IM and midlevels?

[deleted1158258]

How is IM from a mid- level standpoint? Do you feel the field will be saturated or will it be harder to find jobs due to NPs flooding the job market?

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[PikminOC]

Lots of midlevels in every field. Including primary care and specialties.

 

[NewYorkDoctors]

You should probably subspecialize in something from IM. Even if you did palliative/geriatrics and mainly did GIM or hospitalist medicine, you will have something to distinguish you from the pack. Sad but it is what it is. Hospital systems want to hire fewer physicians and more midlevels because it is more "cost effective." I am not sure this accounts for long term cost savings but... that's not a discussion for now.

 

[Sushirolls]

Or you open your own Primary Care practice, and clearly advertise you are a physician and patients who know the difference will seek you out and pay you for your services. I've wanted to change from Big Box shop IM as my PCP, to a direct primary care, but all the ones in my area have PA or ARNPs working with them. I'm not going to pay premium cash for midlevel.

These practices in middle of nowhere, and those in my former larger metro, weren't hurting for patients and even expanding.

Being a subspecialist isn't a requirement.

 

[deleted1158258]

You should probably subspecialize in something from IM. Even if you did palliative/geriatrics and mainly did GIM or hospitalist medicine, you will have something to distinguish you from the pack. Sad but it is what it is. Hospital systems want to hire fewer physicians and more midlevels because it is more "cost effective." I am not sure this accounts for long term cost savings but... that's not a discussion for now.

Do you think hospitalist gigs will just be taken over by midlevels?

 

[NewYorkDoctors]

I don’t know enough the nuances to give any answer besides speculation . All I can say is I know certain hospital systems in nyc are hiring more NPs than MDs for internal medicine . The former can admit super easy patients while the latter gets the disaster train wrecks . Cheaper to get two of the former . After all why give the MDDO hospitalist the easy admits ? Make them earn the revenue, milk their hard work for the admins, and then dole out some RVUs. I would like the BBQ flavor RVU please.

 

[cards67]

There will always be a need for good generalists. Patients want to be seen by doctors and specialists want their referrals to come from doctors.

 

[DrMetal]

There will always be a need for good generalists. Patients want to be seen by doctors and specialists want their referrals to come from doctors.

Not true. The next generation of patients want faster service. If it's for something simple, they'd rather see a mid-level today than wait 2 weeks to see an MD. It's becoming the way of the world . . .

 

[bronx43]

Not true. The next generation of patients want faster service. If it's for something simple, they'd rather see a mid-level today than wait 2 weeks to see an MD. It's becoming the way of the world . . .

huh? If one has to wait 2 weeks to see a doc, then it means there’s always a role for a good generalist. The fact that you can see a midlevel today means no one wants to see them.

 

[NewYorkDoctors]

The corporations want to snatch up all the "easy" patients to feed to the midlevels.

Think:
- healthy patients who need quick labs for pre-employment, pre-school, etc... draw blood for MMRV, HBV, Quantiferon Gold... update vaccinations touch base about screening - a quick 99395-99396 or 99213 done pronto.
- young patients with high deductible insurance but get that "free" 99395 once a year to do not much about
- URIs , cellulitis, UTIs, pharyngitis, sinusitis - quick visits- swab something - give empiric antibiotics
- i'm stable refill my meds and let me move on
- flu shots

they want to give the "good generalists" the
- medicare population chronic (every organ) disease with 20+ meds, chronic (name every joint you can) pain patients, chronic (insert psychiatric condition) patients who sees multiple specialists (questionable how much coordination is going on between PMD and the specialists). things fall through the cracks easily and patients end up in the hospital easily.

it is easier and faster to have NPs crank out 4 99213s than a 'good generalist' struggle with a 99215 level of complexity.


addendum: honestly a good generalist is a physician who does the fundamentals well (i.e. something like get all the appropriate cultures before starting antibiotics or calling ID.. you'd be surprised... or actually showing a patient how to use an inhaler before saying it didnt work and referring to pulm... or getting pre IV fluid urine electrolytes before calling renal... or getting all three trops WITH three 12 lead EKGs before calling cardiology) and someone who can hear out the patient and talk the patient off a ledge so to speak. it is unfair to expect a generalist to solve the world's problems. but basically fixing the easy things (that NPs are taking) and making sure all the Is are dotted and Ts are crossed before sending off to specialist)

 

[DrMetal]

The fact that you can see a midlevel today means no one wants to see them.

No, it means that there's a million of them (mid-levels), so they provide better access to care (not necessarily better quality of care, just more access). And as we move on, no one seems to care about quality any more, just quantity.

The corporations want to snatch up all the "easy" patients to feed to the midlevels.

Think:
- healthy patients who need quick labs for pre-employment, pre-school, etc... draw blood for MMRV, HBV, Quantiferon Gold... update vaccinations touch base about screening - a quick 99395-99396 or 99213 done pronto.
- young patients with high deductible insurance but get that "free" 99395 once a year to do not much about
- URIs , cellulitis, UTIs, pharyngitis, sinusitis - quick visits- swab something - give empiric antibiotics
- i'm stable refill my meds and let me move on
- flu shots

they want to give the "good generalists" the
- medicare population chronic (every organ) disease with 20+ meds, chronic (name every joint you can) pain patients, chronic (insert psychiatric condition) patients who sees multiple specialists (questionable how much coordination is going on between PMD and the specialists). things fall through the cracks easily and patients end up in the hospital easily.

it is easier and faster to have NPs crank out 4 99213s than a 'good generalist' struggle with a 99215 level of complexity.

Yep, pretty much.

We physicians did this to ourselves. We're so busy in our own little worlds, doing the umpteenth fellowship, maintaining our 6 board certifications, back-stabbing each other by creating administrative burdens and monstrosities (MOC, thank you ABIM, ABMS, etc) . . . it's no wonder we couldn't see the freight train coming.

And the Lakers are getting creamed . . . not a good night.

 

[bronx43]

No, it means that there's a million of them (mid-levels), so they provide better access to care (not necessarily better quality of care, just more access). And as we move on, no one seems to care about quality any more, just quantity.

Not really. How many mid levels are there in this country doing primary care? How many doctors are there? With the way nursing is paying, I suspect less and less nurses will go NP route.

Either way, it’s irrelevant. The original point is that there’s always a role for a generalist. And your statement that it takes 2 weeks to see one confirms this fact regardless of how many midlevels there are.

Furthermore, 80% of healthcare dollars are spent on the sickest 20%. Essentially it’s the chronically ill patients cared for by the docs that generate the majority of revenue for hospitals by getting every test and procedure done by every conceivable specialty.

 

[NewYorkDoctors]

No, it means that there's a million of them (mid-levels), so they provide better access to care (not necessarily better quality of care, just more access). And as we move on, no one seems to care about quality any more, just quantity.



Yep, pretty much.

We physicians did this to ourselves. We're so busy in our own little worlds, doing the umpteenth fellowship, maintaining our 6 board certifications, back-stabbing each other by creating administrative burdens and monstrosities (MOC, thank you ABIM, ABMS, etc) . . . it's no wonder we couldn't see the freight train coming.

And the Lakers are getting creamed . . . not a good night.

we cannot hope for the system to save doctors unfortunately. my solution was go fully independent and leverage technology to help care for my patients.


meh traditional Lebron James feel out game. see what the bench players on Denver can do then take that away in the subsequent games.
plus you can tell the altitude is affecting them with their lackluster transition defense

i dunno if anyone at sea level has been to Denver but I was hypoxemic 90-91% the whole time while there on my pulse oximeter! it was a good $600 one also (that I use in my office now). hopefully these world class athletes will adapt in a few games. during time outs I see a world class athlete like lebron (who might on the funny stuff...?) is huffing and puffing at seemingly high VE. slowing the game down with isolation post ups to give his teammates a breather... yet they still have trouble getting back on transition D.

itll go 7 I bet.

 

[DrMetal]

we cannot hope for the system to save doctors unfortunately. my solution was go fully independent and leverage technology to help care for my patients.


meh traditional Lebron James feel out game. see what the bench players on Denver can do then take that away in the subsequent games.
plus you can tell the altitude is affecting them with their lackluster transition defense

i dunno if anyone at sea level has been to Denver but I was hypoxemic 90-91% the whole time while there on my pulse oximeter! it was a good $600 one also (that I use in my office now). hopefully these world class athletes will adapt in a few games.

itll go 7 I bet.

Don't they get to Denver a few days beforehand to acclimate? 7 games, really? I'd love to see it. Not sure if that'll help or hurt the Lakers. I think either (or both) Lebron and AD are secretly playing hurt.

 

[DrMetal]

The original point is that there’s always a role for a generalist. And your statement that it takes 2 weeks to see one confirms this fact regardless of how many midlevels there are.

I use this logic on my wife: that she has to wait 2 weeks to have a dinner date with me (when I'm off service), shows how important, hard-working, and special I am. She then tells me to GF myself, and indeed, that's what happens.

 

[bronx43]

I use this logic on my wife: that she has to wait 2 weeks to have a dinner date with me (when I'm off service), shows how important, hard-working, and special I am. She then tells me to GF myself, and indeed, that's what happens.

Well it does beat the alternative of never being on service (bringing home the bacon).

 

[MD46]

The corporations want to snatch up all the "easy" patients to feed to the midlevels.

Think:
- healthy patients who need quick labs for pre-employment, pre-school, etc... draw blood for MMRV, HBV, Quantiferon Gold... update vaccinations touch base about screening - a quick 99395-99396 or 99213 done pronto.
- young patients with high deductible insurance but get that "free" 99395 once a year to do not much about
- URIs , cellulitis, UTIs, pharyngitis, sinusitis - quick visits- swab something - give empiric antibiotics
- i'm stable refill my meds and let me move on
- flu shots

they want to give the "good generalists" the
- medicare population chronic (every organ) disease with 20+ meds, chronic (name every joint you can) pain patients, chronic (insert psychiatric condition) patients who sees multiple specialists (questionable how much coordination is going on between PMD and the specialists). things fall through the cracks easily and patients end up in the hospital easily.

it is easier and faster to have NPs crank out 4 99213s than a 'good generalist' struggle with a 99215 level of complexity.


addendum: honestly a good generalist is a physician who does the fundamentals well (i.e. something like get all the appropriate cultures before starting antibiotics or calling ID.. you'd be surprised... or actually showing a patient how to use an inhaler before saying it didnt work and referring to pulm... or getting pre IV fluid urine electrolytes before calling renal... or getting all three trops WITH three 12 lead EKGs before calling cardiology) and someone who can hear out the patient and talk the patient off a ledge so to speak. it is unfair to expect a generalist to solve the world's problems. but basically fixing the easy things (that NPs are taking) and making sure all the Is are dotted and Ts are crossed before sending off to specialist)

Heme Onc here, our hospital wanted the NPs to see the “easy” pregnant iron deficiency patient requiring IV iron, independently so they directly bill for the hospital

However s*** hit the fan in a few months when they started missing things. One missed IgA deficiency even though was apparent on testing and patient had history. Didnt know when called to give blood post C section to give washed RBCs.
Another one gave ferrlecit due to insurance preferred drug but its not supposed to be given in pregnancy etc etc

Hence after a few issues they were still told to see the patients upfront by admin as new consult and arrange followups with MDs??? We were like wth, I refused to see those patients as I wasnt involved in initial decision making, hence not taking liability.

This is among other things they miss routinely. Need to reminded of for example they without discussing with MD cant hold or approve chemo if parameters are off, etc etc.

I have had better luck with NPs when they work within RN capacity as apposed to NP. Dont even get me started on the BS consults from primary care NPs

Normal every thing, mchc is borderline high?

One instance of elevated wbc only neutrophils at 12k , obese and smoker

Family history of clots , age 40, never had clots. Worried may get clots, see hematology

Patient having unintentional weight loss, rule out malignancy

…………

 

[PikminOC]

Heme Onc here, our hospital wanted the NPs to see the “easy” pregnant iron deficiency patient requiring IV iron, independently so they directly bill for the hospital

However s*** hit the fan in a few months when they started missing things. One missed IgA deficiency even though was apparent on testing and patient had history. Didnt know when called to give blood post C section to give washed RBCs.
Another one gave ferrlecit due to insurance preferred drug but its not supposed to be given in pregnancy etc etc

Hence after a few issues they were still told to see the patients upfront by admin as new consult and arrange followups with MDs??? We were like wth, I refused to see those patients as I wasnt involved in initial decision making, hence not taking liability.

This is among other things they miss routinely. Need to reminded of for example they without discussing with MD cant hold or approve chemo if parameters are off, etc etc.

I have had better luck with NPs when they work within RN capacity as apposed to NP. Dont even get me started on the BS consults from primary care NPs

Normal every thing, mchc is borderline high?

One instance of elevated wbc only neutrophils at 12k , obese and smoker

Family history of clots , age 40, never had clots. Worried may get clots, see hematology

Patient having unintentional weight loss, rule out malignancy

…………

Yes I haven't seen that the patients are stratified based on complexity. I see that midlevels get very complex patients too

 

[dozitgetchahi]

Heme Onc here, our hospital wanted the NPs to see the “easy” pregnant iron deficiency patient requiring IV iron, independently so they directly bill for the hospital

However s*** hit the fan in a few months when they started missing things. One missed IgA deficiency even though was apparent on testing and patient had history. Didnt know when called to give blood post C section to give washed RBCs.
Another one gave ferrlecit due to insurance preferred drug but its not supposed to be given in pregnancy etc etc

Hence after a few issues they were still told to see the patients upfront by admin as new consult and arrange followups with MDs??? We were like wth, I refused to see those patients as I wasnt involved in initial decision making, hence not taking liability.

This is among other things they miss routinely. Need to reminded of for example they without discussing with MD cant hold or approve chemo if parameters are off, etc etc.

I have had better luck with NPs when they work within RN capacity as apposed to NP. Dont even get me started on the BS consults from primary care NPs

Normal every thing, mchc is borderline high?

One instance of elevated wbc only neutrophils at 12k , obese and smoker

Family history of clots , age 40, never had clots. Worried may get clots, see hematology

Patient having unintentional weight loss, rule out malignancy

…………

Completely agree.

Even “easy” medicine often times isn’t actually easy, and midlevels frankly suck even at the basics.

I’m a rheumatologist. You wouldn’t believe how many silly consults I get from midlevels on ANAs that never should have been ordered, etc etc, never mind them managing the “basics” - take, for example, the 75 y/o lady who somehow has never had a DEXA scan in her life despite having had multiple fragility fractures, all the patients sent to me who somehow are never up to date on vaccines, etc. If this is what NPs are supposed to “be good at”, then what the hell.

(Although to be perfectly fair, across my last two jobs the PCP MD/DOs have generally sucked almost as much as the midlevels. There are a few bright lights who seem to give a crap about their patients and doing a good job, but a lot who don’t. I completely agree with the comments above about how nobody seems to care about quality anymore in medicine, and it’s all about quantity. I always used to wonder how anyone felt NP care could be equivalent to doctor care…after seeing what the docs have been doing in rural America, I totally “get it”. It’s sad. We need to do a lot better as a profession.)

 

[deleted1158258]

So do you guys recommend Internal medicine? Or do you suspect the situation is bleak and to stay away from it?

 

[NewYorkDoctors]

So do you guys recommend Internal medicine? Or do you suspect the situation is bleak and to stay away from it?

It’s not bleak . I would just say don’t go into it thinking the hospitalist gravy train will go on forever .

Still not To bag on the NPs too much , I still think NPs have their value to healthcare but only directly under the supervision of a physician . I mean does the physician want to see every psychosomatic patient who just needs some tlc ? Let the NP see that patient to talk the patient down while the physician monitors the labs workup healthcare screening and steps in when something acutely wrong is happening.

Does the doctor really want to hear chief complaint of where’s mah free stuff and why don’t I have it yet ? (Dme stuff )

 

[aafisahar]

Tbf fragility fracture doesn't need a dexa they need therapy unless something has changed in the past 6-7 years since last I cared about it

 

[thumbz]

So, unpopular opinion, but one actually grounded in experience and not doom and gloom projections of our future.

Wife opened a clinic. Things are going well, time to hire. Hires a midlevel to help out (we can't afford a guaranteed base for a second doc yet, the midlevel was supposed to help fund that).

Patients don't want to see the midlevel. Even patients who establish with the midlevel want to follow up with my wife. Both are female. The midlevel has great bedside manner. Even the midlevel said "a lot of people would rather see you as the doctor."

So now my wife continues to be booked out a month in advance (literally), and is adding extra spots here and there to keep flowing people into the clinic. While our midlevel has 2/3rds of her schedule as white space.

The physician role isn't going anywhere. Hospitals can't replace us with midlevels. It's rare to see a shop hiring midlevels, but not hiring docs into the same group. 5 years ago I believed my IM career was a dead end and I'd be replaced by a midlevel. Now I don't.

Note - I'm a hospitalist.

 

[bronx43]

Tbf fragility fracture doesn't need a dexa they need therapy unless something has changed in the past 6-7 years since last I cared about it

One should still get a dexa even if fragility fracture is itself a strong indication for therapy. You want to know baseline bmd or if it’s severely low then it may affect choice of med.

 

[TooMuchResearch]

Completely agree.

Even “easy” medicine often times isn’t actually easy, and midlevels frankly suck even at the basics.

I’m a rheumatologist. You wouldn’t believe how many silly consults I get from midlevels on ANAs that never should have been ordered, etc etc, never mind them managing the “basics” - take, for example, the 75 y/o lady who somehow has never had a DEXA scan in her life despite having had multiple fragility fractures, all the patients sent to me who somehow are never up to date on vaccines, etc. If this is what NPs are supposed to “be good at”, then what the hell.

(Although to be perfectly fair, across my last two jobs the PCP MD/DOs have generally sucked almost as much as the midlevels. There are a few bright lights who seem to give a crap about their patients and doing a good job, but a lot who don’t. I completely agree with the comments above about how nobody seems to care about quality anymore in medicine, and it’s all about quantity. I always used to wonder how anyone felt NP care could be equivalent to doctor care…after seeing what the docs have been doing in rural America, I totally “get it”. It’s sad. We need to do a lot better as a profession.)

How do the EMRs not just automatically flag when vaccines are due?

 

[dozitgetchahi]

One should still get a dexa even if fragility fracture is itself a strong indication for therapy. You want to know baseline bmd or if it’s severely low then it may affect choice of med.

Exactly! You need to know BMD baseline and it helps for medication choice and following treatment over time.

Obviously, if someone has a fragility fx you start to treat it, but you should also get the DEXA and do the basic osteoporosis workup too. When I see these patients, usually none of the above has occurred (including the treatment).

 

[NewYorkDoctors]

as a private physician who collects all the billings (and does not eat RVUs), i don't really mind when I get a "basics were not done" consult. i'll just do the basics and bag an extra 99213 office visit out of it. i dont gripe over it. i thank the referring physician for the soft ball down the middle of the plate

but i do see how this drains an hospital system of employed salaried physicians who do not get paid extra to do this.

 

[rokshana]

Tbf fragility fracture doesn't need a dexa they need therapy unless something has changed in the past 6-7 years since last I cared about it

They still need a dxa to follow therapy, but treatment definitely needs to be started and so many go without! And unfortunately, this lapse is not just a midlevel issue!

 

[VA Hopeful Dr]

Not true. The next generation of patients want faster service. If it's for something simple, they'd rather see a mid-level today than wait 2 weeks to see an MD. It's becoming the way of the world . . .

Then set up your schedule so patients don't have to wait 2 weeks to see you. Unless I'm just back from vacation, I can see any of my patients that want me within 1-2 days.

Its not that hard.

 

[DrMetal]

Then set up your schedule so patients don't have to wait 2 weeks to see you. Unless I'm just back from vacation, I can see any of my patients that want me within 1-2 days.

Its not that hard.

You guys have to understand that most times when I go off here, I'm not really speaking in my own voice (which absolutely agrees with most of yours).

I'm kinda speaking (rhetorically) from the mindset of the bonehead hospital/clinical administrators that are now in charge. Yes, your bonehead college beer-drinking roommate who went to business school--OR, your medical colleague who got some cracker jack MBA and hasn't touched a patient in 10 years is now your boss---is now calling the shots!

It's the way of the world . . .

I personally agree with all of you! We're all preaching to the choir here

But that matters not.

 

[DrMetal]

Patients don't want to see the midlevel. Even patients who establish with the midlevel want to follow up with my wife.

I'd bet money that most of these instances are a manifestation of psychosocial or 'perceived' needs, vice an actual difference (between the MD and NP) in medical care rendered.

A classic example is the patient who feels spited because the NP (correctly) did nothing further for the patient's chronic, psychosomatic back pain (that has no clear mechanism of injury and has already been fully worked up).

So the patient complains and demands the see the doctor next time, thinking that the physician has some magic cure for his crazy. [What's worse is if the physician then un-necessarily prescribes narcotics, thus justifying the patient's perspective that the MD is somehow the better caregiver in this situation.]

 

[bronx43]

I'd bet money that most of these instances are a manifestation of psychosocial or 'perceived' needs, vice an actual difference (between the MD and NP) in medical care rendered.

A classic example is the patient who feels spited because the NP (correctly) did nothing further for the patient's chronic, psychosomatic back pain (that has no clear mechanism of injury and has already been fully worked up).

So the patient complains and demands the see the doctor next time, thinking that the physician has some magic cure for his crazy. [What's worse is if the physician then un-necessarily prescribes narcotics, thus justifying the patient's perspective that the MD is somehow the better caregiver in this situation.]

In my experience it’s actually the opposite. Midlevels usually over tests and over refers, hoping that some lab, imaging or specialist will solve the problem for them.
So in this scenario, the midlevels usually are quick to just say “let me refer you to the spine doctors.” Many pts don’t like that, because they don’t want to have to see a different doctor for every complaint and pay $250 new visit, take time out of their day, or arrange transportation. Even Medicare advantage patients have to shell out $50-60 copay for specialist referral. Not to mention the patient already will be paying for the pcp clinic visit for nothing more than a referral.

 

[VA Hopeful Dr]

You guys have to understand that most times when I go off here, I'm not really speaking in my own voice (which absolutely agrees with most of yours).

I'm kinda speaking (rhetorically) from the mindset of the bonehead hospital/clinical administrators that are now in charge. Yes, your bonehead college beer-drinking roommate who went to business school--OR, your medical colleague who got some cracker jack MBA and hasn't touched a patient in 10 years is now your boss---is now calling the shots!

It's the way of the world . . .

I personally agree with all of you! We're all preaching to the choir here

But that matters not.

View attachment 371635

I didn't mean you specifically, it was a generic you.

And my post still applies.

 

[NewYorkDoctors]

In my experience it’s actually the opposite. Midlevels usually over tests and over refers, hoping that some lab, imaging or specialist will solve the problem for them.
So in this scenario, the midlevels usually are quick to just say “let me refer you to the spine doctors.” Many pts don’t like that, because they don’t want to have to see a different doctor for every complaint and pay $250 new visit, take time out of their day, or arrange transportation. Even Medicare advantage patients have to shell out $50-60 copay for specialist referral. Not to mention the patient already will be paying for the pcp clinic visit for nothing more than a referral.

that's why one has to "art of medicine" the patient to want the specialist referral.
for something like back pain or knee pain, offer the usual spiel about weight loss (yeah right... aint happening unless GLp1 agonists are used... due to the ghrelin gremlins, lack of motivation of older patients to want to become athletic, joint pains, OSA perhaps), physical therapy, NSAIDs/tylenol, routine exercise... they demand MRI ... inform them about the out of pocket costs and how prior authorization could be done but insurance needs to know that you will "act on it," then do those things then leave them hanging for a bit .... they do their own online research with Dr ChatCPT and they want the ortho referral...

i have found the best way to obtain better adherence is make the patient THINK that the patient was the one who discovered the idea. i'm usually sending email links or providing certain reading materials in the office that leads the patient down that line of thought. does it sound like manipulating a child? most patients behave like children. you betcha. if they were self sufficient adults, then they would likely not come to see the doctor for most issues. do I sound condescending and patronizing? you betcha. do all doctors have these thoughts? you'd be lying if you said you were a virtue signaling hand holding family medicine angel physician all the time. but do I practice paternalism? nope. i'm all about the joint decision making, informed consent, justice, beneficience, autonomy.. etc.... it's just that I find that patients are more adherent when THEY think it was THEIR idea to do something

 

[bronx43]

that's why one has to "art of medicine" the patient to want the specialist referral.
for something like back pain or knee pain, offer the usual spiel about weight loss (yeah right... aint happening unless GLp1 agonists are used... due to the ghrelin gremlins, lack of motivation of older patients to want to become athletic, joint pains, OSA perhaps), physical therapy, NSAIDs/tylenol, routine exercise... they demand MRI ... inform them about the out of pocket costs and how prior authorization could be done but insurance needs to know that you will "act on it," then do those things then leave them hanging for a bit .... they do their own online research with Dr ChatCPT and they want the ortho referral...

i have found the best way to obtain better adherence is make the patient THINK that the patient was the one who discovered the idea. i'm usually sending email links or providing certain reading materials in the office that leads the patient down that line of thought. does it sound like manipulating a child? most patients behave like children. you betcha. if they were self sufficient adults, then they would likely not come to see the doctor for most issues. do I sound condescending and patronizing? you betcha. do all doctors have these thoughts? you'd be lying if you said you were a virtue signaling hand holding family medicine angel physician all the time. but do I practice paternalism? nope. i'm all about the joint decision making, informed consent, justice, beneficience, autonomy.. etc.... it's just that I find that patients are more adherent when THEY think it was THEIR idea to do something

Basically Leo style inception. “An idea is like a virus…”

 

[hotsaws]

as a private physician who collects all the billings (and does not eat RVUs), i don't really mind when I get a "basics were not done" consult. i'll just do the basics and bag an extra 99213 office visit out of it. i dont gripe over it. i thank the referring physician for the soft ball down the middle of the plate

but i do see how this drains an hospital system of employed salaried physicians who do not get paid extra to do this.

Yeah, agree with this. As a PP A/I doc, I am more than happy to see the easy NP/PA referrals. In fact, it’s a lot easier for me if a workup hasn’t been attempted. When referring docs or midlevels start ordering IgE testing and stuff like that, it just makes more work for me to undo. There's nothing worse as an allergist than seeing a new patient who has had some broad food IgE testing panel done. When I introduce myself to referring docs at lunches, I just tell them "send them right over and don't do a thing. If they sneeze or sniffle, please send "

 

[dozitgetchahi]

Yeah, agree with this. As a PP A/I doc, I am more than happy to see the easy NP/PA referrals. In fact, it’s a lot easier for me if a workup hasn’t been attempted. When referring docs or midlevels start ordering IgE testing and stuff like that, it just makes more work for me to undo. There's nothing worse as an allergist than seeing a new patient who has had some broad food IgE testing panel done. When I introduce myself to referring docs at lunches, I just tell them "send them right over and don't do a thing. If they sneeze or sniffle, please send "

Oh I completely agree. In rheumatology I’m also much happier to start the workup myself, and being private practice I’m happy to get the ancillaries for it also.

It’s more the “wtf how did nobody think of this” factor that makes me shake my head at the NPs, and the fact that in my specialty a lot of “easy ANA referrals” etc are anything but - because the PCP is trying to dump a crazy psychosomatic patient under the guise of it being a “positive ANA” or whatever.

 

[hotsaws]

If you order enough ANAs, eventually one will be positive. At least that's what all non-rheumatologists with a train wreck in front of them hope for. I think we all get at least one visit with the same patient. They usually present to me as "concern for food or mold allergy causing X" where X is a countless number of functional illnesses (a la fibro, EDS, POTS, CFS, IBS, MCAS, etc). Often in my initial discussion they'll be like "yeah, I have SLE/MCTD/RA/etc" so I'm like "Oh, so do you follow with a rheumatologist?" Typical response is like "Ugh I've seen two rheumatologists and they were both terrible. They pretty much told me I don't have SLE/MCTD/RA/etc and that there was nothing wrong with me." To which I think "...Well, certainly something is wrong with with you"

 

[NewYorkDoctors]

If you order enough ANAs, eventually one will be positive. At least that's what all non-rheumatologists with a train wreck in front of them hope for. I think we all get at least one visit with the same patient. They usually present to me as "concern for food or mold allergy causing X" where X is a countless number of functional illnesses (a la fibro, EDS, POTS, CFS, IBS, MCAS, etc). Often in my initial discussion they'll be like "yeah, I have SLE/MCTD/RA/etc" so I'm like "Oh, so do you follow with a rheumatologist?" Typical response is like "Ugh I've seen two rheumatologists and they were both terrible. They pretty much told me I don't have SLE/MCTD/RA/etc and that there was nothing wrong with me." To which I think "...Well, certainly something is wrong with with you"

I often like the pull the line "well, I believe that YOU believe that you something is wrong and that is good enough for me. Let's explore some alternatives shall we?" and "just because the test is negative doesn't mean nothing is wrong with you! it just means that the testing finding for these specific reasons is negative. let's explore some alternatives shall we?"

Then I try to use some "jedi mind tricks" on the patients (leading questions, re-framing the question, making references to lay culture references to certain medical topics, talking about their kids and pets for a hot second or two, then leading to providing them UpToDate basics or beyond the basics for patients) in an attempt to steer them into a direction in which they can discover FOR THEMSELVES that they want to do something by the book.


anyway its funny. I order autoimmune workup for ILD workup and GN workup. When those patients get a cheap ANA 1:80 i don't hear any complaints. but I guess these patients don't have debilitating osteoarthritis driving their desire to see a +ANA. I dont get why those patients "want" lupus. for clarity? i tell those same patients that this means they will be on immunosuppressants forever and will never be "cured."

 

[hotsaws]

Pretty sure the types of patients that want lupus also just want to collect as many disease labels as possible to objectify the way the feel and validate victim status. I think there's two phenotypes for these functional illnesses. One is the anxious, worried type that we can probably help quite a bit if we are able to listen and reassure them. The other is a cluster B nightmare and we can't do much but escape with minimal collateral damage and do our best to end up on the good side of a split. I do try to set aside my judgment and hear them out and see if I can help them even in some small way but it can be exhausting. Sometimes they've been so entrenched in the medical system and so over-labeled and over-prescribed, that it just seems like it needs a complete reset.

 

[NewYorkDoctors]

There is another subset of patients who seem to want the primary care provider to fix world peace or something.
These patients like to unload the laundry list and they actually expect answers. They do not want to hear "refer to specialist."
While it is prudent and responsible for the primary provider to hear the patient out and be patient and just listen to all the rambling (sometimes these patients have subtle anxiety, home issues, confidence issue etc... that just getting it off their chest seems therapeutic no matter how inane it all is), sometimes these patients "expect fancy tests." By denying them, they become indignant and feel the doctor was "terrrible" and the health care system is the reason why they are more unhealthy and then they seek out "online remedies."
(sounds like borderline personality disorder , splitting, and projection honestly... typical narcissi tic behavior... but I practice in NYC of course. psychiatrists can correct me)

I gleaned this insight when I see new consults with "dyspnea." The clinical history is all over the place and makes no sense. I pull the "I believe you believe you have issues and that's good enough card for me" and then move onto the workup. I explain to patient just because I am a specialist, I cannot read you like a Magic 8 ball or like Dr McCoy with his tricorder from Star Trek. I listened to your vague nonspecific symptoms for about 10-15 minutes now and your physical exam is normal. This does not mean nothing is wrong. It means there is nothing "easy" or "obvious" about your situation. This is why we must do additional testing. Then I do the full slate of PFTs and CPET (and CT imaging if indicated) and I get deconditioning as the answer. Then I

Usually these patients are grateful and explain "how come my PCP couldnt do this?"
I answer because your PCP is busy monitoring your health care screenign to make sure you are in good shape and do not develop an easily preventable cancer or other chronic health disease. Do not take that for granted. It sounds like you could benefit from a concierge physician. Have you ever looked into that before? The answer is invariably "do they take insurance???"

We have demanding needy patients who believe "top quality concierge healthcare" is a universal "mah healthcare rights". You have a right to ACCESS to healthcare. That should be universal. FREE FREE FREE ... only if you have Medi/Medi/managed.

 

[dozitgetchahi]

There is another subset of patients who seem to want the primary care provider to fix world peace or something.
These patients like to unload the laundry list and they actually expect answers. They do not want to hear "refer to specialist."
While it is prudent and responsible for the primary provider to hear the patient out and be patient and just listen to all the rambling (sometimes these patients have subtle anxiety, home issues, confidence issue etc... that just getting it off their chest seems therapeutic no matter how inane it all is), sometimes these patients "expect fancy tests." By denying them, they become indignant and feel the doctor was "terrrible" and the health care system is the reason why they are more unhealthy and then they seek out "online remedies."
(sounds like borderline personality disorder , splitting, and projection honestly... typical narcissi tic behavior... but I practice in NYC of course. psychiatrists can correct me)

I gleaned this insight when I see new consults with "dyspnea." The clinical history is all over the place and makes no sense. I pull the "I believe you believe you have issues and that's good enough card for me" and then move onto the workup. I explain to patient just because I am a specialist, I cannot read you like a Magic 8 ball or like Dr McCoy with his tricorder from Star Trek. I listened to your vague nonspecific symptoms for about 10-15 minutes now and your physical exam is normal. This does not mean nothing is wrong. It means there is nothing "easy" or "obvious" about your situation. This is why we must do additional testing. Then I do the full slate of PFTs and CPET (and CT imaging if indicated) and I get deconditioning as the answer. Then I

Usually these patients are grateful and explain "how come my PCP couldnt do this?"
I answer because your PCP is busy monitoring your health care screenign to make sure you are in good shape and do not develop an easily preventable cancer or other chronic health disease. Do not take that for granted. It sounds like you could benefit from a concierge physician. Have you ever looked into that before? The answer is invariably "do they take insurance???"

We have demanding needy patients who believe "top quality concierge healthcare" is a universal "mah healthcare rights". You have a right to ACCESS to healthcare. That should be universal. FREE FREE FREE ... only if you have Medi/Medi/managed.

Yep. I see this all the time, including the “weird clinical history that makes no sense”, as well as the “here’s 30 years of unresolved issues, fix me right now, doctor”.

In my patient population, at least, it seems the vast majority of these types people are on Medicaid, which is yet another reason why I refuse to take Medicaid now. A lot of these people come in and describe bizarre, exotic symptoms. You think “damn, this sounds bad, maybe this is something rare”. You work it up, and 99% of the time…there’s nothing there. It’s all fibro and other psychosomatic stuff. I became so much happier as a doc once I stopped taking Medicaid…it blocked like at least 9/10ths of this nonsense out of my clinic.

I used to do the whole “listen to these folks and try to break down the issues and see if I can help with something” bit. However, in my current job I have such a robust referral stream of genuine rheumatology patients that I simply do not want to deal with a bunch of nebulous nonsense anymore (and I don’t have to). Those types of visits are long, exhausting, often unpleasant, and in the case of the Medicaid folks, you’re barely even getting paid to do it. So no.

 

[Splenda88]

Do you think hospitalist gigs will just be taken over by midlevels?

Probably in 15+ yrs. Most don't have the knowledge to do our job. However, the trend right now in many places is ~4:1 ratio doctors to midlevels. I am not sure if that is even cost effective.

As of now, we (hospitalists) have a $$$ printing machine and hopefully this does not end anytime soon.

 

[hotsaws]

Yep. I see this all the time, including the “weird clinical history that makes no sense”, as well as the “here’s 30 years of unresolved issues, fix me right now, doctor”.

In my patient population, at least, it seems the vast majority of these types people are on Medicaid, which is yet another reason why I refuse to take Medicaid now. A lot of these people come in and describe bizarre, exotic symptoms. You think “damn, this sounds bad, maybe this is something rare”. You work it up, and 99% of the time…there’s nothing there. It’s all fibro and other psychosomatic stuff. I became so much happier as a doc once I stopped taking Medicaid…it blocked like at least 9/10ths of this nonsense out of my clinic.

I used to do the whole “listen to these folks and try to break down the issues and see if I can help with something” bit. However, in my current job I have such a robust referral stream of genuine rheumatology patients that I simply do not want to deal with a bunch of nebulous nonsense anymore (and I don’t have to). Those types of visits are long, exhausting, often unpleasant, and in the case of the Medicaid folks, you’re barely even getting paid to do it. So no.

Forgive me for the tangent but...

For sure it's more prevalent in the medicaid population. In the commercial population, I see it in the stay-at-home or otherwise non-working types. There's obviously a disconnect between a patient's perspective and a doctor's perspective when looking at some broad constellation of symptoms that seems to span organs and not behave like organic disease...also while seemingly having no evidence of end organ involvement or biomarker evidence of pathology. They think they're a zebra (heaven forbid some provider at some point told them they're a zebra...they clutch that like a teddy bear). We quickly see that it doesn't pass the sniff test. Most of us with at least a residency background in IM understand sick vs not sick. We understand that diseases that span multiple organ systems and cause debilitating symptoms often leave a very obvious path of destruction. It's like when a 350lb patient looks at me with a straight face and says "I only eat 5 foods and I pretty much never eat at all." Like, what? Really? I don't even think they're lying. I think they believe it. Don't even get me started on the long covid stuff. I am quite a bit more strict than other docs in my field though. I draw a boundary with diseases I basically don't believe in and I politely explain that I'm just not their guy but I validate their frustration and suffering and wish them the best.

I still try and set my bias aside and do the whole "hear them out and see if I can make some small improvement in their QOL" but I'm growing tired of it and I feel like I'm just perpetuating the situation and selfishly trying to end up the good guy in their eyes so that we don't have some awkward conflict. The honorable thing to do would be to just tell them straight up my opinion and for every other doctor to do the same.

So in A/I, one flavor of this we get is the multiple drug intolerance syndrome. the tldr is that these folks are probably not allergic to any med but they report subjective symptoms and sometimes throw themselves into a full blown VCD attack with flushing and all that. Some hospitalist or ED doc treats them with Epi and then...boom, validated. Anyways, so in fellowship we would occasionally do placebo challenges with these patients and essentially we'd placebo them until they reacted. Then they'd react to placebo. It ultimately serves no purpose, not even much of a cathartic gotcha. You can't prove to a patient that they're not sick when they desperately need to be sick as part of their identity.

 

[AlbinoHawk DO]

How do the EMRs not just automatically flag when vaccines are due?

All the outpatient ones I've seen do flag. The thing is these people probably don't look at that bar or just instinctively click X on the pop up. NPs sincerely don't care about patients. I overheard a call of a patient telling the NP she started having headaches with amlodipine and if she could switch to another drug. The NP said "well, amlodipine is a good medicine. You'll have to decide if you want to have good blood pressure or no headaches"

 

[TooMuchResearch]

All the outpatient ones I've seen do flag. The thing is these people probably don't look at that bar or just instinctively click X on the pop up. NPs sincerely don't care about patients. I overheard a call of a patient telling the NP she started having headaches with amlodipine and if she could switch to another drug. The NP said "well, amlodipine is a good medicine. You'll have to decide if you want to have good blood pressure or no headaches"

Wtf

 

[NewYorkDoctors]

All the outpatient ones I've seen do flag. The thing is these people probably don't look at that bar or just instinctively click X on the pop up. NPs sincerely don't care about patients. I overheard a call of a patient telling the NP she started having headaches with amlodipine and if she could switch to another drug. The NP said "well, amlodipine is a good medicine. You'll have to decide if you want to have good blood pressure or no headaches"

Let’s not generalize . There are bad doctors lazy docs (scorched earth Zpaks and refusal to do prior auth because of perceived difficulty so send to specialist. Or refer to specialist but send zero workup becuase it’s just soooo much effort to press the efax button in the EMR …) out there also

NPs do a great job when under direct physician supervision . They do all the crap we physicians for want to do .

When independent is another story …

 

[FutureInternist]

You should probably subspecialize in something from IM. Even if you did palliative/geriatrics and mainly did GIM or hospitalist medicine, you will have something to distinguish you from the pack. Sad but it is what it is. Hospital systems want to hire fewer physicians and more midlevels because it is more "cost effective." I am not sure this accounts for long term cost savings but... that's not a discussion for now.

The same admins that won’t hire an extra Case Manager for peanuts, who can then DC 10 pts a day and save the hospital literally tens of thousands a week if not more…. Yeah those admins can’t think past the immediate bottom line

I go to our LoS meetings and it is a poop-show.

So much spent on how to streamline MRI results, or blood draws for pts being DC’d that day (although other than Hgb, what lab is needed on day of DC 🤔), how to get faster echo reads - ALL of which account for such a minute portion of our daily census that even 100 % improvement in those will affect our LoS minimally.
I asked once what the average $ for one extra hospital day for one pt was - $5K 🤦‍♂️.

Just take 10 % of that potential loss, hire more nurses & CMs and see your LoS & “avoidable days” plummet

 

[NewYorkDoctors]

The same admins that won’t hire an extra Case Manager for peanuts, who can then DC 10 pts a day and save the hospital literally tens of thousands a week if not more…. Yeah those admins can’t think past the immediate bottom line

I go to our LoS meetings and it is a poop-show.

So much spent on how to streamline MRI results, or blood draws for pts being DC’d that day (although other than Hgb, what lab is needed on day of DC 🤔), how to get faster echo reads - ALL of which account for such a minute portion of our daily census that even 100 % improvement in those will affect our LoS minimally.
I asked once what the average $ for one extra hospital day for one pt was - $5K 🤦‍♂️.

Just take 10 % of that potential loss, hire more nurses & CMs and see your LoS & “avoidable days” plummet

that's why any physician who has the opportunity to get weaned off the teat of the hospital and escape the tapeworm bowels of the administrators and bureaucrats should do so ASAP. Non-healthcare workers want to get rich off of the backs of the healthcare workers. Like obscenely rich. Not even make a fair living for your work.

For certain subspecialties that require the access that only a hospital can cover (interventional radiology and interventional cardiology come to mind right away), this may not necessarily be applicable advice.

 

[Splenda88]

Let’s not generalize . There are bad doctors lazy docs (scorched earth Zpaks and refusal to do prior auth because of perceived difficulty so send to specialist. Or refer to specialist but send zero workup becuase it’s just soooo much effort to press the efax button in the EMR …) out there also

NPs do a great job when under direct physician supervision . They do all the crap we physicians for want to do .

When independent is another story …

If there are bad doctors after 11 yrs of rigorous training, just imagine someone who got an online degree w/ 500-700 hrs preceptorship. It's not a good argument saying that there are bad doctors