Inbox management and other lifestyle questions

[MifflinDunder]

Incoming fellow. I made the mistake of joining the multiple physician Facebook groups and found these comments about the heme-onc lifestyle (can delete if this isn't allowed on sdn).

The world today has moved very fast in Oncology, I spend 1 hour every night reviewing the latest data and still cannot keep up. The other half of my free time is fighting for scans and chemotherapy drugs that people need. And during my workout time, I try to answer all patient messages can be 50-100 a day.
We are in the hospital AFTER seeing 20 dying humans in clinic. And answering 50-100 MyChart messages a day and calling people with bad news and we work after we get home and on weekends.
Half of heme-onc work is done from home - inbaskets/chart prep/keeping updated on guidelines.
Not a lifestyle field. Not one bit. Even when you are home- it’s a constant stream of semi-emergent questions, and since the person on the other end of the line has cancer…. It’s never ok to turn off phone.
Heme Onc here. Lifestyle is not good. I just got paged at 4:00 am on a Saturday morning for one of my patients. Our patients our crazy sick and we are on call 24/7 365 generally.
All the Heme/Onc docs I know are literally working themselves to the grave. The workload is unhealthy.
There are multiple posts about never being really off, even while you're on vacation.

For the attendings,
How often are you taking work home or being available off the clock for portal messages on the weekends or holidays?
Do you also feel that you're never truly off? Who answers questions about your patients when you're not on call, weekends, or when you're on vacation?
How rare is it to see only one tumor type in private practice? I heard it's possible if I wanna do breast
Does working inpatient (leukemia/BMT/cell therapy) or at the VA = less inbox burden?

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[Plutarch02]

How often are you taking work home or being available off the clock for portal messages on the weekends or holidays?
- I would say 30 min a day on weekdays. I take call 4-5 weekends a year and 2-3 weekdays a month. I dictate my notes in between rooming patients.
Do you also feel that you're never truly off? Who answers questions about your patients when you're not on call, weekends, or when you're on vacation?
- After hours one of the partners will answer questions or on weekends, whoever is on call.
How rare is it to see only one tumor type in private practice? I heard it's possible if I wanna do breast
- In large cities it's possible, I know my group as predominately breast only docs.
Does working inpatient (leukemia/BMT/cell therapy) or at the VA = less inbox burden?
- Don't do that, inpatient onc/heme is high acuity and a lot of hospice which I feel would lead to burnout faster.

I'm a new attending building a practice in a large group practice setting. I can give you my perspective.

Oncologists are becoming the most in demand field of medicine. As patients with cancer are living longer than ever before with advancing treatments and baby boomers in prime cancer age. Surgeons and radiation oncologists look to oncologists to be the quarterback and primary care doctor for very sick patients. That being said compensation is going up, with partners in pp should expect to be making in the seven figures.

I think it's best to start a new panel rather than work for a hospital and be assigned a panel. It helps a lot that all new patients are yours and you can start their notes in your style and review their cases from the start, rather than trying to inherit very complex patients with multi year histories and seeing 15+ a day right out the gate.

In private practice you should expect to be making over a million dollars a year if you're seeing 18+ patients a day 4 days a week. That day off helps a lot with catching up on chart messages and notes. As you build your practice you can have NPs help with pages during the day and hospital rounding if needed. Palliative care is your friend. If your group doesn't have a palliative care doc find one in pp and refer to them without any inhibition. Oncologists need to be focused on staying up to date on latest treatments and treatment toxicity and we need to offload pain management and coordination of care to palliative care docs, it will make your stress much better.

A lot of frustration is fighting insurance companies to get chemotherapy approved in a timely manner, especially for cancers that are time sensitive like small cell lung cancer or pancreatic cancer. You'll need to make sure your front office is superb and can handle that without much effort on your part. A strong front office will make your life much better.

Overall it comes down to the job you select, there a lot of hospitals taking advantage of oncologists, but in this market with exponentially rising demand for oncologists you can be choosey and have a lot more leverage than you think. You can still make it very much a lifestyle specialty.

That said, you have to be comfortable with handling death in this field it is apart of the job moreso than other specialty. NCCN guidelines are your friend and hemeonc.org will link the latest studies for overall birds eye view plans on patients.

Where things get dicey are hematology which more and more I'm thinking we will eventually move to separating hematology and oncology as the demands of the fields become too much for one person to handle. I personally ship off the complicated heme cases like hemophilia or platelet functional disorders to academic centers.

 

[osprey099]

In private practice you should expect to be making over a million dollars a year if you're seeing 18+ patients a day 4 days a week.

I read an article somewhere that stated something like 53% of oncologists make more than $1m but I feel like that's an exaggeration. Hopefully it's true though..

 

[Ubba]

In private practice you should expect to be making over a million dollars a year if you're seeing 18+ patients a day 4 days a week.

Even if the PP owns an infusion center, I don't quite understand exactly how this would work. Then again, maybe my calculation of simply multiplying (99213 Medicare rate x 18) + (99204 Medicare rate x 2) x 208 days/year is missing something important. Is it the inpatient billings?

 

[osprey099]

Even if the PP owns an infusion center, I don't quite understand exactly how this would work. Then again, maybe my calculation of simply multiplying (99213 Medicare rate x 18) + (99204 Medicare rate x 2) x 208 days/year is missing something important. Is it the inpatient billings?

I think that calculation would only be for E/M billing. I think in private practice, you make most of the money from drug margin (buy chemo then "sell" chemo and profit the difference) whereas in hospital based practices, you see maybe a tiny cut of this profit margin.

Also in pp, you probably get ancillary revenue from lab, imaging and real estate (assuming you own all of them)

 

[Ubba]

I think that calculation would only be for E/M billing. I think in private practice, you make most of the money from drug margin (buy chemo then "sell" chemo and profit the difference) whereas in hospital based practices, you see maybe a tiny cut of this profit margin.

Also in pp, you probably get ancillary revenue from lab, imaging and real estate (assuming you own all of them)

As far as the visit itself goes, is the E/M billing the extent of what the practice makes, or is there additional income from the appointment itself? Or is it just the copay? I've never understood how office-based practices that don't have labs and/or imaging (e.g., general IM) keep the lights on and staff paid from just E/M billings.

 

[osprey099]

As far as the visit itself goes, is the E/M billing the extent of what the practice makes, or is there additional income from the appointment itself? Or is it just the copay? I've never understood how office-based practices that don't have labs and/or imaging (e.g., general IM) keep the lights on and staff paid from just E/M billings.

I'm "just" a fellow so I don't know all that much yet. I will be joining a very well established 100% physician owned private practice (no affiliations with hospital system or management organizations) this summer though so I've been trying to learn as much as possible about the business of oncology.

My research tells me that the main driver of profit is the chemo margin. In fact, I have heard of some places may do AAVD over ABVD for all-comers just because they get more for that brentuximab-v. Likewise, one immunotherapy may be more profitable than another so some may always choose Pembro over Nivo if the margins are higher.

 

[whoknows2012]

I can answer your last question, I’m purely inpatient leukemia. I admit the 24 y/o with T-ALL and start them on a peds inspired regimen, consent and start a patient for an aml cart or new exciting immune therapy bite moAb clinical trial, and also yes take care of the 80 y/o dying of aml. The variety is quite dramatic. Definitely not for everyone. There is essentially no inbox management though occasionally after hours calls or messages/emails to return.

As a whole, I don’t think anyone would describe oncology as a “lifestyle” specialty. It does however pay well and one can have a good work life balance if you work at it

 

[Mehena]

As a newly employed attending physician, my experience somewhat reflects the sentiments shared in the Facebook group. It's not just about being new to practicing oncology; even colleagues with over ten years of experience express similar concerns. The workload, inbox management, difficulty disconnecting, and the need for after-hours and weekend charting are common struggles.

While oncology offers the potential for substantial income through RVUs, it doesn't necessarily support a healthy work-life balance.

Additionally, as an employee, the higher tax rate eats into the income, making it less rewarding than it may initially seem.

 

[gutonc]

As far as the visit itself goes, is the E/M billing the extent of what the practice makes, or is there additional income from the appointment itself? Or is it just the copay? I've never understood how office-based practices that don't have labs and/or imaging (e.g., general IM) keep the lights on and staff paid from just E/M billings.

There are 2 RVU numbers for every encounter. One is total RVU and one is work RVU. You get paid based on the wRVU, the hospital/clinic gets paid on the total. There are also facility fees out there for hospital based clinics that are higher than independent clinics. It's why so many clinics owned by hospital systems are becoming HBOCs.

 

[gutonc]

Incoming fellow. I made the mistake of joining the multiple physician Facebook groups and found these comments about the heme-onc lifestyle (can delete if this isn't allowed on sdn).
The world today has moved very fast in Oncology, I spend 1 hour every night reviewing the latest data and still cannot keep up. The other half of my free time is fighting for scans and chemotherapy drugs that people need. And during my workout time, I try to answer all patient messages can be 50-100 a day.
We are in the hospital AFTER seeing 20 dying humans in clinic. And answering 50-100 MyChart messages a day and calling people with bad news and we work after we get home and on weekends.
Half of heme-onc work is done from home - inbaskets/chart prep/keeping updated on guidelines.
Not a lifestyle field. Not one bit. Even when you are home- it’s a constant stream of semi-emergent questions, and since the person on the other end of the line has cancer…. It’s never ok to turn off phone.
Heme Onc here. Lifestyle is not good. I just got paged at 4:00 am on a Saturday morning for one of my patients. Our patients our crazy sick and we are on call 24/7 365 generally.
All the Heme/Onc docs I know are literally working themselves to the grave. The workload is unhealthy.
There are multiple posts about never being really off, even while you're on vacation.

There's a lot here. And while I certainly won't argue with people's lived experience, The above has not been my experience in the past 12 years. Was I inefficient for 3-4 years while ramping up my clinic? Yes. Do I spend an hour or less on charting outside of my office a week now and still leave <30 min after my last patient most days? Also yes.

Seems like a lot of the complaints here largely come down to s*** practice environments. Despite what we're taught in fellowship, there are almost no true oncologic emergencies, and even the rare ones that exist don't require greater than a decent IM PGY2 to manage initially (Cord compression? Start dex, call neurosurgery and Rad Onc...doesn't take an oncologist to do that).

For the attendings,
How often are you taking work home or being available off the clock for portal messages on the weekends or holidays?

I can check my InBasket as much as I want. On my non-clinic days (assuming not on vacation), I usually check first thing in the morning, once around lunch time and once more around 4:30. Takes longer to load and log-in to the EMR remotely than it does to do any work that is needed.

Do you also feel that you're never truly off? Who answers questions about your patients when you're not on call, weekends, or when you're on vacation?

As with efficiency, this took me some time. But yes, when I'm off, I'm off. Calls can be answered by my NP, one of my covering partners, or can wait until I get back. This is as much a matter of training your staff and setting expectations with your patients as anything.

How rare is it to see only one tumor type in private practice? I heard it's possible if I wanna do breast

Pretty much breast. Anything else is going to be hard to do even in a large community group.

Does working inpatient (leukemia/BMT/cell therapy) or at the VA = less inbox burden?

Inpatient means less patient portal messages, but not less inbasket BS. The VA is worse IMO since in most settings a lot of things that are handled by RN, MA, pharmacy, front desk get pushed off to the physician.

 

[collegestud2013]

I read an article somewhere that stated something like 53% of oncologists make more than $1m but I feel like that's an exaggeration. Hopefully it's true though..

MGMA data from 2021 has median for heme/onc compensation at around $481k and 90th percentile at $810k. So the percentage making over a million is not anywhere near 53%.

Even if the PP owns an infusion center, I don't quite understand exactly how this would work. Then again, maybe my calculation of simply multiplying (99213 Medicare rate x 18) + (99204 Medicare rate x 2) x 208 days/year is missing something important. Is it the inpatient billings?

Heme/onc pays higher than many other non-procedural specialties (without having to see a crazy volume of patients) since most practices profit from chemo by buy-and-bill in addition to billing the usual billing E/M from insurance. For buy and bill, how profitable it is depends largely on how low of a price a practice can purchase chemo. However, profiting from buying and billing is going to become harder and harder in the future as insurers push back on the practice and the government is trying to regulate drug pricing more. For example, more insurers are mandating "white bagging" of chemo drugs which changes payment medical to pharmacy benefit, and bypasses the ability to profit from buy and bill (How ‘White Bagging’ Affects Patients, Physicians and 340B Funding) . If that's the case, would suspect heme-onc pay to be closer other non-procedural IM specialties

As far as the visit itself goes, is the E/M billing the extent of what the practice makes, or is there additional income from the appointment itself? Or is it just the copay? I've never understood how office-based practices that don't have labs and/or imaging (e.g., general IM) keep the lights on and staff paid from just E/M billings.

They have to see a high volume of patients if their only source of income is from E&M; and they often limit payor mix to try to get mostly high-paying private insurers. They will try to limit Medicare patients (though this may be very hard to do in some specialties that have many geriatric patients) and won't take Medicaid at all. Even then it can still be hard to a solo practice so more common nowadays to have partners to split the fixed expenses and split call responsibilities.

 

[randomhemoncpd]

Even if the PP owns an infusion center, I don't quite understand exactly how this would work. Then again, maybe my calculation of simply multiplying (99213 Medicare rate x 18) + (99204 Medicare rate x 2) x 208 days/year is missing something important. Is it the inpatient billings?

Most of my visits are 99215 and the rest are 99214. I have a handful of 99213 a year. New patients are pretty much all 99205. One of the things about Hem/Onc is that the E&M is generally complex since you're treating with very complicated medications; that's part of the value add as far as compensation goes.

 

[sloh]

For example, more insurers are mandating "white bagging" of chemo drugs which changes payment medical to pharmacy benefit, and bypasses the ability to profit from buy and bill (How ‘White Bagging’ Affects Patients, Physicians and 340B Funding) . If that's the case, would suspect heme-onc pay to be closer other non-procedural IM specialties

Good read. Thanks for sharing

 

[dozitgetchahi]

Incoming fellow. I made the mistake of joining the multiple physician Facebook groups and found these comments about the heme-onc lifestyle (can delete if this isn't allowed on sdn).
The world today has moved very fast in Oncology, I spend 1 hour every night reviewing the latest data and still cannot keep up. The other half of my free time is fighting for scans and chemotherapy drugs that people need. And during my workout time, I try to answer all patient messages can be 50-100 a day.
We are in the hospital AFTER seeing 20 dying humans in clinic. And answering 50-100 MyChart messages a day and calling people with bad news and we work after we get home and on weekends.
Half of heme-onc work is done from home - inbaskets/chart prep/keeping updated on guidelines.
Not a lifestyle field. Not one bit. Even when you are home- it’s a constant stream of semi-emergent questions, and since the person on the other end of the line has cancer…. It’s never ok to turn off phone.
Heme Onc here. Lifestyle is not good. I just got paged at 4:00 am on a Saturday morning for one of my patients. Our patients our crazy sick and we are on call 24/7 365 generally.
All the Heme/Onc docs I know are literally working themselves to the grave. The workload is unhealthy.
There are multiple posts about never being really off, even while you're on vacation.

For the attendings,
How often are you taking work home or being available off the clock for portal messages on the weekends or holidays?
Do you also feel that you're never truly off? Who answers questions about your patients when you're not on call, weekends, or when you're on vacation?
How rare is it to see only one tumor type in private practice? I heard it's possible if I wanna do breast
Does working inpatient (leukemia/BMT/cell therapy) or at the VA = less inbox burden?

If someone is answering 50-100 MyChart messages every day, then something is insanely wrong with how that physician is managing patient expectations.

I’m a rheumatologist. I get *maybe* 5-10 of these a day, most of which get intercepted by my office staff. I make it abundantly clear to patients that the vast majority of issues are to be handled at visits, with only a handful of quick/easy issues to be handled by phone or MyChart (obviously if there is an urgent issue, please call).

The MyChart message is not a wide open highway for patients to ask whatever questions pop into their mind randomly at 8:13pm on a Tuesday night (I dealt with that bull crap as a rheumatology fellow, and I swore up and down I’d do it differently when I was an attending). Make ‘em save it for the visit. If it sounds urgent, make ‘em schedule an appointment. It’s straightforward to control that aspect of this.

 

[HemeOncHopeful19]

If someone is answering 50-100 MyChart messages every day, then something is insanely wrong with how that physician is managing patient expectations.

I’m a rheumatologist. I get *maybe* 5-10 of these a day, most of which get intercepted by my office staff. I make it abundantly clear to patients that the vast majority of issues are to be handled at visits, with only a handful of quick/easy issues to be handled by phone or MyChart (obviously if there is an urgent issue, please call).

The MyChart message is not a wide open highway for patients to ask whatever questions pop into their mind randomly at 8:13pm on a Tuesday night (I dealt with that bull crap as a rheumatology fellow, and I swore up and down I’d do it differently when I was an attending). Make ‘em save it for the visit. If it sounds urgent, make ‘em schedule an appointment. It’s straightforward to control that aspect of this.

I have no idea but the person OP is quoting from Facebook may work for a system like Kaiser where the company has a vested interest in minimizing visits and making sure you handle as much as humanly possible for free via mychart

 

[Plutarch02]

I'm still in practice building mode but I see 30-40 pts a week I get maybe 2 MyChart messages a week. Most of the messages are me talking with staff to get things scheduled/p2p/insurance

 

[RainerMaria]

I think the culture of always on 24/7 and after hours text/cell/Mychart availability is highly provider and practice dependent. At the end of the day it's your choice whether you want to be the tortoise or the hare.

If your reimbursement is at all tied to E/M then you are absolutely doing it wrong by spending time doing MyChart messaging after hours. This is unreimbursed work. Now with telemedicine there is no excuse not to turn these "Oh I had a few more questions" into visits. Even if you are not on a wRVU model you should still defer these questions to clinic hours and schedule time for discussions. Most of the time spent in calling patients back is not the actual time spent counseling but time wasted calling the wrong number, calling at the wrong time ("Doc, can I call you back in 20 minutes?"), or calling the 3rd wife's work cell phone number that was listed incorrectly in EPIC as the next number to call.

In terms of charting after hours, the person you are competing against is not the system but yourself. Write less detailed notes. It's not fellowship nor is it an ASCO oral presentation. No one cares if you have citations and if they are in Chicago format. Just do what is needed to stand up to billers and (God forbid) defense lawyers, and make it so that if you leave or die that some one can take over without having a nervous breakdown. Arguably, notes that are overly long and that copy every HPI from prior notes, including the tense from those notes ("Patient is here for cycle 2 of chemo.... Patient is here for cycle 3 of chemo...") are more likely to have copy and paste errors and thus be submitted as evidence of substandard documentation and even medical care during a malpractice suit.

No specialty is perfect. Read about Emergency med and the tragic cases (e.g., Peds) they have to see that is absolutely PTSD inducing. OBGyn and labor that goes badly (I still remember the shoulder dystocia from med school). Or the PCPs and value they provide in preventive care that is totally under-appreciated (not to mention the lack of respect they receive from specialists and patients alike).

We deal with death, yes, but in Medical Oncology a lot of what we see are older patients who have life limiting diseases as a result of not dying from vascular events decades earlier. We are not pedi-hem onc , but we do have to deal with some young people dying or dealing with life limiting diseases and we have to support each other as best we can during those difficult cases.

Just because you may practice in a place where you feel the unstated expectation is to be on all the time - it doesn't mean you have to play along. My spouse joined a practice where all the partners spent all hours doing MyChart messaging because they wanted to give a concierge service. yet they were employed by a hospital system. Spouse refused to play along and is thriving whereas the partners are talking about early retirement 2/2 burnout. The overacheiver that served you well as a med student and in training can really harm you in practice. Again, these organizations need you and your special skill set and board certification much more than you need them. Set up an away message and make it clear you are off. People will get the hint when you don't reply to the urgent email / Epic chat / text message.

 

[Royster33]

Most of my visits are 99215 and the rest are 99214. I have a handful of 99213 a year. New patients are pretty much all 99205. One of the things about Hem/Onc is that the E&M is generally complex since you're treating with very complicated medications; that's part of the value add as far as compensation goes.

A handful of 99213 a year? Do you see any heme?

 

[ShuperNewbie]

I have no idea but the person OP is quoting from Facebook may work for a system like Kaiser where the company has a vested interest in minimizing visits and making sure you handle as much as humanly possible for free via mychart

This is not at all true. I'ma stop you right there.

No medical system has a vested interest or a rational reason for making people handle as much as humanly possible for free via MyChart. Not even vertically integrated systems like Kaiser, U-Pitt, or Partners. Just because you're your own insurance, your department still gets funded based on billing and demand for your services (this, among other reasons, is why the VA still has to "bill/code" for their services and part of the reason why they're moving away from CPRS). I know that at least at Kaiser, people are actively looking into how to make inbox management more sustainable exactly because they don't want people doing this.

If for no other reason, no one's incentivized to force attendings to work like this because attendings tend to leave as a result of this, and it's an insanely competitive endeavor to recruit oncologists right now.

Shoutout to anyone who needs to hear this. As an attending you are not a trainee anymore. You have power. You have agency. You are valuable. You represent what is often one of a handful of profitable departments in an institution. If someone tries to make you do something you don't feel comfortable with, remember that this is predatory. Just leave. Seriously - you can do that. Given the number of desperate locums calls I get multiple times a day, I don't think you'll have an issue finding a job.

 

[NewYorkDoctors]

If someone is answering 50-100 MyChart messages every day, then something is insanely wrong with how that physician is managing patient expectations.

I’m a rheumatologist. I get *maybe* 5-10 of these a day, most of which get intercepted by my office staff. I make it abundantly clear to patients that the vast majority of issues are to be handled at visits, with only a handful of quick/easy issues to be handled by phone or MyChart (obviously if there is an urgent issue, please call).

The MyChart message is not a wide open highway for patients to ask whatever questions pop into their mind randomly at 8:13pm on a Tuesday night (I dealt with that bull crap as a rheumatology fellow, and I swore up and down I’d do it differently when I was an attending). Make ‘em save it for the visit. If it sounds urgent, make ‘em schedule an appointment. It’s straightforward to control that aspect of this.

lol thats what I end up doing.

but usually this is how I funnel a patient to come back to do more procedures. granted I never "hood wink patients" into doing unnecessary ones. But it's sometimes easier to convince that patient who "still has dyspnea despite a good initial workup" to arrange for more testing (not unnecessary CT scans) which usually includes echo, bronchoprovocation testing, and CPET testing. It "saves me time" to discuss this via chart messaging and sharing them with youtube links explaining this rather than having to "sell them on it in a visit."


but yeah if this were "be my ask jeeves doctor" then no. I would ignore the patient for about 2-3 days before I respond with some reading links.

 

[HemeOncHopeful19]

This is not at all true. I'ma stop you right there.

No medical system has a vested interest or a rational reason for making people handle as much as humanly possible for free via MyChart. Not even vertically integrated systems like Kaiser, U-Pitt, or Partners. Just because you're your own insurance, your department still gets funded based on billing and demand for your services (this, among other reasons, is why the VA still has to "bill/code" for their services and part of the reason why they're moving away from CPRS). I know that at least at Kaiser, people are actively looking into how to make inbox management more sustainable exactly because they don't want people doing this.

If for no other reason, no one's incentivized to force attendings to work like this because attendings tend to leave as a result of this, and it's an insanely competitive endeavor to recruit oncologists right now.

Shoutout to anyone who needs to hear this. As an attending you are not a trainee anymore. You have power. You have agency. You are valuable. You represent what is often one of a handful of profitable departments in an institution. If someone tries to make you do something you don't feel comfortable with, remember that this is predatory. Just leave. Seriously - you can do that. Given the number of desperate locums calls I get multiple times a day, I don't think you'll have an issue finding a job.

Sure, you want to be billing all day, I never said they don't. But if you can hire 10 Oncologists and sign 1000 patients up for your HMO while managing 1/3 of their follow-ups via in-basket it works out better for Kaiser (and worse for your average Joe/Jane Oncologist) than hiring 13 Oncologists and scheduling all of those people for a visit.

 

[osprey099]

Can't most in-basket stuff be handled by a nurse? If something needs to be prescribed, then a PA or NP can do it. At my current fellowship, I rarely see attendings replying to MyChart messages. It's always the nurse or mid-level.

I imagine in the community or private practice, it'll be similar setup?

 

[gutonc]

Can't most in-basket stuff be handled by a nurse? If something needs to be prescribed, then a PA or NP can do it. At my current fellowship, I rarely see attendings replying to MyChart messages. It's always the nurse or mid-level.

I imagine in the community or private practice, it'll be similar setup?

Sing along, you know the words..."it depends".

If I want the right answer given, I'm usually going to have to be the one to answer the question. Even physician partners don't always do the right thing.

So, can I have the MA/RN/NP answer the questions? Yes. Is it often more work for me to let somebody else deal with it and then clean up the mess later? Also yes.

 

[randomhemoncpd]

A handful of 99213 a year? Do you see any heme?

Almost all malignant heme.

 

[gutonc]

Sing along, you know the words..."it depends".

If I want the right answer given, I'm usually going to have to be the one to answer the question. Even physician partners don't always do the right thing.

So, can I have the MA/RN/NP answer the questions? Yes. Is it often more work for me to let somebody else deal with it and then clean up the mess later? Also yes.

And yes...responding to myself again.

I got in this morning to find 6 MyChart messages in my InBasket. Total time to reply to them all? 3 minutes...I timed it. If it's going to take longer than 1m to reply, they're getting a visit (virtual or in-person) to discuss it.

ETA: I have personally found that a lot of the stuff that I get called about has nothing to do with cancer or cancer treatment. But we answer the phone and we call back much more quickly than any of our patient's other doctors do, so they call us for everything. This is another area where boundary setting, both with patients and clinic staff, makes a huge difference in how much BS filters into my InBasket. And it's often just as simple as a nurse saying "no, your UTI symptoms are not related to your hereditary hemochromatosis, you need to call your PCP for that".

 

[ShuperNewbie]

Sure, you want to be billing all day, I never said they don't. But if you can hire 10 Oncologists and sign 1000 patients up for your HMO while managing 1/3 of their follow-ups via in-basket it works out better for Kaiser (and worse for your average Joe/Jane Oncologist) than hiring 13 Oncologists and scheduling all of those people for a visit.

Did you mean to link to a primary care reddit thread? I can't really speak to primary care (although I hear through the grapevine that PCPs at Kaiser get worked pretty hard. Specialists are a bit more protected for a variety of reasons)

And it's often just as simple as a nurse saying "no, your UTI symptoms are not related to your hereditary hemochromatosis, you need to call your PCP for that"

I totally hear that. Establishing key boundaries and acknowledging that you're not a PCP is pretty key. Onc is complicated enough without having to manage vaccine schedules. That said my heart goes out to PCPs. They have a really, really tough job.

 

[sloh]

Did you mean to link to a primary care reddit thread? I can't really speak to primary care (although I hear through the grapevine that PCPs at Kaiser get worked pretty hard. Specialists are a bit more protected for a variety of reasons)


I totally hear that. Establishing key boundaries and acknowledging that you're not a PCP is pretty key. Onc is complicated enough without having to manage vaccine schedules. That said my heart goes out to PCPs. They have a really, really tough job.

FM has it the worst at Kaiser but other outpatient facing specialties with inbox message responsibilities also have it rough. I’m PM&R and used to work for Kaiser. I’ve heard the same from Neurologists and pain docs there. Inbox management is soul crushing.

 

[ShuperNewbie]

FM has it the worst at Kaiser but other outpatient facing specialties with inbox message responsibilities also have it rough. I’m PM&R and used to work for Kaiser. I’ve heard the same from Neurologists and pain docs there. Inbox management is soul crushing.

Yo I hear that. Inbox management is absolutely crushing (it's crushing me right now). Is it better elsewhere?

 

[gutonc]

Yo I hear that. Inbox management is absolutely crushing (it's crushing me right now). Is it better elsewhere?

I spend 20-30 minutes a week on it.

 

[whoknows2012]

Would you have gone the inpatient route (BMT/Leukemia/HCT) if you could go back?

I'm guessing most of us chose heme/onc because we don't like the hospital. I'm a weirdo who likes inpatient medicine. I wouldn't mind inpatient heme/onc unless the salary is literally half the typical 450k-500k the outpatient docs make.

If you work hard it doesn’t need to be and can definitely be close to those numbers even in academics (presuming you work a lot and have rvu incentives)

 

[whoknows2012]

Thank you! Is it becoming more common to get these jobs? And will they pay you like an oncology hospitalist (250k-300k)

Responded to your first question didn’t realize you directly responded to my post. Without being too specific (though happy to discuss via pm) there are several institutions I know of including my own looking for inpatient sub specialty trained docs. Leukemia, lymphoma, cell therapy and bmt. These pay well as a base (often a tad more than the traditional outpatient). Of course they tend to be present at larger academic centers and cancer hospitals so mostly bigger cities and thus maybe Lower range of base but still 250 as a floor is realistic. The way to turn that 250 into something more meaningful is to make sure you have incentives built in that pay for more billing, ie rvu bonus. Not all institutions offer it. I’ve seen as high as 90-100 at hybrid and satellite affiliates to as low as 15-40 at the main sites. Can pm me if you want more info

 

[dozitgetchahi]

And yes...responding to myself again.

I got in this morning to find 6 MyChart messages in my InBasket. Total time to reply to them all? 3 minutes...I timed it. If it's going to take longer than 1m to reply, they're getting a visit (virtual or in-person) to discuss it.

ETA: I have personally found that a lot of the stuff that I get called about has nothing to do with cancer or cancer treatment. But we answer the phone and we call back much more quickly than any of our patient's other doctors do, so they call us for everything. This is another area where boundary setting, both with patients and clinic staff, makes a huge difference in how much BS filters into my InBasket. And it's often just as simple as a nurse saying "no, your UTI symptoms are not related to your hereditary hemochromatosis, you need to call your PCP for that".

I get a lot of this too - “you’re the only doctor I have that listens/you guys call back faster/etc, so I called you first”. No bueno. If your PCP sucks, find another one…but I’m not becoming your surrogate PCP and/or treating your anxiety and UTIs because your PCP isn’t…

 

[MD46]

I get a lot of this too - “you’re the only doctor I have that listens/you guys call back faster/etc, so I called you first”. No bueno. If your PCP sucks, find another one…but I’m not becoming your surrogate PCP and/or treating your anxiety and UTIs because your PCP isn’t…

Ditto, I inherited a practice from a retiring doctor, he would even give patients long term meds like statins, antidepressants, anti-hypertensives etc, first thing I did was transition everything back to their PCPs and establish from the get-go that I won't be doing any PCP stuff, none at all. This makes the in-basket much more manageable. I also tell my RN or NP to just reply, " Please forward the query to your PCP, this is outside our realm of expertise".

 

[Legend of Link]

So would you say overall heme/onc is in middle tier in terms of lifestyle? (Better than cards, GI but worse than allergy, rheumatology, endo etc)

 

[whoknows2012]

So would you say overall heme/onc is in middle tier in terms of lifestyle? (Better than cards, GI but worse than allergy, rheumatology, endo etc)

Probably yes

 

[checkpointinhibitor]

So would you say overall heme/onc is in middle tier in terms of lifestyle? (Better than cards, GI but worse than allergy, rheumatology, endo etc)

ofcourse. it is much worse then allergy, rheum, endo. but pays really well compared to endo, ID and rheum. not sure about allergy.

 

[MifflinDunder]

Thought I would revive this thread with the recent survey done (I'm not sure if we can post links, so I’ll post a screenshot)

Heme-onc easily takes the cake, coming in at #1. I'm now almost done my first year as a fellow, and honestly, this isn't even a surprise.

For the ones practicing for a couple of years now, do you feel that you're getting better at this?

How many of you complete and sign your notes while in the room with the patient?

Have you implemented AI at all, and is it helping?

Any particular health systems you've encountered where they try to minimize some of this (I read up there that Kaiser may or may not be better)

Any field where you feel this might be better controlled? I can tell benign heme would be the best for this, by far. From solid onc side, the more GI onc you see, the more work you'll probably have off hours.

 

[gutonc]

Thought I would revive this thread with the recent survey done (I'm not sure if we can post links, so I’ll post a screenshot)

View attachment 401365

Heme-onc easily takes the cake, coming in at #1. I'm now almost done my first year as a fellow, and honestly, this isn't even a surprise.

For the ones practicing for a couple of years now, do you feel that you're getting better at this?

Yes. I’m over a decade out and extremely efficient.

How many of you complete and sign your notes while in the room with the patient?

Not usually, but I finish about 80% of them before seeing the next patient (on time) and 95% before I leave for the day. The few I don’t finish are because I’m in a hurry to get out, exhausted from the day or just annoyed about that particular encounter and need to walk away from it for a bit.

Have you implemented AI at all, and is it helping?

Yes and yes. It’s also why I don’t finish my notes in the exam room anymore. It takes the AI agent a minute or so to spit out the note once I stop it listening. Usually by the time I get back to my desk, the note is ready and I need 30-90s to review and edit it. I do chart some things in the exam room, but I do think that the AI scribe allows me to better interact with the person in front of me while not losing efficiency.

Any particular health systems you've encountered where they try to minimize some of this (I read up there that Kaiser may or may not be better)

Any field where you feel this might be better controlled? I can tell benign heme would be the best for this, by far. From solid onc side, the more GI onc you see, the more work you'll probably have off hours.

Why do you say that?

I personally think it all comes down to the individual physician. An inefficient doc will be inefficient doing benign heme or GI Onc. I suspect that you’re extrapolating from your mentors and not from reality.

My GI Onc fellowship mentor never left clinic with an open note and rarely stayed more than 3 minutes after her last patient.

 

[osprey099]

@gutonc are you using Dax copilot (epic integrated AI scribe) or a different scribe software and then copy/pasting into epic?

 

[gutonc]

@gutonc are you using Dax copilot (epic integrated AI scribe) or a different scribe software and then copy/pasting into epic?

Yes. I might be able to get better results from a different AI scribe but it's not worth the trouble.

 

[IM_to_ortho_hopeful]

Just work somewhere without epic. No inbox. Problem solved. Cerner, allscripts are your new best friend.

 

[HemeOncHopeful19]

Just work somewhere without epic. No inbox. Problem solved. Cerner, allscripts are your new best friend.

It really is a super unappreciated downside of Epic IMO

 

[gutonc]

Just work somewhere without epic. No inbox. Problem solved. Cerner, allscripts are your new best friend.

There are still patient calls to answer. It's just much less efficient.

 

[HemeOncHopeful19]

There are still patient calls to answer. It's just much less efficient.

My nurse will make 95% of calls for me, I am guessing that isn’t the norm at many places?

 

[dozitgetchahi]

There are still patient calls to answer. It's just much less efficient.

Yeah, I’ve never understood this line of reasoning.

Lousy EMRs (of which Allscripts is definitely one) don’t get you around the inbox work. They just make it a lot less efficient, and a lot more likely that you’re going to have to deal with that same work on paper rather than through the EMR - which is something I’d rather avoid.

This also may be the first time in recorded history anyone has expressed a preference for Allscripts to Epic. Aside from the inbox, Allscripts is a dog of an EMR - slow as molasses, kludgy, complicated, not intuitive etc. I’ve never met a doc using Allscripts that didn’t detest it.

 

[gutonc]

My nurse will make 95% of calls for me, I am guessing that isn’t the norm at many places?

They cover many of them for me as well. But they obviously can't manage everything.

I think there's a lot of drama here about how horrible the inbasket is. If I can't answer a phone or MyChart message in a sentence, they get an appointment with me at my convenience.

 

[HemeOncHopeful19]

Yeah, I’ve never understood this line of reasoning.

Lousy EMRs (of which Allscripts is definitely one) don’t get you around the inbox work. They just make it a lot less efficient, and a lot more likely that you’re going to have to deal with that same work on paper rather than through the EMR - which is something I’d rather avoid.

This also may be the first time in recorded history anyone has expressed a preference for Allscripts to Epic. Aside from the inbox, Allscripts is a dog of an EMR - slow as molasses, kludgy, complicated, not intuitive etc. I’ve never met a doc using Allscripts that didn’t detest it.

Disagree here especially as millennial generation becomes more of our patient population

People don't like making phone calls and having to talk to people. I believe it filters out a solid chunk of silly questions that may end up waiting until the next appointment or spontaneously resolve themselves

 

[dozitgetchahi]

Disagree here especially as millennial generation becomes more of our patient population

People don't like making phone calls and having to talk to people. I believe it filters out a solid chunk of silly questions that may end up waiting until the next appointment or spontaneously resolve themselves

What you’re talking about isn’t the “inbox” per se, it’s the MyChart message.

I dislike MyChart messages as much as anyone else, but that feature is by no means unique to Epic. Even back when I was at a job that used the otherwise crappy Centricity EMR (which did not have an “inbox”), patients could still send messages to the doctor through the EMR. If you want to avoid these messages, then set boundaries with the patients, have your staff handle most of the messages, or even negotiate to have the messaging function shut off for your office (I have heard of doctors getting this put into their contracts).

The rest of the “inbox” is simply a way for the EMR to gather basic tasks for you to handle in one place. And that is just fine, in my opinion. Epic does this pretty well.

 

[IM_to_ortho_hopeful]

Disagree here especially as millennial generation becomes more of our patient population

People don't like making phone calls and having to talk to people. I believe it filters out a solid chunk of silly questions that may end up waiting until the next appointment or spontaneously resolve themselves

Agree. There’s a huge difference in activation energy between texting your doctor (10 seconds) and having to call deal with a secretary that routes you to a pager etc (3-5 min endeavor).