Is outpatient really that bad?

[Osteoth]

And this is essentially why I detest outpatient medicine. Everyone thinks they know better. Well then, go do WTF you want, what do you need me for?

I never understand why people care so much about people ordering nonsense…doesn’t hurt you or them and it’s good customer service.

If you’re DPC or concierge slap a 10% profit margin on the set call it a holistic health package and go on your way.

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Members don't see this ad.

 

[greatnt249]

I never understand why people care so much about people ordering nonsense…doesn’t hurt you or them and it’s good customer service.

If you’re DPC or concierge slap a 10% profit margin on the set call it a holistic health package and go on your way.

Because ultimately I'm responsible for the results of the tests I order. I suppose if there was an alternate incentive to ordering tests, maybe I'd think differently. There's also a secondary incentive (for me, at least) to not really have these types of patients on your panel altogether, so ordering what the naturopath wants reinforces the idea that you're a "naturopath friendly" physician.

 

[NITRAS]

Can. Could. Will. Wont?

Just so we are clear that they can do it, and this forgiveness stuff is so that the poor physicians, who largely have the ability to make $300-400k a year, can buy more stuff at the expense of the taxpayer.

 

[sloh]

Because ultimately I'm responsible for the results of the tests I order. I suppose if there was an alternate incentive to ordering tests, maybe I'd think differently. There's also a secondary incentive (for me, at least) to not really have these types of patients on your panel altogether, so ordering what the naturopath wants reinforces the idea that you're a "naturopath friendly" physician.

Is it possible for a DPC practice to thrive in Colorado without pandering to patients like this? These patients often times can’t be reasoned out of their beliefs that they didn’t reason into in the first place

 

[smq123]

I always find it hilarious that boujee healthy people who otherwise exercise, follow complicated diets for “longevity” or “anti-inflammatory effects”, and “don’t like taking medication” also want to have dozens of weird and obscure labs checked and also take dozens of weird and obscure supplements. You’re healthy, guys…less is more…

I saw one such patient last week. He asked what special screenings did I (outpatient only family med) or my husband (oncology) do. He was floored when I told him that we don't do anything outside of the regular screenings. Pap, mammogram, colonoscopy when age appropriate, flu shot annually, etc.

It really is about an attempt to manage anxiety. Like - if I am vigilant enough, get the right screenings, do the right exercises, eat the right diet, take the right supplements, then the bad things won't happen to ME. They'll happen to those losers who smoke or drink or eat junk food all day, but not ME.

Those same patients realllllllly don't like it when I remind them that I have patients, many patients, who have bad cancers who didn't smoke, drink, eat massive amounts of junk food, and actually exercised regularly, got regular screenings, got their teeth cleaned twice a year, paid their taxes, and literally did EVERYTHING "right."

Always question the intelligence of people who follow Peter Attia and Huberman. Midwit alert.

Peter Attia, in particular, is SO ATTRACTIVE to patients because "you know, he's a surgeon from Hopkins." No, he was a surgical resident who left a little over the halfway point.

I get it - he is selling reassurance to patients. Like I said before, he reassures them that if they just take the right medications (Metformin, Rapamycin) and use the right supplements and check all the right labs that the bad things won't happen to them. And it frustrates me that he can do this with a straight face. I can't believe that someone with 5 years of post-grad experience in such a busy hospital wouldn't have seen his fair share of patients who just have terrible luck. RNs with half a dozen years of floor experience can tell you about the patients that they remember who "did everything right" but still had bad outcomes.

 

[smq123]

I never understand why people care so much about people ordering nonsense…doesn’t hurt you or them and it’s good customer service.

If you’re DPC or concierge slap a 10% profit margin on the set call it a holistic health package and go on your way.

- Annual PET-CT. Definitely wouldn't say that it "doesn't hurt the patient." Maybe one doesn't have enough radiation to cause problems, but doing so annually for several years is probably not great.

- With the advent of EHR, ordering these really esoteric labs is a huge pain in the rear. These are not labs that are available in Epic. You have to manually look up the lab codes (in either the Quest/Labcorp book or their website) and than often manually enter them into an order form. It might have been easier in the old days when you could just scribble a bunch of codes on a prescription pad, but it doesn't work that way anymore.

- The more you go digging, the more random crap that you uncover that you now have to chase down. And it can be really hard to reassure patients that things that are not clinically significant (an elevated TPO antibody but with a normal TSH and a normal T4) don't require some aggressive treatment.

 

[sloh]

- Annual PET-CT. Definitely wouldn't say that it "doesn't hurt the patient." Maybe one doesn't have enough radiation to cause problems, but doing so annually for several years is probably not great.

Even radiation aside, diagnostic cascades!

Diagnostic Cascade of Incidental Findings

The authors discuss a case exemplifying the importance of clarifying a patient’s goals of care before conducting a surveillance computed tomographic scan of an asymptomatic tumor.

jamanetwork.com

 

[greatnt249]

Is it possible for a DPC practice to thrive in Colorado without pandering to patients like this? These patients often times can’t be reasoned out of their beliefs that they didn’t reason into in the first place

I feel like DPC would be a different situation altogether. I will clarify that I am not a family physician.

 

[dozitgetchahi]

Because ultimately I'm responsible for the results of the tests I order. I suppose if there was an alternate incentive to ordering tests, maybe I'd think differently. There's also a secondary incentive (for me, at least) to not really have these types of patients on your panel altogether, so ordering what the naturopath wants reinforces the idea that you're a "naturopath friendly" physician.

This.

I’m rheum and I’m not interested in picking up the ostriches who want to try an “anti inflammatory diet” while I watch RA destroy their joints. If they want to do stupid **** on their own, that’s their prerogative. But leave me out of it.

I also don’t want naturopaths to start “referring” patients to me. I prefer to keep my days in clinic as kooky-free as possible.

 

[gutonc]

And this is essentially why I detest outpatient medicine. Everyone thinks they know better. Well then, go do WTF you want, what do you need me for?

I'm at the point in my career where I actually just tell those people this. "Don't want what I'm selling? There's the door. Have a nice day." And if they want a CT or PET scan to see how their magic beans are working on their cancer, I tell them to ask the magic bean "doctor" to order and interpret it.

 

[end stage fibro]

Peter Attia, in particular, is SO ATTRACTIVE to patients because "you know, he's a surgeon from Hopkins." No, he was a surgical resident who left a little over the halfway point.

I get it - he is selling reassurance to patients. Like I said before, he reassures them that if they just take the right medications (Metformin, Rapamycin) and use the right supplements and check all the right labs that the bad things won't happen to them. And it frustrates me that he can do this with a straight face. I can't believe that someone with 5 years of post-grad experience in such a busy hospital wouldn't have seen his fair share of patients who just have terrible luck. RNs with half a dozen years of floor experience can tell you about the patients that they remember who "did everything right" but still had bad outcomes.

I am by no means a Peter Attia apologist but am an avid listener. I never got the impression that he is advertising his teachings as the key to biologic immortality. Rather, that if you want to maximize your "healthspan" (as opposed to lifespan), you need to start working on things now and with intention towards whatever goal you have in mind. I do think his recs are sometimes evidence lacking and it is weird to me how often he switches his supplement regimen, though he has admitted to these things. i do like the overall attitude of being aggressive regarding one's own health.

Huberman preached findings from 1 research paper as if they are infallible. i listen occasionally but don't like his advice as much

 

[Osteoth]

- Annual PET-CT. Definitely wouldn't say that it "doesn't hurt the patient." Maybe one doesn't have enough radiation to cause problems, but doing so annually for several years is probably not great.

- With the advent of EHR, ordering these really esoteric labs is a huge pain in the rear. These are not labs that are available in Epic. You have to manually look up the lab codes (in either the Quest/Labcorp book or their website) and than often manually enter them into an order form. It might have been easier in the old days when you could just scribble a bunch of codes on a prescription pad, but it doesn't work that way anymore.

- The more you go digging, the more random crap that you uncover that you now have to chase down. And it can be really hard to reassure patients that things that are not clinically significant (an elevated TPO antibody but with a normal TSH and a normal T4) don't require some aggressive treatment.

Obviously not PET CT every year but I feel like there are some utility to things like every 5 years pan CT for cancer screening or some of the novel blood based cancer detection systems. Of course assuming the patients can pay.

And yeah for those with weird labs or whatever you can always refer.

 

[greatnt249]

Obviously not PET CT every year but I feel like there are some utility to things like every 5 years pan CT for cancer screening or some of the novel blood based cancer detection systems. Of course assuming the patients can pay.

And yeah for those with weird labs or whatever you can always refer.

I can assure you that, as a subspecialist, I am not exactly thrilled to be put in the position of clarifying out-of-context imaging/lab "abnormalities" that 1) I wouldn't have ordered to begin with and 2) that you have no idea why you ordered them either, or what you planned to do other than "refer out."

 

[DrMetal]

I'm at the point in my career where I actually just tell those people this. "Don't want what I'm selling? There's the door. Have a nice day." And if they want a CT or PET scan to see how their magic beans are working on their cancer, I tell them to ask the magic bean "doctor" to order and interpret it.

You're probably closer to retirement than I am. I still fear the almighty Yelp review, and shlew of hospital administrators who admire such posts/reviews and never defend the physician.

 

[Drrrrrr. Celty]

Obviously not PET CT every year but I feel like there are some utility to things like every 5 years pan CT for cancer screening or some of the novel blood based cancer detection systems. Of course assuming the patients can pay.

And yeah for those with weird labs or whatever you can always refer.

You'll find pancreatic cysts, adrenal nodules, thyroid nodules, liver hemangiomas, etc. That otherwise no one would have bothered to biopsy or intervene upon because they would have otherwise not harmed the patient. And it's not like these biopsies don't get messed up, the pathology need repeating or show the wrong thing, etc.

Incidental neck and abdominal findings are annoying. Especially in the elderly who are medically complicated. What are we accomplishing in terms of limiting mortality or morbidity?

 

[dozitgetchahi]

I'm at the point in my career where I actually just tell those people this. "Don't want what I'm selling? There's the door. Have a nice day." And if they want a CT or PET scan to see how their magic beans are working on their cancer, I tell them to ask the magic bean "doctor" to order and interpret it.

This.

When I started out as an attending, sometimes I’d give multiple impassioned pleas across visits trying to convince someone to do something about their clearly hazardous rheumatologic illness etc. That got stupid quick.

What I’ve settled on now is that I will give you one visit where I outline my opinion of what should be done. If you don’t like it, I’ll give you information and tell you to go think about it and come back if you’re interested in what I’m selling. But what I will not do is spend multiple visits debating the merits of modern Western medicine with you while you try to argue that there must be a diet, a supplement, something natural that you can do about this. Because there isn’t. And coming back to argue with me about it over and over again isn’t going to change that fact.

If you want to go to Kookytown, you’re free to do so. It’s a free country. But again, head to your naturopath/witch doctor/medicine man/chiropractor/whatever and leave me out of it.

 

[dozitgetchahi]

I am by no means a Peter Attia apologist but am an avid listener. I never got the impression that he is advertising his teachings as the key to biologic immortality. Rather, that if you want to maximize your "healthspan" (as opposed to lifespan), you need to start working on things now and with intention towards whatever goal you have in mind. I do think his recs are sometimes evidence lacking and it is weird to me how often he switches his supplement regimen, though he has admitted to these things. i do like the overall attitude of being aggressive regarding one's own health.

Huberman preached findings from 1 research paper as if they are infallible. i listen occasionally but don't like his advice as much

I support the idea of vigorously doing the “basics” when it comes to health - stop smoking. Eat a healthy diet. Exercise. Wear seat belts etc etc etc.

But that’s where I get off the bus. The rest of it strikes me as unnecessary at best and potentially toxic at worst, with lots of side effects and other issues at play. The “basics” can do a lot of good. I work in rural America where my patient panel is largely obese, sedentary, smoking etc so we have a long way to go just to get to baseline health. But most Americans need to focus on those things for “health span”, not scanning their full bodies with PET/CT and such.

 

[gutonc]

You're probably closer to retirement than I am. I still fear the almighty Yelp review, and shlew of hospital administrators who admire such posts/reviews and never defend the physician.

I might or might not be closer to retirement. But I have put myself in a position where I am largely insulated from that BS, and where they need me FAR more than the other way around.

It's not like I walk around telling these *****s to F off, but the days of trying to convince these people to change their minds is over. I give them 2 or 3 changes to hear me and then tell them they are welcome to follow up with me in the future if there's anything I can do for them.

And my employer would much rather me see 3 or 4 patients who want chemo than wasting that same amount of time on the patient they're only getting the visit fee for. And IME, these folks tend to be the uninsured/medicaid population, not the commercially insured.

 

[end stage fibro]

I support the idea of vigorously doing the “basics” when it comes to health - stop smoking. Eat a healthy diet. Exercise. Wear seat belts etc etc etc.

But that’s where I get off the bus. The rest of it strikes me as unnecessary at best and potentially toxic at worst, with lots of side effects and other issues at play. The “basics” can do a lot of good. I work in rural America where my patient panel is largely obese, sedentary, smoking etc so we have a long way to go just to get to baseline health. But most Americans need to focus on those things for “health span”, not scanning their full bodies with PET/CT and such.

Fully agree…I would even say the basics are all you need. No need to be quibbling about anything until there is an excellent foundation of diet and exercise.

 

[BillBill1219]

It's crazy how we always seem to ask, "Which is the lesser of all the evils, which will I hate the least?!"

Does anybody like this profession?

IM pgy-2. Perhaps much too early in my career to state an opinion like this, but I am really not sure if I would choose this path again. I simply don’t think it’s worth the amount of time, sacrifice, energy, and commitment. I really can’t imagine anyone enjoying medicine THAT much to put up with everything we have to deal with. If a person is smart and motivated enough to become a doctor, there are many things he can do to earn a similar income, which requires nowhere near the amount of time and sacrifice. So far I’ve experienced very little reward in this career.

 

[Redpancreas]

PGY-3 with some redundant training:

From a General IM perspective, I would prefer inpatient to outpatient. General IM is super broad and highly unpredictable. I would rather have the certainty of immediate lab values, the CT scanner, and patient's to examine at the bedside as opposed to vague in-basket complaints and an inconsistent history with labs/scans/consults that take weeks to schedule assuming the patient's are compliant, etc. The pay and lifestyle of inpatient GIM (i.e. Hospitalist) seems better too.

That said, I do love the idea of clinic and feel subspecialty clinic is a lot more focused/deliberate than General Internal Medicine clinic. I think the key with GIM clinic is that if you choose it, you should try to find a fool-proof way to catch things you're not familiar (i.e. when to send to ED or stat refer) but otherwise find a few areas (ex. HTN, DM, etc.) that you can get really good at and manage those.

The thing that really irks me about the outpatient clinic is that there's no real respect/recognition of your value. Everyone from idiots to educated/less ignorant folk who should know better disregard your opinion and see you as their barrier to specialist care. Why study/train for 10+ years just to do that? I would have rather done something more cognitive and advanced.

 

[DrMetal]

IM pgy-2. Perhaps much too early in my career to state an opinion like this, but I am really not sure if I would choose this path again. I simply don’t think it’s worth the amount of time, sacrifice, energy, and commitment. I really can’t imagine anyone enjoying medicine THAT much to put up with everything we have to deal with. If a person is smart and motivated enough to become a doctor, there are many things he can do to earn a similar income, which requires nowhere near the amount of time and sacrifice. So far I’ve experienced very little reward in this career.

To be honest, being an Attending isn't so bad. I can pick and chose what I care about, I can put on blinders and just do whatever I think is right.

Having the time and money to engage in hobbies is also nice, you gotta find ways to take your mind of things.

Being a medical student/resident sucks . . . and it's because we don't teach what we actually practice. There's a ton of hypocrisy and inconsistency in medical education/training. We teach a lot of stupid things that nobody does or uses in practice. Like the physical exam!

 

[gutonc]

IM pgy-2. Perhaps much too early in my career to state an opinion like this, but I am really not sure if I would choose this path again. I simply don’t think it’s worth the amount of time, sacrifice, energy, and commitment. I really can’t imagine anyone enjoying medicine THAT much to put up with everything we have to deal with. If a person is smart and motivated enough to become a doctor, there are many things he can do to earn a similar income, which requires nowhere near the amount of time and sacrifice. So far I’ve experienced very little reward in this career.

You are too early in your career to have a truly informed and nuanced opinion on this, but you're still allowed your opinion as it stands and it's no less valid for your inexperience.

As a PGY1-6 I tried to bend my training/experience to a career that I thought I could be happy in. Once I actually completed fellowship and found myself unable to find a position in that career, I pivoted to something I convinced myself I could tolerate. Turns out, that career (FT outpatient clinical hem/onc in a generalist setting, previously in an academish setting and now in a rural setting) is absolutely f***ing amazing and I'm profoundly happy with my work life.

I can't guarantee that you'll have the same experience I did, but I do think there are a lot of opportunities you can avail yourself of in order to have a good, happy, remunerative career in medicine.

 

[NewYorkDoctors]

PGY-3 with some redundant training:

From a General IM perspective, I would prefer inpatient to outpatient. General IM is super broad and highly unpredictable. I would rather have the certainty of immediate lab values, the CT scanner, and patient's to examine at the bedside as opposed to vague in-basket complaints and an inconsistent history with labs/scans/consults that take weeks to schedule assuming the patient's are compliant, etc. The pay and lifestyle of inpatient GIM (i.e. Hospitalist) seems better too.

That said, I do love the idea of clinic and feel subspecialty clinic is a lot more focused/deliberate than General Internal Medicine clinic. I think the key with GIM clinic is that if you choose it, you should try to find a fool-proof way to catch things you're not familiar (i.e. when to send to ED or stat refer) but otherwise find a few areas (ex. HTN, DM, etc.) that you can get really good at and manage those.

while I had the similar thoughts when I was a PGY-3, it has become abundantly clear to me now years later that GIM as an attending is primarily meant to 1) have a relatively low acuity job with no weekend call or major emergencies or 2) go private practice, make a 99213 mill, and refer everything out that is beyond the basics. maximize the revenue / effort ratio.

side note, one of the PMDs I work with opened a second office location in the same general vicinity. At first I was rather confused what the point of this was and how this doctor could be stretched so thin. I found this doctor now has 5 PAs and these PAs see patients INDEPENDENTLY without the physician also seeing the patient (like the resident - attending dynamic). At first I was perplexed as I knew NPs with doctorate degrees could do that in NY.

A closer look at the NY PA organization FAQs reveals that is not the case

https://www.nysspa.org/page/NYFAQ

Do PAs require supervision in New York State (NYS)?

>> PAs must be supervised by a physician (MD or DO). Supervision must be continuous but does not require the supervisor to be on-site, or to countersign notes or orders except when deemed appropriate and necessary by the supervising physician. Reference: N.Y. EDUC. LAW § 6542(2).

How many PAs can a physician supervise?

>> Outpatient = 4, Inpatient = 6, Hospital = 6. Reference: Education Law Article 131-B and N.Y. EDUC. LAW § 6542 (3)-(5).

Does a PA need to have a signed supervising physician (SP) agreement?

>> There is no legal requirement for a signed agreement between a PA and a physician. This can be implemented at the practice level but is more restrictive than state law and potentially increases liability for both the PA and physician. Reference: N.Y. PUB. HEALTH LAW § 3702.

How many chart reviews does a SP have to do with the PAs?

>> None. Reference: State Law Chart.

Does a SP need to be on site for the PA to bill for services?

>> No - “Supervision shall be continuous but shall not be construed as necessarily requiring the physical presence of the supervising physician at the time and place where such services are performed.” Reference: N.Y. EDUC. LAW § 6542 (2).

Does a SP need to co-sign the notes a PA writes?

>> Only if there is an institutional policy. There is no New York State law or regulation requiring such. Reference: Education Law Article 131-B.

Does a SP need to countersign orders written by PAs?

>> State law only requires countersignature if deemed necessary and appropriate by the SP. In no event should a countersignature be required prior to execution. Reference: N.Y. PUB. HEALTH LAW § 3702.

time for more to do GIM and open up PA ran 99213 mills to really maximize that revenue / effort ratio! Dont' work harder work smarter!

something is hard or not getting better? refer to specialist.

 

[Redpancreas]

while I had the similar thoughts when I was a PGY-3, it has become abundantly clear to me now years later that GIM as an attending is primarily meant to 1) have a relatively low acuity job with no weekend call or major emergencies or 2) go private practice, make a 99213 mill, and refer everything out that is beyond the basics. maximize the revenue / effort ratio.

side note, one of the PMDs I work with opened a second office location in the same general vicinity. At first I was rather confused what the point of this was and how this doctor could be stretched so thin. I found this doctor now has 5 PAs and these PAs see patients INDEPENDENTLY without the physician also seeing the patient (like the resident - attending dynamic). At first I was perplexed as I knew NPs with doctorate degrees could do that in NY.

A closer look at the NY PA organization FAQs reveals that is not the case

https://www.nysspa.org/page/NYFAQ

time for more to do GIM and open up PA ran 99213 mills to really maximize that revenue / effort ratio! Dont' work harder work smarter!

something is hard or not getting better? refer to specialist.

Definitely don't want to do that even if it maximizes revenue. Willing to sacrifice that additional 20% income for better care if possible!

 

[Redpancreas]

I love how we think $300K isn't a lot of debt.

The other consideration is, we lose a good decade of our adult lives, there's a profound loss of potential earnings there [We're all smart people, especially me. We could've gone into business, law, engineering, and made well into six figures.]

So if you're 35-yo and just out of training, starting to practice . . .not only might you have a $500K debt, but that's potentially 10 years of your life wasted, not making an adult salary. So really, compared to your MBA friends (who are now your boss), you're in the red some $750K to $1 mill.

It's no wonder physicians demand large salaries, and they deserve it. Problem is, the industry is starting to disagree.




They're absolutely worthless. I gave up my SHM membership as soon as they started to support the mid-level agenda. I'm about done with ACP too. The ABIM? Forget that fascist regime.

The only organization that I've seen actually advocate for physicians and try to do something for them (with respect to BS MOC) is NBPAS. [whether they succeed or not is still TBD, but they're trying.]

To be fair, 75K+50K moonlighting in my early 30s as a single trainee isn't big of a gap as 300K+ w/ taxes while married if you consider stressors of kids, spouse, mortgage, etc. Or maybe I'm just trying to justify my existence...

 

[Splenda88]

To be honest, being an Attending isn't so bad. I can pick and chose what I care about, I can put on blinders and just do whatever I think is right.

Having the time and money to engage in hobbies is also nice, you gotta find ways to take your mind of things.

Being a medical student/resident sucks . . . and it's because we don't teach what we actually practice. There's a ton of hypocrisy and inconsistency in medical education/training. We teach a lot of stupid things that nobody does or uses in practice. Like the physical exam!

Being an attending is actually good--even as a lowly hospitalist.

Lifestyle iis actually good. I can choose how much I want to make every year (from 200k to 600k). Of course, the more you want to make, the worst your lifestyle will be.

If you are a problematic patient, I am very quick to say that you can fire me so I can dump you into my PD lap. Lol

 

[Splenda88]

To be fair, 75K+50K moonlighting in my early 30s as a single trainee isn't big of a gap as 300K+ w/ taxes while married if you consider stressors of kids, spouse, mortgage, etc. Or maybe I'm just trying to justify my existence...

No matter how you put it, 300k is a lot money.

 

[NewYorkDoctors]

Definitely don't want to do that even if it maximizes revenue. Willing to sacrifice that additional 20% income for better care if possible!

i'm not saying it's right or wrong. it's just market forces here in NYC.

as a subspecialist, I get fed a steady diet of "softball consults." While I eat well, I do find myself ending up doing a lot of primary care level of management.

A very common thing I manage is GERD related cough.
While I could very easily turf the patient back to PCP after I have ruled out asthma, bronchiectasis, COPD, etc... after all appropriate CT scans, PFTs, bronchoprovocation testing etc..... the PCP keeps sending these patients back to me and the patient pleads and begs me... and out of the kindness of my heart because I know the PCP (or PAs) are not doing their jobs, I counsel the patient on sleeping head of bed elevated, buying a wedge pillow, ordering semi automatic beds for some elderly patients to prevent aspiration, go through a dietary history, comment on how PPIs are meant to be used continuously to reduce acid secretion, and I have also convinced a few patients to go to ACADEMIC GI for esophageal manometry and 24 hour pH probe (because community GI usually does not do those things due to... not a very high revenue / effort ratio....)

there is a serious step down of care in the community. Many community subspecialists like me are doing what academic IM should be doing. while I "eat well" i guess with an easy consult, it very quickly becomes not very profitable when I am just doing 99213 visits and talking when I could be doing 99203-5 with all of the other procedural codes. Plus that time slot takes up the time of someone who might need something more urgently done.

(again I am not trying to sound like a money hungry person. I am just saying, it's ultimately not as efficient as it sounds to have a subspecialist see what a primary care should be donig)

 

[Redpancreas]

i'm not saying it's right or wrong. it's just market forces here in NYC.

as a subspecialist, I get fed a steady diet of "softball consults." While I eat well, I do find myself ending up doing a lot of primary care level of management.

A very common thing I manage is GERD related cough.
While I could very easily turf the patient back to PCP after I have ruled out asthma, bronchiectasis, COPD, etc... after all appropriate CT scans, PFTs, bronchoprovocation testing etc..... the PCP keeps sending these patients back to me and the patient pleads and begs me... and out of the kindness of my heart because I know the PCP (or PAs) are not doing their jobs, I counsel the patient on sleeping head of bed elevated, buying a wedge pillow, ordering semi automatic beds for some elderly patients to prevent aspiration, go through a dietary history, comment on how PPIs are meant to be used continuously to reduce acid secretion, and I have also convinced a few patients to go to ACADEMIC GI for esophageal manometry and 24 hour pH probe (because community GI usually does not do those things due to... not a very high revenue / effort ratio....)

there is a serious step down of care in the community. Many community subspecialists like me are doing what academic IM should be doing. while I "eat well" i guess with an easy consult, it very quickly becomes not very profitable when I am just doing 99213 visits and talking when I could be doing 99203-5 with all of the other procedural codes. Plus that time slot takes up the time of someone who might need something more urgently done.

(again I am not trying to sound like a money hungry person. I am just saying, it's ultimately not as efficient as it sounds to have a subspecialist see what a primary care should be donig)

I actually figured that's where the GIM cynicism was coming from.

 

[hotsaws]

For the most part my patients are great. But I do get some referrals for the mast cell activation stuff or "immune problems", which is essentially a later stop on the journey of the fibro/EDS/brain fog/IBS/POTS/ETC patient. I try to be kind but I set boundaries. I don't order a bunch of unnecessary labs because I don't want to have to get caught up in the futile false positives and frankly I don't want to end up on the good side of a cluster B's split, only to pay for it later. My experience has shown that these patients then end up on the panel and the doc can basically continue to add unnecessary medications (in my world it becomes a step ladder of 2nd gen antihistamines, 1st gen antihistamines, ketotifen, cromolyn, Xolair, allergy shots, IVIG, ...) or end up being the bad guy. The patients remain chronically ill with periods of seemingly subjective improvement followed by a return to baseline chronic unwellness. I occasionally see other doc's patients in follow up who have been down this road for years. I'd rather just politely hear them out and tell them I'm not their guy. Most patients take this pretty well but sometimes they are angry because they feel dismissed. There's no winning in those cases...but they usually don't come back. I don't quite understand why some allergists go down this road. Maybe its good intentions, maybe its fear of conflict, maybe there's some profit incentive...i don't really know. I will say that if I was getting paid by the minute or reimbursed for all the testing...it would be much more palatable and tempting. I suspect this is the primary motivator behind the naturopaths and chiropractors driving a lot this stuff (or maybe its the midwit complex...learned a new word on this thread today and I like it).

On the topic of the healthy searching for a life hack...

It's funny because I'm at the stage in my life where I have quite a few friends who are 30s to 40s males making a good income and also very much living in the role of the suburban upper middle class (marriage, kids, steady job...etc). What seems like the recipe for happiness often becomes a form of stagnation. These guys are generally healthy and active but they become obsessed with finding something to make them better. I suppose motivated by stagnation/boredom or maybe some fear of mortality starting to enter the consciousness. I'm the token doctor in the group so I get lots of questions about supplements, diets, and wellness interventions (cold plunges, red light, frickin magnets, you name it). These guys end up seeing naturopaths and the like and then showing me their lab results of a bunch of random hormones and other substances measured in their blood. Like I have no idea what to tell you about your Taurine levels, bro. I pretty much tell them that sleep, exercise, moderating vices, minimizing stress, and eating a reasonably healthy diet is the ticket. I'd say testosterone or ozempic is perhaps the only legit pharmacological "hack" that yields results (but probably not actually gonna fix the true underlying problem). Like you're probably better off spending that extra cash on a boat or something if you want some temporary boost in happiness. I can at least relate to this thinking though. Sometimes I even go down the rabbit hole reading about some supplement they mention and honestly it sounds enticing and believable until I inevitably tear it apart.

Outpatient private practice is wonderful though. When I have med students interested in clinical medicine, I make a strong case for A/I. When I have med students who are interested in something like rads or anesthesia, I certainly don't try to talk them out of it.

 

[PikminOC]

The same patients who don't want evidence based meds will take 10 non evidence based horse sized pill supplements 4 times a day.

One patient wanted all those crazy labs so I ordered them. They were charged 7 grand by the lab and were mad at me. There's no medical justification that the insurance company would cover for those labs.

 

[NewYorkDoctors]

The same patients who don't want evidence based meds will take 10 non evidence based horse sized pill supplements 4 times a day.

One patient wanted all those crazy labs so I ordered them. They were charged 7 grand by the lab and were mad at me. There's no medical justification that the insurance company would cover for those labs.

this is why I caution and/or guilt trip patients who want a billion dollar workup have commercial insurance with high deductibles and out of pocket expenses.

heck i do the same thing when commercial insurance patients want to check 25 Vitamin D. I inform them theres no medical necessity and you'll on the hook for $100 for a vitamin D test. you sure?

when they ask me how much individual tests cost i google some charges number (higher than the real thing) to scare them off

when they ask me" why don't you know? you're the doctor shouldn't you know?"

I respond blithely "if I knew and dictated those prices, I would be the laboratory director and not have to talk to you about this."

this is the beauty of being in my own private practice. as long as i do the standard of care and also some more by going to bat for the patient and making sure I do all that I must do appropriately, then i can call out patients for their nonsense BS and put them in their place and no administrator will be fearing for his/her bonuses due to potential patient hurt feelings.

 

[Drrrrrr. Celty]

this is why I caution and/or guilt trip patients who want a billion dollar workup have commercial insurance with high deductibles and out of pocket expenses.

heck i do the same thing when commercial insurance patients want to check 25 Vitamin D. I inform them theres no medical necessity and you'll on the hook for $100 for a vitamin D test. you sure?

when they ask me how much individual tests cost i google some charges number (higher than the real thing) to scare them off

when they ask me" why don't you know? you're the doctor shouldn't you know?"

I respond blithely "if I knew and dictated those prices, I would be the laboratory director and not have to talk to you about this."

this is the beauty of being in my own private practice. as long as i do the standard of care and also some more by going to bat for the patient and making sure I do all that I must do appropriately, then i can call out patients for their nonsense BS and put them in their place and no administrator will be fearing for his/her bonuses due to potential patient hurt feelings.

So I don't fully comprehend this. But the attendings at my institute are very very worried about patient satisfaction scores.
I am totally happy being reasonable and letting patient's go and shop around for other physicians.

But I am concerned if this means that I am out a bonus or something...

 

[NewYorkDoctors]

So I don't fully comprehend this. But the attendings at my institute are very very worried about patient satisfaction scores.
I am totally happy being reasonable and letting patient's go and shop around for other physicians.

But I am concerned if this means that I am out a bonus or something...

i dunno either as I am free of the shackles of the hospital

My colleagues have just told me that for every antagonistic patient encounter that lowers satisfaction scores, this leads to some kind of penalty and the administrators are particularly peeved off because they are not getting some kind of bonus or award. whether that is monetary or based on reputation is unclear to me.

I was trying to convey that no administrator tells me what to do as I am my own administrator and I will tell off my patients (if utterly appropriate to do so... not my first move as that ruins the patient-doctor relationship) if the patient becomes unreasonable, antagonistic, and confrontational despite attempts to work things out amicably.

Usually these antagonistic attempts came about because of patients who wanted to receive concierge level of care from me and instant access while using managed medicaid insurance. I have quite a number of these entitled patients New Yorkers. I am born and raised in NYC but I deride new yorkers as "always in a rush to go no where in particular." They get angry when their PET/CT scan cannot be done on the same day in MY OFFICE.

If anyone tried to put a 1 star review with unintelligible twitter / X levels of stupidity amongst my sea of 5s, you bet I am creating a burner account and then 5 starring myself and doing a "community notes" stating (without PHI or anything) that the "above 1 star review was from a spoiled patient who did not get concierge level of care."

While this level of seemingly unprofessional behavior by myself seems to be something that will land most doctors in hot water, this is why I am independent from the hospital system. I do not have to answer to any administrators.

I operate by always do right by the patient and always go to bat for them. But I am not in the (expletive)-kissing and (expletive)-licking business. I will make my patients satisfied by treating them fully, properly, and completely with open communication. Heck, I even email and portal message people at odd hours of the night. As long as patients do things in good faith with me, I will respond in kind.
but if they want special VIP concierge treatment or get mad because they did not, they can find another doctor.
An administrator would be aghast at this from an employed doctor lol.


Addendum: just so no one thinks I am a miserable person who hates his patients...

yesterday I consulted on two patients with dyspnea and CT with definite UIP. I run PFTs in my office on the same as the visit (with modifier -25 this can be done and i get paid) moderate restriction and 6MWT shows reduced walking distance and desaturations to 80% or so.

oxygen ordered personally (I use this great online DME portal that connects to the local Community Surgical DME store in NYC)
oxygen concentrator and portable Inogen confirmed received this morning for both.

PA for Ofev done personally on CoverMymeds - approved right away

my front desk staff three way calls the patients with Optum specialty pharmacy (as the patients have a hard time navigating) and Ofev will be sent to their door overnight tomorrow for the Medi/Medi patient for $4 a month copay

one patient has Managed Medicare without medicaid - his out of pocket monthly copay is going to be nearly $1000.
my front desk coordinates via hipaa secure email to fill out the BI Cares financial assistance form. this is sent in. usually the company will find a way to get 1-2 years of free Ofev depending on his financial status

all this is done in record time. i do not expect any patients to give me flowers. I expect patients not to complain about not getting concierge care ever again.

in PP my motto doing things this fast is get it done so the patient enters the follow up phase in 2-3 months and then get to the next new patient/consultation. keep the assembly line flowing but never cut corners or compromise care. I will always try to do the "full workup and management" as any academic doctor would do. I just speed the process up to Warp 9.99999 (in the old star trek canon, warp 10 is not reachable)

 

[Drrrrrr. Celty]

IM pgy-2. Perhaps much too early in my career to state an opinion like this, but I am really not sure if I would choose this path again. I simply don’t think it’s worth the amount of time, sacrifice, energy, and commitment. I really can’t imagine anyone enjoying medicine THAT much to put up with everything we have to deal with. If a person is smart and motivated enough to become a doctor, there are many things he can do to earn a similar income, which requires nowhere near the amount of time and sacrifice. So far I’ve experienced very little reward in this career.

I'm a PGY5 now. I honestly love what I do.
It took a long time to get here though. And I will still admit that I am more cynical and more lonely. And I think that's how a lot of physicians feel. Their jobs become part of their family. Their connection to something meaningful.

That being said as I mentioned above here. My goal is to buy a nice house in the next 12 months. And that's pretty reasonable. A lot of my high school friends won't be able to do that in the next 10 years.

 

[Drrrrrr. Celty]

i dunno either as I am free of the shackles of the hospital

My colleagues have just told me that for every antagonistic patient encounter that lowers satisfaction scores, this leads to some kind of penalty and the administrators are particularly peeved off because they are not getting some kind of bonus or award. whether that is monetary or based on reputation is unclear to me.

I was trying to convey that no administrator tells me what to do as I am my own administrator and I will tell off my patients (if utterly appropriate to do so... not my first move as that ruins the patient-doctor relationship) if the patient becomes unreasonable, antagonistic, and confrontational despite attempts to work things out amicably.

Usually these antagonistic attempts came about because of patients who wanted to receive concierge level of care from me and instant access while using managed medicaid insurance. I have quite a number of these entitled patients New Yorkers. I am born and raised in NYC but I deride new yorkers as "always in a rush to go no where in particular." They get angry when their PET/CT scan cannot be done on the same day in MY OFFICE.

If anyone tried to put a 1 star review with unintelligible twitter / X levels of stupidity amongst my sea of 5s, you bet I am creating a burner account and then 5 starring myself and doing a "community notes" stating (without PHI or anything) that the "above 1 star review was from a spoiled patient who did not get concierge level of care."

While this level of seemingly unprofessional behavior by myself seems to be something that will land most doctors in hot water, this is why I am independent from the hospital system. I do not have to answer to any administrators.

I operate by always do right by the patient and always go to bat for them. But I am not in the (expletive)-kissing and (expletive)-licking business. I will make my patients satisfied by treating them fully, properly, and completely with open communication. Heck, I even email and portal message people at odd hours of the night. As long as patients do things in good faith with me, I will respond in kind.
but if they want special VIP concierge treatment or get mad because they did not, they can find another doctor.
An administrator would be aghast at this from an employed doctor lol.

I like the idea of being free of the shackles of the hospital lol.

 

[dozitgetchahi]

I can assure you that, as a subspecialist, I am not exactly thrilled to be put in the position of clarifying out-of-context imaging/lab "abnormalities" that 1) I wouldn't have ordered to begin with and 2) that you have no idea why you ordered them either, or what you planned to do other than "refer out."

This.

There are several PCP NPs near me that will order an ANA for damn near any reason (one is apparently performing “annual screening ANAs”). One of my last genius consults from one of these NPs was a young woman who was having abdominal cramps whenever she had an orgasm. ANA was positive, of course. She had no other symptoms of any ANA associated disease whatsoever.

 

[greatnt249]

This.

There are several PCP NPs near me that will order an ANA for damn near any reason (one is apparently performing “annual screening ANAs”). One of my last genius consults from one of these NPs was a young woman who was having abdominal cramps whenever she had an orgasm. ANA was positive, of course. She had no other symptoms of any ANA associated disease whatsoever.

Your ANA is my high-sensitivity troponin, except more recently rheumatologists have been trying to get it right by creating "choosing wisely" guidelines with regard to ANA. High-sensitivity troponin, well, not so much.

 

[dozitgetchahi]

Your ANA is my high-sensitivity troponin, except more recently rheumatologists have been trying to get it right by creating "choosing wisely" guidelines with regard to ANA. High-sensitivity troponin, well, not so much.

The guidelines may be there, but I promise you…no healthcare provider in America is listening to them lol.

Also, I’d really love if PCPs stopped telling every ANA 1:80 patient with zero relevant symptoms they’re referring to rheumatology “you have lupus”. Patient then reads up on “lupus” from WebMD and a bunch of silly support group websites, and stumbles into my office thinking they have some sort of lethal disease when they usually have…nothing.

 

[NewYorkDoctors]

This.

There are several PCP NPs near me that will order an ANA for damn near any reason (one is apparently performing “annual screening ANAs”). One of my last genius consults from one of these NPs was a young woman who was having abdominal cramps whenever she had an orgasm. ANA was positive, of course. She had no other symptoms of any ANA associated disease whatsoever.

yep.

i just got a consult for a patient who had a CT scan for no reason... for "annual physical."
This patient wasn't even an executive. While I would not take this statement at face value and give the PCP the benefit of the doubt, this patient literally said "oh I am a non smoker and have no dyspnea, chest pain, or cough. I didn't even want to do it but my PCP asked me to get a CT scan for my annual physical." This patient has straight Medicare so no prior authorization is required for CT imaging.

some subcentimeter nodules and borderline 1cm lymph nodes.

i thoroughly enjoyed opening up the PACS images, showing the patient, pulling out a little ruler , and using my human anatomy model to explain what this is why and its too small to biopsy and how we don't have to scan her again as her risk score is low but we she is too anxious about things and we will have to scan her again to allay her fears. sigh


also I noticed the ANA is found in the "arthritis panel."
when I do some primary care, if a patient is ever concerned that the OA pain (that they are not doing PT, exercises, oral or topical analgesics for) is something more, I first try to talk about how the morning stiffness would be far longer than 30 minutes and then show them google images pictures of RA... if they still aren't convinced I usually risk it by going for hsCRP (assuming they have no reason why that would be high) and state "this also helps with your cholesterol risk estimation." if that turns out not high I tell them "see? this magical test says you have no inflammatory arthritis!"

While that is not how that test is meant to be used, it makes sense to the patient and it has helped me prevent sending ANA, RF, CCPs, SSA/SSB, etc...

 

[Drrrrrr. Celty]

i dunno either as I am free of the shackles of the hospital

My colleagues have just told me that for every antagonistic patient encounter that lowers satisfaction scores, this leads to some kind of penalty and the administrators are particularly peeved off because they are not getting some kind of bonus or award. whether that is monetary or based on reputation is unclear to me.

I was trying to convey that no administrator tells me what to do as I am my own administrator and I will tell off my patients (if utterly appropriate to do so... not my first move as that ruins the patient-doctor relationship) if the patient becomes unreasonable, antagonistic, and confrontational despite attempts to work things out amicably.

Usually these antagonistic attempts came about because of patients who wanted to receive concierge level of care from me and instant access while using managed medicaid insurance. I have quite a number of these entitled patients New Yorkers. I am born and raised in NYC but I deride new yorkers as "always in a rush to go no where in particular." They get angry when their PET/CT scan cannot be done on the same day in MY OFFICE.

If anyone tried to put a 1 star review with unintelligible twitter / X levels of stupidity amongst my sea of 5s, you bet I am creating a burner account and then 5 starring myself and doing a "community notes" stating (without PHI or anything) that the "above 1 star review was from a spoiled patient who did not get concierge level of care."

While this level of seemingly unprofessional behavior by myself seems to be something that will land most doctors in hot water, this is why I am independent from the hospital system. I do not have to answer to any administrators.

I operate by always do right by the patient and always go to bat for them. But I am not in the (expletive)-kissing and (expletive)-licking business. I will make my patients satisfied by treating them fully, properly, and completely with open communication. Heck, I even email and portal message people at odd hours of the night. As long as patients do things in good faith with me, I will respond in kind.
but if they want special VIP concierge treatment or get mad because they did not, they can find another doctor.
An administrator would be aghast at this from an employed doctor lol.


Addendum: just so no one thinks I am a miserable person who hates his patients...

yesterday I consulted on two patients with dyspnea and CT with definite UIP. I run PFTs in my office on the same as the visit (with modifier -25 this can be done and i get paid) moderate restriction and 6MWT shows reduced walking distance and desaturations to 80% or so.

oxygen ordered personally (I use this great online DME portal that connects to the local Community Surgical DME store in NYC)
oxygen concentrator and portable Inogen confirmed received this morning for both.

PA for Ofev done personally on CoverMymeds - approved right away

my front desk staff three way calls the patients with Optum specialty pharmacy (as the patients have a hard time navigating) and Ofev will be sent to their door overnight tomorrow for the Medi/Medi patient for $4 a month copay

one patient has Managed Medicare without medicaid - his out of pocket monthly copay is going to be nearly $1000.
my front desk coordinates via hipaa secure email to fill out the BI Cares financial assistance form. this is sent in. usually the company will find a way to get 1-2 years of free Ofev depending on his financial status

all this is done in record time. i do not expect any patients to give me flowers. I expect patients not to complain about not getting concierge care ever again.

in PP my motto doing things this fast is get it done so the patient enters the follow up phase in 2-3 months and then get to the next new patient/consultation. keep the assembly line flowing but never cut corners or compromise care. I will always try to do the "full workup and management" as any academic doctor would do. I just speed the process up to Warp 9.99999 (in the old star trek canon, warp 10 is not reachable)

How many patients do you see though with doing all of this though? This sounds like you gave this patient a 2 hour visit.

Like with endo it feels like almost everything needs a PA. Ozempic? Needs a PA. Patient needs a DexCOM because they're on 4-5 shots of insulin a day? PA. Patient needs short acting insulin? PA. Anything that's not Fosamax for Osteoporosis? PA. Hell, I literally had an insurance company deny my patient insulin for their pump told me to use pens lol...

Albeit I suspect once my population goes from 3/5th medicare/medicaid to private it might be easier. But I am starting to get worn down on the PA front.

 

[NewYorkDoctors]

How many patients do you see though with doing all of this though? This sounds like you gave this patient a 2 hour visit.

Like with endo it feels like almost everything needs a PA. Ozempic? Needs a PA. Patient needs a DexCOM because they're on 4-5 shots of insulin a day? PA. Patient needs short acting insulin? PA. Anything that's not Fosamax for Osteoporosis? PA. Hell, I literally had an insurance company deny my patient insulin for their pump told me to use pens lol...

Albeit I suspect once my population goes from 3/5th medicare/medicaid to private it might be easier. But I am starting to get worn down on the PA front.

Honestly not that long. The patient was in the room talking to me for perhaps 15 minutes in total . While my MA rooms the patient and does vitals and ekg (hey pcp doesn’t send me one I need an ekg for dyspnea ), I am pregaming the chart . Although pcps send me nothing , I can access the local lab portals and radiology portals for reports and pacs images . I also use something called surescripts to download their medication dispensed list (which has inactive and active meds so I still have to reconcile ) . Once I know what script to use I ask the relevant history questions and “fill in the blanks.” I show the patient the CT scan . I discuss the disease state . I use intra office LaN chat to instruct my RT to perform pft with bronchodilator and 6mwt - I inform the patient the plan - I text nurse to come in to do phlebotomy for cvd labs - patient goes to pft testing .

While that patient is occupied for 20 minutes I have my MA fire up that portal for the dme and PA and auto populate the forms . I pop in to answer a few clinical questions .

I move onto next patient . When next patient is doing testing I rotate back to patient 1 and discuss pft results then and there and discuss the Ofev medication and oxygen .

The patient was in my office for a visit for about 1 hour in total but I had thing staggered and flow around .

I do not use mid levels for pulmonary consults . I have a mid level to help with my legacy primary care patients (I did moonlight pcp for a period of time in fellowship )


So in nys now , all managed medicaids and straight Medicaid have been mandated to follow the states universal drug formulary. Ozempic is on there as no Pa . Ozempic is flying off the shelves now for off label weight loss (as wegovy for weight loss is not a Medicaid benefit )

 

[dozitgetchahi]

How many patients do you see though with doing all of this though? This sounds like you gave this patient a 2 hour visit.

Like with endo it feels like almost everything needs a PA. Ozempic? Needs a PA. Patient needs a DexCOM because they're on 4-5 shots of insulin a day? PA. Patient needs short acting insulin? PA. Anything that's not Fosamax for Osteoporosis? PA. Hell, I literally had an insurance company deny my patient insulin for their pump told me to use pens lol...

Albeit I suspect once my population goes from 3/5th medicare/medicaid to private it might be easier. But I am starting to get worn down on the PA front.

The osteoporosis situation is really maddening. Nowadays it seems like insurance companies and Medicare are even pushing back on Reclast, despite the fact that it’s actually pretty cheap (list price on a bag of Reclast is like $4.75 the last time I checked). It’s also especially frustrating that virtually all of the osteoporosis biologics have only officially been FDA approved in women…as if men don’t get bad osteoporosis, or don’t have comorbidities like renal failure that preclude the use of bisphosphonates…

 

[dozitgetchahi]

For the most part my patients are great. But I do get some referrals for the mast cell activation stuff or "immune problems", which is essentially a later stop on the journey of the fibro/EDS/brain fog/IBS/POTS/ETC patient. I try to be kind but I set boundaries. I don't order a bunch of unnecessary labs because I don't want to have to get caught up in the futile false positives and frankly I don't want to end up on the good side of a cluster B's split, only to pay for it later. My experience has shown that these patients then end up on the panel and the doc can basically continue to add unnecessary medications (in my world it becomes a step ladder of 2nd gen antihistamines, 1st gen antihistamines, ketotifen, cromolyn, Xolair, allergy shots, IVIG, ...) or end up being the bad guy. The patients remain chronically ill with periods of seemingly subjective improvement followed by a return to baseline chronic unwellness. I occasionally see other doc's patients in follow up who have been down this road for years. I'd rather just politely hear them out and tell them I'm not their guy. Most patients take this pretty well but sometimes they are angry because they feel dismissed. There's no winning in those cases...but they usually don't come back. I don't quite understand why some allergists go down this road. Maybe its good intentions, maybe its fear of conflict, maybe there's some profit incentive...i don't really know. I will say that if I was getting paid by the minute or reimbursed for all the testing...it would be much more palatable and tempting. I suspect this is the primary motivator behind the naturopaths and chiropractors driving a lot this stuff (or maybe its the midwit complex...learned a new word on this thread today and I like it).

On the topic of the healthy searching for a life hack...

It's funny because I'm at the stage in my life where I have quite a few friends who are 30s to 40s males making a good income and also very much living in the role of the suburban upper middle class (marriage, kids, steady job...etc). What seems like the recipe for happiness often becomes a form of stagnation. These guys are generally healthy and active but they become obsessed with finding something to make them better. I suppose motivated by stagnation/boredom or maybe some fear of mortality starting to enter the consciousness. I'm the token doctor in the group so I get lots of questions about supplements, diets, and wellness interventions (cold plunges, red light, frickin magnets, you name it). These guys end up seeing naturopaths and the like and then showing me their lab results of a bunch of random hormones and other substances measured in their blood. Like I have no idea what to tell you about your Taurine levels, bro. I pretty much tell them that sleep, exercise, moderating vices, minimizing stress, and eating a reasonably healthy diet is the ticket. I'd say testosterone or ozempic is perhaps the only legit pharmacological "hack" that yields results (but probably not actually gonna fix the true underlying problem). Like you're probably better off spending that extra cash on a boat or something if you want some temporary boost in happiness. I can at least relate to this thinking though. Sometimes I even go down the rabbit hole reading about some supplement they mention and honestly it sounds enticing and believable until I inevitably tear it apart.

Outpatient private practice is wonderful though. When I have med students interested in clinical medicine, I make a strong case for A/I. When I have med students who are interested in something like rads or anesthesia, I certainly don't try to talk them out of it.

I agree with your “gatekeeping”. My approach to the somatic/functional patients is to try to decline the consults as much as possible before they get to the office. In my experience, these types of vague consults go three different ways:

1) Patient is clearly fibro/CFS etc, and I don’t have a magical solution for that aside from promoting exercise, sleep, reduce your stress, PT, go to counseling etc. Patient is pissed.

2) (Less common, but worse) Patient’s symptoms ride the line between somatization and actual rheumatologic disease. It can be really hard to determine signal from noise in these vague situations (and in rheumatology, these are the patients who end up in the bin titled “seronegative RA” or “undifferentiated seronegative arthritis”). They have typical fibro symptoms, but maybe if I examine the joints a couple of times I can convince myself that they have synovitis, and perhaps the ESR and CRP are somewhat elevated (not uncommon, and obviously nonspecific)…now we’re off to the races. Pt joins the panel. Sometimes they have a very pronounced response to DMARDs and it’s clear that they actually did have inflammatory arthritis etc…but other times they hang around on the panel for years, different meds are tried, they have an equivocal or temporary response, and you always wonder if they actually have anything inflammatory going on. I’d almost rather miss a real case of RA etc than pick up a bunch of these vague situations where you always wonder if their “improvement” is just placebo effect etc.

3) (less common) PCP sends in something that on paper sounds like fibro or even pure nonsense, but a quick glance/exam of the patient reveals rip roaring inflammatory arthritis or other obvious rheumatic disease. This is part of the reason that I’m somewhat uncomfortable just bouncing large numbers of referrals, because I’ve seen this happen often enough that I don’t want to deny people access to rheumatologic care who really truly need it.

There’s two halves to this coin. There are a certain percentage of patients who get mislabeled “fibro” who actually have pronounced rheumatologic disease, and languish for years getting gabapentin, duloxetine, etc (or even worse, opioids and benzos) when they really needed to be treated for their illnesses. The flip side is the people who really just have fibro, but then get hammered with DMARDs for years for no good reason. There’s a spectrum of approach from rheumatologists on this…I’ll admit that I’m more on the “let’s try treating it” side of the spectrum, because I’m often the 3rd or 4th doctor (or sometimes the 3rd or fourth rheumatologist!) someone is seeing, and I’m basically batting cleanup after a bunch of other attempts have tried/failed. But I make the risk/benefit ratio very clear to the patient, and I’m also aggressive about stopping drugs that don’t seem to be helping in vague situations. I’m also aggressive in treating bad biomechanics, isolated MSK issues, sleep apnea, etc. I send a lot of “fibro” types for PT and sleep studies. Good PT + exercise plan + treating your latent undiagnosed OSA “fixes” a lot of fibromyalgia.

I also make it clear to patients and providers alike that I’m always happy to render an opinion and/or help diagnose in a vague situation…but that doesn’t mean the patient is necessarily going to join my panel. If I don’t have anything to offer, then that’s it and you need to take the ball from there. I’m not a surrogate pain management doctor, and I won’t manage isolated back pain, fibromyalgia etc. I’m not the dumping zone for problems you don’t feel like dealing with.

 

[NewYorkDoctors]

Since I ride both sides of the road (in that i do PCP also), I often get patients coming back from another subspecialist who did not find anything major or wrong. the patient is often complaining to me.

but i take that opportunity to tell them something along the lines of
"well im glad the specific subspecialist did that evaluation and deemed you do not have that serious disease. while I understand that it would have been satisfying to have an answer, if you had RA or IBD or (insert whatever other chronic disease) then you would be on immunosuppresants would never be cured of a debilitating disease. I do not have the expertise to have made that call. But now that we know nothing that bad is wrong, I would like to talk to you about getting more exercise. Just walking is fine. No one has time to go to a gym, find parking, shower, look at big strong muscular steroid users and get shy, etc... here is a pedometer. plase reach 10,000 steps a day. while that is 100 minutes of brisk walking, you could just move around throughout the day and incorporate this into your lifestyle. once you reach this kind of walk exercise, you will feel much better. trust me. here's a $3 pedometer from amazon. dont say i never give you anything"

if the patients are sincere and try this they do feel better with that exercise endorphins and lose some weight too.

if they don't, then I know they have primary gain going on

 

[greatnt249]

Since I ride both sides of the road (in that i do PCP also), I often get patients coming back from another subspecialist who did not find anything major or wrong. the patient is often complaining to me.

but i take that opportunity to tell them something along the lines of
"well im glad the specific subspecialist did that evaluation and deemed you do not have that serious disease. while I understand that it would have been satisfying to have an answer, if you had RA or IBD or (insert whatever other chronic disease) then you would be on immunosuppresants would never be cured of a debilitating disease. I do not have the expertise to have made that call. But now that we know nothing that bad is wrong, I would like to talk to you about getting more exercise. Just walking is fine. No one has time to go to a gym, find parking, shower, look at big strong muscular steroid users and get shy, etc... here is a pedometer. plase reach 10,000 steps a day. while that is 100 minutes of brisk walking, you could just move around throughout the day and incorporate this into your lifestyle. once you reach this kind of walk exercise, you will feel much better. trust me. here's a $3 pedometer from amazon. dont say i never give you anything"

if the patients are sincere and try this they do feel better with that exercise endorphins and lose some weight too.

if they don't, then I know they have primary gain going on

For a while now, I've been telling patients up front that I'm here to evaluate potential causes related to my specialty that could be causing your symptoms, but if I rule those things out, I will likely not be able to tell you why you're having the symptoms you're experiencing. Then followed by "but at least we now know it's not *insert serious diagnosis.*" I would like to think/hope that staves off some of the "dissatisfaction" with not having a diagnosis walking out of my clinic. I've noticed since giving this speech the number of calls/messages I have to then field about "well what's wrong with me then" have dropped off significantly.

 

[NewYorkDoctors]

For a while now, I've been telling patients up front that I'm here to evaluate potential causes related to my specialty that could be causing your symptoms, but if I rule those things out, I will likely not be able to tell you why you're having the symptoms your experiencing. Then followed by "but at least we now know it's not *insert serious diagnosis.*" I would like to think/hope that staves off some of the "dissatisfaction" with not having a diagnosis walking out of my clinic. I've noticed since giving this speech the number of calls/messages I have to then field about "well what's wrong with me then" have dropped off significantly.

yep. not every patient is a primary gain patient.

some patients just need to have the conversation framed the proper way.

 

[Drrrrrr. Celty]

Honestly not that long. The patient was in the room talking to me for perhaps 15 minutes in total . While my MA rooms the patient and does vitals and ekg (hey pcp doesn’t send me one I need an ekg for dyspnea ), I am pregaming the chart . Although pcps send me nothing , I can access the local lab portals and radiology portals for reports and pacs images . I also use something called surescripts to download their medication dispensed list (which has inactive and active meds so I still have to reconcile ) . Once I know what script to use I ask the relevant history questions and “fill in the blanks.” I show the patient the CT scan . I discuss the disease state . I use intra office LaN chat to instruct my RT to perform pft with bronchodilator and 6mwt - I inform the patient the plan - I text nurse to come in to do phlebotomy for cvd labs - patient goes to pft testing .

While that patient is occupied for 20 minutes I have my MA fire up that portal for the dme and PA and auto populate the forms . I pop in to answer a few clinical questions .

I move onto next patient . When next patient is doing testing I rotate back to patient 1 and discuss pft results then and there and discuss the Ofev medication and oxygen .

The patient was in my office for a visit for about 1 hour in total but I had thing staggered and flow around .

I do not use mid levels for pulmonary consults . I have a mid level to help with my legacy primary care patients (I did moonlight pcp for a period of time in fellowship )


So in nys now , all managed medicaids and straight Medicaid have been mandated to follow the states universal drug formulary. Ozempic is on there as no Pa . Ozempic is flying off the shelves now for off label weight loss (as wegovy for weight loss is not a Medicaid benefit )

That's a pretty nice and functional office then. As much as I love my clinic it has too many problems. Well that and I probably take it upon myself to tackle a lot at once.

 

[VA Hopeful Dr]

So I don't fully comprehend this. But the attendings at my institute are very very worried about patient satisfaction scores.
I am totally happy being reasonable and letting patient's go and shop around for other physicians.

But I am concerned if this means that I am out a bonus or something...

Hospital dependant. Some care a bunch, some don't care at all.