Mid fellowship clinical skills, community oncology bound

[soccerusa]

Hi all. I am a 2nd year fellow who just switched over to research time and I was hoping to get some advice about where I am at clinically and where I need to get to start practice. I am at a very research heavy east coast program but for a variety of reasons I am clear I will be taking a community job. I feel quite confused about where my clinical skills are and how I should be using my second half of fellowship to prepare for practice. Appreciate anyone's time and advice very much.

My clinical (and research) focus is GI. I have been in the same GI clinic doing mostly colon with a smattering of rectal cancer for the last 18 months and feel very comfortable practicing quasi independently with very few of my plans being changed by the attending and a good grasp of the important literature. All of my feedback both formal and informal has been excellent but 90+% of this is in the subspecialty clinic where it is quite a narrow focus. When I do get feedback in other settings, I feel to some degree I am being graded on a curve as I am known as "a GI guy".

In other solid clinics (thinking of thoracic where I was recently), it takes me significant preparation (i.e. spending 30-45 minutes) of chart review and uptodate/NCCN review to feel ready to see a new patient. After this review, I feel relatively comfortable with straightforward cases but feel I end up relying on tumor board more than I would ideally want to for anything that is not straightforward. When I have been on consults, I also feel pretty comfortable working up new cases of any specialty but this relies heavily on literature review and not de novo knowledge.

If you've read this far and are willing to take a stab at the questions below - thank you! I have had trouble getting well informed answers from my faculty as most cannot even conceive of a generalist practice. I care deeply about providing excellent patient care and really want to be prepared.

Questions
1) Is this a normal place to be clinically halfway through fellowship?
2) What is the expectation starting as an attending in generalist practice? How much lit/guideline review is normal for each new patient?
3) To prepare for a generalist job, I've considered adding in some other clinics. Given the exact job I'll get is unclear, is there any rhyme or reason in which subspecialties I should try to pick up some experience?
4) Other than joining extra clinics and doing the usual reading before patients, are there other things you would suggest to maximize readiness for practice?
5) Can anyone comment on the depth of heme knowledge I will need? Many of the jobs say something like 20-30% heme. I feel comfortable with cytopenias and thrombosis. I could also do some basic CLL (like BTK, less comfort with VO etc) although thats about the limit of my comfort level. Is it needed to have more skills than this for a basic community job?

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[guildsman]

Hi all. I am a 2nd year fellow who just switched over to research time and I was hoping to get some advice about where I am at clinically and where I need to get to start practice. I am at a very research heavy east coast program but for a variety of reasons I am clear I will be taking a community job. I feel quite confused about where my clinical skills are and how I should be using my second half of fellowship to prepare for practice. Appreciate anyone's time and advice very much.

My clinical (and research) focus is GI. I have been in the same GI clinic doing mostly colon with a smattering of rectal cancer for the last 18 months and feel very comfortable practicing quasi independently with very few of my plans being changed by the attending and a good grasp of the important literature. All of my feedback both formal and informal has been excellent but 90+% of this is in the subspecialty clinic where it is quite a narrow focus. When I do get feedback in other settings, I feel to some degree I am being graded on a curve as I am known as "a GI guy".

In other solid clinics (thinking of thoracic where I was recently), it takes me significant preparation (i.e. spending 30-45 minutes) of chart review and uptodate/NCCN review to feel ready to see a new patient. After this review, I feel relatively comfortable with straightforward cases but feel I end up relying on tumor board more than I would ideally want to for anything that is not straightforward. When I have been on consults, I also feel pretty comfortable working up new cases of any specialty but this relies heavily on literature review and not de novo knowledge.

If you've read this far and are willing to take a stab at the questions below - thank you! I have had trouble getting well informed answers from my faculty as most cannot even conceive of a generalist practice. I care deeply about providing excellent patient care and really want to be prepared.

Questions
1) Is this a normal place to be clinically halfway through fellowship?
2) What is the expectation starting as an attending in generalist practice? How much lit/guideline review is normal for each new patient?
3) To prepare for a generalist job, I've considered adding in some other clinics. Given the exact job I'll get is unclear, is there any rhyme or reason in which subspecialties I should try to pick up some experience?
4) Other than joining extra clinics and doing the usual reading before patients, are there other things you would suggest to maximize readiness for practice?
5) Can anyone comment on the depth of heme knowledge I will need? Many of the jobs say something like 20-30% heme. I feel comfortable with cytopenias and thrombosis. I could also do some basic CLL (like BTK, less comfort with VO etc) although thats about the limit of my comfort level. Is it needed to have more skills than this for a basic community job?

I am an APD at a hybrid program, so that's my starting point. Unfortunately, most academic centers are not designed to facilitate community / hybrid practice curricula for fellows or provide sufficient community exposure for those who change career trajectories.

1) In general, it is appropriate to feel this way at this point given the structure of your fellowship and your exposure to primarily GI. I would recommend getting more exposure to upper GI and pancreatic cancer +/- hepatobiliary / NET / GIST at the very least and not just lower GI.
2) There are colleagues and support at most practices to help you. You definitely will need to review NCCN / Uptodate / ASCO/ASH guidelines for cases. Our fellows in practice still phone us for help for particularly tricky cases. Over time, you'll become more efficient, but you need a strong foundation otherwise it will be a very uphill struggle.
3) From point 2, you need to do thoracic / breast/ GU clinic for solid tumor at least for 2 months each. Cases in the community are proportional to incidence, e.g. breast, prostate, lung, colon. It will be extremely helpful to have a firm foundation in those 4. Start reading / listening to the Fellow on Call series podcast, they have great discussion on most common tumor types.
4) You will need exposure to the business side of medicine, billing, etc. It is really hard to do when you need to catch up on the clinical side first. You'll get that in the practice and your partners and colleagues will help. You can also join community oncology alliance, they have a business of medicine series. If you are interested or have colleagues interested in this, PM me as I am developing a practice of medicine curriculum for fellows to teaching billing / etc. since that is essentially not taught in fellowship.
5) It's mostly general hematology, there's rarely going to be a case of vWD Type Vincenza. If that's the case you're going to refer those patients to a tertiary hematology clinic / hemophilia center. Regarding malignant hematology, that's up to the practice mix and patterns. Myeloma / CLL / Lymphoma (DLBCL, Follicular) / MDS are relatively common and some benign heme consults become cases of those. MPN hard to say. True leukemia I would not suggest managing in a general practice unless you are giving Aza/Ven and are very confident.

 

[HemeOncHopeful19]

I am an APD at a hybrid program, so that's my starting point. Unfortunately, most academic centers are not designed to facilitate community / hybrid practice curricula for fellows or provide sufficient community exposure for those who change career trajectories.

4) You will need exposure to the business side of medicine, billing, etc. It is really hard to do when you need to catch up on the clinical side first. You'll get that in the practice and your partners and colleagues will help. You can also join community oncology alliance, they have a business of medicine series. If you are interested or have colleagues interested in this, PM me as I am developing a practice of medicine curriculum for fellows to teaching billing / etc. since that is essentially not taught in fellowship.

You sound like a good dude/dudette and I wish there were more fellowship attendings with this attitude.

 

[gutonc]

Hi all. I am a 2nd year fellow who just switched over to research time and I was hoping to get some advice about where I am at clinically and where I need to get to start practice. I am at a very research heavy east coast program but for a variety of reasons I am clear I will be taking a community job. I feel quite confused about where my clinical skills are and how I should be using my second half of fellowship to prepare for practice. Appreciate anyone's time and advice very much.

My clinical (and research) focus is GI. I have been in the same GI clinic doing mostly colon with a smattering of rectal cancer for the last 18 months and feel very comfortable practicing quasi independently with very few of my plans being changed by the attending and a good grasp of the important literature. All of my feedback both formal and informal has been excellent but 90+% of this is in the subspecialty clinic where it is quite a narrow focus. When I do get feedback in other settings, I feel to some degree I am being graded on a curve as I am known as "a GI guy".

In other solid clinics (thinking of thoracic where I was recently), it takes me significant preparation (i.e. spending 30-45 minutes) of chart review and uptodate/NCCN review to feel ready to see a new patient. After this review, I feel relatively comfortable with straightforward cases but feel I end up relying on tumor board more than I would ideally want to for anything that is not straightforward. When I have been on consults, I also feel pretty comfortable working up new cases of any specialty but this relies heavily on literature review and not de novo knowledge.

If you've read this far and are willing to take a stab at the questions below - thank you! I have had trouble getting well informed answers from my faculty as most cannot even conceive of a generalist practice. I care deeply about providing excellent patient care and really want to be prepared.

In case you haven't been following my exhilarating career day by day here on SDN, I am an MD/PhD who, until about 6 mos before the end of my fellowship, was convinced that I was going to be an academic sub-specialist working in a lab and only seeing 1 cancer type (pancreatic in my case) until I died. I have in fact been practicing in a community setting (academ-ish for the first 11 years, now solo, rural CAH with quasi-academic tertiary/quaternary backup an hour or so away for the past 2 years).

Questions
1) Is this a normal place to be clinically halfway through fellowship?

Absolutely. There are some fellows who have a particular disease interest from day one (like you and me) and focus on that, and others who go broad at the beginning and then narrow down (or not) as fellowship goes on. I'm sure you're stronger in GI and weaker in other things than many of your co-fellows and you'll level out as the next year goes on.

2) What is the expectation starting as an attending in generalist practice? How much lit/guideline review is normal for each new patient?

I can't tell you what is normal, but I can tell you what I experienced. A lot of this will depend on the type of practice you join and whether or not you're starting with an established panel or building one. I was mostly building my own so I had plenty of time over the first year to read as much as I wanted/needed. For the first 2 or 3 years in practice, I would review my clinic the night before and write notes to myself that I referenced before and after seeing the patient. Now I typically look at my schedule over a glass of wine the night before, spend 5 or 10 minutes looking at referral notes (mostly useless), labs, path and imaging on new patients (usually helpful) and call it good. I use Epic and find the sticky note function to be super helpful as I can just look at the day's schedule and see my last sticky note on every follow up patient. I don't even have to open the chart.

As for guidelines, literature, etc, I probably still ready something about 1/4-1/3 of my patients every single day. Sometimes it's just a quick glance at the surveillance guidelines on NCCN, sometimes it's a deep dive into recent clinical trial results. It's not usually a lot of time (20-30 min total a day which works out to 1-2 min/pt spread out over the whole day). I spent a lot more time and looked up a lot more stuff early in my career. After 3-5 years, you have to look up less and you're better at finding what you need.

3) To prepare for a generalist job, I've considered adding in some other clinics. Given the exact job I'll get is unclear, is there any rhyme or reason in which subspecialties I should try to pick up some experience?

Spend time with the stuff you don't care for much. I had plenty of time (and good mentors) in GI, Breast and Lung, and we had a very malignant heme heavy first year (6 months total between inpatient leukemia/lymphoma, inpatient BMT (this was pre cellular therapy), outpatient heme/mal and heme mal consults. I should have sought out more time in GU (I only did 2 months total), GYN (we didn't have any required) and benign heme. One thing you will learn in the community is that there are a huge number of PCPs out there (physicians, PA/NP and god forbid you work somewhere with a lot of naturopaths) who will literally refer any CBC abnormality to heme for evaluation...there are also some who should refer them, but don't, until they've f***ed things up so badly that they finally realize they need help. At first this used to bug me, but now I just look at it as job security.

4) Other than joining extra clinics and doing the usual reading before patients, are there other things you would suggest to maximize readiness for practice?

Go to every single tumor board you can and participate. I know it's intimidating, but the best thing that ever happened to me in terms of feeling comfortable about my own knowledge, and knowing where it was weak, was having an attending (surg onc actually, not on of mine) ask me for my thoughts in tumor board. So go, pay attention and speak up.

5) Can anyone comment on the depth of heme knowledge I will need? Many of the jobs say something like 20-30% heme. I feel comfortable with cytopenias and thrombosis. I could also do some basic CLL (like BTK, less comfort with VO etc) although thats about the limit of my comfort level. Is it needed to have more skills than this for a basic community job?

See above. You're going to need to know how to workup and manage a lot of classical and malignant hematology. The jobs that say "20-30%" are disingenuous at best and flat out lying at worst.

 

[guildsman]

In case you haven't been following my exhilarating career day by day here on SDN, I am an MD/PhD who, until about 6 mos before the end of my fellowship, was convinced that I was going to be an academic sub-specialist working in a lab and only seeing 1 cancer type (pancreatic in my case) until I died. I have in fact been practicing in a community setting (academ-ish for the first 11 years, now solo, rural CAH with quasi-academic tertiary/quaternary backup an hour or so away for the past 2 years).

Absolutely. There are some fellows who have a particular disease interest from day one (like you and me) and focus on that, and others who go broad at the beginning and then narrow down (or not) as fellowship goes on. I'm sure you're stronger in GI and weaker in other things than many of your co-fellows and you'll level out as the next year goes on.

I can't tell you what is normal, but I can tell you what I experienced. A lot of this will depend on the type of practice you join and whether or not you're starting with an established panel or building one. I was mostly building my own so I had plenty of time over the first year to read as much as I wanted/needed. For the first 2 or 3 years in practice, I would review my clinic the night before and write notes to myself that I referenced before and after seeing the patient. Now I typically look at my schedule over a glass of wine the night before, spend 5 or 10 minutes looking at referral notes (mostly useless), labs, path and imaging on new patients (usually helpful) and call it good. I use Epic and find the sticky note function to be super helpful as I can just look at the day's schedule and see my last sticky note on every follow up patient. I don't even have to open the chart.

As for guidelines, literature, etc, I probably still ready something about 1/4-1/3 of my patients every single day. Sometimes it's just a quick glance at the surveillance guidelines on NCCN, sometimes it's a deep dive into recent clinical trial results. It's not usually a lot of time (20-30 min total a day which works out to 1-2 min/pt spread out over the whole day). I spent a lot more time and looked up a lot more stuff early in my career. After 3-5 years, you have to look up less and you're better at finding what you need.

Spend time with the stuff you don't care for much. I had plenty of time (and good mentors) in GI, Breast and Lung, and we had a very malignant heme heavy first year (6 months total between inpatient leukemia/lymphoma, inpatient BMT (this was pre cellular therapy), outpatient heme/mal and heme mal consults. I should have sought out more time in GU (I only did 2 months total), GYN (we didn't have any required) and benign heme. One thing you will learn in the community is that there are a huge number of PCPs out there (physicians, PA/NP and god forbid you work somewhere with a lot of naturopaths) who will literally refer any CBC abnormality to heme for evaluation...there are also some who should refer them, but don't, until they've f***ed things up so badly that they finally realize they need help. At first this used to bug me, but now I just look at it as job security.

Go to every single tumor board you can and participate. I know it's intimidating, but the best thing that ever happened to me in terms of feeling comfortable about my own knowledge, and knowing where it was weak, was having an attending (surg onc actually, not on of mine) ask me for my thoughts in tumor board. So go, pay attention and speak up.

See above. You're going to need to know how to workup and manage a lot of classical and malignant hematology. The jobs that say "20-30%" are disingenuous at best and flat out lying at worst.

This is a great answer! To second the amount of hematology, even in a hybrid academic medical center our inpatient service + consults is 60- 70% hematology (classic + malignant). You definitely need to know how to see a lot of varied hematology.

 

[soccerusa]

Thanks all for your insightful feedback. Much appreciated!

 

[HemeOncHopeful19]

There's not enough time in 3 years to be great at everything.

Just learn everything you can and then be prepared to work on your weaknesses and lean on your strengths once you graduate. When you interview for jobs don't downplay yourself, just be ready to work / read after clinic for the first few years (decades?)

Case in point: I'm like a PGY10 and never heard of this VWD Type Vincenza crap, unless it's just a nerd way of saying type 1c (which I've also never seen in real life).

 

[gutonc]

There's not enough time in 3 years to be great at everything.

Just learn everything you can and then be prepared to work on your weaknesses and lean on your strengths once you graduate. When you interview for jobs don't downplay yourself, just be ready to work / read after clinic for the first few years (decades?)

Case in point: I'm like a PGY10 and never heard of this VWD Type Vincenza crap, unless it's just a nerd way of saying type 1c (which I've also never seen in real life).

Absolutely. I'm a PGY 18 and at least once a month (and probably more like once a week if I'm honest) I see something that I've never seen before and can only find case reports (usually originally printed in non-English language journals). I do the best I can, transfer care or get consultation when possible, and admit defeat when necessary.

 

[gutonc]

This is a great answer! To second the amount of hematology, even in a hybrid academic medical center our inpatient service + consults is 60- 70% hematology (classic + malignant). You definitely need to know how to see a lot of varied hematology.

Just to follow up on this. Today I had 3 new classical heme consults on my schedule that were all unnecessary if the NP/PAs managing them had followed my verbal and/or written instructions to just repeat the labs.

One was a 19yo with post-mono AIHA. Getting better now that his mono is better...no he doesn't have acute leukemia. I told you to repeat the CBC in 7-10 days, not daily and calling my office twice a day to say he has leukemia and needs to be seen ASAP is a good way to piss me off.
One was a 48yo with reactive polycythemia in the setting of an acute GI bleed due to a gastric ulcer. Resolved with treatment of the gastritis. Hemoglobin normal today. I told you to repeat the CBC in 6-8 weeks, but I guess I can do that too.
One was an active alcoholic Child-Pugh B9/C10 (depending on whether his encephalopathy is due to ESLD - Bili is 4.5 and rising without obstruction, or intoxication). Platelets have been 40-50K since 2019. I told you he didn't need to see me, he just needs to quit drinking. But I guess I can tell him that too.

Hooray for another boat payment!

 

[checkpointinhibitor]

Just to follow up on this. Today I had 3 new classical heme consults on my schedule that were all unnecessary if the NP/PAs managing them had followed by verbal instructions to just repeat the labs.

One was a 19yo with post-mono AIHA. Getting better now that his mono is better...no he doesn't have acute leukemia. I told you to repeat the CBC in 7-10 days, not daily and calling my office twice a day to say he has leukemia and needs to be seen ASAP is a good way to piss me off.
One was a 48yo with reactive polycythemia in the setting of an acute GI bleed due to a gastric ulcer. Resolved with treatment of the gastritis. Hemoglobin normal today. I told you to repeat the CBC in 6-8 weeks, but I guess I can do that too.
One was an active alcoholic Child-Pugh B9/C10 (depending on whether his encephalopathy is due to ESLD - Bili is 4.5 and rising without obstruction, or intoxication). Platelets have been 40-50K since 2019. I told you he didn't need to see me, he just needs to quit drinking. But I guess I can tell him that too.

Hooray for another boat payment!

Same in my clinic.
Mildly abnormal FLC ratio gets heme onc consultation. recommend no further follow up, no need for repeat SPEP but the NP/PA repeats the labs including SPEP in 6 months and sends another consultation for "myeloma". Lady ! quit checking SPEP and FLC in patient with CKD3, it's always going ot be mildly abnormal !!! But I guess, i can tell that too. lol.

Only thing that keep sanity is that it's production at the end day.

I wonder what the MBA overlords will do if the fee-for-service model goes away and bundled or quality based payments come in to play. Or like Canada - MDs will be capped to max compensation and they will close their offices because they saw the max patients need to be seen in the year.

 

[gutonc]

Same in my clinic.
Mildly abnormal FLC ratio gets heme onc consultation. recommend no further follow up, no need for repeat SPEP but the NP/PA repeats the labs including SPEP in 6 months and sends another consultation for "myeloma". Lady ! quit checking SPEP and FLC in patient with CKD3, it's always going ot be mildly abnormal !!! But I guess, i can tell that too. lol.

Only thing that keep sanity is that it's production at the end day.

I honestly stopped d/c'ing these patients from clinic for this reason. I make sure they get 2 sets of myeloma labs 3 mos apart and when they're unchanged and asymptomatic, I just put them on a 6 month recall. Is it good medicine? Not particularly. Is it a good use of my time? No. Is it less annoying than trying to get some mail order FNP to read and understand my note and do what I tell them to do? Absolutely.

 

[bobsmith]

One was a 48yo with reactive polycythemia in the setting of an acute GI bleed due to a gastric ulcer. Resolved with treatment of the gastritis. Hemoglobin normal today. I told you to repeat the CBC in 6-8 weeks, but I guess I can do that too.
One was an active alcoholic Child-Pugh B9/C10 (depending on whether his encephalopathy is due to ESLD - Bili is 4.5 and rising without obstruction, or intoxication). Platelets have been 40-50K since 2019. I told you he didn't need to see me, he just needs to quit drinking. But I guess I can tell him that too.

Same in my clinic.
Mildly abnormal FLC ratio gets heme onc consultation. recommend no further follow up, no need for repeat SPEP but the NP/PA repeats the labs including SPEP in 6 months and sends another consultation for "myeloma". Lady ! quit checking SPEP and FLC in patient with CKD3, it's always going ot be mildly abnormal !!! But I guess, i can tell that too. lol.

I think you both are underselling how much at ease patients feel hearing it "officially" from the expert / us - especially when the referring provider has made it pretty clear to the patient that they have no idea what to do with the result and/or are freaking out about it

I wonder what the MBA overlords will do if the fee-for-service model goes away and bundled or quality based payments come in to play. .

My guess would be e-consults; I think some of the non-production based systems like Kaiser, the VA, etc use a decent amount of this for specialty care

 

[gutonc]

I think you both are underselling how much at ease patients feel hearing it "officially" from the expert / us - especially when the referring provider has made it pretty clear to the patient that they have no idea what to do with the result and/or are freaking out about it

I'm happy to tell them this. And I also specifically tell them (and their PCP) the reasons that they should come back and see me. With specific lab parameters, red flag symptoms and everything. But inevitably, 6-12 months later, they're back as a "new patient" for the same damn thing. So I just gave up. It's 5 minutes of work and $160 in my pocket.

My guess would be e-consults; I think some of the non-production based systems like Kaiser, the VA, etc use a decent amount of this for specialty care

I actually love e-consults. I was using them to get appropriate workup done before I saw the patient as a new consult. But I've been told (probably incorrectly, but I can't find the answer myself) that because we're a rural CAH, we're not allows to bill E-consults per CMS.

 

[HemeOncHopeful19]

I think you both are underselling how much at ease patients feel hearing it "officially" from the expert / us - especially when the referring provider has made it pretty clear to the patient that they have no idea what to do with the result and/or are freaking out about it


My guess would be e-consults; I think some of the non-production based systems like Kaiser, the VA, etc use a decent amount of this for specialty care

Yep at the VA we saw a lot of E-consults for stuff like this (we had referrals meeting XYZ criteria auto-convert to an E-consult).

I was jealous of the Endocrine guys their department flat out said “you must order all of these labs before placing an E-consult” - I wanted to look into doing something like that for mild Thrombocytopenia

It’s cool idea in theory but I would be pissed if I worked at Kaiser - good way to get your name in a ton of extra charts but no medmal protection like at the VA. Also admin will consider an E-consult as “easy” work you get no credit for whatsoever.

 

[bobsmith]

I'm happy to tell them this. And I also specifically tell them (and their PCP) the reasons that they should come back and see me. With specific lab parameters, red flag symptoms and everything. But inevitably, 6-12 months later, they're back as a "new patient" for the same damn thing. So I just gave up. It's 5 minutes of work and $160 in my pocket.

Yeah I guess the point of my post was to justify my approach - which is also to not fight it and convince myself I'm helping in some way 🙂

I actually love e-consults. I was using them to get appropriate workup done before I saw the patient as a new consult. But I've been told (probably incorrectly, but I can't find the answer myself) that because we're a rural CAH, we're not allows to bill E-consults per CMS.

I don't have the answer either, but sounds made up

 

[checkpointinhibitor]

I think you both are underselling how much at ease patients feel hearing it "officially" from the expert / us - especially when the referring provider has made it pretty clear to the patient that they have no idea what to do with the result and/or are freaking out about it


My guess would be e-consults; I think some of the non-production based systems like Kaiser, the VA, etc use a decent amount of this for specialty care

Oh ofcourse, I don't mind seeing the patients and explaining the pathophysiology of FLCs and how renal clearance affects that and that they don't have cancer. Consults are legit and very very educational with excellent documentation. Alas, the referring mail order APP does not understand any of it or are "too busy" chasing abnormal labs. Reassurance is clearly the part of our package. Goal is to make system more efficient and clear time for someone who actually needs to see a specialist. Alas, the mid-level run primary care model is really terrible for patients IMO.

 

[gutonc]

Yep at the VA we saw a lot of E-consults for stuff like this (we had referrals meeting XYZ criteria auto-convert to an E-consult).

I was jealous of the Endocrine guys their department flat out said “you must order all of these labs before placing an E-consult” - I wanted to look into doing something like that for mild Thrombocytopenia

It’s cool idea in theory but I would be pissed if I worked at Kaiser - good way to get your name in a ton of extra charts but no medmal protection like at the VA. Also admin will consider an E-consult as “easy” work you get no credit for whatsoever.

To this point, I literally only used them to get labs ordered before a real visit. So no liability there. And at least in our E-consult text there is boilerplate stating that the use of an E-consult does not establish a physician/patient relationship.

I said, "order labs X, Y and Z (i started including the Epic order codes because somehow people were using the words I gave them and getting weird labs I'd never even heard of) and place referral once labs have been drawn". That plus "case reviewed, recommendations are as follows" gets you enough to bill for it and only takes a minute or 2. It's basically an InBasket or secureChat message you can get paid for.

 

[MD46]

I actually love e-consults. I was using them to get appropriate workup done before I saw the patient as a new consult. But I've been told (probably incorrectly, but I can't find the answer myself) that because we're a rural CAH, we're not allows to bill E-consults per CMS

Our billers said the same thing, they state it has been extended through March 2025, after that they are awaiting final decision per CMS, if they vote against it then in rural cant do televisits.

 

[gutonc]

Our billers said the same thing, they state it has been extended through March 2025, after that they are awaiting final decision per CMS, if they vote against it then in rural cant do televisits.

Thanks for that confirmation. I still don't really trust billers, but hearing it from 2 people does increase (slightly) the chance that it might not be complete BS.