Is outpatient really that bad?

[NewYorkDoctors]

some i had a realization today...

I have come to the conclusion that the root of all patient dissatisfaction comes down to three things

1) not having instant concierge access to their doctors when they don't actually pay for concierge medicine
2) not having around the clock instant message / inbox / email access to their doctors - because our society is all electronic now and want instant satisfaction
3) not being insta-cured like the pokemon center. they watch too much Star Trek (like me! paramount plus is awesome ) in which Dr McCoy/Crusher/ Bashir/Robert Picardo's hologram EMH doctor / (i never watched star trek enterprise or discovery so i dont know those doctors names), Dr T'ana, Dr Mbenga etc... are using painless hyposprays to cure everything and tricorders to instantly diagnose something...

because the vast majority of patients who are satisfied ... just need some communication and taking a few moments to spell things out for them...

but those that are never satisfied can always fall under one of the three above.

now all patients should have a doctor who listens and is empathetic. I am saying after the doctor has done all of those "by the book proper steps," then the remaining issues are 1-3.

I always take great care to ensure all the "proper steps" such as open communication, frequent communication, and showing empathy and "aww you poor thing" is demonstrated to patients. I do that whole "family doctor" open the conversation by "asking about the family or the pets" thing. those "by the book steps" are usually sufficient to get the patient to open up and work with you collaboratively.

I am saying AFTER the doctor does everything right and by the book, when patients are STILL not satisfied, it is usually due to 1-3 as above.

for those patients I often ask... so what do YOU want to do?

then I get some very outlandish answers lol.


Addendum: I must reiterate - we must do our part by being empathetic, open, kind, and understanding of certain "social determinants of health, cultural competency, that DEI stuff..." that interfere with the patients situation. if all patients were as self sufficient as we are, then they would not need to see us and we would be out of a job...

but I am saying AFTER we do the right by the books "good doctor" approach and we have "gotten the ball out of our court," then I have noticed unsatisfied patients fall under 1-3.

Addendum 2 : to give some concrete examples , one brand new patient was a young 30s non smoker who was recently admitted to local hospital with cough and found ti have hilar LAN and nodules - transthoracic needle biopsy diagnosed lung adeno egfr positive . Saw Heme onc already on Tagrisso . Hosptial navigators helped schedule to see me two weeks after discharge . I prepped the entire visit ahead of her visit (primarily to save me time during the visit but also to show patients I care ) and the visit went smoothly . Restrictive lung disease will get better with time . Some air trapping maybe a bronchodilator will help. Utmost care and empathy given . She was a nice person overall. But this patient just had to chime in “it’s so hard to see you ! I waited so long!”

I responded you know there are other pulmonologists .

Yeah but you have the highest reviews and I wanted to see you .

Thanks for your praise but I have to attend to the patients who already scheduled .



This is a tame and lighter example of a very nice patient whose disappointment was rooted in how a scarce resource (I’m not saying I’m he scarce resource in just making an analogy ) was not given to a patient and the patient was not allowed to cut in line and this was the root of her disappointment .

This was a pleasant encounter actually but still highlights my point


Addendum #3:
I think I will place a sign in my waiting room. I will custom make a sign. It will say something like

"The patient is always right. But the customer is not always right."

I think that captures the frustrations of outpatient medicine in a succinct and pithy way.

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[end stage fibro]

some i had a realization today...

I have come to the conclusion that the root of all patient dissatisfaction comes down to three things

1) not having instant concierge access to their doctors when they don't actually pay for concierge medicine
2) not having around the clock instant message / inbox / email access to their doctors - because our society is all electronic now and want instant satisfaction
3) not being insta-cured like the pokemon center. they watch too much Star Trek (like me! paramount plus is awesome ) in which Dr McCoy/Crusher/ Bashir/Robert Picardo's hologram EMH doctor / (i never watched star trek enterprise or discovery so i dont know those doctors names), Dr T'ana, Dr Mbenga etc... are using painless hyposprays to cure everything and tricorders to instantly diagnose something...

because the vast majority of patients who are satisfied ... just need some communication and taking a few moments to spell things out for them...

but those that are never satisfied can always fall under one of the three above.

now all patients should have a doctor who listens and is empathetic. I am saying after the doctor has done all of those "by the book proper steps," then the remaining issues are 1-3.

I always take great care to ensure all the "proper steps" such as open communication, frequent communication, and showing empathy and "aww you poor thing" is demonstrated to patients. I do that whole "family doctor" open the conversation by "asking about the family or the pets" thing. those "by the book steps" are usually sufficient to get the patient to open up and work with you collaboratively.

I am saying AFTER the doctor does everything right and by the book, when patients are STILL not satisfied, it is usually due to 1-3 as above.

for those patients I often ask... so what do YOU want to do?

then I get some very outlandish answers lol.


Addendum: I must reiterate - we must do our part by being empathetic, open, kind, and understanding of certain "social determinants of health, cultural competency, that DEI stuff..." that interfere with the patients situation. if all patients were as self sufficient as we are, then they would not need to see us and we would be out of a job...

but I am saying AFTER we do the right by the books "good doctor" approach and we have "gotten the ball out of our court," then I have noticed unsatisfied patients fall under 1-3.

Addendum 2 : to give some concrete examples , one brand new patient was a young 30s non smoker who was recently admitted to local hospital with cough and found ti have hilar LAN and nodules - transthoracic needle biopsy diagnosed lung adeno egfr positive . Saw Heme onc already on Tagrisso . Hosptial navigators helped schedule to see me two weeks after discharge . I prepped the entire visit ahead of her visit (primarily to save me time during the visit but also to show patients I care ) and the visit went smoothly . Restrictive lung disease will get better with time . Some air trapping maybe a bronchodilator will help. Utmost care and empathy given . She was a nice person overall. But this patient just had to chime in “it’s so hard to see you ! I waited so long!”

I responded you know there are other pulmonologists .

Yeah but you have the highest reviews and I wanted to see you .

Thanks for your praise but I have to attend to the patients who already scheduled .



This is a tame and lighter example of a very nice patient whose disappointment was rooted in how a scarce resource (I’m not saying I’m he scarce resource in just making an analogy ) was not given to a patient and the patient was not allowed to cut in line and this was the root of her disappointment .

This was a pleasant encounter actually but still highlights my point


Addendum #3:
I think I will place a sign in my waiting room. I will custom make a sign. It will say something like

"The patient is always right. But the customer is not always right."

I think that captures the frustrations of outpatient medicine in a succinct and pithy way.

i surmised you were a good doctor from your posts on here; I can tell for sure you are good person because you did not include Dr. Pulaski on your list

 

[NewYorkDoctors]

i surmised you were a good doctor from your posts on here; I can tell for sure you are good person because you did not include Dr. Pulaski on your list

and yes i honestly cant think of any really great episodes from S2 of TNG (or S1 for that matter). Maybe it was because roddenberry was still around and hampering the creative input. shrugs.

 

[VA Hopeful Dr]

and yes i honestly cant think of any really great episodes from S2 of TNG (or S1 for that matter). Maybe it was because roddenberry was still around and hampering the creative input. shrugs.

First Borg episode. Sherlock Holmes episode.

That said, it was a pretty weak season compared to the rest.

 

[NewYorkDoctors]

First Borg episode. Sherlock Holmes episode.

That said, it was a pretty weak season compared to the rest.

true. Q Who was a memorable episode.
still S2 of TNG was probably still better than S2 of Picard. S2 Picard was borderline unwatchable (and not because of the heavy handed politics... the fictional star trek universe is supposed to espouse utopia ideals) with its meandering plot lines.

 

[NewYorkDoctors]

saw this on doximity

i totally agree with the premise

I will say that is that many private practice PCPs who opened his/her own practice here in NYC really do make bank. high 6 figures and some with 7 figures. how? good IPA negotiated insurance rates, lots of zero deductible / low deductible and no copay or low copay managed medicaid and essential plans (obamacare) for which the more the patients come, the more you get paid (the idea being keep them away from the hospital)

in general in medicine if you want more money, you do not be an employee of a hospital or corporation (unless your specialty is super duper advanced and specialized and needs the hospitals for the technology)

 

[dgdg]

Do you have a link for the Doximity video pls?

 

[NewYorkDoctors]

another annoying thing is when patients come to me claiming "they saw the super duper professor of medicine super specialist."

Cool... why are you seeing me then? I'm just a doc in the community. Oh sure I stay up to date and try to be as "academic" as I can (which to me means i don't do original research but I follow all the latest guidelines / updates and take zero shortcuts no matter how painful or time consuming certain steps are) but why come to me with ZERO records and some entitled and arrogant claim that "I saw the best doctors already?"

the real reason is these patients do have a chronic disease but feel "every 3 / 6 months follow up is too long" and they want constant, frequency follow up. sounds like what they really need is a "caring and talkative PCP like Dr Leonard McCoy who can be the patient's friend as well."

I tell these patients if you get me the "super duper academic professor of medicine" workup then I can be your community liaison of sorts. If not, what do you want me to do? cure you with magic fairy pixie dust? for those patients who are NOT able to procure records or prior workup, I tell them i'm not charging this office visit today. leave now and don't come back unless you have records.

 

[NewYorkDoctors]

just wondering, how does everyone else keep track of surveillance workup in your subspecialty?

for my patients who need their follow up CT scans (nodules, abnormal findings, lung cancer screening etc...) I have a spreadsheet I keep that is always updated. This is something stored on the cloud on a HIPAA secure server i pay for so I can update it anywhere and have my staff check anywhere. About 1-2 weeks before said scan is due, I have my staff run the PA (if needed), create the prescription, send to the local radiology center for their patient navigators to schedule the patient, then have my staff a quick notification to the patient via text and the PCP as well.
this sure beats having them come in to pick up a piece of paper then asking my staff to help schedule for them
If a patient declines, I sent the PCP the PA referral and say help me out here and then document carefully.

when I am doing PCP, I have my own flowsheet to keep track of certain screening items. But it is sometimes out of my control regarding something like EGD and colonoscopy.
While I follow up my own BIRADS mammo/US results and DEXAs and all that the same way in a spreadsheet, I have much less power over the GI procedures.

When I review that a patient had a tubulovillous adenoma or intestinal metaplasia/dysplasia/barrett's esophagus 2-3 years ago... and I ask the patient so did the GI doctor call you for a repeat... and I get "i dont know..." am I to believe the GI doctor:
A) did follow up with their staff but the patient declined and the patient is lying to me now (or really did forget?)
B) the GI doctor's office forgot because they do not have a proper system of surveillance?
C) or it was done already, the GI doctor did not send me results (what else is new), and the patient forgot about his/her history?

I would HOPE C is the answer...

 

[NewYorkDoctors]

anyway I have developed a new maxim regarding my patient care in private practice.

"While the patient is always right, the customer is not."

I have been increasingly aggressive towards unruly patients and high maintenance patients who behave belligerently or unrealistically. While I start off sweet and nice and polite, if a patient begins to become a "bad patient," I let the patient know I do not appreciate passive-aggressive behavior, antagonistic standoff behavior, or just in general being a malcontent.

For these patients, I do take care of their tasks ASAP and I purposely do this in the middle of the night via email.
For instance a patient who sends me an URGENT request to document medical clearance for an ELECTIVE SURGERY in one week on a FRIDAY EVENING. I just take care of it Friday at 11PM and send an email with efax confirmation at 11PM on Friday and purposely tell the patient I did this ASAP for the patient's mental well being. Why? so I have the high horse when I tell the patient off. "I did everything medically for you ASAP and did the whole workup. Go ahead I dare you to review me low on google. I have 4.9 stars and over a hundred reviews. Even if you put a 1, I will comment 'well with this ratio the problem obviously lies with the patient'."

the best thing about private practice is that I don't give a **** about hurt feelings for patients. While my first move is to be nice and caring (you catch more bees with honey than with spice), I want all high maintenace patients to know Press ganey does not affect me one bit at all. There are no hospital administrators for you to "tell on me to." You wanna start something? you better finish it. In the meantime, i'll be sure to attend to your high maintenance issues ASAP with utmost professionalism so you have no legs to stand on for criticism. Hurt feelings? boo hoo snowflakes.

This is what I mean by "the patient is always right, but not the customer."

Edit: i do listen to all patients. the first initial visit I am all ears and I literally type everything they tell me like a court room stenographer. I need to take a pain staking history and put it all in writing. this serves a few purposes.
A) the history is all over the place. I need to write everything so I can get the appropriate clinical impression
B) no patient can call me out and say "that's not what I said." Well let's rewind you said this then that did you not? I can make an addendum if you'd like
C) so i recall what the patient talked about before so I can wipe it from my short term memory ASAP
D) I can tell the patient - you already said the same thing verbatim 5 times already. do you think the more you tell me that suddenly I will have a Eureka moment and I diagnosed you without any workup like reading your palm or something?


that's the beauty of private practice.
as long as I operate at the standard of care (or better), document everything carefully, "go the extra mile" for their care, and "virtue signal" to the patient that I am going above and beyond for their medical care .... then I can feel free to light a fire under a patient's *** if said patient is being unreasonable and give them a good kick in the rear for their own good without fear of any serious reprisal.
Working as a hospital employed doctor, said doctor would have to fear for his/her job and kowtow to all patient demands for fear that the administrators would punish the doctor. smh.


and if said patient wants to leave to find another doctor, I inform said patient "you have the right to do so. but just know I did everything medically and professionally for you. I just did not kowtow to your whims or demands as the doctor does not get on all fours for patients. If you need help transferring your records let me staff know whom to send things to." Then I BAN SAID PATIENT from ever coming back.

this has not yet happened... but I am waiting for the opportunity to do so...

 

[Nocturnist]

anyway I have developed a new maxim regarding my patient care in private practice.

"While the patient is always right, the customer is not."

I have been increasingly aggressive towards unruly patients and high maintenance patients who behave belligerently or unrealistically. While I start off sweet and nice and polite, if a patient begins to become a "bad patient," I let the patient know I do not appreciate passive-aggressive behavior, antagonistic standoff behavior, or just in general being a malcontent.

For these patients, I do take care of their tasks ASAP and I purposely do this in the middle of the night via email.
For instance a patient who sends me an URGENT request to document medical clearance for an ELECTIVE SURGERY in one week on a FRIDAY EVENING. I just take care of it Friday at 11PM and send an email with efax confirmation at 11PM on Friday and purposely tell the patient I did this ASAP for the patient's mental well being. Why? so I have the high horse when I tell the patient off. "I did everything medically for you ASAP and did the whole workup. Go ahead I dare you to review me low on google. I have 4.9 stars and over a hundred reviews. Even if you put a 1, I will comment 'well with this ratio the problem obviously lies with the patient'."

the best thing about private practice is that I don't give a **** about hurt feelings for patients. While my first move is to be nice and caring (you catch more bees with honey than with spice), I want all high maintenace patients to know Press ganey does not affect me one bit at all. There are no hospital administrators for you to "tell on me to." You wanna start something? you better finish it. In the meantime, i'll be sure to attend to your high maintenance issues ASAP with utmost professionalism so you have no legs to stand on for criticism. Hurt feelings? boo hoo snowflakes.

This is what I mean by "the patient is always right, but not the customer."


that's the beauty of private practice.
as long as I operate at the standard of care (or better), document everything carefully, "go the extra mile" for their care, and "virtue signal" to the patient that I am going above and beyond for their medical care .... then I can feel free to light a fire under a patient's *** if said patient is being unreasonable and give them a good kick in the rear for their own good without fear of any serious reprisal.
Working as a hospital employed doctor, said doctor would have to fear for his/her job and kowtow to all patient demands for fear that the administrators would punish the doctor. smh.


and if said patient wants to leave to find another doctor, I inform said patient "you have the right to do so. but just know I did everything medically and professionally for you. I just did not kowtow to your whims or demands as the doctor does not get on all fours for patients. If you need help transferring your records let me staff know whom to send things to." Then I BAN SAID PATIENT from ever coming back.

this has not yet happened... but I am waiting for the opportunity to do so...

Man, the only thing that comes to mind when I read and re read this is...
"If it costs you your peace, it's too expensive"

 

[NewYorkDoctors]

Man, the only thing that comes to mind when I read and re read this is...
"If it costs you your peace, it's too expensive"

yeah I see what you mean

However, the NYC patients are literally nuts. If i ignore their high maintenance demands, they will rush into the front desk area and go off on a tirade and demand instant concierge access.

I would rather nip these issues in the bud ASAP. I would prefer to do it with honey and solve their issues and work collaboratively, but I have no qualms laying the smackdown on unruly patients.


but ultimately all of my tirades highlight the point that

yes outpatient medicine can be highly lucrative... but at the same time very high maintenance as well.

you know what the term "high risk high reward?"

outpatient medicine / private practice is "high maintenance high reward"

 

[FamilymedMD]

outpatient medicine / private practice is "high maintenance high reward"

I worry about this every time we increase prices or reopen my DPC to new patients but so far it's still a reasonable mix. Not sure if that's price point, location, or what.
I do find that I can't manage 600 patients as I initially expected. Much over 525 tends to be quite a bit of work. That probably is due, in part, to my practice style and the shortage and long waits for many specialty consults in my rural area.

 

[bronx43]

I worry about this every time we increase prices or reopen my DPC to new patients but so far it's still a reasonable mix. Not sure if that's price point, location, or what.
I do find that I can't manage 600 patients as I initially expected. Much over 525 tends to be quite a bit of work. That probably is due, in part, to my practice style and the shortage and long waits for many specialty consults in my rural area.

How much do you charge per patient?

 

[NewYorkDoctors]

I worry about this every time we increase prices or reopen my DPC to new patients but so far it's still a reasonable mix. Not sure if that's price point, location, or what.
I do find that I can't manage 600 patients as I initially expected. Much over 525 tends to be quite a bit of work. That probably is due, in part, to my practice style and the shortage and long waits for many specialty consults in my rural area.

nice website

how remote is your practice? Im sure the density of "very sick" patients requiring lots of subspecialty care and tertiary care access is proabbly no where near as high as in NYC. But do you find taking care of those patients to be cost effective for you?

 

[FamilymedMD]

How much do you charge per patient?

What does it cost? — Megunticook Family Medicine

www.megunticookfamilymedicine.com

 

[FamilymedMD]

how remote is your practice? Im sure the density of "very sick" patients requiring lots of subspecialty care and tertiary care access is proabbly no where near as high as in NYC. But do you find taking care of those patients to be cost effective for you?

Two hours from the big tertiary care center in Portland, one hour from a smaller one in Bangor. A few small community hospitals within an hour. The density of everything here is lower including the density of other PCPs and consulting specialists and no idea how the ratio of sick patients to consultants compares to NYC.

Taking care of sick patients can be cost effective but it depends on how many of them relative to the ones who only come in once in a while. Too many of the former and you need a smaller panel, higher rates, etc. Lots of the latter and you can charge less and sustainably manage a bigger panel of patients.

 

[NewYorkDoctors]

so if a patient "demands to see you right away" you must acquiesce and find time in the middle of your day?

I have patients and family's who "demand to be seen right away." Our office tells them schedule is full. Get in line bub.

Usually all concerning issues like lung nodules, lung cancer, ILD, etc... i have the PA call ASAP and then plug someone into my lunch hour ASAP.

Therefore when patients "demand to be seen right away" i know they are full of it usually.

My front desk gets a lot of new consult requests from patients never before seen "demanding to be seen ASAP." Sure... if PCP or other doctor ever requested it for a legit reason (usually concern for lung cancer, RHC finds precapillary PH, etc...) then I would plug them into my after hours and stay late. But withotu that, get in line bub. You don't pay for concierge medicine (lol) you get in line.

 

[FamilymedMD]

so if a patient "demands to see you right away" you must acquiesce and find time in the middle of your day?

I "acquiesce" because I have plenty of time on my schedule to see them if needed. If I don't have time that day (very rare unless they call at 3:30 PM, etc) then I see them the next day or they can go to the ER. Part of why they pay me is to be available. If they're super anxious, I can spend a few minutes on the phone, sometimes that's all they need.
It works fine from my side because I don't need to squeeze people into a packed schedule. I work a full day between visits,messages, phone calls and paperwork but the schedule is deliberately loose and flexible.

We DON'T schedule patients quickly who want to join the practice and get seen right away for some chronic or acute issue. We did that in the beginning and a huge percentage of those patients leave the practice quickly once you've spent time sorting out their problems.

We're not concierge medicine; we're DPC. We don't bill insurances, only the monthly fee so it's simpler and the fee is a lot lower than what most concierge medicine places charge.

 

[NewYorkDoctors]

I "acquiesce" because I have plenty of time on my schedule to see them if needed. If I don't have time that day (very rare unless they call at 3:30 PM, etc) then I see them the next day or they can go to the ER. Part of why they pay me is to be available. If they're super anxious, I can spend a few minutes on the phone, sometimes that's all they need.
It works fine from my side because I don't need to squeeze people into a packed schedule. I work a full day between visits,messages, phone calls and paperwork but the schedule is deliberately loose and flexible.

We DON'T schedule patients quickly who want to join the practice and get seen right away for some chronic or acute issue. We did that in the beginning and a huge percentage of those patients leave the practice quickly once you've spent time sorting out their problems.

We're not concierge medicine; we're DPC. We don't bill insurances, only the monthly fee so it's simpler and the fee is a lot lower than what most concierge medicine places charge.

nice. good luck with everything

 

[Osteoth]

I "acquiesce" because I have plenty of time on my schedule to see them if needed. If I don't have time that day (very rare unless they call at 3:30 PM, etc) then I see them the next day or they can go to the ER. Part of why they pay me is to be available. If they're super anxious, I can spend a few minutes on the phone, sometimes that's all they need.
It works fine from my side because I don't need to squeeze people into a packed schedule. I work a full day between visits,messages, phone calls and paperwork but the schedule is deliberately loose and flexible.

We DON'T schedule patients quickly who want to join the practice and get seen right away for some chronic or acute issue. We did that in the beginning and a huge percentage of those patients leave the practice quickly once you've spent time sorting out their problems.

We're not concierge medicine; we're DPC. We don't bill insurances, only the monthly fee so it's simpler and the fee is a lot lower than what most concierge medicine places charge.

I know some DPCs bill insurance but people tell me the juice isn’t worth the squeeze. Agree or disagree?

 

[VA Hopeful Dr]

I know some DPCs bill insurance but people tell me the juice isn’t worth the squeeze. Agree or disagree?

DPC by definition should be billing insurance.

 

[FamilymedMD]

DPC by definition should be billing insurance.

I think you meant the opposite. The whole point of DPC is to not bill insurance. Concierge practices charge a monthly fee AND bill insurance but that's not DPC.

 

[FamilymedMD]

I know some DPCs bill insurance but people tell me the juice isn’t worth the squeeze. Agree or disagree?

Billing insurance usually isn't worth it except possibly as a transitional step from insurance/FFS practice to DPC but generally it's too much hassle and the extra staff and costs increase your overhead. It's like pulling the bandaid off slowly...

 

[VA Hopeful Dr]

I think you meant the opposite. The whole point of DPC is to not bill insurance. Concierge practices charge a monthly fee AND bill insurance but that's not DPC.

Ugh, yes. I meant to type shouldn't.

I did DPC for a few years so I do know the drill.

 

[Bropranolol]

so if a patient "demands to see you right away" you must acquiesce and find time in the middle of your day?

I have patients and family's who "demand to be seen right away." Our office tells them schedule is full. Get in line bub.

Usually all concerning issues like lung nodules, lung cancer, ILD, etc... i have the PA call ASAP and then plug someone into my lunch hour ASAP.

Therefore when patients "demand to be seen right away" i know they are full of it usually.

My front desk gets a lot of new consult requests from patients never before seen "demanding to be seen ASAP." Sure... if PCP or other doctor ever requested it for a legit reason (usually concern for lung cancer, RHC finds precapillary PH, etc...) then I would plug them into my after hours and stay late. But withotu that, get in line bub. You don't pay for concierge medicine (lol) you get in line.

I get that all the time.

I sometimes think about my life and what I am doing to entertain these worried well. I am in also a top 3 metro in the US so the bane of my existence is the "worried well", usually the corporate executive, MBA, rich little old lady with nothing else going on. 90% of the time these patients have massive underlying anxiety that manifests as annoying my day.

I usually call the patient and bill a quick 99442. Otherwise I tell my nurse to double book them, I order 3 labs on their acute visit and a medication, bill a 99214, and collect my ~$100. I don't do this at 4:30 PM though