Pearl for new grads on safe, efficient, and effective practice

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22yis

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New group of fellows coming out, myself included. Would love to get some advice from the experienced physicians about practice changing tips they wish they knew sooner, tips on maintaining practice efficiency, providing good outcomes, and most importantly avoiding legal trouble.
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worry less about perfect documentation. dont spend too much time making charts perfect. use shortcuts like smartphrases. a lot. develop smartphrases for everything. definitely for asking for auth for procedures to reduce risk of denial. you should be able to click a smartphrase and only have to input 3-4 details to complete the smartphrase (ie epidural - add level of injection, the particular nerve distribution, whether they had prior successful injection, and how many in the past 12 months)

documentation is key but keep it brief, to the point, and written in a way that you know what your next step will most likely be in 1 sentence when you look back.



dont spend too much time "debating" with patients. they will always be right even when they arent. not worth your effort to try to change their minds particularly if they are not interested in what you have to offer or are fixated on one treatment that you dont.


it is okay to say "im sorry, i dont have anything to offer you."


some people like to predocument. if that saves time, go for it.

however, the cardinal rule still applies. the one that says "the longer you are here, the longer you are here."


oh and avoid local anethetics in epidurals...
 
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Don't get stuck in a sh** job/contract.

Learn how to gently interrupt the patient to redirect the conversation. Maximum of two tangents that are relatively short.

Some patients you know you have no treatment to offer, so allow 5-8 min for them to feel heard, commiserate about their pain, or show you pictures of their dog (while you document, place orders, etc as stated above).
 
I don’t think I’ve ever spent time in a patient room charting in 15 years of practic and I’ve never been that behind on charts. It’s all been private practice though. As I embark on hopd employment, in a few days actually, I’m assuming this recommendation to chart in the room comes from hopd employees with more onerous documentation requirements? Just curious
 
Dr. Ice said:
I don’t think I’ve ever spent time in a patient room charting in 15 years of practic and I’ve never been that behind on charts. It’s all been private practice though. As I embark on hopd employment, in a few days actually, I’m assuming this recommendation to chart in the room comes from hopd employees with more onerous documentation requirements? Just curious
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Yes I’m HOPD and use EPIC. We now have an AI tool but I still use templates and dot phrases. I feel as though my charting is fairly efficient while still being detailed. I however chart in every room. Otherwise I would spend my entire noon hr charting frantically to get done before my 1pm injection. Sadly my entire day feels like a race against the clock
 
clubdeac said:
Yes I’m HOPD and use EPIC. We now have an AI tool but I still use templates and dot phrases. I feel as though my charting is fairly efficient while still being detailed. I however chart in every room. Otherwise I would spend my entire noon hr charting frantically to get done before my 1pm injection. Sadly my entire day feels like a race against the clock
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How is epic to use? I’m switching from using Athena
 
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Agast said:
If someone approaches you with a product or procedure with reimbursement that is too good to be true, and only Medicare and Tricare cover it, it’s fraud
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That’s like half of what’s out there right now lmao
 
Dr. Ice said:
How is epic to use? I’m switching from using Athena
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it's not terrible once you get used to it I suppose. I probably only know how to use a fraction of its functions but get by pretty well
 
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You don't have to see everyone who calls the office. You are not the ED. Tell your schedulers what issues/pathologies you do/don't want to see. You cannot help everybody, better to fill your practice with people you can help based on your preferences and expertise.

Also, don't schedule anybody who is abusive to the office staff from the start, it is bad for the office and practice.
 
Ligament said:
You don't have to see everyone who calls the office. You are not the ED. Tell your schedulers what issues/pathologies you do/don't want to see. You cannot help everybody, better to fill your practice with people you can help based on your preferences and expertise.

Also, don't schedule anybody who is abusive to the office staff from the start, it is bad for the office and practice.
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you recommend filtering what you want and dont want to see straight from the bat? Wouldnt that hurt volume when he/she/they are starting?
 
Status Sciaticus said:
you recommend filtering what you want and dont want to see straight from the bat? Wouldnt that hurt volume when he/she/they are starting?
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I gave a lot of people their copay back and canceled their first consult when it became clear to me I would not want that person to darken my doorstep again. You have to protect your future self. There was a self-pay guy who showed up, opened his wallet to fat wads of cash and asked if I prescribed norco. His appointment was canceled at the front desk.
 
Status Sciaticus said:
you recommend filtering what you want and dont want to see straight from the bat? Wouldnt that hurt volume when he/she/they are starting?
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Yes I recommend that, why bring negativity into the clinic? Yes it will hurt volume when starting but prevent the practice from filling with patients that cannot be helped or malignant personalities.
 
Agast said:
I gave a lot of people their copay back and canceled their first consult when it became clear to me I would not want that person to darken my doorstep again. You have to protect your future self. There was a self-pay guy who showed up, opened his wallet to fat wads of cash and asked if I prescribed norco. His appointment was canceled at the front desk.
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Ligament said:
Yes I recommend that, why bring negativity into the clinic? Yes it will hurt volume when starting but prevent the practice from filling with patients that cannot be helped or malignant personalities.
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hopefulgasman said:
Just think about that patient on the schedule at 230P that you’re dreading to see. Besides the 2 RVUs you’d lose out on, how many RVUs on top would you give back to not see them and skip straight to your 245P or 3P encounter
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fair enough. Im not super busy atm 10-20 per day so I dont have the luxury of turning anyone away at the moment. I did let one go that wanted to pay cash for norco, though.
 
Agast said:
I gave a lot of people their copay back and canceled their first consult when it became clear to me I would not want that person to darken my doorstep again. You have to protect your future self. There was a self-pay guy who showed up, opened his wallet to fat wads of cash and asked if I prescribed norco. His appointment was canceled at the front desk.
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grasshopper
 
Not only that but need to teach the referring doctors what you will and won’t accept. Get a reputation early with the community for not being a free hand with opiates.

If your schedule is light, use that time to call referring doctors, thank them for the referral, and give them your cell number in case they need to get someone in urgently. If you’re rejecting a referral give them a heads up. Let them know what you are and aren’t comfortable with especially as far as med management.
 
hopefulgasman said:
Just think about that patient on the schedule at 230P that you’re dreading to see. Besides the 2 RVUs you’d lose out on, how many RVUs on top would you give back to not see them and skip straight to your 245P or 3P encounter
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Ah yes when I was getting started last year I took on a patient (now known in clinic as "butthole lady") who I still dread seeing.
 
Don’t prescribe medications. At all. Leave that to the pcps and extenders that refer to you. Too many clicks and too many phone calls. Plus, they don’t really work
 
SSdoc33 said:
Don’t prescribe medications. At all. Leave that to the pcps and extenders that refer to you. Too many clicks and too many phone calls. Plus, they don’t really work
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In a zero medication clinic, what's your schedule look like? I assume slightly fewer office visits per clinic day seeing as you've removed all the 60 second med refill visits. I'd also assume relatively higher procedural volume otherwise I don't know why people would be coming in at all.
 
Status Sciaticus said:
yea, good luck getting referrals if you dont do any medication management.
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I have no problem with referrals. 3 month waiting list. You eval the patient. Rx pt, order imaging and labs, refer to surgeons, do emgs. The other half of the schedule is shots. No haggling with patients over medications. No phone calls to the office for refills. No pharmacy crap. Occasionally I’ll do a short course of prednisone. But that’s about it. Didn’t start off that way but kind of evolved to it. Primarily a spine and ortho practice. Not a ‘pain’ practice per se
 
Status Sciaticus said:
yea, good luck getting referrals if you dont do any medication management.
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I prescribe very little opioids, maybe 1-2% of patients, all short-term except I think 5-6 patients total I see chronically. I do prescribe adjuvant meds though. I see about 60 clinic patients a week, half of them new. About 50-60 procedures per week, including shots, rfa, scs, kypho. Ortho practice. I only see spine. Booked out 4-6 weeks for clinic.
 
SSdoc33 said:
I have no problem with referrals. 3 month waiting list. You eval the patient. Rx pt, order imaging and labs, refer to surgeons, do emgs. The other half of the schedule is shots. No haggling with patients over medications. No phone calls to the office for refills. No pharmacy crap. Occasionally I’ll do a short course of prednisone. But that’s about it. Didn’t start off that way but kind of evolved to it. Primarily a spine and ortho practice. Not a ‘pain’ practice per se
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Well its not really a true pain practice then, is it?
Its basically a churn and burn ortho block shop.
I envy you.

22yis said:
Are you saying it’s naive to think one can run an opioid free clinic? Or like rly low opioid volume <<<10%
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Yes.
Also, opioids are a very effective pain therapy, for the right indications - cancer pain, sickle cell pain, etc..
I think most people dont run a true opioid free practice. I am not advocating a candy-for-shots setup.
But managing medications is within your purview as a pain physicians (not just opioids) and you probably will do a better job than some overloaded PCP.
 
No pills here either. actually just got rid of the eprescribe function on my emr. Didn’t use it enough for the $30/month …

I’m booked out about a day for last 15 years. Always have time to squeeze in a telehealth to order an mri or schedule a shot.

Don’t do uncompensated care.
 
nvrsumr said:
No pills here either. actually just got rid of the eprescribe function on my emr. Didn’t use it enough for the $30/month …

I’m booked out about a day for last 15 years. Always have time to squeeze in a telehealth to order an mri or schedule a shot.

Don’t do uncompensated care.
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What is your referral base like? Are you a solo pain practice?
 
Yes solo. All my surgeons and PCPs have been bought out by big health systems over the years so mainly Google now.
 
Status Sciaticus said:
Well its not really a true pain practice then, is it?
Its basically a churn and burn ortho block shop.
I envy you.


Yes.
Also, opioids are a very effective pain therapy, for the right indications - cancer pain, sickle cell pain, etc..
I think most people dont run a true opioid free practice. I am not advocating a candy-for-shots setup.
But managing medications is within your purview as a pain physicians (not just opioids) and you probably will do a better job than some overloaded PCP.
Click to expand...

if the difference is solely prescribing medications, then i suppose. but i see all of my own patients and decide who gets the shots and who doesnt. and i say no all the time. but i see sports patients, spine, non operative ortho, a smattering of general PM&R that sneak thru.
 
You won’t survive in Texas unless you prescribe. PCPs don’t even manage pain anymore, they go straight to a pain clinic. If you’re part of a Ortho group, cash regen clinic, or hospital system getting in house referrals that might be a different story. Otherwise good luck.
 
Learn everything you can about regenerative medicine. It’s the future of our specialty. I predict in 10 yrs we’ll be done with steroids, ablation and even neuromodulation, at least I hope that’s the case
 
one can be a non-prescriber but provide medical management by providing recommendations to the primary care provider.

i try to do this as much as possible. for example, i do not start any new prescriptions for workers comp. patients are given med recommendations to discuss with their primary care providers (or a referral to a workers comp practice if they do not have one) with the express purpose for PCP to review for interactions and to prescribe if appropriate.




regenerative medicine will have its role. its good to learn. but regenerative medicine will always remain in the realms of those who can self-pay for treatment.
 
I think especially early on filling your schedule with LOLs on like 10 MME/day isn't a bad thing. They are easy appointments and those folks end up being your best referral source. They also all have osteoporosis.
 
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22yis said:
New group of fellows coming out, myself included. Would love to get some advice from the experienced physicians about practice changing tips they wish they knew sooner, tips on maintaining practice efficiency, providing good outcomes, and most importantly avoiding legal trouble.
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Don't eat the home-made lasagna/soup/pastry your patient brings you, no matter how nice they are.
 
K-hole said:
You won’t survive in Texas unless you prescribe. PCPs don’t even manage pain anymore, they go straight to a pain clinic. If you’re part of a Ortho group, cash regen clinic, or hospital system getting in house referrals that might be a different story. Otherwise good luck.
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nice. PCPs had a huge hand in starting the opioid train. Now they've jumped off just to let the train crash into the Pain station. You can't convince me why a non-pain doctor cant prescribe pain meds within guidelines and MED <20. It's not rocket science.
 
GoBeers said:
nice. PCPs had a huge hand in starting the opioid train. Now they've jumped off just to let the train crash into the Pain station. You can't convince me why a non-pain doctor cant prescribe pain meds within guidelines and MED <20. It's not rocket science.
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I think pain docs are equally complicit and an equally proportionate number refuse to prescribe opioids despite calling themselves pain docs. There are numerous young PCPs that had nothing to do with the pain train that feel the same way you do about their local pain docs. Just look at this thread 🤣
 
I've received a few beautiful cakes, dumped in the trash after the patient leaves. Or left on a break room table, where the vultures devour it...

I've been in practice 4 years. Learn to be very comfortable telling a patient no, or that you unfortunately may not have much to offer them. Also, you don't have to do ANYTHING that you don't want to do. Don't want to prescribe over some certain MME? Don't want to ever Rx opioids if someone is on a benzo? Don't want to do any opioids at all? Want to do stim trials but refer out for stim implants? Don't want to see any Worker's Comp? You can do whatever you'd like to do, and decline to do whatever in the world you don't want to do. That realization was incredibly freeing. The kind of patients you receive into your practice, the med levels you take over or initiate, the procedures that you do...how you are in the first year of practice with these things will by and large dictate what things will be like in later years. Be patient, do things well from the start, and you'll build your practice into a fairly low-stress and oftentimes enjoyable place to earn a good living.
 
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