Is outpatient really that bad?

[NewYorkDoctors]

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I try my best to take consults as long as they're not egregious, but if I see “fatigue” or “hair loss” or “weight gain” then I refuse the consult. I’m the only one in town so if people want to drive 45-90 min away to argue with a rheumatologist about their symptoms of existence then so be it.

i have noticed that the private practice docs police their google reviews much much more than hospital employed. Usually hospitals collect their own satisfaction scores so there’s an outlet for patients to voice their dissatisfaction. However, some still go to Google to trash your name.

The major physician owned pcp group in a major metro in my state keep a tight ship with their google reviews. All their docs are 4.5-5 stars on google and I suspect they ask all their happy patients to submit reviews in order to drown out the angry Karens.

for me it's a matter of pride. Aint no body better be ****talking me because Ken or Karen did not feel the concierge pampering. You wanna dish the the heat and eat some ghost peppers? well you better be ready when it's burning coming out the other orifice!

I tell these people to go to Northwell health (a local NYC/LI large health system that focuses primarily on patient satisfaction first and foremost)

Other PP doctors rely on the reviews to drive business and revenue. This is not so for me.
I am in a part of town that has a "drought" of pulmonologists. Even though NYC has a lot of pulmonologists, most new yorkers do not want to go anywhere out of their comfort zone if they can help it.

I don't do that "5 minute mill" crap. primary care can pull that off for "established long term patients who have medicaid and zero deductible and come all the time anyway so every visit is diluted." For my pulmonary patients, every new patient is a one hour visit and I do a ton of talking. If I do not do the talking ahead of time, then the patients come back with "Y I NO BETTER YET? Y???" those 99213 follow up visits are NOT worth my time and overall is less efficient patient care.

basically new yorkers are ****ed in the head honestly (coming from someone who lived in NYC for 20+ years now). they have this "constant rush to go nowhere in particular" and have this kind of tough person confrontational mentality at all times. I have just learned how to deal with it accordingly.

Treat the patient right... then let the have it hard if they are out of line.



also in general (not just patient reviews but think amazon reviews for something you brought yourself), most peple do NOT go out of their way to leave a 5 star review. Most people are too selfish, too self absorbed, and too busy with life to leave apositive review. But you bet they will want to leave a bad review in an attempt to "regain the lost power they felt from the experience." It's really sad these people need to get some online BetterHelp and keep chugging that Diet Cope.

 

[sloh]

Is it common for PCPs to get part of their salary tied to patient satisfaction?

I assume you practice in a major metro area?

Definitely for Kaiser. And their docs will also fail to make partnership if patient satisfaction scores are too low.

 

[VA Hopeful Dr]

I try my best to take consults as long as they're not egregious, but if I see “fatigue” or “hair loss” or “weight gain” then I refuse the consult. I’m the only one in town so if people want to drive 45-90 min away to argue with a rheumatologist about their symptoms of existence then so be it.

i have noticed that the private practice docs police their google reviews much much more than hospital employed. Usually hospitals collect their own satisfaction scores so there’s an outlet for patients to voice their dissatisfaction. However, some still go to Google to trash your name.

The major physician owned pcp group in a major metro in my state keep a tight ship with their google reviews. All their docs are 4.5-5 stars on google and I suspect they ask all their happy patients to submit reviews in order to drown out the angry Karens.

Those are fair to refuse.

The local guy who refused my internist wife's 70 year old patient with a 1:320 ANA and swollen hands with erosive changes on x-ray is not OK to refuse.

My hospital does its own in-house patient satisfaction scores. If you score all 5's it then offers to port that review to Google for you. If you don't do all 5's, it doesn't offer.

 

[VA Hopeful Dr]

I feel for you and I want to say pcp have a hard job .

But I do pcp also . Yes I have midlevels to help me filter the garbage and do the TLC . But when I see patients for pcp and they have vague nonspecific symptoms , I just “do the whole workup” no matter how tedious or annoying . All those headache patients (I hate neuro ) I’m doing as much neuro exam , headache diaries , and taking the extra step with doing funduscipic exam (the retinavue retinal photography is great ) and ocular sono (I have a linear probe so easy enough to measure ocular nerve diameter ) . Then I get the auth for MRI if “red flags “ . Then it’s mostly a migraine . Those who go to neurology come back confused and dazed . I end up having to use Nurtec or amovig or something myself and they get better !

Anyway community PCPs and community specialists around me leave much to be desired . The goal seems to be “cut corners take shortcuts to maximize the revenue / time spent ratio “ and assume “someone else will take care of it .”

My approach is then Buck stops here with me

Anyway I have been having more success with chronic cough (most of which gerd cough ) by a) doing a bronchoprovocation up front now b) and just doing the pcps job of going through the gerd diet / lifestyle in great detail with print outs , ordering them wedge pillows as dme , and instructing them that a PPI must taken daily and not PRN for the month or two , must be taken thirty minutes before a meal as proton pumps are maximally expressed while eating , (all “little things “ I’m sure no one told them before …)



Anyway back to inhalers , I have a lot of inhalers in my exam room . Some are demos , some are old samples , and others are ones I prescribed and picked with my personal insurance . For the demo inhalers with nothing in them I often just demostrate by putting it on my mouth .
The real med inhalers I often pantomime it

Then if I plan to prescribe something I have samples for (trelegy Breztri airsupra stiolto are the samples that I have now ) , I’ll have the RT open one up and go over it .


I was inspired to always do this in med school. On the family medicine rotation was an old school doctor who would always go over technique with his patients. One of the great “old school “ doctors whom did it all himself , took no shortcuts and , always had his patients first .


As for the consumer stuff and google reviews , I whole heartedly agree with that crud . As I am my own practice and boss , I have gone to town shredding the $hit out of some negative reviews who did so for the stupidest of reasons . My reviews are mostly 5s . A few are 1 because of some “I didn’t get pampered or spoiled by the doctor .” I go Kevin Durant with his burner accounts and mercilessly reply and rip into these patients (without revealing PHI of course ) . I’m not a ****ing restaurant with a thin profit margin and no manager is “apologizing to you and promising to make a better experience .”

I have also gone to colleagues google reviews in which colleagues replied firmly (but more courtesouly than I do ) to a bad review stating the real story and not the libel version . I comment “lol this patient got owned . What a nothingburger . Hey you want some Diet Cope also ? Lololol “

Are you always talking about the 99213 mills in NYC.

Can't expect quality care with that mindset.

 

[NewYorkDoctors]

Are you always talking about the 99213 mills in NYC.

Can't expect quality care with that mindset.

that is the "standard of care" in NYC outside of the academic medical centers and concierge / DPI practices.

sad but true.

the only way "some semblance" of quality is achieved is patients come literally every 1-4 weeks all the time for little things. each time do something that adds up over time.
while this form of "makes more money and costs more money" approach might be acceptable, I have noticed many of these patients don't even have their A1c, UACR, LDL at goal, their BIRADS3/4 is floating aroud, their TIRADS4/5 nodules are floating around, they had tubular adenomas before but PCP is using stool FOBT to continue screening, etc... at first I thought hey maybe the patinet is nonadherent... then I probe into it and ask patient and patients invariably tell me "oh my last doctor told me it was fine!"

there are also patients who are on ergocalciferol 50,000 q1 week FOREVER because their insurance does not cover OTC calcium+D. heaven forbid a patient has to spend some money (or use the OTC card for Medicare Medicaid patients) to actually BUY AN OTC MED!
instead i get patients whose 25D is 100+. wonderful.

not only internal medicine/primary care but also any other subspecialty that is nonprocedural

some of the psych practices around me are so bad it's satirical.

Patients have told me there is no psychology therapist around and the psychiatrist will do a 5 minute psych visit only for initial consultation.

"are you sad? do you want to kill yourself? take these pills. don't argue with me! (insert some gaslighting comments to the patients"


while I am not against doctors who make a lot of money, I am against it when it is being done at the expense of the patient.
far too many non-academic doctors "lose their interest" as they get older.
their interest and gaf levels tends to be inversely correlated with their waist circumference and body fat %. sad

Making a ton of money in service of the patient is fine by though

 

[sloh]

How do those practices still keep attracting patients in NYC? Isn’t competition stiff there?

 

[NewYorkDoctors]

How do those practices still keep attracting patients in NYC? Isn’t competition stiff there?

Instant quick access.
Spoil the patient rotten . Convenience all else does not matter .

To some patients sure beat three month wait time to see pcp and no urgent acute hours

 

[gutonc]

someone said they called and blasted a pcp over a referral like that. if i get a call like that from a specialist they are going to get it.

TBH...I'm fine with the stupid referrals. If you have a minute to call/text/Teams/InBasket me ahead of time so that we can get any additional workup done before they see me and make their time with me count, that's great.

If all you have time for is a 1 sentence explanation of why you're referring them, that's fine, just please do that. "Patient wants to talk to heme about why their MCHC is high despite otherwise normal CBC" can get me in and out of the room, and get them off your back about it, in 10 minutes.

I know how busy you all are. I know how hard you're getting pulled and from how many different directions. I'm more than happy to help you out where I can. But you investing 30 seconds in setting all 3 of us (you, me and our patient) up for success will save all of us a ton of time and frustration in the long run.

 

[Splenda88]

Yes. Its a Medicare quality metric so its becoming increasingly common to tie it into bonus structure.. Between this and just getting tired of fighting with patients, I will typically acquiesce to requests if a) doesn't involve chronic controlled meds, b) isn't fraud, or c) isn't going to hurt them.

I'm in a small-ish town in upstate SC (not Greenville).

Our healthcare system is broken. Patients have too much power. The most unrealistic patients are the ones that are non compliant. They are quick to call patient relation on you.

 

[NewYorkDoctors]

TBH...I'm fine with the stupid referrals. If you have a minute to call/text/Teams/InBasket me ahead of time so that we can get any additional workup done before they see me and make their time with me count, that's great.

If all you have time for is a 1 sentence explanation of why you're referring them, that's fine, just please do that. "Patient wants to talk to heme about why their MCHC is high despite otherwise normal CBC" can get me in and out of the room, and get them off your back about it, in 10 minutes.

I know how busy you all are. I know how hard you're getting pulled and from how many different directions. I'm more than happy to help you out where I can. But you investing 30 seconds in setting all 3 of us (you, me and our patient) up for success will save all of us a ton of time and frustration in the long run.

totally agreed

in my case, many of the local NYC community PCPs (I do not want to sound like I hate PCPs. I do not. I am one part time. I just hate the local PCPs in NYC who run 99213 mills and talk **** and can't walk the walk) not only do NOT do this but ACTIVELY gaslight the patient. I cannot for the life of me understand why they do this other than a "get the **** out of my office now" tactic or a "i'm so full of myself and too proud to say I don't know the details but i won't admit it". even then that's very underhanded.

I did not believe it at first but i carefully probed the patient... "so after showing you this 3mm nodule that has been stable for 3 years, what exactly did your PCP tell you?"

"HE TOLD ME IT COUDL BE CANCER!"

I said did not say anything else?


this sounds satirical and like a "one off" issue that I might be blowing out of proportion

nope this is my day to day.

NYC is truly a clown world in more than one ways.

 

[hotsaws]

As a young A/I doc building a practice, I welcome the referrals. I actually market myself to PCPs, GI, Derm, and ENT for that very reason. My pitch is basically along the lines of "I know you can manage the simple rhinitis, asthma, rash, etc. But I'm more than happy to take it off your hands if it frees up even a couple minutes of your time." and "We both know all these IBS patients don't actually have food allergies, but please send them my way and I'll deal with it" and "don't bother with any sort of pre-workup, just send em."

I'm lucky that in my field, these are both lucrative and relatively simple. Most of them will get (and very much want) the allergy testing. It's a win win because even simple asthma can be a pain in the *** for PCPs with how stupid inhaler prescribing/coverage/prior auth stuff can be. You can order a food panel from the lab but watch a couple false positives come back and now you've got labs to interpret and explain and all that garbage....or just send them to me and wash your hands of it. I also get plenty of young, healthy, normal patients who are entering that age of life (30s, typically) where they don't have a PCP but probably should establish even for just annual labs/check up -- I do my best to send these patients in the direction of the PCPs who send me patients. Same with those who self refer to me first but end up needing to see derm/gi/ent/pulm -- I try to plug them in with the private docs that I know and like. It's nice to be a part of a network of docs who still practice in a physician-owned setting and try to keep these patients plugged in with quality docs outside of the corporate/PE owned places.

The google review pressure is real. I'm newish in the area and I need 5 star reviews to remain competitive (or at least I think I do). There's a customer satisfaction pressure that sucks when it's some entitled cluster Bish type person. I'm sure most people are like me and don't go out of their way to leave a positive review when they have a good experience. I try not to shamelessly solicit them but when a patient makes a point to mention how grateful or happy they are, I do reply with something like "well you know I hate to come off like a businessman plugging my marketing but the best way to show your gratitude is to leave a google review reflecting what you told me today." So far I'm killing it in the google review space.

 

[NewYorkDoctors]

As a young A/I doc building a practice, I welcome the referrals. I actually market myself to PCPs, GI, Derm, and ENT for that very reason. My pitch is basically along the lines of "I know you can manage the simple rhinitis, asthma, rash, etc. But I'm more than happy to take it off your hands if it frees up even a couple minutes of your time." and "We both know all these IBS patients don't actually have food allergies, but please send them my way and I'll deal with it" and "don't bother with any sort of pre-workup, just send em."

I'm lucky that in my field, these are both lucrative and relatively simple. Most of them will get (and very much want) the allergy testing. It's a win win because even simple asthma can be a pain in the *** for PCPs with how stupid inhaler prescribing/coverage/prior auth stuff can be. You can order a food panel from the lab but watch a couple false positives come back and now you've got labs to interpret and explain and all that garbage....or just send them to me and wash your hands of it. I also get plenty of young, healthy, normal patients who are entering that age of life (30s, typically) where they don't have a PCP but probably should establish even for just annual labs/check up -- I do my best to send these patients in the direction of the PCPs who send me patients. Same with those who self refer to me first but end up needing to see derm/gi/ent/pulm -- I try to plug them in with the private docs that I know and like. It's nice to be a part of a network of docs who still practice in a physician-owned setting and try to keep these patients plugged in with quality docs outside of the corporate/PE owned places.

The google review pressure is real. I'm newish in the area and I need 5 star reviews to remain competitive (or at least I think I do). There's a customer satisfaction pressure that sucks when it's some entitled cluster Bish type person. I'm sure most people are like me and don't go out of their way to leave a positive review when they have a good experience. I try not to shamelessly solicit them but when a patient makes a point to mention how grateful or happy they are, I do reply with something like "well you know I hate to come off like a businessman plugging my marketing but the best way to show your gratitude is to leave a google review reflecting what you told me today." So far I'm killing it in the google review space.

yep that's nice

having some workup is nice i guess... but the lag time from referral to seeing specialist with "unclear results" wil drive a patient to Dr Google and ChatGPT.

 

[WIFEL585]

I switched from outpatient to now inpatient. They both have their pros and cons. I'd say the main downside to each is the meddling of low intelligence administrators with MBA/business degrees. Unfortunately due to the health care system in the US there's too much interference by these non-medical (therefore unqualified to give input on medical issues) people. I'd probably prefer inpatient to outpatient but they're both doable.

 

[NewYorkDoctors]

one of the biggest "consumer driven trends" in healthcare is how patients seem to expect "same day instant answers."

I tell patients for some basic issues, this can be achieved. but more complex, multi-system, chronic issues tends to need some more workup.

While many patients get it after explaining for about 15-20 minutes, it does not change the fact that many patients seem to have "
instant answers" like chatGPT. This is not how it works for complex issues.

I give patients a differential (with the frequent House MD style fellows interrupting - no it's not that because of this that or that) and inform the patients about how to workup.

 

[Drrrrrr. Celty]

totally agreed

in my case, many of the local NYC community PCPs (I do not want to sound like I hate PCPs. I do not. I am one part time. I just hate the local PCPs in NYC who run 99213 mills and talk **** and can't walk the walk) not only do NOT do this but ACTIVELY gaslight the patient. I cannot for the life of me understand why they do this other than a "get the **** out of my office now" tactic or a "i'm so full of myself and too proud to say I don't know the details but i won't admit it". even then that's very underhanded.

I did not believe it at first but i carefully probed the patient... "so after showing you this 3mm nodule that has been stable for 3 years, what exactly did your PCP tell you?"

"HE TOLD ME IT COUDL BE CANCER!"

I said did not say anything else?


this sounds satirical and like a "one off" issue that I might be blowing out of proportion

nope this is my day to day.

NYC is truly a clown world in more than one ways.

Idk if this is medicolegal liability or that people are just so overwhelmed and inundated they cannot actually do basic medicine anymore or maybe more insidiously the fact that folks will and can order labs without regard to their implications or the frank reality that even the best test has both a certain positive and negative predictive ability.

It goes beyond the simple reality that a person should be able to look up Fleschier guidelines without 5 seconds. It's the fact that incidental imaging and lab findings without clinical correlates are not the backbone of how medicine works. And yet it is now where we find ourselves.

 

[NewYorkDoctors]

dont get me wrong, pulmonologists order far more CT scans of the chest than other providers (within IM that is). but usually its done with the proper guidelines for screening or with a reasonable rationale for diagnostic purposes.

If a PCP told me "i tried to tell the patinet its likely benign but patient wants to see a specialist" I would say "sure cool happy to help."

that is not what happens.

 

[NewYorkDoctors]

Idk if this is medicolegal liability or that people are just so overwhelmed and inundated they cannot actually do basic medicine anymore or maybe more insidiously the fact that folks will and can order labs without regard to their implications or the frank reality that even the best test has both a certain positive and negative predictive ability.

It goes beyond the simple reality that a person should be able to look up Fleschier guidelines without 5 seconds. It's the fact that incidental imaging and lab findings without clinical correlates are not the backbone of how medicine works. And yet it is now where we find ourselves.

agreed.

the deductive vs inductive reasoning debate.

i would say the "classic" way of doing things with deductive reasoning may not be feasible unless you are a front line provider who also happens to be the primary team. i cannot really think of this being the case within IM unless its the MICU who takes a shock patient that the ED resuscitated, lined up and tubed and then asked for admission. The other situation is an internist who "gives a ****" who likes to work things up.

but many times the internal medicine hospital admission is inductive reasoning. Worku pdone by ED. Subspecialists clled and some workup already done.
or an IM subspecialist who gets a referral outpatient and has imaging, labs etc.. done.. has to build up the picture


That building up takes time.... and sometimes whteher its administrative burden put on by a hospital system or a private doctor who is older and no longer GAF because he/she found out can just submit billing codes and get paid with no note (unless audited).. this does not always happen

 

[Drrrrrr. Celty]

dont get me wrong, pulmonologists order far more CT scans of the chest than other providers (within IM that is). but usually its done with the proper guidelines for screening or with a reasonable rationale for diagnostic purposes.

If a PCP told me "i tried to tell the patinet its likely benign but patient wants to see a specialist" I would say "sure cool happy to help."

that is not what happens.

I think that's fine. You know what to do with what you find and you're ordering it within an indication.

Within endocrinology I am constantly left scratching my head about whether or not the global manufacturer of an assay ****ed up ( It has happened last twice since I was in fellow where the FT4 assay was inappropriately produced and read wrong - thus sending me at least 20 consults for central hypothyroidism in completely euthyroid patients. And labs which are incompatible with clinical findings ex. pt not only steroids, normotensive, no weight loss with a Cortisol of 3 at 8am, checked because they felt stressed, which then needed to be scheduled for stim tests with baselines that already exceeded 15.

 

[NewYorkDoctors]

one annoying thing I see some doctors aroud me do is try to get a CT chest by getting a "backdoor low dose CT scan."
The prior auth questions for LDCT screening are very easy usually
Just click yes on 20 pack years, current/quite less than 15 yaers ago, no debilitating medical issues and approved
only thing is the radiology center ha to also ask the patients on pack years.
If the patient says i dont smoke. the scan is rejected because the ordering doctor/office lied about the prior auth to get an "easier time."

Getting a regular CTC authed needs documentation of chronic cough, hemoptysis, abnormal CXR, or follow up from prior CTC for some abnormality.

I have seen patients come to me with 3mm nodules found on LDCT screening - when I asked patient so how much you smoke? I am a never smoker.
uh huh.....

I've tried to call radiology but they are unable to change the report as that would lead to an eventual audit and return of the money they charged.


sigh...


I just make it abundantly clear in my note what the patient said and then I just shift over to Fleischner criteria...


but yeah... "gaming the system...."

 

[VA Hopeful Dr]

one annoying thing I see some doctors aroud me do is try to get a CT chest by getting a "backdoor low dose CT scan."
The prior auth questions for LDCT screening are very easy usually
Just click yes on 20 pack years, current/quite less than 15 yaers ago, no debilitating medical issues and approved
only thing is the radiology center ha to also ask the patients on pack years.
If the patient says i dont smoke. the scan is rejected because the ordering doctor/office lied about the prior auth to get an "easier time."

Getting a regular CTC authed needs documentation of chronic cough, hemoptysis, abnormal CXR, or follow up from prior CTC for some abnormality.

I have seen patients come to me with 3mm nodules found on LDCT screening - when I asked patient so how much you smoke? I am a never smoker.
uh huh.....

I've tried to call radiology but they are unable to change the report as that would lead to an eventual audit and return of the money they charged.


sigh...


I just make it abundantly clear in my note what the patient said and then I just shift over to Fleischner criteria...


but yeah... "gaming the system...."

Yeah that's called fraud and I can't imagine that blatant of a lie in the medical record.

 

[NewYorkDoctors]

independent doctors not part of a health system are not beholden to any rules unless the insurances audit them and threaten to take payment back.

another issue in the community is when another doctor (does not matter specialty) has the patient deliver a message to me from the other doctor...

this is something along the lines of patient telling me "so my other doctor asks me to ask you to send your results to them or asks you to also check my blood for X,Y,Z."

I would say well patient THX1138, I have efax proof here in this efax log of mine that shows success to doctor 24601. I guess doctor 24601 is being paid to LEAD and not to READ.

In addition, doctor 24601 could have picked up the phone... or if that was too much effort sent an efax or email to me... now if you excuse me I going to go Javert on your other doctor now.


Addendum: i get a fair number of referrals for "My PCP tried to get auth for CTC but got denied saying only a specialist can get it."
I don't know why they bothered to gaslight the patient like this. To save face?
Thank you for the easy referral.
But one time the patient brought in the denial letter. I read it carefully and the explanation says "while we deny 71271 ldct for lung cancer screening, we will approve 71260 CTC without contrast if someone calls us and requests it."

i thought gosh... seriously now....

to virtue signal to the patient, I dial that number and say im the doctor asking for the alterate study. approved done.

 

[dozitgetchahi]

one annoying thing I see some doctors aroud me do is try to get a CT chest by getting a "backdoor low dose CT scan."
The prior auth questions for LDCT screening are very easy usually
Just click yes on 20 pack years, current/quite less than 15 yaers ago, no debilitating medical issues and approved
only thing is the radiology center ha to also ask the patients on pack years.
If the patient says i dont smoke. the scan is rejected because the ordering doctor/office lied about the prior auth to get an "easier time."

Getting a regular CTC authed needs documentation of chronic cough, hemoptysis, abnormal CXR, or follow up from prior CTC for some abnormality.

I have seen patients come to me with 3mm nodules found on LDCT screening - when I asked patient so how much you smoke? I am a never smoker.
uh huh.....

I've tried to call radiology but they are unable to change the report as that would lead to an eventual audit and return of the money they charged.


sigh...


I just make it abundantly clear in my note what the patient said and then I just shift over to Fleischner criteria...


but yeah... "gaming the system...."

As rheum, I see this sort of weird crap going on sometimes when a PCP wants to start the workup for ILD but for whatever reason doesn’t want to do a full prior auth for an HRCT chest…so now I have an SLE/dermatomyositis/whatever patient in front of me with dyspnea and other symptoms who had an LDCT, which is equivocal…but an LDCT isn’t ideal for ILD screening by any means. It’s just stupid.

 

[NewYorkDoctors]

while I love the 1mm slice HRCT with prone and supine and inspiratory/expiratory cuts... not every radiology center adheres with that protocol sadly. even radiology centers sometimes skimp on the time to maximize that "revenue / (effort + time ^2) ratio."

sometimes i get someone who has a standard protocol or screening LDCT with interstitial lung abnormalities.

if I am lucky it is already definite UIP pattern and I'm done. CVD workup , PFTs/6MWt, then antifibrotic.

if its not i am often weighing the need to irradiate the patient again versus if I buy time with some follow up time period.

lucky for me the CPET machine I have helps me out with that decision without too much hedging.

 

[VA Hopeful Dr]

As rheum, I see this sort of weird crap going on sometimes when a PCP wants to start the workup for ILD but for whatever reason doesn’t want to do a full prior auth for an HRCT chest…so now I have an SLE/dermatomyositis/whatever patient in front of me with dyspnea and other symptoms who had an LDCT, which is equivocal…but an LDCT isn’t ideal for ILD screening by any means. It’s just stupid.

It's not that we don't want to, it's often that we try and fail because we don't know the right words to put in the chart to get it covered.

 

[NewYorkDoctors]

It's not that we don't want to, it's often that we try and fail because we don't know the right words to put in the chart to get it covered.

i hear ya. I hope my post did not sound like PCP bashing

As you know from my other posts, I am do PCP partially as well. I am running prior auths for MRI brains, CT Abdomen pelvis, MRI Lumbar spines/cervical spines fairly often.

I run my own "prior auth department" in my office. While I trained a staff member to go to the online portals to initiate and perform PAs. If clinical questions are needed, I would have to guide them through it to prevent getting an instant rejection. Sometimes I will have to write my medical note and upload it to the web portal

Of note when more information is needed or when a denial is put forth, the letter is sent to my efax/inbox and i read it and i find the reason why it got denied and reply right away. Usually this letter explains why not and "how to get it approved if certain circumstances are met."

Back in residency clinic, we had no one to help with prior auths. We also could not set up theo nline portals for prior auth as we were residents and not attendings

In fellowship clinic, there was also a "prior auth department," but those were EPIC messages or phone calls from someone giving the bad news about a denial usually. The reason for denial document was stuffed somewhere in the EPIC media manager somewhere.. never to be seen again.... it just leads to confusion and the inevitable waste of time just calling for peer to peer.

I usually only ever order these things if there is a medical basis for it so I have an easier time climbing over the hurdle
(i.e. headache with neurological deficits, night time awakening, change in characteristic over time for MRI brain; chronic lower back pain worsening over 3 months despite PT, analgesics, and now some neurological issue like DTR changes, etc... ; CTAP is usually very hard to get approved but I usually only order this for clear cut indications like hematuria or abnormal US abdomen/renal/bladder and not for "stomach pain due to being overweight and constipated")

It is when an advanced scan is ordered because "the patient wants it" that the wall becomes insurmountable.

Of course sometimes when a patient wants a scan... but clearly does not need it... I get it denied on purpose then show them the letter and say you can always call radiology center and offer to pay for it out of pocket.
CANT YOU APPEAL?
I already did. Insurance still denied. Listen the doctor is not INSURANCE GOD and I cannot force your insurance to pay for something they will not pay for. Why don't you get onto the phone with your insurance instead of wasting my time like this more than you already have?


Speaking of which, I have a fair number of patients who get medical care in their home countries (think latin america and Asia) and spend some cash money in their home country for a lot of unnecessary testing. Then they bring their incidental findings over to the US and want to get follow up using US Medicaid dollars. wonderful. THese are usually unnecessary CT chests (for health screening done in home country) that shows some small nodule.

Seldom can I just say "nah bugger off fool" because usually PCP already sees calcified granuloma and is nice enough to tell patient "bugger off fool."


But it's those indeterminate nodules with a smoker/occupation history or groudn glass nodules that then require extended follow up per Fleischner. What a waste of US taxpayer resources. Yet guidelines are guidelines I cannot tell them to bugger off.


Of not I work in the "poor part of town" in NYC. A fair number of patients are undocumented.
If someone is over 65 and has medicare then I know they have SSN for sure and documentation
If someone has an Essential plan/ obamacare ACA plan then I know they are working and likely have an SSN
If someone has Medicaid only, it becomes likely they are undocumented
This is not a bashing "visitor/migrant" line. Recall I am not Caucasian so I have no "power" lol.
Rather, a few patients tell me actively they crossed the border a few months ago and tell me of their harrowing journeys. But what is more harrowing is they have Managed Medicaid in less than 3 months time and they tell me they get food stamps too.
What a great time to be sanctuary new york city!

 

[NewYorkDoctors]

a someone recent outpatient issue I am coming across are how the local mom and pop pharmacies are no longer able to fill all medications. Even if this medication is on an insurance formulary without prior auth (or in cases in which I get prior authorization), the pharamcy is unable to fill for a patient and are directing the patient to the large chains

The pharmacist would not divulge why but upon getting into the details from a pharmacist I know, it seems like some large insurance companies and only paying the proper medication rate to the big chains and are giving such bad payment rates to the mom and pops that it becomes a net loss to dispense certain medications

This is infinitely annoying to me as I see a lot of immigrants who do not speak English (and do not have any patience to go to the big chains and wait for an interpreter translation line). It becomes a big headache when patients rush to my office complaining "YOU SAID IT's COVERED Y U LIE TO ME?"

i said it is covered. its on your insurance formulary. let's call the pharmacy together... waste 10 minutes of my life... pharmacist say "we already told the patient we cannot fill this medication due to insurance limitations..." patient what the heck? you think by barging in here and making a scene something magical would happen? (new yorkers seriously...)

anyway this seems like corporate greed... though on closer investigatino with said pharmacist I have found many local mom and pop pharmacies were doing illegal things such as asking patinets to get prescriptinos for Vascepa DAW or Flector patch.. asking doctor to prescribe... then not giving the patient's the med but giving the patients a cut of the money.... illegal.

or certain things such as giving little prizes or gift certificates to patients the more prescriptions they get filled....


in that case.. good this new rule will quash those greedy little mom and pops who are trying to game the system



the big chains are beholding to the rules due to the large chain of command and authority they have
the small mom and pops can cook the books it seems

 

[VA Hopeful Dr]

a someone recent outpatient issue I am coming across are how the local mom and pop pharmacies are no longer able to fill all medications. Even if this medication is on an insurance formulary without prior auth (or in cases in which I get prior authorization), the pharamcy is unable to fill for a patient and are directing the patient to the large chains

The pharmacist would not divulge why but upon getting into the details from a pharmacist I know, it seems like some large insurance companies and only paying the proper medication rate to the big chains and are giving such bad payment rates to the mom and pops that it becomes a net loss to dispense certain medications

This is infinitely annoying to me as I see a lot of immigrants who do not speak English (and do not have any patience to go to the big chains and wait for an interpreter translation line). It becomes a big headache when patients rush to my office complaining "YOU SAID IT's COVERED Y U LIE TO ME?"

i said it is covered. its on your insurance formulary. let's call the pharmacy together... waste 10 minutes of my life... pharmacist say "we already told the patient we cannot fill this medication due to insurance limitations..." patient what the heck? you think by barging in here and making a scene something magical would happen? (new yorkers seriously...)

anyway this seems like corporate greed... though on closer investigatino with said pharmacist I have found many local mom and pop pharmacies were doing illegal things such as asking patinets to get prescriptinos for Vascepa DAW or Flector patch.. asking doctor to prescribe... then not giving the patient's the med but giving the patients a cut of the money.... illegal.

or certain things such as giving little prizes or gift certificates to patients the more prescriptions they get filled....


in that case.. good this new rule will quash those greedy little mom and pops who are trying to game the system



the big chains are beholding to the rules due to the large chain of command and authority they have
the small mom and pops can cook the books it seems

NYT did a great piece of pharmacy benefit managers recently if you haven't already read it.

 

[Osteoth]

NYT did a great piece of pharmacy benefit managers recently if you haven't already read it.

PBMs are literally by definition just rent seeking. Literally no purpose but to extort money out of the system.

 

[goldsummer]

As for the consumer stuff and google reviews , I whole heartedly agree with that crud . As I am my own practice and boss , I have gone to town shredding the $hit out of some negative reviews who did so for the stupidest of reasons . My reviews are mostly 5s . A few are 1 because of some “I didn’t get pampered or spoiled by the doctor .” I go Kevin Durant with his burner accounts and mercilessly reply and rip into these patients (without revealing PHI of course ) . I’m not a ****ing restaurant with a thin profit margin and no manager is “apologizing to you and promising to make a better experience .”

At my organization, they send out their own surveys to the patient by a 3rd party to collect patient satisfaction... my score is 4.9/5. over 1000 reviews. Many amazing reviews. HOWEVER. The unhappy patients, mad at either me or my intitution (or both), dont trust our surveys and opt to go to google to express their frustration. So my google reviews are worse as thats where the unhappy patients go. Average is around 3. Half 5's and half 1's. only 10 reviews though. but still....when you google, it doesnt look good. Also the discrepancy makes it look like my organization fudges my scores. maybe they do idk.

Does anyone have any tips to mitigate this?
If all patients were just directed to google to review i feel it would be a non issue.
Someone told me to just ask the favorable patients to write one, but I feel ick asking anyone to write a google review for me. Maybe i just need to get over it.
Also, i thought another option would be to ask my institution to just make a google link available too when they send out our reviews, but not sure theyd go for it, and not sure id want to draw attention to it with admin since im not sure the MBA or whatever would understand that the patient was unhappy cause i refused to give them 90 tablets of xanax for 1 month for anxiety like they asked after they rejected all the other options i presented.

 

[VA Hopeful Dr]

At my organization, they send out their own surveys to the patient by a 3rd party to collect patient satisfaction... my score is 4.9/5. over 1000 reviews. Many amazing reviews. HOWEVER. The unhappy patients, mad at either me or my intitution (or both), dont trust our surveys and opt to go to google to express their frustration. So my google reviews are worse as thats where the unhappy patients go. Average is around 3. Half 5's and half 1's. only 10 reviews though. but still....when you google, it doesnt look good. Also the discrepancy makes it look like my organization fudges my scores. maybe they do idk.

Does anyone have any tips to mitigate this?
If all patients were just directed to google to review i feel it would be a non issue.
Someone told me to just ask the favorable patients to write one, but I feel ick asking anyone to write a google review for me. Maybe i just need to get over it.
Also, i thought another option would be to ask my institution to just make a google link available too when they send out our reviews, but not sure theyd go for it, and not sure id want to draw attention to it with admin since im not sure the MBA or whatever would understand that the patient was unhappy cause i refused to give them 90 tablets of xanax for 1 month for anxiety like they asked after they rejected all the other options i presented.

My system uses a 3rd party survey but if the patient gives 5 stars they are then asked if they would like the review also posted on Google. Anything below 5 stars doesn't get that option.

 

[NewYorkDoctors]

At my organization, they send out their own surveys to the patient by a 3rd party to collect patient satisfaction... my score is 4.9/5. over 1000 reviews. Many amazing reviews. HOWEVER. The unhappy patients, mad at either me or my intitution (or both), dont trust our surveys and opt to go to google to express their frustration. So my google reviews are worse as thats where the unhappy patients go. Average is around 3. Half 5's and half 1's. only 10 reviews though. but still....when you google, it doesnt look good. Also the discrepancy makes it look like my organization fudges my scores. maybe they do idk.

Does anyone have any tips to mitigate this?
If all patients were just directed to google to review i feel it would be a non issue.
Someone told me to just ask the favorable patients to write one, but I feel ick asking anyone to write a google review for me. Maybe i just need to get over it.
Also, i thought another option would be to ask my institution to just make a google link available too when they send out our reviews, but not sure theyd go for it, and not sure id want to draw attention to it with admin since im not sure the MBA or whatever would understand that the patient was unhappy cause i refused to give them 90 tablets of xanax for 1 month for anxiety like they asked after they rejected all the other options i presented.

since I am self employed and own my own business (and have a large referral base anyway and dont really care about google) , I go Kevin Durant burner account hard at the angry trolls. I call them out for their lies, libel, and slander (noPHI of course. just the general gist of the patient's bad behavior... like a Community notes). I often open up their review history and mock them for their ridiculous 1 star reviews of other businesses


feels good to be self employed and not gaf lol.


you could report the low scores to google and cite a reason why this is unacceptable and untrue.

I have gotten angry 1 star reviews scrubbed before because the patient wrote " bad service." and nothing else


that patient was late and has chronic cough due to m****f****ing GERD. he was under the impression pulmonary would cure him with "one single treatment." PFt, bronchoprovocation, CTC, all ruled out primary lung pathology. esophagram , nasopharyngoscopy, and EGD all showed GERD

"PPIs don't work"

I explained to him what the GI failed to explain... PPis must be taken 30 minutes before a meal and not fasting because proton pumps get maximally

I gave that m*****f****er a wedge pillow (gave one ahead of time as this guy was never going to go spend $30 of his own money. I can get it back from the DME store later on though) and went over the detailed GERD diet list and print out. I "did the hold your hands and empathize with patient and put yourself in their shoes" stuff by explaining i know how he loves the GERD foods but let's compromise and eat less at night so you reduce nocturnal reflux.

"I DONT HAVE ACID"

***** who the **** said anything about acid? I carefully explain how there are digestive enzymes, GI flora, bile acids and other non-acid that comes up



anyway he followed up later and was on his best behavior after that. i got that review scrubbed by petitioning google. his cough also got better with strict adherence to GERD lifestyle modifications (which honestly his PCP, GI, and ENT should have mentioned ahead of time.... but alas no money in talking to patients about lifestyle management...)

I had my PA call him at one month to check in and he begrudgingly said "yeah its better thanks."


that's the other thing... patients who get better never stop by to say thanks. they just dont show up.
the ones who are not better, you know they are going to come with a fire and brimstone of "Y U NO MAKE ME BETTER YET????"



anyway, bottom line is you can petititon google to remove a bad review and explain why it is not fair or accurate

 

[HistaMEAN]

As a young A/I doc building a practice, I welcome the referrals. I actually market myself to PCPs, GI, Derm, and ENT for that very reason. My pitch is basically along the lines of "I know you can manage the simple rhinitis, asthma, rash, etc. But I'm more than happy to take it off your hands if it frees up even a couple minutes of your time." and "We both know all these IBS patients don't actually have food allergies, but please send them my way and I'll deal with it" and "don't bother with any sort of pre-workup, just send em."

I'm lucky that in my field, these are both lucrative and relatively simple. Most of them will get (and very much want) the allergy testing. It's a win win because even simple asthma can be a pain in the *** for PCPs with how stupid inhaler prescribing/coverage/prior auth stuff can be. You can order a food panel from the lab but watch a couple false positives come back and now you've got labs to interpret and explain and all that garbage....or just send them to me and wash your hands of it. I also get plenty of young, healthy, normal patients who are entering that age of life (30s, typically) where they don't have a PCP but probably should establish even for just annual labs/check up -- I do my best to send these patients in the direction of the PCPs who send me patients. Same with those who self refer to me first but end up needing to see derm/gi/ent/pulm -- I try to plug them in with the private docs that I know and like. It's nice to be a part of a network of docs who still practice in a physician-owned setting and try to keep these patients plugged in with quality docs outside of the corporate/PE owned places.

The google review pressure is real. I'm newish in the area and I need 5 star reviews to remain competitive (or at least I think I do). There's a customer satisfaction pressure that sucks when it's some entitled cluster Bish type person. I'm sure most people are like me and don't go out of their way to leave a positive review when they have a good experience. I try not to shamelessly solicit them but when a patient makes a point to mention how grateful or happy they are, I do reply with something like "well you know I hate to come off like a businessman plugging my marketing but the best way to show your gratitude is to leave a google review reflecting what you told me today." So far I'm killing it in the google review space.

For clarity, as a fellow A/I doc, if someone comes in to your practice saying "I want to see what foods I'm allergic to" and they've never had a reaction of any kind (or any reaction that's IgE-mediated) would you do skin testing or serum IgE-testing on them?

 

[gutonc]

For clarity, as a fellow A/I doc, if someone comes in to your practice saying "I want to see what foods I'm allergic to" and they've never had a reaction of any kind (or any reaction that's IgE-mediated) would you do skin testing or serum IgE-testing on them?

What insurance do they have and which pays better?

 

[hotsaws]

For adults, I give them my spiel about how IgE (skin or blood) testing is not a validated or reliable way to identify IBS triggers and bla bla bla, but if they push back at all I pretty much do it. I also make it clear what their out of pocket is before we start so they're not surprised. The majority of adults want the testing. They're adults and they can choose to waste their money on a poorly validated test. They do it all the time with other things. Sometimes they just want to visually see normal results so they can move on or whatever. Same way I'm happy to send a celiac panel on someone who has absolutely no sign of celiac disease but has some irrational distrust of gluten.

In fellowship, I would argue with these patients all the time and end up with an awkward tension and an unhappy patient. If there are positives on the test, I essentially tell them to avoid and reintroduce sequentially. Many report benefit, probably placebo. If you get a placebo benefit for your IBS because you eliminated squash and strawberry or something, good for you.

For kids, I do not do any kind of panel testing or any testing I deem excessive. If parents are really leaning into the food thing, I hand them my list of foods and ask them to specifically pick which ones they are concerned about. My goal is always to limit any unnecessary dietary restrictions for kids from their neurotic parents.

 

[NewYorkDoctors]

This is a selection of the google reviews from the PCPs who frequently refer patients to me for "undifferentiated symptoms" rather than for a specific referral reason. Don't get me wrong in private practice the expectation is specialists will manage their organ system.

But when PCps gaslight patient for the sake of "saving a few minutes per patient and adding up the 99213 time... all the while writing nonexistent notes... and going home on time to not worry about anything" and then I tell the patient that the cough is not due a pulmonary issue but due to GERD... then the PCP gaslights the patient right back to me for bronchoprovocation test ruled out asthma, empiric ICS ruled out asthma, normal CTC, EGD proven gastritis, bravo test proven reflux high demeester score.... then you know the PCP is NOT reading the thoughtful notes i am sending.

so i decided to look into these google reviews

2 years ago
Terrible place!!! DO NOT GO!!

The doctor here has a super weird attitude. I came feeling terrible and hoped to get some professional care, BUT THE DOCTOR SAYS SHE CAN'T TREAT ME IF I DON'T HAVE THE RIGHT ATTITUDE OF A PATIENT. Said the exact sentence to my face because I didn't give the perfect answer to her questions. DO NOT COME because she will remind you of your high school counselor. I never heard anything like this from a doctor. Do not come because they expect you to be the perfect patient.

Weirdest doctor I ever met in my life

2 years ago
Doesn't listen to the concerns of her patients. Sells you on debunked water diet and furthered my progressive relationship with food. Claimed my mother had a gluten issue with her stomach problems for a year - no she had a tumor and Dr. [redacted] kept telling her it was nothing. Please see an internist, Dr. [redacted] doesn't care for her patients.

6 years ago
Worst doctor in [redacted]. Rude. Doesn't care about helping her patients. She treats patients with no respect. Dismissive of patient concerns. Only interested in making MONEY

5 years ago
Don't care about the patient only care about money, let you have a medical examination, feeling like a cheater.

3 years ago
TLDR: too many cons than pros, I would never recommend this office even if I were dying

I have been receiving herself primary care at this office for years and encountered different problems every year. One of the major issues is that the manager, who entitled with some certain authority in the office, always behaved arrogant and impatient every time when I talked to her in the past. She seemed being preoccupied with her judgments as that patients know nothing more than her and would NOT listen to what you try to address. Once she heard the first sentence or so, she would react very offended and do nothing but try to justify herself in a rude manner, emphasizing she's not the wrong one without further rooting the problem or providing any favor. Another thing I encountered was that it took forever for them to change your pharmacy so that you could receive your prescribed medications at the desired site. Till today my pharmacy still hasn't received the prescription even though I called the front desk and asked them to send it over. Not to mention that they would bs something that they perhaps never ask during your office visit in your medical chart ( i.e. sexual history) to earn some easy money by their fraud claim and billing. Meanwhile don't be surprised that sometimes your legit office visit only take 5mins.

2 years ago
If it is possible, I would like to give 0 star. When I was diagnosed with COVID, I called the clinic, and the doctor named [redacted ] prescribed me allergy medicine. The entire conversation took less than 5 minutes. A month later the clinic called and asked me for money. I questioned why the allergy medicine was prescribed to me, but none of the doctors gave me any explanation. I started calling around 10 am, either hung up the phone or asked me to hold on the phone, and finally the lady at the front desk told me the owner of the clinic, Dr. [redacted] said it's okay this time, give me credit, and won't serve me in the future. It is unfair! which medical document records allergy medicine as a treatment for COVID-19? They even told me to find a lawyer myself. I don't need you to serve me, but I need an explanation from you. Please stay away the terrible clinic!

5 years ago
It is not recommended to see this doctor. He is very sarcastic and does not respect the feelings of patients. He has some medical equipment and some medicines in the clinic and often asks us to buy his medicines. If you don't buy it, it will look bad on your face, your attitude will be bad, and you will be prescribing medicine in a haphazard way. I open a bunch every time. I open four boxes of a cold medicine and I open several bottles for cough medicine. Is medicine considered a tonic? We can’t waste government money like this.

5 years ago
I have been seeing this doctor for a long time. It was very good at the beginning. He is also very patient and will explain many things to you. I have also introduced many friends to him. But in the past two or three years, I don’t know if something happened. My whole person has changed, and my smell of copper has become particularly strong. Some time ago, I did some genetic testing. As soon as I told her that I seemed very tired, she called me. It cost me hundreds of dollars to do a genetic test. It was just taking a small cotton swab in my mouth and taking some breath. Moreover, she said it would depend on what was missing in my body. If I was missing ten kinds of medicine, I would need to take ten medicines. If I was missing 20, I would have to pay for 20. And I had to pay out of pocket. Insurance does not cover it. the scariest thing is that you have to eat it until you die. She said this can help you live longer. well! In short, they all charge you various fees and ask you to buy her medicine, but don't buy the one with an ugly face. Oh, it's really not the past to see a doctor just to be angry. I don’t know if she has been sued recently and I haven’t heard her talk about this DNA test for a long time, but her attitude is getting worse and worse. Some time ago, I suddenly had a fever that wouldn’t go away, so I went in to look for her. The result was not her, but a rookie doctor who kept asking for a long time. After a long time, he finally told me that I wanted to ask the next doctor, but Dr. Ren came and asked me to do a urine test with just a few words. (There was also a problem with the machine in their clinic. There were no problems with urine tests in other clinics, but there was a problem with her test.) The result came out OK. The question is: How can she gain face in front of the rookie when she is so powerful? Then she tells the rookie in English not to listen to the patient talking too much, because they will talk to you a lot, which is a waste of time. (This is what it means) As a result, my fever got even higher when I went back, and I ended up having to go to the emergency room. Later, I didn’t know if it was because they had fewer and fewer patients. Even if you didn’t call to make an appointment, she would automatically give you an appointment time and even if you were fine, she would send you appointment emails all the time. It got annoying to death and I finally decided to change doctors. He is still making an appointment for you and finally calls you to urge you to go in for a consultation. I have never seen a doctor like her. It’s not like she is really short of money. And if you ask her to prescribe medicine, she will always do it. There are a lot of them. If you can estimate that she can prescribe all the medicines in the pharmacy to you, in short, don’t choose her. There are still many things that have not been mentioned. If you talk about it, maybe you can publish a book

6 years ago
The worst family doctor, bar none. They told me that my insurance had charged me, but after seeing the doctor, they sent me a bill of several hundred dollars three months later saying that my insurance card was not charged and asked me to pay. Especially the front desk staff, who started to shirk responsibility. If you don't want to be asked to pay then, please don't go. Do not go, worst family doctor ever!!!!!!

8 years ago
The first time the blood was drawn, they actually told us that the blood sample was not sent to the laboratory and asked us to have it drawn again the next day. The doctor himself said that the injection was for us. When we went back to send the certificate after the injection, he immediately changed his mind and said that the injection was of a different type and that he wanted to have it again. He also refused to admit what he said. Very unreliable clinic, would not recommend to anyone. Very unprofessional!

5 years ago
Very rubbish doctor. I strongly do not recommend this doctor. His speech is very immoral. He has fallen into a pile of money. His speech is very exaggerated. My eyes were very red before I went in to take a look. They say I have trachoma and my eyes will go blind. She was so scared that I went to see an ophthalmologist. The doctor said it was caused by pollen allergy and sometimes I would catch a cold. He was very exaggerated and worried that I would infect him. He stood far away from me, showed no respect for the patient's feelings, and had no moral integrity. One moment he said I would have stomach cancer, another moment he said I would faint while walking, and the next moment he said I was blind. Even if you are really not sick, he will scare you to death. They also said that I defrauded the government and took free medicines. I was reluctant to spend money on expensive medicines.

yes these are the primary care "doctors" that refer patients me.

I prefer midlevel PAs and NPs referring me a blank slate so I don't have years and years of gaslighting to peel through.

 

[NewYorkDoctors]

so I am not quite sure where to put these thoughts I had, so I figure I would put it in this thread so I don't make a new thread unnecessarily

I just purchased the new MKSAP to review for upcoming 10 year recert (10 years is fine by me. I'm not into the whole 2 year LKA(

It's a decent read. I am doing pulmonary first (they separated the chapter from Critical Care this time around).

The way the text goes seems to suggest that an Internist should not only know about every single disease entity (no matter how rare it is) but also manage it complete and do not refer to subspecialist unless it is very complex, needs a procedure, or needs more complicated therapeutics.

1) In the real world, this almost never happens because the time constraints of managing complex patients and their psychosocial, polypharmacy, and patient navigation issues prevents this from happening.
2) More money is made seeing patients for as little time as possible to get more 99213s in.
3) If you don't see a rare disease often enough, you often can't remember all of these "book details" and would be better served just having the subspecialist manage it.

For the primary care patients I see with my NPs, I try to manage everything as much as possible as I can. I have the benefit of several subspecialties so I have more confidence in myself. But I also know when not to dawdle and waste time and will send a patient to the subspecialist once I get the basic "MKSAP" workup done.
For community doctors who do procedures, I don't bother ordering an echo or vascular ultrasounds from radiology so as not to steal the cardiologist's procedures (lol). but I do get the 12L sent to them.

anyway my point here is do you know of any "master Internists" in real life who are able to "be a master of MKSAP" and confidently manage literally everything without "copping out and referring every little thing out?"

This doctor would probably exist only in the academic landscape? even then, this Internist is probably just managing patients who ALREADY saw the subspecialist and a "NTD monitor for this" consult has already been done? Moreover, this Internist is salaried, has no incentive to see more patients, and has a capped patient panel already.

 

[dgdg]

Starting to prep for the Big Enchilada causes, F32.9: Major depressive disorder, single episode, unspecified, based 23% of respondents in an unqualified, not peer reviewed study from some unknown journal. LOL I know how you feel.

Everyone has different MOC study strategies. From reading others' experiences here, it does vary quite a bit. Some don't even study. I didn't study for the initial cert and first recert, but I didn't think that would work well for me this last time. So I studied.
My anecdotal experience, and what I've read here, focusing on MKSAP may not be the way to go. YMMV.
Board prep question banks like Uworld and NEJM seemed to have a mix of tough vs standard questions, but by studying the topic/question fully, I learned a lot and certainly performed better on the exam. Those would be the basis of my exam prep if I were to take it again.

I also try to manage everything as much as I can. When I do refer, I still begin the prep work so the initial specialist visit already has additional labs and imaging studies already in hand, sometimes a trial of medication.
Lately, I think of the next step in an evaluation for a few of my recent patients - oral salt loading test for equivocal hyperaldo screening, thyroid imaging for amiodarone toxicity, possible bx vs excision of a renal lesion, bone marrow biopsy, etc. These need a specialist to do.

Then there are some other times, like for routine new onset plain vanilla afib, by the time they can get into the cardiologist, he/she says that I've done everything (tests and treatments) already. The only discussion at the cardiologist initial visit is to consider a trial of cardioversion.

For me, I enjoy the learning, relearning, and managing my patients as much as possible. This usually speeds up their care to relief and appreciation of my patients. I left a prior career very early in life in order to be more intellectually stimulated and have a greater meaningful impact in the lives of others. I can't just do the minimum for an RVU mill.

 

[NewYorkDoctors]

for inpatient hospitalist medicine, I know there is no realistic way to be a "master internist and do it all" because

1) you have a census of 20-30 patients and primary job is to keep LOS down and help the hospital administrators make money (those parasites)
2) these are not your outpatient GIM patients. If "admitted patinet saw every single specialist as outpatient, what would hospitalist internist do any differently?"

though I would imagine in some more remote locations in which the PCP is also the hospital admitting doctor and knows everything about the patient, this kind of "one doctor show" may be feasible. even then I doubt that internist has the time to manage everything and will just text message their fee for service specialists anyway to help see the patient.


maybe a concierge doctor would really need to "do it all" within realistic limits (cant ask concierge doctor to prescribe Rituximab... or do surgery... ) in order to justify the retainer fee?

 

[hotsaws]

I knew one guy in training that may have been the single best doctor I've ever met and this was widely agreed upon by everyone in the hospital. He was a long time pulm crit doc. Super humble. He was probably in his late 60s when I was a resident. He would be pre rounding at 5 am as a 60+ year old attending. He knew everything about everything, even when he tried to act like he didn't. Like he wouldn't pontificate but he'd throw out the most subtle comment and everyone knew he knew more about the case than anyone in the room. Rare to see a guy who the students and residents love and who the niche surgeons and ego maniacs have mad respect for.

With that said. I live in a nice house and, while a good handyman can probably do most jobs, I'd prefer the tile guy do the tile, the plumber do the plumbing, and the garage guy replace the garage spring. Probably 9.9/10 times the handyman could replace the spring...but on that off chance something isn't typical, I'd rather have the garage guy who just works on garage doors all day, every day.

 

[NewYorkDoctors]

I knew one guy in training that may have been the single best doctor I've ever met and this was widely agreed upon by everyone in the hospital. He was a long time pulm crit doc. Super humble. He was probably in his late 60s when I was a resident. He would be pre rounding at 5 am as a 60+ year old attending. He knew everything about everything, even when he tried to act like he didn't. Like he wouldn't pontificate but he'd throw out the most subtle comment and everyone knew he knew more about the case than anyone in the room. Rare to see a guy who the students and residents love and who the niche surgeons and ego maniacs have mad respect for.

With that said. I live in a nice house and, while a good handyman can probably do most jobs, I'd prefer the tile guy do the tile, the plumber do the plumbing, and the garage guy replace the garage spring. Probably 9.9/10 times the handyman could replace the spring...but on that off chance something isn't typical, I'd rather have the garage guy who just works on garage doors all day, every day.

Good point

But in my neck of the woods (and I suspect the same for many others), the Internists who refer to me do not refer to any specific reason but refer for undifferentiated symptoms.

From a pulmonary standpoint, not all "dyspnea" is often classic text book.

But often I get referrals for sub 6mm lung nodules (that I teased out in the history is not just the patient being anxious and needing TLC but due to outright gaslighting from the PCP), dyspnea without a basic CXR or 12L EKG done by PCP (not just not sent to me but on asking not even done), ACUTE (not even subacute or chronic cough) cough in which "Z-pak didnt work, here you go" is the referral.

These "simple referrals" are not so simple when the patients wont stop bothering me when the final prognosis is "time will heal this."

Often times I think what is the point of an Internist when this is the same thing I get from a PA/NP referral?

Anyway, there are a few very good Internists who only refer to me for things that actually need subspecialty diagnostic/therapeutics/management. It is a delight to work with those Internists. They ACTUALLY follow up my recommendations and know how to take care of GINA Step 1/2 mild intermittent asthma themselves or know how to manage GERD cough themselves...

And no... this is not a ****ing on internists post as I PERSONALLY also do some PCP work as well. I walk the walk in this case.