Is it possible to practice as subspecialist + primary care?

[NewYorkDoctors]

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Hello:

Is it possible to practice outpatient cardiology and primary care?

Now I have been made aware that if one were to do this publicly, then one will not get many referrals for fear of stealing the patient. Moreover, it is usually the ones who cannot attain a sufficient referral base (for whatever reason) who need to get their own patients (apparently this is done in less populated places for Endocrine and Primary care)

But let's say I end up as a half way decent cardiologist down the line with a good referral base and patient clientele. However, I still very much like the internal medicine aspect of preliminary diagnosis and workup. I know being a full time cardiologist will very busy and demanding... as will be keeping up with all of the Internal Medicine guidelines...

But just humor me for a second, is there a way to work primarily as a cardiologist and then "choose" some "VIP" patients from scratch (not to steal from other physicians; also to avoid taking on too many socioeconomic cases) for primary care? Or at least adopt those with chronic and debilitating cardiac issues for primary care as well?

Thanks for your input

 

[gutonc]

Many sub-specialists, particularly cardiologists, pulmonologists and oncologists will assume primary care duties when the issue that falls under their purview (and it's complications) is the patient's major problem. Like a cardiologist taking over PC in someone where CHF is their major issue.

But trust me when I say that, by the time you get done with fellowship, you're not going to want to have anything to do with most primary care issues.

And FWIW, if I had to choose between a panel full of Medicaid medical disasters and the patient population you're talking about, I'd choose the former in a hot second. The folks you're talking about are entitled, needy and have a different specialist for every little complaint.

Do not want.

 

[DIce3]

Is it possible to practice outpatient cardiology and primary care?
...yes

Now I have been made aware that if one were to do this publicly, then one will not get many referrals for fear of stealing the patient. Moreover, it is usually the ones who cannot attain a sufficient referral base (for whatever reason) who need to get their own patients (apparently this is done in less populated places for Endocrine and Primary care)
...you will likely not get many cardiology consults if you are known also as a general internist

But let's say I end up as a half way decent cardiologist down the line with a good referral base and patient clientele. However, I still very much like the internal medicine aspect of preliminary diagnosis and workup. I know being a full time cardiologist will very busy and demanding... as will be keeping up with all of the Internal Medicine guidelines...
...it is doable

But just humor me for a second, is there a way to work primarily as a cardiologist and then "choose" some "VIP" patients from scratch (not to steal from other physicians; also to avoid taking on too many socioeconomic cases) for primary care? Or at least adopt those with chronic and debilitating cardiac issues for primary care as well?
...yes

But trust me when I say that, by the time you get done with fellowship, you're not going to want to have anything to do with most primary care issues.
... ok, but you may get so tired of seeing patients mismanaged by their primary doctors, or worse, midlevels, that you will want to take over as the primary and fix the mess your patients' are in.

 

[gutonc]

... ok, but you may get so tired of seeing patients mismanaged by their primary doctors, or worse, midlevels, that you will want to take over as the primary and fix the mess your patients' are in.

That's what the phone is for.

 

[NewYorkDoctors]

Thanks for your reply.

If I were able to gain access to select clientele who are actually adherent and listen to good advice and are generally healthy for primary care? Okay, yes that would be everyone's dream, why would I even ask?

 

[jdh71]

I don't know how'd you'd have time to do both honestly. I kind of feel like diluting my patient pool with PCP patients will probably make me a worse pulmonologist and a worse primary care provider.

I do handle meds related the issues that may be having problems such as PPIs, or nasal decongestants on a basic level for cough, but I won't touch someone's blood pressure meds, or their stuff for cholesterol or diabetes. I could give af about that stuff.

I know our transplant docs at the U take on PCP responsibilities on post-lung transplant patients. That's probably the kind of niche you could find where you can do both without too much extra difficulty.

 

[Cornell IM]

Hello:

Is it possible to practice outpatient cardiology and primary care?

Now I have been made aware that if one were to do this publicly, then one will not get many referrals for fear of stealing the patient. Moreover, it is usually the ones who cannot attain a sufficient referral base (for whatever reason) who need to get their own patients (apparently this is done in less populated places for Endocrine and Primary care)

But let's say I end up as a half way decent cardiologist down the line with a good referral base and patient clientele. However, I still very much like the internal medicine aspect of preliminary diagnosis and workup. I know being a full time cardiologist will very busy and demanding... as will be keeping up with all of the Internal Medicine guidelines...

But just humor me for a second, is there a way to work primarily as a cardiologist and then "choose" some "VIP" patients from scratch (not to steal from other physicians; also to avoid taking on too many socioeconomic cases) for primary care? Or at least adopt those with chronic and debilitating cardiac issues for primary care as well?

Thanks for your input

Yes, this happens a fair bit in NYC where patients see a sub-specialist for all of their primary care, too. Usually they have high end patients, and probably patients like it so they can boast that their PCP is 'also a cardiologist'. Some sub-specialists that routinely deal with multi-organ dysfunction (pulm, cards etc.) are probably better suited as PCPs than others (allergy, rheum etc.).

Private practice will essentially be gone in the next 10 years as more of them join hospitals out of necessity to survive, so this set-up will become less common.

 

[Kahreek]

the objective answer is yes, the true answer after you have completed your education and ask yourself is: "no"

 

[DrWBD]

It is feasible to be a primary care physician as a specialist. It is much much harder to be a GOOD primary care physician as a specialist.

 

[LoudBark]

www.imcnorthshore.com

The above link is to a site for a cardiologist in the Chicago area that also practices primary care.
This is a good example of what you are looking for.

Dr. Katsamakis trained in interventional cardiology at Rush, but also is a primary care doctor.

He is not just a cardiologist who provides primary care to his heart patients who need a primary care doctor, but he provides primary care to anyone, regardless if they are a cardiac patient or not.

There are some specialists that may provide primary care to their subset of patients (the rheumatologist who provides primary care to their RA or SLE patients.....but not just to anyone).......but Dr. Katsamakis takes all patients.

This is a unique set up. It really can't be done if you are in a cardiology group. It is best for the solo practitioner, but it can certainly be done if you want to do it.

Hello:

Is it possible to practice outpatient cardiology and primary care?

 

[jabreal00]

It would be tough. I am a gastroenterologist. There are some complex GI patients that I take care of many primary care related issues (IBD or chronic viral hepatitis). I managed their vaccines, replace B12, iron ets. I've even managed the diabetes in someone who had unmasking of diabetes on steroids for a Crohn's flare. However, it would not be feasible for me to also see purely primary care patients in addition to busy referrals for gastroenterology service. I love internal medicine as well but primary care can be fairly mundane and much lower acuity than what an internist is typically trained for. I was an internist for one year prior to sub-specializing. 20-30% of my patients were internal medicine worthy (chronic adult ailments). 70-80% could be easily managed by a mid-level or even a very competent RN. You'd see a lot of people for chronic musculoskeletal complaints (back, neck and knee pain), plenty of URIs, plenty of headaches and filling out forms for disability insurance of handicap tags.

As a cardiologist you will see and be able to do plenty of internal medicine for patients referred for complex cardiovascular issues. There's a lot of physiology in chronic cardiovascular chronic ailments that can affect multiple organs. Many PCPs may not have the time or the expertise to deal with such patients and would gladly let you take the helm. Oncologist (advanced cancer) and nephrologist (dialysis or transplant patients) often take over internal medicine related issues in complex patients. Same goes for transplant hepatologists or GI docs who specialize in IBD.

But if you also did primary care in those without any cardiovascular disease processes you would quickly get inundated with non cardiology work.

 

[NewYorkDoctors]

Thanks for your answer jabreal00. That was actually very helpful.
Indeed, I do not want to deal with too much of the "non-academic" IM outpatient workup. I am willing to do it, but only if these social and "miscellaneous" issues stem from real disease. Convincing patients to to sign pain contracts, doing pill counts, checking ISTOP (NYS thing), and then firing patients is too tedious a process..

So ideally I suppose I can label myself as IM/CV for the patients, promise other PMDs I will not steal their patients, communicate with other PMDs how much general IM I can do with patients (and of course fax them very detailed records... I have seen partnerships dissolve over this), and for new patients that I stumble upon who have real and interesting issues without previous PMDs to be worked up I may just take them aboard.

But your last line was very revealing at helpful.

 

[babdoc]

I'd say it'd be hard for our generation of docs. Everything is segmented. My dad is a GI doc that worked in a small multi-specialty group for years. They had a couple GI docs, a couple cardiologists, a pulmonologist, and a couple of general internists. They all shared the primary care for the group and had the specialty referrals built in. Mind you, they were in a small city and all docs were in private practices that contracted with the hospital. After 15 or 20 years, the hospital bought all the practices out and the whole specialty + primary care thing went out the window. It combined the small groups of subspecialists into larger departments and split my dad's multi-specialty group apart. I guess it makes more reimbursement sense to do your subspecialty only, but they lost the idyllic multi-specialty team practice in the process. If you enjoy both and can get it to work, I can see the appeal.