Job offer advice

[Psych25]

I am a 4th year psychiatry resident currently starting to interview. I am receiving offers in the 300-330k range. I've spoken to around 6 hospitals so far. All jobs are located in the southeast. I will break down some of the offers. Things not mentioned (ie benefits fairly equal).

Job 1:
Patient load average is 18-20
Base is 300K
Inpatient 7 on 7 off
$ per RVU is 52
Target RVU is 4000
Compensated for call (380 a night)

Job 2:
Patient load of 20-24
Base is 320K
$ per RVU is 70
Target RVU is unknown at this time
Call is every night (light call and emergency only)- no additional compensation

Job 3
Patient load of 12-14
300K base, no production
7 on 7 off
Split call with another provider (no extra comp.)

Job 4
Patient cap is 20
300K base
Each additional patient over 20 pays out $65/patient
M-F; no required weekends

Job 5
Patient load of 18-20
310K base
RVU production model (uncapped; don't know the pay per RVU or target yet)
Call is split with another provider (no extra pay)

Job 6
Patient load of 22-24
Base is 330K (no state income tax)
RVU production (don't know details)

My questions:

Is the base that I am being offered about right? A few of these locations are rural and feel that they should be higher because of that (closer to 350K).

How much per RVU should I be expecting? I have heard around $70 per RVU.

Is 4000 target for 300K average?

Does the 1.75 rvu per inpatient encounter still sound about right?

These offers seem comparable as far as I can tell. What should I be paying attention to to help me decide? (outside of location, schools, income tax).

I would greatly appreciate any help!

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[clozareal]

I mean you have 6 data points that are all within 10% of each other. I would think that the base is right.

 

[Ironspy]

20+ patients is high volume and only sustainable if the system functions well and provides good support. I would ask about SW and care coordination.

 

[wolfvgang22]

All these jobs look like meat grinders to me unless you have fantastic staff support. Like an NP or residents that see half the patients and good social workers to help with disposition and good nursing staff. Maybe I have gotten soft.

 

[Merovinge]

All these jobs look like meat grinders to me unless you have fantastic staff support. Like an NP or residents that see half the patients and good social workers to help with disposition and good nursing staff. Maybe I have gotten soft.

You aren't soft. This is how these hospitals make $$$ off of us. They find 4th year residents, throw them into the grinder for a few years until they inevitably leave and then replace them with more new grads. Every once in a while they find a doc who wants to spend 5 min/day with inpatients and promote them as the paragon of inpatient psychiatry. This is the literal playbook for all of the for-profit IP units in my metro.

To answer the OP: If you want to meat grind, you need to know the RVU pay above what target and then estimate out or ask the current doctors how many RVUs they generate. If you want to practice good psychiatry the answer is obviously job 3. 12-14/day on a 7 on/7 off structure is a reasonable load to do good work with a pretty good lifestyle (provided that working 1/2 of weekends isn't a concern). If you have kids and need weekends off then it's a different story.

 

[Stagg737]

Most of these do seem like grind jobs as already mentioned, but we really need more info on some of them to know if this is fair. That base is low for every job other than #3. $300k for 20+ patients isn't good, so is totally dependent on what production bonuses would look like.

Job 1: Should easily hit that target wRVU. At 1.75/encounter (which is low depending on how many new you see) you should hit 6,000 wRVU. $52/wRVU is low, $380 per night is bad if being paid.

Job 2: wRVU rate seems solid. Call is okay if true. Completely depends on the production expectation/bonus.

Job 3: Fine other than call being less than ideal.

Job 4: I don't understand what "Each additional patient over 20 pays out $65/patient" means. As in, if there's 22 patients on your census you get an extra $130 for that day? If so, that's bad. Nice not having call though, pick your trade-offs I guess.

Job 5: If wRVU production model then why $310k base? Or is this salary + production bonus?

Job 6: Same as 5, and again depends on production model.

Can't really tell you what's fair or not without more info. For comparison, a job I interviewed at was 16-20 patients per day with a base of $250k + production bonus. Idk what the exact production model was but was told the lowest paid physician of the 3 working there was clearing $450k/yr and the other two made well over that. Another poster on here sent me a job posting for a similar position (~20 pts/day) which advertised that pay was $650k-750k/yr after production incentives, so pretty massive difference.

 

[Stagg737]

Is the base that I am being offered about right? A few of these locations are rural and feel that they should be higher because of that (closer to 350K).

How much per RVU should I be expecting? I have heard around $70 per RVU.

Is 4000 target for 300K average?

Does the 1.75 rvu per inpatient encounter still sound about right?

These offers seem comparable as far as I can tell. What should I be paying attention to to help me decide? (outside of location, schools, income tax).

As already said, even if base is bad that seems standard for your area. Last I checked/saw, average for psych as a whole was bout $65/wRVU. Others can correct me if that's wrong.

4,000 wRVU for $300k comes out to $75/wRVU, seems about right.

1.75 per inpt encounter seems low. A 99232 is 1.59 wRVU and a 99233 is 2.4 wRVU, so follow-ups should average 2 wRVU/encounter or more if they're using updated billing, if not then 1.75 is about right for f/ups. New encounters should average no less than 4 wRVU.

So a census of 20 patients with an average LOS of 4 days (acute psych) means averaging 4-5 new patients per day. If you're 50/50 on 99232/3 then using the old numbers that's ~26 wRVU/day in f/ups + 16-20 wRVUs in new patients, so around 40-45 wRVU/day. Multiply that by half a year and that's 7200-8100 wRVU per year. You can math out how much you'd make annually at different production thresholds and wRVU rates.

On the financial side, compare benefits. Look at what numbers you have to hit to start making the production bonus and how much you get per wRVU or patient or whatever metric used. It may look better to get $80/wRVU in production bonus vs. $65, but not if the base wRVU expectation is much higher. How often do you get bonuses and what are they like? Loan forgiveness? CME? Retention bonuses? Etc.

On the clinical/administrative side, try and gauge what staff and available resources are like. 20 patients with an amazing staff can be very manageable, if staff and support are terrible then it can be hell. Ask how busy overnight call is. I don't get paid for overnight call, but I got called a whole 2 times last year, so it's nbd. If I were getting multiple calls per night or even per week that wouldn't fly with me. Do these hospitals take involuntary patients? If so, what are the involuntary laws like? Some states this burden is pretty low on you, in others it can take significant time and effort. Some hospitals just don't accept invol patients at all. What are the laws for physical restraints? Will you have to come in overnight if a patient has to stay in restraints? Who covers when you're sick? When your colleagues are sick do you get paid extra to cover their patients? Are the other docs at these places happy?

 

[SmallBird]

Those caseloads are too high, but the first job you could make a lot of money as you should be doing about 8000 RVUs (groan!) with that case load so your salary will be over $500k with production bonus. Job 2 - that caseload is too intense for everyday, you would hate your job I think. $65/extra patient is like minimum wage kinda stuff, that's ridiculous. I guess you could make a lot of money with options 1 and 2 and maybe 5 and 6 but the work is too much. The most recent inpatient job I had was $68/rvu but averaged about 2.7 RVU's per patient so it was easy to make a good salary with a case load of 11.

 

[Psych25]

Thank you all for the information! Especially thank you to @Stagg737 for the detailed breakdown and helpful tips.

I should've clarified. These jobs (except #3) are base with rvu production.

Correct, Job 4 would pay $130 for 2 patients over cap of 20. Seems extremely low

For new evals (ie 99222/3), I should be getting 4 wRVU?

This is what was sent from me from one of the hospitals today with CPT code and wRVU.

If this looks off, where can I get more accurate data?

Thank you all again!

 

[Sushirolls]

*Outpatient example:
Q2 this year I grossed 37.5K for 9.7 clinical hours per week (average of the 13 week period, 0 hour vacation days and weeks are in there, too, pulling number down).
Insurance based. One main insurance pays well and is driving force behind the hourly rate.
That gross also factors in money not paid by some patients, 'bad debt' etc

37.5K / 13 weeks / 9.7 hours per week = $297/hr rate for clinical work.
Very low if any 90833 used. Mostly 99214.

Assuming you will work a true 40 hours with almost all of those meat grinder jobs:
Here is a relative hourly comparison for outpatient
36 clinical hours * $297 * 52 weeks = 555K gross for a real world head-to-head outpatient comparison.
555K - overhead? 110K to 150K = 400K net in pocket to then remove retirement and taxes from.

400K Net in pocket
-90K taxes
-66K Retirement max
244K true spending in your pocket

The employed 300K job still needs deductions for taxes, retirement, possible health insurance contribution, too.
-54K taxes
-22.5K retirement
-2K health insurance contribution
221.5K true spending in your pocket

Something to think about regarding the world of numbers.
Those who are doing the employed 300k gig, please feel free to correct those taxes, retirement, health insurance numbers I conjured up.

 

[splik]

For new evals (ie 99222/3), I should be getting 4 wRVU?

new evals on RVU is 90792 which is 4.16 no one uses 99223 anymore if working on rvus.

 

[Psych25]

new evals on RVU is 90792 which is 4.16 no one uses 99223 anymore if working on rvus.

Thank you for clarifying! The hospital that I moonlight at uses 99222/3. Not RVU based though

 

[wolfvgang22]

new evals on RVU is 90792 which is 4.16 no one uses 99223 anymore if working on rvus.

Doesn't 99205 E&M reimburse better than 90792? (Documentation complexity or time differences matter either way for me because I spend 60 minutes an MD evaluate every new patient very thoroughly, and so 99205 is easy for me.)

 

[Sushirolls]

99205 often, not always, pays better.
90792 has more wRVUs... go figure.
Choose wisely.

 

[Stagg737]

Thank you all for the information! Especially thank you to @Stagg737 for the detailed breakdown and helpful tips.

I should've clarified. These jobs (except #3) are base with rvu production.

Correct, Job 4 would pay $130 for 2 patients over cap of 20. Seems extremely low

For new evals (ie 99222/3), I should be getting 4 wRVU?

This is what was sent from me from one of the hospitals today with CPT code and wRVU.

If this looks off, where can I get more accurate data?

Thank you all again!

So that hospital is using updated 2023 reimbursement, that’s a good sign. 99223 is 3.5 wRVUs now, so unless you’re spending a ton of time on that patient where you can use time based add-ons (at least 104 minutes), you should be using 90792 for new patients.

Again, some of those jobs could make a killing, but completely depends on the how the production incentives are set up. For job 4 they’re terrible, scrap that one unless the no call means that much to you. $300k for 20 patients and garbage production bonus isn’t worth it imo.

Doesn't 99205 E&M reimburse better than 90792? (Documentation complexity or time differences matter either way for me because I spend 60 minutes an MD evaluate every new patient very thoroughly, and so 99205 is easy for me.)

99205 is an outpatient code, doesn’t apply to OP. Similarly though, I only use it in my outpt clinic when an eval runs very long and I do time based add-ons. Otherwise 90792 still pulls in more wRVUs. If you’re in PP or earning a percentage of collections where your pay isn’t tied to number of wRVUs, you’d need to know what the insurance companies are actually paying out for each code like Sushi pointed out.

 

[clausewitz2]

*Outpatient example:
Q2 this year I grossed 37.5K for 9.7 clinical hours per week (average of the 13 week period, 0 hour vacation days and weeks are in there, too, pulling number down).
Insurance based. One main insurance pays well and is driving force behind the hourly rate.
That gross also factors in money not paid by some patients, 'bad debt' etc

37.5K / 13 weeks / 9.7 hours per week = $297/hr rate for clinical work.
Very low if any 90833 used. Mostly 99214.

Assuming you will work a true 40 hours with almost all of those meat grinder jobs:
Here is a relative hourly comparison for outpatient
36 clinical hours * $297 * 52 weeks = 555K gross for a real world head-to-head outpatient comparison.
555K - overhead? 110K to 150K = 400K net in pocket to then remove retirement and taxes from.

400K Net in pocket
-90K taxes
-66K Retirement max
244K true spending in your pocket

The employed 300K job still needs deductions for taxes, retirement, possible health insurance contribution, too.
-54K taxes
-22.5K retirement
-2K health insurance contribution
221.5K true spending in your pocket

Something to think about regarding the world of numbers.
Those who are doing the employed 300k gig, please feel free to correct those taxes, retirement, health insurance numbers I conjured up.

I gotta ask, if all of your follow-ups are always 30 mins, and you are rarely billing 90833, what on earth are you doing with all that time?

 

[jbomba]

Also curious what 150k in overhead is going to. That's over 12k a month in a overhead. Billing at 7% fee would be about 2600 a month..where's the other 10k going?

 

[Sushirolls]

Also curious what 150k in overhead is going to. That's over 12k a month in a overhead. Billing at 7% fee would be about 2600 a month..where's the other 10k going?

Full time employee: 50k, 10K or more in employee benefits, lease in likely higher end medical building, 50K per year. 5-7K liability insurance. 1k office insurance. 1.3K EMR. Website maintenace, 1.4K. Enevelopes/stamps/letter head/ business cards/ bathroom supplies for ensuite bathroom, etc, etc. 120K-150k if full time and in HCOL area, as most places where Psych land.

 

[Sushirolls]

I gotta ask, if all of your follow-ups are always 30 mins, and you are rarely billing 90833, what on earth are you doing with all that time?

I've just gotten faster over the years for many patients, or they are on the up and up and things just go faster. Or therapy was only like 10min and just wasn't hitting the time requirement.

If I finish early, I try to wrap up the note, billing submission, Rx refill, portal 'after visit summary' update.
Get the next few follow up notes tee'd up in template form ready to go.
Or email/message with assistant and put out fires, etc.
Reviewing possible charts of patients that need to be sent letters to either re-schedule or we will exit you.
Patient messages.
Bathroom break, coffee has physiologic effects.
*or SDN

 

[J ROD]

Devil is in the details.......have to have better incentive pay information. Easiest job is 3. Personally, I like uncapped incentive pay scale. #5 would interest me most based on patient load assumed solo. Over 20 alone is good amount.

 

[Bartelby]

Presuming you can stand being on every other weekend (and that call is not excessive), job 3 sounds way better than the others. Lower cap (making your days much more reasonable) plus every other week off sounds very nice. I don't know how much productivity bonuses would add to the others, but it sounds to me like you will work hard for that added income. I would go with #3 unless it would be too disruptive to family life etc.

 

[nexus73]

The patient load and what's manageable will depend on type of patients. If it's 20 involuntary patients with psychosis/mania, much more doable than 20 patients with mixed diagnoses who actually want time with you and/or have involved families adding to demand on physician. Of course, this can be mitigated with good support staff, if such staff exist. 20 per day with mix of depression plus various personality disorders is going to cause burn out for most docs.

 

[rjs2131]

I've just gotten faster over the years for many patients, or they are on the up and up and things just go faster. Or therapy was only like 10min and just wasn't hitting the time requirement.

If I finish early, I try to wrap up the note, billing submission, Rx refill, portal 'after visit summary' update.
Get the next few follow up notes tee'd up in template form ready to go.
Or email/message with assistant and put out fires, etc.
Reviewing possible charts of patients that need to be sent letters to either re-schedule or we will exit you.
Patient messages.
Bathroom break, coffee has physiologic effects.
*or SDN

To each their own, but I’m structuring my practice to where patients expect the 90833 for a typical 30-min visit and if they don’t feel it’s necessary, we space things out (q3-4 months, usually plenty to chat about over that time and utilize supportive therapy for) or transition to PCP. I’m a mix of CAP and young adults, but I can’t imagine rarely using 90833 and feeling satisfied with compensation. Unless you’ve negotiated >$200 for a 99214, which would be impressive, not sure how that’s sustainable with overhead costs and 30-min visits. For my practice, I’d make 80-100k less/year not using 90833s.

Recently discovered a nearby hospital system was being reimbursed >$300 for a solo 99214, and this really put things into perspective.

 

[Sushirolls]

My old location had Big Box shops getting ~290 and 300+ for 99214
I've got 1 main insurer now doing +200 for 99214.
But absolutely, 90833 is a real world valuable code.
I just don't have the attitude to simply 'check a box' like I've seen in some many records I've acquired.
Maybe some day I'll start doing/documenting/billing it more.

 

[Sushirolls]

Job 3 looks to be the best of the options, IMO.

 

[sloh]

.
I just don't have the attitude to simply 'check a box' like I've seen in some many records I've acquired.

Why not? Physician income makes up such a small sliver of healthcare expenses. We are always getting screwed by the government, employers, and insurers.

 

[Sushirolls]

Ethics? If I play the 'woe' is me card I can start justifying anything, playing the victim card. The left does this all the time, its nauseating - non stop victim Olympics.
90833 has requirements, and if I don't meet them I won't bill them.
I signed the the contract with the insurance company, so I'll play the game.
If I really get distraught, I can always pull out, do cash only.

 

[sirspamalot]

1099 and make your own rules.

This is the way.

 

[Bartelby]

Ethics? If I play the 'woe' is me card I can start justifying anything, playing the victim card. The left does this all the time, its nauseating - non stop victim Olympics.
90833 has requirements, and if I don't meet them I won't bill them.
I signed the the contract with the insurance company, so I'll play the game.
If I really get distraught, I can always pull out, do cash only.

I totally agree no one should document providing services they didn't. That's fraudulent.

Still, if you are often spending 25 minutes face to face with a patient in a 30-min appointment, I suspect you provide at least 16 mins of supportive therapy. If you don't, as you mentioned play the game and gear your practice toward doing so. That's what I have done in RVU-producing systems, and I think it adds something to intentionally try to provide >16 minutes of therapy in each interaction (even if it's just supportive). The amount of time genuinely needed for E&M is often pretty low (you are still depressed at Prozac 40, symptoms reviewed and are all roughly the same, no side effects... let's increase the dose). The "soft" stuff, like talking about lifestyle changes, how to address stressors, how to reframe thoughts and situations... that's all therapy! And if you start billing the therapy codes that likely more accurately reflect your effort and expertise, you can basically double up the RVUs (or in private practice substantially increase revenue). And if you regularly do 30-minute 99213/4-only visits, I have a hard time seeing how you can earn anything approaching fair and reasonable compensation.

That said, sometimes you genuinely spend most of the appointment reviewing symptoms, talking about medication options, educating about medication, etc. Or you find that the person is doing really well and only needs a five-minute check in and a refill. In those cases you don't add the 90833, but I find those are maybe one third of appointments for me.

 

[Merovinge]

I totally agree no one should document providing services they didn't. That's fraudulent.

Still, if you are often spending 25 minutes face to face with a patient in a 30-min appointment, I suspect you provide at least 16 mins of supportive therapy. If you don't, as you mentioned play the game and gear your practice toward doing so. That's what I have done in RVU-producing systems, and I think it adds something to intentionally try to provide >16 minutes of therapy in each interaction (even if it's just supportive). The amount of time genuinely needed for E&M is often pretty low (you are still depressed at Prozac 40, symptoms reviewed and are all roughly the same, no side effects... let's increase the dose). The "soft" stuff, like talking about lifestyle changes, how to address stressors, how to reframe thoughts and situations... that's all therapy! And if you start billing the therapy codes that likely more accurately reflect your effort and expertise, you can basically double up the RVUs (or in private practice substantially increase revenue). And if you regularly do 30-minute 99213/4-only visits, I have a hard time seeing how you can earn anything approaching fair and reasonable compensation.

That said, sometimes you genuinely spend most of the appointment reviewing symptoms, talking about medication options, educating about medication, etc. Or you find that the person is doing really well and only needs a five-minute check in and a refill. In those cases you don't add the 90833, but I find those are maybe one third of appointments for me.

Absolutely agree. Keep in mind how fast some specialists are seeing outpatients and using those same 99213/99214 codes (i.e. 5-10 min). If you are spending a full 25 min face to face (which I think is ideal psychiatric care) it really aught to qualify for something additional ala 90833.

 

[sloh]

Ethics? If I play the 'woe' is me card I can start justifying anything, playing the victim card. The left does this all the time, its nauseating - non stop victim Olympics.
90833 has requirements, and if I don't meet them I won't bill them.
I signed the the contract with the insurance company, so I'll play the game.
If I really get distraught, I can always pull out, do cash only.

Yes a lot of codes have requirements but just by making a couple modifications in how you practice you can still qualify for the code while adding something substantive and meaningful to the patient encounter.

These codes aren't completely black/white and there's considerable variance in how physicians of the same specialty practice. If you practice as if any slight deviance will lead to audits, clawbacks, and rejections you're going to leave a ton of money on the table and take it in the a**. The left would just complain "woe is me." The right would take matters into their own hands so they are compensated fairly despite the "system." Achieve financial independence asap and you can practice however you like.

As @Bartelby stated:

I totally agree no one should document providing services they didn't. That's fraudulent.

Still, if you are often spending 25 minutes face to face with a patient in a 30-min appointment, I suspect you provide at least 16 mins of supportive therapy. If you don't, as you mentioned play the game and gear your practice toward doing so. That's what I have done in RVU-producing systems, and I think it adds something to intentionally try to provide >16 minutes of therapy in each interaction (even if it's just supportive). The amount of time genuinely needed for E&M is often pretty low (you are still depressed at Prozac 40, symptoms reviewed and are all roughly the same, no side effects... let's increase the dose). The "soft" stuff, like talking about lifestyle changes, how to address stressors, how to reframe thoughts and situations... that's all therapy! And if you start billing the therapy codes that likely more accurately reflect your effort and expertise, you can basically double up the RVUs (or in private practice substantially increase revenue). And if you regularly do 30-minute 99213/4-only visits, I have a hard time seeing how you can earn anything approaching fair and reasonable compensation.

 

[Ellomate]

Hello,
I'm a Psych PGY1.
Can someone quickly break down how to interpret RVU in baby language?

That would be super helpful!

 

[Bartelby]

Hello,
I'm a Psych PGY1.
Can someone quickly break down how to interpret RVU in baby language?

That would be super helpful!

RVU = Relative Value Units. Medicare (and other third party payors) need a way to determine how much "value" we create in various medical encounters. A committee figures out how many points healthcare providers get for a wide range of activities and call it the "RVU system."

In employed settings people often expect you to rack up enough points / RVUs. On the old scale (which a system I work for still uses) a "moderate complexity evaluation and management" encounter (99214) gives 1.5 RVUs. By adding "thirty minutes of psychotherapy" code 90833 (which you can do if you did >16 minutes of therapy) you add another 1.5 RVUs. That means you can do your evaluation and management (E&M) in, say, eight minutes, do sixteen minutes of psychotherapy, document the visit for five minutes, and be ready for your next patient legitimately getting 3.0 RVUs for your 30-minute visit (with documentation done) instead of 1.5 RVUs without adding psychotherapy.

As a resident this stuff is less important in many settings. In attending life or insurance-based private practice gearing your billing correctly makes a huge difference in how productive you look or in how much money you collect.

 

[claypigeon]

Not to be nitpicky and great explanation. 99214 bumped to 1.92 wRVUs.

 

[splik]

Not to be nitpicky and great explanation. 99214 bumped to 1.92 wRVUs.

This is true, but they may be on the old system. many organizations have not updated their RVUs to the 2021 system, I would estimate at least half of places only give you 1.5 for 99214.

 

[TerraceHouse]

Dude, job 3

-edit- and let me elaborate... crunching the details in a excel file is one thing but actually living it out is different. Take job 3.

 

[Ellomate]

RVU = Relative Value Units. Medicare (and other third party payors) need a way to determine how much "value" we create in various medical encounters. A committee figures out how many points healthcare providers get for a wide range of activities and call it the "RVU system."

In employed settings people often expect you to rack up enough points / RVUs. On the old scale (which a system I work for still uses) a "moderate complexity evaluation and management" encounter (99214) gives 1.5 RVUs. By adding "thirty minutes of psychotherapy" code 90833 (which you can do if you did >16 minutes of therapy) you add another 1.5 RVUs. That means you can do your evaluation and management (E&M) in, say, eight minutes, do sixteen minutes of psychotherapy, document the visit for five minutes, and be ready for your next patient legitimately getting 3.0 RVUs for your 30-minute visit (with documentation done) instead of 1.5 RVUs without adding psychotherapy.

As a resident this stuff is less important in many settings. In attending life or insurance-based private practice gearing your billing correctly makes a huge difference in how productive you look or in how much money you collect.

Thank you so much for this explanation!
So as an example, using $ per RVU is 52.
If you do 1.5RVU/30 min --> 3.0RVU/1hr, working 8 hours a day would give you 24RVU (so $52 x 24 = $1248/day?).
When RVU comes to play, is it soley on production/volume or do you have RVU in addition to base salary?

 

[comp1]

What the heck is this? You shouldn't be carrying 20+ inpatients! How would you even remember them!?!? This might be okay on a weekend/holiday situation where you solely need to put out fires and won't be discharging, but it is not okay for weekday care. Inpatients are not outpatients. Each one should, by definition, be extremely sick and in need of significant attention. Admittedly, some of them are not going to be talkers, but a great number will. Regardless, the care coordination needs will be massive. Just the legal paperwork and testimony is going to be a lot. I concur job 3 is the best of the bunch, but it's still not acceptable. The appropriate number of inpatients per day for a physician by themselves with an average support system is 8. Now if these jobs come with a significant number (2+) of senior residents or supervised NPs, it does allow for a bit more patient load, but I am not hearing that from the OP...

 

[ObsequiousAplomb]

What the heck is this? You shouldn't be carrying 20+ inpatients! How would you even remember them!?!? This might be okay on a weekend/holiday situation where you solely need to put out fires and won't be discharging, but it is not okay for weekday care. Inpatients are not outpatients. Each one should, by definition, be extremely sick and in need of significant attention. Admittedly, some of them are not going to be talkers, but a great number will. Regardless, the care coordination needs will be massive. Just the legal paperwork and testimony is going to be a lot. I concur job 3 is the best of the bunch, but it's still not acceptable. The appropriate number of inpatients per day for a physician by themselves with an average support system is 8. Now if these jobs come with a significant number (2+) of senior residents or supervised NPs, it does allow for a bit more patient load, but I am not hearing that from the OP...

I agree that 20+ is a lot and likely to lead to an increased risk of adverse events, especially without a large support team.

I'm surprised to hear 8. I think 8 would be great. I thought usually people say 12-16 is the floor though for most situations. What's your basis for saying 8 here, though? If you have something good to point me to to read up on and use so I can also advocate for 8, I'd really appreciate it.

 

[comp1]

Physicians don't have max staffing ratios like nurses (they should!). Mostly my numbers come from personal experience in a salaried based model. 12-16 is doable with some really good residents or NPs, but it's still going to be tough unless you're looking at several week long stays for the large majority of patients. I expect roughly half of my patients to discharge in under 5 days and no more than 1 at any given time to be an extreme long termer awaiting placement. For what it is worth, here is some data on medicine inpatients in a similar governmental run agency: https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(20)30453-3/fulltext

 

[ObsequiousAplomb]

Physicians don't have max staffing ratios like nurses (they should!). Mostly my numbers come from personal experience in a salaried based model. 12-16 is doable with some really good residents or NPs, but it's still going to be tough unless you're looking at several week long stays for the large majority of patients. I expect roughly half of my patients to discharge in under 5 days and no more than 1 at any given time to be an extreme long termer awaiting placement. For what it is worth, here is some data on medicine inpatients in a similar governmental run agency: https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(20)30453-3/fulltext

Thanks for this article! I haven't finished reading it, just skimming the abstract. Looks like they're saying fewer deaths than on average as long as the patient count stays below 5.4 (senior doctors), 14.6 (middle grade doctors), and 9.0 (junior doctors).