this, I stopped seeing medicaid patients when I realized that they were making me crazier than they are.
My point is that to be healthy you need balance. I don't want him to wake up some day and find that he has a great practice, millions of dollars, but his kids are grown up and gone and his wife divorcing him and taking half the money anyway. I've seen it, they die miserable but rich

You should be paid for this: "I stopped seeing medicaid patients when I realized that they were making me crazier than they are."

If I can figure out how to make it my signature line I will.

 

[mille125]

I have not worked Fridays in over 13 years. Reduce the problem patients, drop the bad payers, the crazy (medicaid) patients and those just on medications. Then you will have time for new patients who really need help, not drugs (medication management and almost all medicaid ) You can do this, I stopped seeing medicaid patients when I realized that they were making me crazier than they are.
My point is that to be healthy you need balance. I don't want him to wake up some day and find that he has a great practice, millions of dollars, but his kids are grown up and gone and his wife divorcing him and taking half the money anyway. I've seen it, they die miserable but rich

I understand your point. If you have dont work any Fridays and you are in solo practice and you arent an injection only practice and new patients can see you in a reasonable time then you have some magic but more power to you. With that said, I work 45 hours per week average and I have more than enough time to see my kids grow up. I dont think that 60 + hours per week is the normal.

 

[facets]

60 hours is not normal, that was my point, if 45 leaves enough time for your family then thats ok, but if he does not want to work Friday, don't push him if he feels family time is compromised

 

[jsaul]

I've opened my own practice just shy of a year ago and have been lucky to where my practice has grown very fast. I'm currently at about 26-29 patients per day and am scheduling >5 new patients per day on average. It's been a blessing and a curse. I've recently changed my office hours to M-Th from 8-6 to try and accommodate and free up some time but am still finding myself working all of the time. I'm doing a lot paperwork and notes and taking care of business related issues in my "free" time. Don't get me wrong, it's better than the alternative of struggling for patients and I'm very thankful for where I am but it's kind of becoming overwhelming. I of course would like to spend more time with my wife and family and get back to my hobbies. I have one front desk girl, one MA full time, one MA part time, and I outsource my billing.

Has anyone been in this situation? Anyone want to chime in on how to make things more efficient or how to handle the volume? Should I stop accepting new patients? Look to hire more help? Cut back on hours? Heeeelp! 😱

question for you-- who does your pre-auths for your procedures?

 

[Pain Applicant1]

First off, thank you all for the great insight!

What exactly are you doing on the admin fridays?

I think that's the problem, I'm not sure. I think a lot of it is notes and different admin stuff for a new practice. For instance, I've outgrown my current location and am purchasing a commercial building so the loan, blueprints, design, may be taking up a lot of time. I'm also still creating templates and filling out different forms (DEMPOS) which can take time. What I'll do is now keep track of exactly what I'm doing after hours. It's hard to tell because everything just kind of melts into everything else I don't mind putting in the time now, but I don't want to do it forever. I'm glad to hear that most practices don't require 60 hours/week of work and I'm sure things will smooth out as I gain more experience.

Why do you need to grow it further? Is your family being supported on 4 days a week? Really, your kids are only small once, spend time with your family. I disagree with the others on this board, people get by on much less. You don't want to be a success at work and a failure at life. If you all are living on 4 days a week, spend that time with loved ones, they might not be there tomorrow

This is an excellent point. I feel that I am doing very well financially but if I can't make myself more efficient then it's definitely not worth it. I would take take time over income if possible.

Why would you not consider hiring a PA/NP or even consider expanding your practice by hiring another physician?

I've thought about this also. I'm just not convinced that this would save much time. It's one more person to manage and the pt population would likely build itself up again.

I am impressed you have done this one year outta the gate. Good job!

Thank you!

Are these mostly medication pts or interventional pts? If you are getting dumped on by PCPs, like "I'm here because Dr. Whats-his-name said you'd take over my Dillies", then that's a place to drop the hammer.

It's a mix but no dumps anymore. Those patients don't come back to me. The PCPs and I work together and they're on my side when I taper the patients. I meet with them periodically for lunch and discuss our program. I do mostly non-opioid or low dose opioid and procedures.

question for you-- who does your pre-auths for your procedures?

I've trained my front desk girl to do my pre auths. She does the job of about 3 people.

 

[PMR 4 MSK]

I'd be very careful about expanding too quickly. As things get busier, it often feels like that velocity will continue. The natural order of things is cyclical. You might find things slowing down in 6 month. As payment for services go down, as they do every year, you might not feel the same this time next year as you do now.

With the ACA coming into play, I'd be especially careful about expansion.

I'd concentrate on weeding out the worst payors, especially Medicaid.

Make sure you staff is efficient. Let under-performers, if any, go. Keep only the best.

Consider hiring someone to take notes for you to save time, or have someone obtain the history before you see the patient. we do the latter and it saves a lot of time.

Even consider contracting with a practice evaluator to see if there are things you could be doing better, see where you might be losing money.

 

[specepic]

I'd be very careful about expanding too quickly. As things get busier, it often feels like that velocity will continue. The natural order of things is cyclical. You might find things slowing down in 6 month. As payment for services go down, as they do every year, you might not feel the same this time next year as you do now.

With the ACA coming into play, I'd be especially careful about expansion.

I'd concentrate on weeding out the worst payors, especially Medicaid.

Make sure you staff is efficient. Let under-performers, if any, go. Keep only the best.

Consider hiring someone to take notes for you to save time, or have someone obtain the history before you see the patient. we do the latter and it saves a lot of time.

Even consider contracting with a practice evaluator to see if there are things you could be doing better, see where you might be losing money.

++1 excellent advice. the focus of uncle sam will be on getting us to do less. being lean and mean makes sense

 

[SSdoc33]

if you are too busy, try to cut down on your follow-ups. dont eliminate them, but get em in, get em what they need, and get em out. you dont want to choke off your practice by seeing too many f/u over and over again. new patietns are he lifeblood of a growing practice.

 

[ghost dog]

I'd be very careful about expanding too quickly. As things get busier, it often feels like that velocity will continue. The natural order of things is cyclical. You might find things slowing down in 6 month. As payment for services go down, as they do every year, you might not feel the same this time next year as you do now.

With the ACA coming into play, I'd be especially careful about expansion.

I'd concentrate on weeding out the worst payors, especially Medicaid.

Make sure you staff is efficient. Let under-performers, if any, go. Keep only the best.

Consider hiring someone to take notes for you to save time, or have someone obtain the history before you see the patient. we do the latter and it saves a lot of time.

Even consider contracting with a practice evaluator to see if there are things you could be doing better, see where you might be losing money.

I was just about to post something along the lines of taking on an associate to increase your bottom line, but from the many American posts I read here seems to reflect the fact that interventional medicine is under attack.

My neck of the woods is under similiar attack - pretty much all the procedures I do just got a nice healthy slashing of around - 38 %.

 

[Ducttape]

if you are too busy, try to cut down on your follow-ups. dont eliminate them, but get em in, get em what they need, and get em out. you dont want to choke off your practice by seeing too many f/u over and over again. new patietns are he lifeblood of a growing practice.

i took over a practice where this was the case. way too many follow ups, not enough new patients, averaging 3 follow up days and 2 procedure days a week.

it has taken a long time to dig the clinic out of the hole to where it is profitable. that included cutting some patients off (i.e. WC patients who are at MMI/not interested in any procedures, those interested in nothing), and (in my case, mind you) hiring more staff and a midlevel to improve flow and efficiency.

f/u dont pay enough - you need new pt. and, unfortunately, you need a fair proportion of procedures are necessary to stay afloat. maybe that does give pain medicine a bad name, but that is what we uniquely provide and get paid for. as long as the procedure is medically necessary...

 

[Tenesma]

i too felt overwhelmed when i hit the milestone of 17 patients/day --- working 12 hours a day... then I re-balanced my practice, improved efficiencies, started delegating small/unimportant tasts... and I was able to increase to 25 patients/day... re-balance, improved efficiencies... now seeing 40pts/day... i am not going to increase beyond that.

Not because I can't see more than that per day... but rather because 40pts/day generate just sooo much extra work (phone calls, imaging reports, issues) that it is just too painful...

1) you are at 25pts/day by year 1 mark - that is GREAT -
2) work smarter, not harder - analyze the tasks that are simple that can be handed off (ie: do you really need to read every PT report and sign it? not really ... I have my staff read it, any patient who is struggling in PT report gets automatically sched for f/u and the ones that are doing same or better get a stamp of my signature... that change literally saved me about 20 mins per day)... etc.
3) look at your staff, how efficicient/productive are they? what can you do improve efficiency? I remember in my first year, that for one task, my staff would print something out, then scan it, then insert it into the EHR - and I taught them how to just save a file as a PDF and download right into EHR... that saves them time, and allows them do more for you.
4) analyze your contracts... start going out of network with the worst payers, or if you can't do that - start spacing out the worst payers as much as possible....
5) good luck

 

[Pain Applicant1]

Thanks again for the insight! One thing that I've been doing that is freeing up some time is making sure every note is finished and signed prior seeing the next patient regardless of whether or not I'm running late. I'm also documenting exactly what I'm doing so as to figure out what the problem is.

now seeing 40pts/day... i am not going to increase beyond that.

Not because I can't see more than that per day... but rather because 40pts/day generate just sooo much extra work (phone calls, imaging reports, issues) that it is just too painful...

How do you see 40 pts/day??? That's amazing. How many hours per day are you working? 2 questions:
1. What state are you in?
2. Do you let other docs shadow you to learn from you?

 

[bedrock]

Thanks again for the insight! One thing that I've been doing that is freeing up some time is making sure every note is finished and signed prior seeing the next patient regardless of whether or not I'm running late. I'm also documenting exactly what I'm doing so as to figure out what the problem is.



How do you see 40 pts/day??? That's amazing. How many hours per day are you working? 2 questions:
1. What state are you in?
2. Do you let other docs shadow you to learn from you?

Seriously. How do you see 40pts a day and still pick up all the weird diagnoses you tell us about?

40pts in how many hours start to finish including all charting?

 

[powermd]

Seriously. How do you see 40pts a day and still pick up all the weird diagnoses you tell us about?

Ha ha.. the "gluteal artery aneurysm" in the ddx of buttock pain comes to mind! Still haven't forgotten that one.

 

[emd123]

i too felt overwhelmed when i hit the milestone of 17 patients/day --- working 12 hours a day... then I re-balanced my practice, improved efficiencies, started delegating small/unimportant tasts... and I was able to increase to 25 patients/day... re-balance, improved efficiencies... now seeing 40pts/day... i am not going to increase beyond that.

Not because I can't see more than that per day... but rather because 40pts/day generate just sooo much extra work (phone calls, imaging reports, issues) that it is just too painful...

1) you are at 25pts/day by year 1 mark - that is GREAT -
2) work smarter, not harder - analyze the tasks that are simple that can be handed off (ie: do you really need to read every PT report and sign it? not really ... I have my staff read it, any patient who is struggling in PT report gets automatically sched for f/u and the ones that are doing same or better get a stamp of my signature... that change literally saved me about 20 mins per day)... etc.
3) look at your staff, how efficicient/productive are they? what can you do improve efficiency? I remember in my first year, that for one task, my staff would print something out, then scan it, then insert it into the EHR - and I taught them how to just save a file as a PDF and download right into EHR... that saves them time, and allows them do more for you.
4) analyze your contracts... start going out of network with the worst payers, or if you can't do that - start spacing out the worst payers as much as possible....
5) good luck

That's flyin'. 40 patients in 8 hrs? 10? 12?

 

[Tenesma]

1) 40 pts in 7 hours 8-12am and 1-4pm (this includes procedures 8-10 procedures). - so really 30-32 pts in 5 hours... of which 4-6 are new and 25 are f/u...
2) I do catch some cool diagnoses - not because of being smarter, but rather because of persistence (ie: patient with buttock pain with underwhelming lumbar/pelvic imaging, poor response to a variety of modalities including diagnostic blocks, and weird symptom descriptions - will get more testing)
3) I am constantly optimizing my efficiencies within my practice - looking at where patients waste time, where I waste time and where staff waste time...

Visit:
1) For new patients - between procedures in the AM I review all of the uploaded/scanned documents on each new patient I am seeing (incl. referral notes, imaging reports, background check, prescription monitoring, med lists, etc)... so that data is already stored in my head.
2) the patient's charts, imaging, etc is already all pulled up for me to peruse as soon as I walk into the room
3) the patient's Allergies/Med list - ROS changes etc - is already reviewed/loaded into the EHR by the MA (as are vitals)
4) I flesh out the history (because the history is usually already laid out in the note from the intake w/ the MA), do an exam, review the imaging in depth (if indicated) with each patient on a wide-screen, and make a plan... I have a sheet w/ instructions that I check off for MA (ie: Referral to spine surgeon, Referral to PT w/ dx, record requests, f/u time) - shake hands, and ask "do you have any other concerns related to this issue?" - then walk out - the MA comes in, follows my instructions, makes appropriate scheduling.

But there is so much more attention to detail - ie: MA makes sure each morning that everything is set up so that I don't have to go looking for pins, hammers, ballpoint pens, gloves, etc...

I also have a system that tracks my more complex/difficult (usually due to psych issues) patients and thus those patients are given 2 slots as opposed to one slot.

What happens is that as you see more patients, you become more succinct, you laser in on the problem, you are running algorithms of treatment in your head, and you actually do become more efficient... in fact, all of my patients plans have back-up plans - so that when I see them in follow-up, I know what to do as my next step without having to re-invent the wheel each time (ie: Patient scheduled for PT, but if poor response, will proceed with a left L4 TFESI - or - If poor response to gabapentin, would consider tricyclics for the neuropathic component, etc...)

we track patient satisfaction - including "Did the doctor spend enough time with you" "Did you get all of your questions answered" - and for those who do respond to surveys, there haven't been any complaints (as of yet)

 

[Ducttape]

so 10 minute appointments, including procedures, to get to 40 patients a day...

good for you, tho i might wonder if the most common answer to "did the doctor spend enough time with you" would be "did the doctor actually see me?"

 

[hyperalgesia]

I think an MA or PA or ARNP can be a great way for the pt to say all the inane things they want to get off their chest and get the important things documented.

After talking their head off to the MA, 10 minutes with a doc can feel like 30 minutes to them... I need one of these...

 

[Jcm800]

I think an MA or PA or ARNP can be a great way for the pt to say all the inane things they want to get off their chest and get the important things documented.

After talking their head off to the MA, 10 minutes with a doc can feel like 30 minutes to them... I need one of these...

MA are a dime dozen, they make like 12-14 bucks an. Hour.... Getting good ones can be more difficult.

 

[neuropathic]

1) 40 pts in 7 hours 8-12am and 1-4pm (this includes procedures 8-10 procedures). - so really 30-32 pts in 5 hours... of which 4-6 are new and 25 are f/u...
we track patient satisfaction - including "Did the doctor spend enough time with you" "Did you get all of your questions answered" - and for those who do respond to surveys, there haven't been any complaints (as of yet)

I found this quite hard to achieve. 10 procedures in 2 hours? What kind of procedures? It's even hard to do 10 interlaminar epidurals, the quickest spine procedure in 2 hours (12 minutes per epidural). 4-6 new patients, even if you are very brief and fast, take a brief history, examine the patient, explain your diagnoses and plan, review records, finish your note, easily 30 min. Let's assume you are superman and you can do it it 20min.That leaves 3 hours to see 25 follow-ups, or 7 minutes per patient. And you can only do all of the above when all 40 pts are on time. What a job and no one complains about you not spending enough time?

 

[Jcm800]

I found this quite hard to achieve. 10 procedures in 2 hours? What kind of procedures? It's even hard to do 10 interlaminar epidurals, the quickest spine procedure in 2 hours (12 minutes per epidural). 4-6 new patients, even if you are very brief and fast, take a brief history, examine the patient, explain your diagnoses and plan, review records, finish your note, easily 30 min. Let's assume you are superman and you can do it it 20min.That leaves 3 hours to see 25 follow-ups, or 7 minutes per patient. And you can only do all of the above when all 40 pts are on time. What a job and no one complains about you not spending enough time?

Does that 40 include the NP seeing patients?

I don't know, I know of an ortho that 70 patients in a clinic day. But everyone says he rushes you and they never get ask a question, and a lot are post ops, which are quick.

30 is my max, I just can't bring myself to do more notes in one day than that. 25 feels good

 

[101N]

Does that 40 include the NP seeing patients?

I don't know, I know of an ortho that 70 patients in a clinic day. But everyone says he rushes you and they never get ask a question, and a lot are post ops, which are quick.

30 is my max, I just can't bring myself to do more notes in one day than that. 25 feels good

1+

This is a block shop being described. I would not send my momma there.

 

[mille125]

Does that 40 include the NP seeing patients?

I don't know, I know of an ortho that 70 patients in a clinic day. But everyone says he rushes you and they never get ask a question, and a lot are post ops, which are quick.

30 is my max, I just can't bring myself to do more notes in one day than that. 25 feels good

I think that NP's/PA's are involved...I see 25-30 by myself and that is plenty. I will pass on the 40. I do not want a PA/NP at this point.

 

[mille125]

1) 40 pts in 7 hours 8-12am and 1-4pm (this includes procedures 8-10 procedures). - so really 30-32 pts in 5 hours... of which 4-6 are new and 25 are f/u...
2) I do catch some cool diagnoses - not because of being smarter, but rather because of persistence (ie: patient with buttock pain with underwhelming lumbar/pelvic imaging, poor response to a variety of modalities including diagnostic blocks, and weird symptom descriptions - will get more testing)
3) I am constantly optimizing my efficiencies within my practice - looking at where patients waste time, where I waste time and where staff waste time...

Visit:
1) For new patients - between procedures in the AM I review all of the uploaded/scanned documents on each new patient I am seeing (incl. referral notes, imaging reports, background check, prescription monitoring, med lists, etc)... so that data is already stored in my head.
2) the patient's charts, imaging, etc is already all pulled up for me to peruse as soon as I walk into the room
3) the patient's Allergies/Med list - ROS changes etc - is already reviewed/loaded into the EHR by the MA (as are vitals)
4) I flesh out the history (because the history is usually already laid out in the note from the intake w/ the MA), do an exam, review the imaging in depth (if indicated) with each patient on a wide-screen, and make a plan... I have a sheet w/ instructions that I check off for MA (ie: Referral to spine surgeon, Referral to PT w/ dx, record requests, f/u time) - shake hands, and ask "do you have any other concerns related to this issue?" - then walk out - the MA comes in, follows my instructions, makes appropriate scheduling.

But there is so much more attention to detail - ie: MA makes sure each morning that everything is set up so that I don't have to go looking for pins, hammers, ballpoint pens, gloves, etc...

I also have a system that tracks my more complex/difficult (usually due to psych issues) patients and thus those patients are given 2 slots as opposed to one slot.

What happens is that as you see more patients, you become more succinct, you laser in on the problem, you are running algorithms of treatment in your head, and you actually do become more efficient... in fact, all of my patients plans have back-up plans - so that when I see them in follow-up, I know what to do as my next step without having to re-invent the wheel each time (ie: Patient scheduled for PT, but if poor response, will proceed with a left L4 TFESI - or - If poor response to gabapentin, would consider tricyclics for the neuropathic component, etc...)

we track patient satisfaction - including "Did the doctor spend enough time with you" "Did you get all of your questions answered" - and for those who do respond to surveys, there haven't been any complaints (as of yet)

If you can do all of this and your patients feel that you spend time with them more power to you. What do you do if someone gets into an argument with you about not writing opioids (which you dont do). If you get two or three of those, it could blow your whole system....

 

[Pain Applicant1]

I think that NP's/PA's are involved...I see 25-30 by myself and that is plenty. I will pass on the 40. I do not want a PA/NP at this point.

Why no NP/PA? What's the reasoning?

 

[mille125]

Why no NP/PA? What's the reasoning?

If I am going to go down, I want it to be from something that I do. I do not like "supervising" mid levels. Patients dont like seeing them and I dont like trying to follow something that they did especially concerning opioids.

No disrespect intended but they dont work in my practice.

 

[Pain Applicant1]

If I am going to go down, I want it to be from something that I do. I do not like "supervising" mid levels. Patients dont like seeing them and I dont like trying to follow something that they did especially concerning opioids.

No disrespect intended but they dont work in my practice.

Interesting point.

 

[Ducttape]

If I am going to go down, I want it to be from something that I do. I do not like "supervising" mid levels. Patients dont like seeing them and I dont like trying to follow something that they did especially concerning opioids.

No disrespect intended but they dont work in my practice.

to each his/her own, but do you let your nurses talk to your patients? my point is, working with a nurse practitioner does not mean that the nurse practitioner dictates care of your patients. the NP/PA is an extension of you and your practice patterns. My NP never makes changes to opioids. I do.

the advantages - it allows me to make the clinic near profitable, and i doubt very few have a profitable clinic that is over 60% care/caid...

 

[101N]

the advantages - it allows me to make the clinic near profitable, and i doubt very few have a profitable clinic that is over 60% care/caid...

Your environment, and perspective, is different than a lot of the guys here. But, it sounds like your adapting to it. That's a good thing.

Going forward, your way may be the way that most clinics are run.

 

[PMR 4 MSK]

to each his/her own, but do you let your nurses talk to your patients? my point is, working with a nurse practitioner does not mean that the nurse practitioner dictates care of your patients. the NP/PA is an extension of you and your practice patterns. My NP never makes changes to opioids. I do.

the advantages - it allows me to make the clinic near profitable, and i doubt very few have a profitable clinic that is over 60% care/caid...

And in a couple years, your NP will have learned enough from you on the job to strike out on her own and be your competitor, and state laws will allow it. No supervision, no fellowship, not even a residency. Just on the job training and vicarious learning.

 

[Ducttape]

And in a couple years, your NP will have learned enough from you on the job to strike out on her own and be your competitor, and state laws will allow it. No supervision, no fellowship, not even a residency. Just on the job training and vicarious learning.

except, at the present time, some of the insurance companies, at this juncture, do not allow non-ABMS certified providers to perform interventional procedures. and the state i am in is fairly strict with the supervisory requirements of NPs. in fact, the state i am in is one of the most regulated and controlled states in the US.

if she were to strike out on her own, and do medication management, so be it. save the procedures to me 😛

 

[Tenesma]

1) Not a block shop - 8-10 procedures per day and 30 f/u/NPs per day would show that my % of procedures to office visits is actually on the low end...
2) I don't do E/M at same time as procedure - procedures are procedures, no reviewing charts, no re-examing patients... i have an efficient procedure suite... i mean, really --- how long does it take to do an SI joint? (20 seconds?) and ESI 3-4 minutes???
3) Some of my visits are 20-30 minutes (my more complicated NP and f/u) - but a lot of visits don't need to be that long
4) Because I don't rx narcs - I don't need to spend time playing the negotiating games - I just say :"Narcotics are not indicated, but here are the options I can offer you..." if they try to negotiate, then i say "I am sorry that I can't meet your perceived needs here, I'd be glad to refer you to another pain doc to get a 2nd opinion".
5) it is all about efficiency --- think about sitting down with a follow-up patient - how much time does it really take to 1) chit-chat about their grandchildren 2) examine them while chit-chatting 3) look at your plan from 2 months ago and tell them what the next step is...
6) the way i stop myself from rushing is that I do ask them if they have any further questions... when they say no, then I know that my job is done and that i can move onto the next patient.

 

[neuropathic]

1) Not a block shop - 8-10 procedures per day and 30 f/u/NPs per day would show that my % of procedures to office visits is actually on the low end...
2) I don't do E/M at same time as procedure - procedures are procedures, no reviewing charts, no re-examing patients... i have an efficient procedure suite... i mean, really --- how long does it take to do an SI joint? (20 seconds?) and ESI 3-4 minutes???

It is a waste if you don't teach others how to be as "efficient" as you. You can locate the SI joint using fluoro, get your local, inject, position the needle intraarticular, +/- contrast, inject steroids, all in 20 seconds. Seriously, I would be scared or ask anyone to come to you.

 

[ultm8frisbee]

It is a waste if you don't teach others how to be as "efficient" as you. You can locate the SI joint using fluoro, get your local, inject, position the needle intraarticular, +/- contrast, inject steroids, all in 20 seconds. Seriously, I would be scared or ask anyone to come to you.

Dude, If it takes you longer than 20 seconds to perform an SI, I would be scared to send someone to YOU.

 

[Jcm800]

Dude, If it takes you longer than 20 seconds to perform an SI, I would be scared to send someone to YOU.

it takes me a lot longer. Maybe 3-4 minutes. I put the local in, put the needle where it goes, if i dont get an arthrogram right away, which is common, i reposition, and then i inject the steroid at a reasonable pace. This takes me longer than 20 seconds. Please do not send me any patients, as i must be awful.

 

[101N]

1) Not a block shop - 8-10 procedures per day and 30 f/u/NPs per day would show that my % of procedures to office visits is actually on the low end...
2) I don't do E/M at same time as procedure - procedures are procedures, no reviewing charts, no re-examing patients... i have an efficient procedure suite... i mean, really --- how long does it take to do an SI joint? (20 seconds?) and ESI 3-4 minutes???
3) Some of my visits are 20-30 minutes (my more complicated NP and f/u) - but a lot of visits don't need to be that long
4) Because I don't rx narcs - I don't need to spend time playing the negotiating games - I just say :"Narcotics are not indicated, but here are the options I can offer you..." if they try to negotiate, then i say "I am sorry that I can't meet your perceived needs here, I'd be glad to refer you to another pain doc to get a 2nd opinion".
5) it is all about efficiency --- think about sitting down with a follow-up patient - how much time does it really take to 1) chit-chat about their grandchildren 2) examine them while chit-chatting 3) look at your plan from 2 months ago and tell them what the next step is...
6) the way i stop myself from rushing is that I do ask them if they have any further questions... when they say no, then I know that my job is done and that i can move onto the next patient.

"You can put lipstick on a sow and call her Monique. But, she's still just a pig."