Nursing home rounding

[cyanide12345678]

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Any of you guys transition to nursing homes?

My wife does it, her life is incredible. She probably works 20-25 hrs a week and has complete flexibility.

Talking to recruiters a lot these days, getting offered a gig from team health for 4 nursing homes, 300k w2 with benefits. 20 patients a day. Haven’t dived into negotiation or anything. Just don’t know if I’m ready to quit emergency medicine to do something I’m not trained to do.

I know i want out, this seems like a legit out without further fellowship training and without a significant drop in the $/hr of work done. Plus 6-ish hour days, no circadian rhythm disruptions, be there every day for my kids, flexibility in work hours, no after hour calls.

This is tempting. The only thing holding me back is the fear of the unknown.

 

[Groove]

I've been seeing the same offers, what job site are you using out of curiosity? I've been so far out of the loop in hunting for non traditional physician jobs that I'm not sure what the major ones are these days. Did it sound like something you could pick up fairly easily? I didn't know it paid so well. Any major malpractice risk?

 

[Groove]

NM, I forgot this is the age of AI doing all the grunt work for me.

 

[cyanide12345678]

I've been seeing the same offers, what job site are you using out of curiosity? I've been so far out of the loop in hunting for non traditional physician jobs that I'm not sure what the major ones are these days. Did it sound like something you could pick up fairly easily? I didn't know it paid so well. Any major malpractice risk?

I live in the best state for malpractice in the country. Team health clearly said they hire EM docs for this job as well.

I didn’t use any job boards, but basically started responding to every recruiter text and started having conversations with them.

My wife makes $1550/20 patients seen, prorated so essentially $77.5/patient. There’s a NP that rounds M-F and is the first call for the staff, the NP reaches out if she needs help. After hours, there’s a teledoc that gets called, my wife is never on call. She gets 60% of facility medical director fees for which she basically does nothing. Which on average Is $1250/facility/month. She’s rounding on 5 places, 3 of those weekly, 2 of them biweekly. So she works 3.5 days per week.

Other than every other Monday when she visits the two places on the same day, she’s usually home at around 1-2 pm. She usually leaves at around 8:30 to 9 am for work. Her driving is 1 hr on average to each site, she probably spends 3-4 ish hours max at each site.

She’s basically making 70k for medical director stipend alone. And then $77.5/patients seen.

It’s a sweet gig, except I’m not trained to manage chronic illnesses…. Just the thought of managing those nursing home patients with 20+ chronic medications seems intimidating 🤣

 

[Groove]

It’s a sweet gig, except I’m not trained to manage chronic illnesses…. Just the thought of managing those nursing home patients with 20+ chronic medications seems intimidating 🤣

Sounds awesome honestly. I'm reading more about it right now. Oh come now, you know where that easy button is located. "Send them to the ER!" 😆

 

[cyanide12345678]

I mean family medicine docs were the OG jack of all trades and master of none - they did OB, nursing homes, inpatient medicine, outpatient medicine.

I mean….. we’re kind of the jack of all trades too. Any of you guys done nursing homes and just hated managing chronic illnesses?

 

[cyanide12345678]

Sounds awesome honestly. I'm reading more about it right now. Oh come now, you know where that easy button is located. "Send them to the ER!" 😆

It’s actually frowned about. Its the one metric the administrators track - return to hospital rate.

But yeah…when things get dicey - hit the easy button and send then to the ER.

 

[JacobMcCandles]

You probably wouldn’t be any worse than most nursing home medical directors out there. Personally, I don’t think I’d be giving the appropriate care these patients need/deserve.

 

[cyanide12345678]

You probably wouldn’t be any worse than most nursing home medical directors out there. Personally, I don’t think I’d be giving the appropriate care these patients need/deserve.

I think after 6 months of reading a lot of uptodate as i manage some of these chronic patients, ill probably get to the level of competence that i would say is appropriate. The first 6 months yeah ill probably struggle and provide subpar care. But i can always run cases by my spouse and get help with management too.

Yeah the fear of the unknown and the fear of incompetence is holding me back. But at the same time, i could get a normal life, better hrs, more flexibility, and no massive paycut. The pace would be slower too.

 

[cyanide12345678]

You probably wouldn’t be any worse than most nursing home medical directors out there. Personally, I don’t think I’d be giving the appropriate care these patients need/deserve.

And you’re right, id probably still not give any worse care than some medical directors out there who don’t even come in to see the patients and just keep copy pasting previous notes. It happens a lot in nursing homes. Some of these docs literally don’t even come in.

The last doc my wife replaced in one of the facilities was someone who had physically not come in for 6 months, not a single nurse had seen him there. He used to say he comes over the weekends - nope. He didnt. Just kept copy pasting previous notes.

 

[Groove]

Well, I sent some feelers out on post acute care, urgent care and telemedicine. I have more questions than anything else but am interested in learning more. I quit my CMG job and am going to work for another CMG in town for about $50/hr more pay, fewer nights (FMD told me 1/mo so we'll see if that happens but that would be pretty amazing to me since I've been doing closer to 30% overnights certain months.) 100 hours/mo with flexibility to go down to 60 anytime I want. I get a couple months off before starting the new job so am definitely looking forward to the R&R. Part of me just feels like I should continue doing what I know, especially if I can reduce overnights to only 1/mo. The question is how many late swings would I be scheduled and there's a lot of unknowns so I'm a bit skeptical. Still though...it's tempting to just keep reducing hours which would basically equate to the same amount of money I'd make doing one of these other jobs, even if it's a better schedule. I think I'd rather have the free time. Decisions, decisions. One thing is for certain. I think when I hit 5M, I am 100% done with emergency medicine entirely.

 

[cyanide12345678]

Well, I sent some feelers out on post acute care, urgent care and telemedicine. I have more questions than anything else but am interested in learning more. I quit my CMG job and am going to work for another CMG in town for about $50/hr more pay, fewer nights (FMD told me 1/mo so we'll see if that happens but that would be pretty amazing to me since I've been doing closer to 30% overnights certain months.) 100 hours/mo with flexibility to go down to 60 anytime I want. I get a couple months off before starting the new job so am definitely looking forward to the R&R. Part of me just feels like I should continue doing what I know, especially if I can reduce overnights to only 1/mo. The question is how many late swings would I be scheduled and there's a lot of unknowns so I'm a bit skeptical. Still though...it's tempting to just keep reducing hours which would basically equate to the same amount of money I'd make doing one of these other jobs, even if it's a better schedule. I think I'd rather have the free time. Decisions, decisions. One thing is for certain. I think when I hit 5M, I am 100% done with emergency medicine entirely.

Ive hit 2.7M. We’re officially at the 4% rule. Even if i drop my income to 250k, our family income still would remain at around 550-600k.

We’re obviously going to keep investing more. Plus 3 years later my expenses drop another 25k/yr as our youngest one exits daycare.

Then honestly our expenses are in the 7-8k/month range. We’re more than financially independent.

Just need to take a leap of faith and jump ship from what is safe and secure.

 

[emergentmd]

I would like everyone to think about shutting things down or dropping work hours if you can in your 40's or early 50's if you are able. Life is short. I know it is hard to take a big pay cut esp when many of us grew up poor. I know my parents who made $3/hr would roll over in their graves when I am giving up a in a shift what they made in a year.

But once you start to slow down, you will start to realize that you should have tried it earlier. It is life changing, you are happier, and as you get older you will figure out time becomes more important than money,.

 

[Groove]

 

[Groove]

I would like everyone to think about shutting things down or dropping work hours if you can in your 40's or early 50's if you are able. Life is short. I know it is hard to take a big pay cut esp when many of us grew up poor. I know my parents who made $3/hr would roll over in their graves when I am giving up a in a shift what they made in a year.

But once you start to slow down, you will start to realize that you should have tried it earlier. It is life changing, you are happier, and as you get older you will figure out time becomes more important than money,.

Wise words and something I am learning to embrace as I move forward, especially now that our financial situation is better than it was years back. It doesn't come natural though and it's difficult having discussions with people about contemplating retiring early as most just stare at you like they have no idea what you're talking about and wonder if you're dealing with some sort of health or mental problem. Inevitably, it leads to a discussion on investing (since that's what I'd like to do full time) and then I just end up sounding like an idiot. "So....you wanna quit work because you can't sleep very well and you wanna be a um....trader like one of those stock traders on Wall Street? Do you have a finance degree or something? Oh, you don't? Ah...umm, well I hope that works out! How does your wife feel about it? Oh, you're burned out! Like a firefighter? You work in the ER though, right?"

 

[WhatJobDoIPick]

I would like everyone to think about shutting things down or dropping work hours if you can in your 40's or early 50's if you are able. Life is short. I know it is hard to take a big pay cut esp when many of us grew up poor. I know my parents who made $3/hr would roll over in their graves when I am giving up a in a shift what they made in a year.

But once you start to slow down, you will start to realize that you should have tried it earlier. It is life changing, you are happier, and as you get older you will figure out time becomes more important than money,.

I'll be down to 1ish shift / week by my.mid 40s. You don't gotta tell me twice.

Pay...down
Aggravation...up
Expectations...up
Litigation...up

I have a whole list of hobbies that I'll be able to dedicate more time to.

 

[VA Hopeful Dr]

I think after 6 months of reading a lot of uptodate as i manage some of these chronic patients, ill probably get to the level of competence that i would say is appropriate. The first 6 months yeah ill probably struggle and provide subpar care. But i can always run cases by my spouse and get help with management too.

Yeah the fear of the unknown and the fear of incompetence is holding me back. But at the same time, i could get a normal life, better hrs, more flexibility, and no massive paycut. The pace would be slower too.

I never tire of this.

"I'll just study for 6 months and be fine at chronic disease management".

Instead of almost certainly providing bad care (maybe for only 6 months, likely for longer), why not just cut way back on your ED shifts? Sounds like your finances will be fine.

 

[RustedFox]

I would absolutely do something like this; but I would want some variety of formalized training because I'm very attuned to the rather valid criticisms of @VA Hopeful Dr .

Being real: there's not enough FM to do the job.

 

[Brigade4Radiant]

I never tire of this.

"I'll just study for 6 months and be fine at chronic disease management".

Instead of almost certainly providing bad care (maybe for only 6 months, likely for longer), why not just cut way back on your ED shifts? Sounds like your finances will be fine.

Yeah like NP/PA or FM that can do hospitalist, peds OB and ER. Nursing home mostly SNF care’s biggest issue is basically if they can send them to the ER.

See so many IM and FM in the ED you might as well do the same like how junior residents and fellows give bad care then improve

 

[MavFab]

I live in the best state for malpractice in the country. Team health clearly said they hire EM docs for this job as well.

I didn’t use any job boards, but basically started responding to every recruiter text and started having conversations with them.

My wife makes $1550/20 patients seen, prorated so essentially $77.5/patient. There’s a NP that rounds M-F and is the first call for the staff, the NP reaches out if she needs help. After hours, there’s a teledoc that gets called, my wife is never on call. She gets 60% of facility medical director fees for which she basically does nothing. Which on average Is $1250/facility/month. She’s rounding on 5 places, 3 of those weekly, 2 of them biweekly. So she works 3.5 days per week.

Other than every other Monday when she visits the two places on the same day, she’s usually home at around 1-2 pm. She usually leaves at around 8:30 to 9 am for work. Her driving is 1 hr on average to each site, she probably spends 3-4 ish hours max at each site.

She’s basically making 70k for medical director stipend alone. And then $77.5/patients seen.

It’s a sweet gig, except I’m not trained to manage chronic illnesses…. Just the thought of managing those nursing home patients with 20+ chronic medications seems intimidating 🤣

Is your wife billing exclusively 99309s or being subsidized by the facility or group she is with? Where I am 99309 only reimburses about $80 and 99308 around 60 so you would need to bill almost all 99309s to make that much per patient. And this doesn't include deductions for overhead like billing and malpractice.

 

[cyanide12345678]

Is your wife billing exclusively 99309s or being subsidized by the facility or group she is with? Where I am 99309 only reimburses about $80 and 99308 around 60 so you would need to bill almost all 99309s to make that much per patient. And this doesn't include deductions for overhead like billing and malpractice.

It’s not rvu based. They really tried to get us into rvu based compensation after a fixed number but we didn’t like that option.

Her compensation is purely based on the number of patients seen. She gets $1550/20 patients seen + 60% of all medical director fees that the company collects. And that number is prorated, so basically $77.5/patient if she sees less or more.

She keeps track of number of patients seen each visit, and then every month turns in her excel with the number of patients seen.

 

[MavFab]

It’s not rvu based. They really tried to get us into rvu based compensation after a fixed number but we didn’t like that option.

Her compensation is purely based on the number of patients seen. She gets $1550/20 patients seen + 60% of all medical director fees that the company collects. And that number is prorated, so basically $77.5/patient if she sees less or more.

She keeps track of number of patients seen each visit, and then every month turns in her excel with the number of patients seen.

That sounds like a good setup. $77.50 per patient is great reimbursement for SNF.

 

[VA Hopeful Dr]

Yeah like NP/PA or FM that can do hospitalist, peds OB and ER. Nursing home mostly SNF care’s biggest issue is basically if they can send them to the ER.

See so many IM and FM in the ED you might as well do the same like how junior residents and fellows give bad care then improve

Oooh I love this one too.

"There's already substandard card from undertrained doctors/midlevels so I don't have to feel guilty about providing that same substandard care".

With a side helping of "FPs are doing bad work in the ED so I should get to do bad work in FP jobs".

 

[VA Hopeful Dr]

All of my snark aside, it's a nursing home. It's already death's waiting room so in all honesty who cares.

Oh no, you screwed up and now meemaw is dead at 96. She could've lived to be 97!!!!!

 

[WhatJobDoIPick]

Oooh I love this one too.

"There's already substandard card from undertrained doctors/midlevels so I don't have to feel guilty about providing that same substandard care".

With a side helping of "FPs are doing bad work in the ED so I should get to do bad work in FP jobs".

Write a letter to your congressman

 

[end stage fibro]

I do a lot of nursing home work on the side. $77.50 Per patient is fantastic reimbursement. Actually,that is unheard of to me. Does she bill 99310 (highest level) very often? The 60% of medical director fees is interesting ...Where's the other 40% going? . More common in my neck of the woods is around 55 to 60 per patient (averaging out all follow ups and H&Ps and discharges in one boat ). However, I do get 100 percent of the medical director fee, which averages about $1000 to $2000/per month depending on the facility.

Most skilled patients are there for the rehab/iv antibiotics/what have you. you will be babysitting them. every now and then you'll get a lab/imaging/exam finding and be like oh **** and have to weigh sending them to the ED or treating in house. Stat orders are not like the hospital...usually takes 6 hours easy just for the collection. There is the rub...most SNFs are heavily judged on their return to hospital rate. Do not mess up that rate. I have definitely delivered hospital level care at these places.

i have a large panel of long term care patients. you will probably need to brush up on chronic med management but it isnt rocket science. they will usually have cardis or nephro or someone seeing them too i bet.

Two of the bigger players in the game are Ensign and Genesis, they're both for profit SNF chains, They will grind down their employees and probably provide suboptimal care in the name of the almighty dollar, but they tend to be more well run facilities.

my main annoyance in this job is that I feel like i am prolonging the inevitable with some of these patients...merely slowing down the rehab - hospital death wheel. also, its annoying how much finances matter. theres a lot of literature on how SNF discharges spike at 21 days (when the patient is responsible for copay) and the snf discharges them on that day, like it or not.

 

[Brigade4Radiant]

Oooh I love this one too.

"There's already substandard card from undertrained doctors/midlevels so I don't have to feel guilty about providing that same substandard care".

With a side helping of "FPs are doing bad work in the ED so I should get to do bad work in FP jobs".

I'll bite.

How is nursing home care a FP job? is it office hospitalist or working with children. Because you are saying that an FP hospitalist offers the same care as an IM doctor in hospitalist, OB in taking care of pregnant women or IM clinic in taking care of adult patients or a pediatrician seeing patients in the office. You are saying that you provide equivelent care as IM or Peds?

"Gee since its a rural area I can practice how I want to and don't have to feel guilty about providing the same standard of care as other specialties."

Also why do you guys get to work in the ED and then cry foul when other fields expand their practice

 

[VA Hopeful Dr]

I'll bite.

How is nursing home care a FP job? is it office hospitalist or working with children. Because you are saying that an FP hospitalist offers the same care as an IM doctor in hospitalist, OB in taking care of pregnant women or IM clinic in taking care of adult patients or a pediatrician seeing patients in the office. You are saying that you provide equivelent care as IM or Peds?

"Gee since its a rural area I can practice how I want to and don't have to feel guilty about providing the same standard of care as other specialties."

Also why do you guys get to work in the ED and then cry foul when other fields expand their practice

If we're being nitpicky, most nursing home jobs in my area are IM and/or geriatricians (the latter being a fellowship that we also have access to).

Also nitpicky, I don't recall being in favor of FPs in the ED as a general rule.

Of course we're not as good at managing pregnancy as an OB. I don't know anyone who thinks that. That's why 99% of us don't do it. The ones who do are so rural that either there is no OB or there are not enough OBs to be on call every night.

More and more places are going IM only for hospital medicine. I've never done that myself and my former hospitalist wife never worked with FPs so can't comment directly but I would expect IM to be, on the whole, better than we are at that. The question here, and this applies to outpatient peds as well, is whether the difference is significant when it comes to outcomes. I don't have an answer for that, but I suspect the answer is maybe.

Adult outpatient is trickier. Most IM residencies, at least when my wife and I were still in training, sucked at teaching outpatient medicine. Outside of a once/year month of clinic my wife did a half day per week of clinic. Contrast that with my training: 2nd and 3rd year I had at minimum 2.5 clinic days per week, usually more.

My wife has been doing outpatient medicine for 8 years now. We talk shop pretty much every day. I'd say we're interchangable for the most part. I'm better at Ortho, she's got me beat at rheum.

Funny thing is, the only reason I even get involved in these conversations is because some of y'all hate that we can in theory practice in the ED but then think it's so easy to do outpatient medicine.

It's either OK for everyone to encroach or it's OK for no one.

 

[VA Hopeful Dr]

Write a letter to your congressman

I don't actually care in real life, more than enough patients to go around.

 

[cyanide12345678]

Honestly - considering how much outpatient stuff is sent to the ER and how I’m frequently finding myself doing chronic management because of people with no pcp, it’s really not that bad.

I mean…. If you don’t know something, you have time to read and figure it out, bring them back and reassess. Emergency medicine on the other hand, if someone is crashing and dying, you can’t just necessarily wait a week and wait it out. You just have to know things and next steps.

Nursing home patients do require subacute care often and sometimes work ups - which most likely I’ll be better at that than the average out patient doctor.

A hospitalist is most likely the best trained at nursing home medicine other than geriatricians. I think it’s an equivalent learning curve for someone who purely practices outpatient medicine too to practice in a nursing home setting.

Regardless, we can all learn. I mean emergency medicine docs manage copd, ckd, chf, CAD, DM, HTN, strokes just as much as anyone else. And we do usually have a very good idea of the outpatient treatment as well, we choose not to mess around with those things because its not something needed in an emergent setting, but most of the time, we know what needs to be done even after someone leave the ER.

 

[cyanide12345678]

I do a lot of nursing home work on the side. $77.50 Per patient is fantastic reimbursement. Actually,that is unheard of to me. Does she bill 99310 (highest level) very often? The 60% of medical director fees is interesting ...Where's the other 40% going? . More common in my neck of the woods is around 55 to 60 per patient (averaging out all follow ups and H&Ps and discharges in one boat ). However, I do get 100 percent of the medical director fee, which averages about $1000 to $2000/per month depending on the facility.

Most skilled patients are there for the rehab/iv antibiotics/what have you. you will be babysitting them. every now and then you'll get a lab/imaging/exam finding and be like oh **** and have to weigh sending them to the ED or treating in house. Stat orders are not like the hospital...usually takes 6 hours easy just for the collection. There is the rub...most SNFs are heavily judged on their return to hospital rate. Do not mess up that rate. I have definitely delivered hospital level care at these places.

i have a large panel of long term care patients. you will probably need to brush up on chronic med management but it isnt rocket science. they will usually have cardis or nephro or someone seeing them too i bet.

Two of the bigger players in the game are Ensign and Genesis, they're both for profit SNF chains, They will grind down their employees and probably provide suboptimal care in the name of the almighty dollar, but they tend to be more well run facilities.

my main annoyance in this job is that I feel like i am prolonging the inevitable with some of these patients...merely slowing down the rehab - hospital death wheel. also, its annoying how much finances matter. theres a lot of literature on how SNF discharges spike at 21 days (when the patient is responsible for copay) and the snf discharges them on that day, like it or not.

The other 40% is going to the company she works for. So they’re probably breaking even or slightly losing money on the rvu side of hiring her, but making 50k-60k/year in medical director fees that are not going to my wife. And they are likely making money on the visits of the nurse practitioner who sees patients every day. They’ve been struggling with recruiting so much that without her, they would lose those contracts because they wouldn’t have a supervising physician, which is required in my state. All these sites are in rural Indiana - the drives are as far as 1.5 hours away from a major city. The shortest drive is 45-50 minutes away. So…. It’s not like people are dying to get into these jobs.

 

[Janders]

I may do a lot of COPD and CHF and DM but I do very little cutting edge evidence based titration of outpatient medications in these areas. I’m sure I could learn.

But we should be intellectually honest about our abilities and experiences.

As to the moral and ethical quandary of “Hell I’ll just figure it out as I go”, ignoring that you’ll be blind to some of your own blind spots… 🤷‍♂️

 

[JacobMcCandles]

I think we overestimate the amount of true chronic medical management we do. We will deal with it acutely but I feel like the majority of chronic medical management I do is to tell people to take their medications as prescribed. I’m not routinely adjusting and titrating medications.

 

[Brigade4Radiant]

I think we overestimate the amount of true chronic medical management we do. We will deal with it acutely but I feel like the majority of chronic medical management I do is to tell people to take their medications as prescribed. I’m not routinely adjusting and titrating medications.

I do when I discharge a chronic patient that has bounced back. I call the specialist, pulmonology, cardiology and then titrate or readjust medication on their recs also I read up.

 

[end stage fibro]

The other 40% is going to the company she works for. So they’re probably breaking even or slightly losing money on the rvu side of hiring her, but making 50k-60k/year in medical director fees that are not going to my wife. And they are likely making money on the visits of the nurse practitioner who sees patients every day. They’ve been struggling with recruiting so much that without her, they would lose those contracts because they wouldn’t have a supervising physician, which is required in my state. All these sites are in rural Indiana - the drives are as far as 1.5 hours away from a major city. The shortest drive is 45-50 minutes away. So…. It’s not like people are dying to get into these jobs.

what a position of power! the SNF company i contract for is owned by one MD that got a SNF directorship and slowly kept getting more.Now, he has an NP and MD at each shop to take care of the day to day and he handles all the quality stuff that the SNF cares about. I can churn patients, he takes a tiny cut, and I don't deal with admin BS (even though i get the med director stipend). everyone is happy...he has been able to get like 25 SNFs under his belt this way and only rounds at 1. your wife could probably do something similar easy if she so desires.

SNF work is not sexy to the avg MD...but it pays well and the freedom is amazing. wish i knew about it earlier.

 

[JacobMcCandles]

I do when I discharge a chronic patient that has bounced back. I call the specialist, pulmonology, cardiology and then titrate or readjust medication on their recs also I read up.

I’m not sure I would say you’re the one doing the chronic medical management in the situation you just described. It sounds like you just got the recommendations from someone else.

 

[cyanide12345678]

I think we overestimate the amount of true chronic medical management we do. We will deal with it acutely but I feel like the majority of chronic medical management I do is to tell people to take their medications as prescribed. I’m not routinely adjusting and titrating medications.

I think you’re also over estimating the difficulty of titrating up or down meds. It’s not hard.

You make a change, you measure results, you adjust your change. Honestly as someone who did 2 FM rotations in med school, i didn’t have any issue managing these things as a 4th year med student even. Now i have a decade of experience as a clinician. This is easy stuff.

I mean as a second year residents i was the senior resident running the trauma and ICU services on those months. Yes, attendings had input, but not anything drastically different from what my second and third yr self planned. We didn’t have trauma fellows or icu fellows. The EM residents were literally running the ICUs at second and third year. We did fine. Again, that was 10+ years ago, i likely learned a thing or two in that time.

This isn’t rocket science. There’s 10-15 diseases with 3-4 or so meds each. That’s 95%+ of your management right there. Honestly, i could learn that in 1 week if i sat down and studied.

And to be honest, it depends on the individual. My community ED occasionally gets FM residents rotate. Last year 50% of the residents rotating through my ER were complete idiots - and they were third year residents 3-4 months from graduating. One resident for example could not work up the simplest things, took 40 minutes in each room, and had the knowledge base of what i had as a med student. And she barely knew outpatient management of things either. I know A lot more than her. A co resident of my wife’s, literally repeatedly didn’t know how to interpret a UA result all the way through second year of residency. I mean…. No offense, but some of these Caribbean grads who are barely passing their USMLE exams are just terrible. But yeah…. They come out becoming doctors too.

On the other hand, I’ve personally been 99th percentile in every exam in my life (except English lol) including step 1, 2, 3 and my EM board exam - have gone to top tier schools and graduated with almost perfect GPAs from those top tier schools. This is after immigrating with no support system in the US with a cultural and initially some language barrier. So I’m not an idiot. These things aren’t rocket science. I come from a family of geniuses - mother was literally the no. 1 student of her era with 20+ gold medals for academic performance for being no. 1 in the country of Pakistan in all national exams. Literally - she was no. 1 in every national exam except one year in her med school when she was no. 2. All pakistan exams are on a national level and not on a school level. Father built a multi million dollar engineering firm with 70 employees at its peak. Brother who sold his startup to a japanese company for 8 figures 3 years ago and had 100+ employees and was on the inc 5000 list 3 times in a row and was literally the 7th or 8th fastest growing company in Austin for several years in a row. He also had perfect scores all of his life in academics without even trying - and a full ride to Stanford (again as an immigrant who left everything in pakistan at age 17).

So yeah…I’m not an idiot. And don’t over value the difficulty of chronic management. I’ve self taught myself a lot of things that i had 0 back ground in - and medicine is something in my wheelhouse where i already have significant foundational knowledge.

So yeah….i hesitate because i care about providing the best care i can. But there’s no part of me that doesnt think i can’t self learn.

 

[cyanide12345678]

what a position of power! the SNF company i contract for is owned by one MD that got a SNF directorship and slowly kept getting more.Now, he has an NP and MD at each shop to take care of the day to day and he handles all the quality stuff that the SNF cares about. I can churn patients, he takes a tiny cut, and I don't deal with admin BS (even though i get the med director stipend). everyone is happy...he has been able to get like 25 SNFs under his belt this way and only rounds at 1. your wife could probably do something similar easy if she so desires.

SNF work is not sexy to the avg MD...but it pays well and the freedom is amazing. wish i knew about it earlier.

Yeah same for her. Owner is a MD. They are rapidly growing and have 200 or so nursing homes now.

They are building something bigger though - they have their own in house EMR specifically built for nursing homes. They are rapidly tying in AI into their EMR and the AI now reviews the chart, and you can have it all summarize things in the HPI. It pretty much does the note. And my wife says its the best emr she’s seen in a nursing home setting. The company’s large scale goal is to refine their EMR and AI texhnology and license that to other places. Their nursing homes business basically funds their EMR and AI ambition.

 

[JacobMcCandles]

I think you’re also over estimating the difficulty of titrating up or down meds. It’s not hard.

So yeah….i hesitate because i care about providing the best care i can. But there’s no part of me that doesnt think i can’t self learn.

Of course it’s easy to start/stop and titrate up/down meds. The biggest issue today in the world of the chronically ill patient is to do it correctly.

We do see a lot of chronic stuff in the ED but the difference is they come to see me, I don’t go see them. I think the standard is certainly different in those scenarios.

Anybody can learn anything. I think it all depends on the motives. Given your posts, making the change doesn’t seem to be because you have a passion for managing the elderly chronically ill patient but maybe I’m misinterpreting between the lines. With that said, I do think you can learn more about the niche but, for me, if I didn’t have that passion then I don’t think I’d really be doing that patient population any favors.

 

[cyanide12345678]

what a position of power! the SNF company i contract for is owned by one MD that got a SNF directorship and slowly kept getting more.Now, he has an NP and MD at each shop to take care of the day to day and he handles all the quality stuff that the SNF cares about. I can churn patients, he takes a tiny cut, and I don't deal with admin BS (even though i get the med director stipend). everyone is happy...he has been able to get like 25 SNFs under his belt this way and only rounds at 1. your wife could probably do something similar easy if she so desires.

SNF work is not sexy to the avg MD...but it pays well and the freedom is amazing. wish i knew about it earlier.

Are you EM/IM/FM trained? If you’re EM, please share your transition, what resources you used, if it felt hard, if you regret the move. And how long did it take you to feel 100% in your element and fully comfortable.

 

[cyanide12345678]

Of course it’s easy to start/stop and titrate up/down meds. The biggest issue today in the world of the chronically ill patient is to do it correctly.

We do see a lot of chronic stuff in the ED but the difference is they come to see me, I don’t go see them. I think the standard is certainly different in those scenarios.

Anybody can learn anything. I think it all depends on the motives. Given your posts, making the change doesn’t seem to be because you have a passion for managing the elderly chronically ill patient but maybe I’m misinterpreting between the lines. With that said, I do think you can learn more about the niche but, for me, if I didn’t have that passion then I don’t think I’d really be doing that patient population any favors.

You’re right about that. Motive isn’t necessarily because i have a passion for managing elderly chronically ill people.

And that’s really what I’m trying to figure out and looking to talk to other EM guys/gals about their experience and transition.

My motivations are lifestyle motivated. But i also think that’s the biggest motivator for me at my stage of life. I don’t want nights, i don’t want weekends. I don’t want to go 2-3 days without even seeing my kids (happens all the time with my 12 hr shifts plus 1 hr commute). I don’t want circadian rhythm disruptions. I genuinely have started to struggle recovering after a night shift, and feel like a zombie the next day. I also don’t want something that’s a huge paycut, and i don’t want something where I’m working a lot of days or a lot of hours.

I want to have a healthy lifestyle, regular schedule, regular routine where i work out, am present for my kids, and no longer am in hairy or stressful situations.

I also don’t want a job where i feel unsafe. Im a father with little kids. 1.5 months ago i got punched 6-7 times by a psychotic patient. 1 month ago i saw a truly deranged psychotic guy with a gruesome list of ‘10 ways to murder’ who was threatening to come to kill us at our critical access hospital the moment he gets out in the same gruesome way he had written down. And then just 2 weeks ago i unfortunately had to take care of the same guy who punched me 1.5 months ago. This time he came out swinging again - not at me but at our officer. Will i seriously have to take care of that A-hole next month again when he’s back for psych??????? Ughhh. I literally don’t even want to see his face, let alone care for him as a patient.

So yeah…..a lot of these events have happened and honestly i have F You money now. So F YOU EMERGENCY MEDICINE.

initially i was thinking VA as an escape, but the more i think about it, the more i want out.

Time will tell…. Maybe I’ll feel better about emergency medicine in a couple weeks. But right now, at this minute, i just don’t.

 

[RustedFox]

Best thread on here in a good bit.

 

[end stage fibro]

Yeah same for her. Owner is a MD. They are rapidly growing and have 200 or so nursing homes now.

They are building something bigger though - they have their own in house EMR specifically built for nursing homes. They are rapidly tying in AI into their EMR and the AI now reviews the chart, and you can have it all summarize things in the HPI. It pretty much does the note. And my wife says its the best emr she’s seen in a nursing home setting. The company’s large scale goal is to refine their EMR and AI texhnology and license that to other places. Their nursing homes business basically funds their EMR and AI ambition.

pretty cool. i am stuck using godforsaken pointclickcare

Are you EM/IM/FM trained? If you’re EM, please share your transition, what resources you used, if it felt hard, if you regret the move. And how long did it take you to feel 100% in your element and fully comfortable.

FM trained that did hospitalist immediately after graduating and now admin. i will say i think the impetus is the same for everyone at leaves their primary specialty: grinding patients and notes in a scenario outside your control sucks. i wanted out of that asap

 

[Brigade4Radiant]

Also I don’t think many or any em physican wants to to do pcp they want a clinic that does a small amount of things like glp cosmetics and so on no one wants to do prior authorizations.

I’m not sure I would say you’re the one doing the chronic medical management in the situation you just described. It sounds like you just got the recommendations from someone else.

I’m prescribing and you learn from it so I’m pretty good at HTN and hld you also follow the patients chart

 

[Janders]

I have very little concern with anyone in this thread managing HTN or Lipids.

I think there is much more nuance with diabetes, and a lot of other chronic conditions like deteriorating CKD, rheum conditions, transplants, and other stuff that comes into me from SNFs all the time.

But if a genius is hell bent on doing it because the Grind of EM sucks, I’m sure a genius can apply themselves and learn. A genius would be wise to have an actual mentor and some oversight the first few months out, unless said genius is omniscient.

As well, if you don’t give a **** about a bunch of gomers in a SNF bc their baseline care is crap, then I guess this discussion is moot. I’m aware of establishments that any one of us could walk into tomorrow and improve their standard of care just by reading the med lists and meeting the patients once.

 

[Brigade4Radiant]

I have very little concern with anyone in this thread managing HTN or Lipids.

I think there is much more nuance with diabetes, and a lot of other chronic conditions like deteriorating CKD, rheum conditions, transplants, and other stuff that comes into me from SNFs all the time.

But if a genius is hell bent on doing it because the Grind of EM sucks, I’m sure a genius can apply themselves and learn. A genius would be wise to have an actual mentor and some oversight the first few months out, unless said genius is omniscient.

As well, if you don’t give a **** about a bunch of gomers in a SNF bc their baseline care is crap, then I guess this discussion is moot. I’m aware of establishments that any one of us could walk into tomorrow and improve their standard of care just by reading the med lists and meeting the patients once.

For CKD and transplant you need a nephrologist an IM doc or FM consult full stop. You are not the catch all doctor

 

[VA Hopeful Dr]

Also I don’t think many or any em physican wants to to do pcp they want a clinic that does a small amount of things like glp cosmetics and so on no one wants to do prior authorizations.


I’m prescribing and you learn from it so I’m pretty good at HTN and hld you also follow the patients chart

I'll take that bet.

 

[VA Hopeful Dr]

I'm going to quote myself from a few years ago:

Just because you can manage sepsis and I can't doesn't make my job intellectually easier than yours nor does it mean you can easily do my job. Good primary care without being a referral machine isn't easy. Sometimes it is, just like some ED patients require little thought/effort on your part to deal with. Often times is isn't. Uncontrolled HTN with CKD, uncontrolled DM with known retinopathy, and sky high triglycerides and oh by the way having a gout flare. That sort of thing isn't all that unusual for me. 2 of the most popular DM meds are contraindicated with retinopathy with another running the risk of worsening CKD and another dependent on the exact GFR to know if its safe while a 4th is known to cause hypoglycemia with CKD. 2 of the 3 acute gout meds are contraindicated by CKD and uncontrolled DM. 1 of our first line BP meds is contraindicated with uncontrolled gout while another can worsen CKD and a 3rd can worsen lipid levels and if that triglyceride level is high enough combined with bad enough DM you run the risk of pancreatitis which oh by the way is a known side effect of yet another class of DM meds. But if its just the triglycerides it could be caused by the hyperglycemia so do you treat now or wait and see what it does when the sugar level gets better? So you have to decide what to do about all of these, how soon to follow up, things the patient needs to monitor and what to do if X, Y, or Z happens symptom wise, what testing to order and when. Oh, and you have 15 minutes to do all of that and an exam and listen to their story about the time they had gout back in '73 because they tied an onion on their belt which was the style at the time.

I'm not at all saying you aren't capable of that sort of thing because there are plenty of problems y'all see in the ED that require just as many thoughts going on at the same time with other patients waiting some of whom are critically ill. But you're trained for ED problems and the ED work flow while I'm trained to do my scenario with the resources and time-constraints dictated by outpatient practice (for example, stat labs aren't a thing - its 12 hours minimum for any non-POC testing).

As I've said before, we're all physicians first. We did the same 4 years of medical training. So you in all likelihood could do CME and reading and with time get to be pretty good at outpatient primary care. But I would truly appreciate it if you didn't pretend that a 4 hour CME course and some light reading would make you my equal in primary care. It would not.

 

[Pinner Doc]

You’re right about that. Motive isn’t necessarily because i have a passion for managing elderly chronically ill people.

And that’s really what I’m trying to figure out and looking to talk to other EM guys/gals about their experience and transition.

My motivations are lifestyle motivated. But i also think that’s the biggest motivator for me at my stage of life. I don’t want nights, i don’t want weekends. I don’t want to go 2-3 days without even seeing my kids (happens all the time with my 12 hr shifts plus 1 hr commute). I don’t want circadian rhythm disruptions. I genuinely have started to struggle recovering after a night shift, and feel like a zombie the next day. I also don’t want something that’s a huge paycut, and i don’t want something where I’m working a lot of days or a lot of hours.

I want to have a healthy lifestyle, regular schedule, regular routine where i work out, am present for my kids, and no longer am in hairy or stressful situations.

I also don’t want a job where i feel unsafe. Im a father with little kids. 1.5 months ago i got punched 6-7 times by a psychotic patient. 1 month ago i saw a truly deranged psychotic guy with a gruesome list of ‘10 ways to murder’ who was threatening to come to kill us at our critical access hospital the moment he gets out in the same gruesome way he had written down. And then just 2 weeks ago i unfortunately had to take care of the same guy who punched me 1.5 months ago. This time he came out swinging again - not at me but at our officer. Will i seriously have to take care of that A-hole next month again when he’s back for psych??????? Ughhh. I literally don’t even want to see his face, let alone care for him as a patient.

So yeah…..a lot of these events have happened and honestly i have F You money now. So F YOU EMERGENCY MEDICINE.

initially i was thinking VA as an escape, but the more i think about it, the more i want out.

Time will tell…. Maybe I’ll feel better about emergency medicine in a couple weeks. But right now, at this minute, i just don’t.

This is how I found myself in hospice/palliative

 

[cyanide12345678]

I'm going to quote myself from a few years ago:

Just because you can manage sepsis and I can't doesn't make my job intellectually easier than yours nor does it mean you can easily do my job. Good primary care without being a referral machine isn't easy. Sometimes it is, just like some ED patients require little thought/effort on your part to deal with. Often times is isn't. Uncontrolled HTN with CKD, uncontrolled DM with known retinopathy, and sky high triglycerides and oh by the way having a gout flare. That sort of thing isn't all that unusual for me. 2 of the most popular DM meds are contraindicated with retinopathy with another running the risk of worsening CKD and another dependent on the exact GFR to know if its safe while a 4th is known to cause hypoglycemia with CKD. 2 of the 3 acute gout meds are contraindicated by CKD and uncontrolled DM. 1 of our first line BP meds is contraindicated with uncontrolled gout while another can worsen CKD and a 3rd can worsen lipid levels and if that triglyceride level is high enough combined with bad enough DM you run the risk of pancreatitis which oh by the way is a known side effect of yet another class of DM meds. But if its just the triglycerides it could be caused by the hyperglycemia so do you treat now or wait and see what it does when the sugar level gets better? So you have to decide what to do about all of these, how soon to follow up, things the patient needs to monitor and what to do if X, Y, or Z happens symptom wise, what testing to order and when. Oh, and you have 15 minutes to do all of that and an exam and listen to their story about the time they had gout back in '73 because they tied an onion on their belt which was the style at the time.

I'm not at all saying you aren't capable of that sort of thing because there are plenty of problems y'all see in the ED that require just as many thoughts going on at the same time with other patients waiting some of whom are critically ill. But you're trained for ED problems and the ED work flow while I'm trained to do my scenario with the resources and time-constraints dictated by outpatient practice (for example, stat labs aren't a thing - its 12 hours minimum for any non-POC testing).

As I've said before, we're all physicians first. We did the same 4 years of medical training. So you in all likelihood could do CME and reading and with time get to be pretty good at outpatient primary care. But I would truly appreciate it if you didn't pretend that a 4 hour CME course and some light reading would make you my equal in primary care. It would not.

Equal probably not. You being an experienced physician. I will not be as good as you in the outpatient setting today or for the next few years.

But an ER doc with 10+ years of experience may provide very similar care to someone new, fresh residency grad as far as hospitalist/outpatient/SNF care. And once any particular ER doc has done outpatient/SNF practice for 3+ years, I think they'll provide better care than any new-ish attending. After 5 or so years, I doubt there would be any measurable difference.

Just like that, I know several FM docs who have been in the ER for decades who provide excellent care equivalent to any EM residency trained doc.

Residency is experience. It's just all experience. Do something for long enough and you'll learn it.