Practice Structure

[DJ Mobitz]

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First year fellow here. I'm curious how private practice vs academic GI attendings in 2021 set their schedule especially given the pandemic. Specifically, how many patients do they see in a typical clinic day? What's the normal procedure volume they do per day? I can barely reach the cecum consistently in less than 20 minutes, so each colon still takes 45 minutes+ (and that's with the attending taking over more than 50% of the time). I'm interested in seeing the trajectory as well (early vs late career). I appreciate everyone's advice.

 

[1Cor1557]

First year fellow here. I'm curious how private practice vs academic GI attendings in 2021 set their schedule especially given the pandemic. Specifically, how many patients do they see in a typical clinic day? What's the normal procedure volume they do per day? I can barely reach the cecum consistently in less than 20 minutes, so each colon still takes 45 minutes+ (and that's with the attending taking over more than 50% of the time). I'm interested in seeing the trajectory as well (early vs late career). I appreciate everyone's advice.

You are a first year fellow. Your procedure efficiency will be completely different at the conclusion of training and even several years into attendinghood. You can have any kind of practice you desire for a lifestyle and structure if you are willing to move to a location that will permit it. I know some in academics or even private who see four patients during half day because they love a slow cush lifestyle taking hours to complete a single case or clinic encounter without being rushed at all and don't mind less pay and having the fellows do all their work and private groups that run 4 rooms at once completing 80 cases a day. Then there's the rest of us with everything in between. Bread and butter GI might have 20 to 25 encounters a day some less, some more depending where you're at and what you're trying to accomplish . Work hard do well put your patients first be a good teammate and take time for yourself every now and then and soon enough you can choose what you like, good luck.

 

[Scope 22]

When you are practicing, goal is 3 minutes or less till cecum, scope length 70-80 cm. Goal In pp is 100 encounters a week. 50/50 or 60:40 endo/clinic. That’s hard In covid with cancellations. This goes down when you are covering the hospital. Academic different game as there is no overhead and the academic center will take the loss. You can do as low as 5 cases a day.

 

[ChessMaster3000]

When you are practicing, goal is 3 minutes or less till cecum, scope length 70-80 cm. Goal In pp is 100 encounters a week. 50/50 or 60:40 endo/clinic. That’s hard In covid with cancellations. This goes down when you are covering the hospital. Academic different game as there is no overhead and the academic center will take the loss. You can do as low as 5 cases a day.

you must be an east coast GI? I'm in PP and 100 encounters per week is a lot. Our practice is set up for less than that (70-80) and financially we are doing just fine.

further, 3 minutes or less till cecum is aspirational. I think 5 minutes or less is a reasonable goal. not saying one shouldnt get to cecum in 3 minutes in many cases, but I think saying that's the 'goal' is deceiving.

as for the OP, you gotta be kidding me. you havent even finished 6 months of fellowship and youre posting on SDN worried that you take 20 minutes to get to the cecum? I thought neuroticism was for medical students. My scoping skills took a huge leap each year, 1st to 2nd to 3rd. even since i left fellowship i have continued to get better. everyone goes through the same process.

 

[1Cor1557]

you must be an east coast GI? I'm in PP and 100 encounters per week is a lot. Our practice is set up for less than that (70-80) and financially we are doing just fine.

further, 3 minutes or less till cecum is aspirational. I think 5 minutes or less is a reasonable goal. not saying one shouldnt get to cecum in 3 minutes in many cases, but I think saying that's the 'goal' is deceiving.

as for the OP, you gotta be kidding me. you havent even finished 6 months of fellowship and youre posting on SDN worried that you take 20 minutes to get to the cecum? I thought neuroticism was for medical students. My scoping skills took a huge leap each year, 1st to 2nd to 3rd. even since i left fellowship i have continued to get better. everyone goes through the same process.

Professional reputable consulting practice management firms (that shall not be named... wink wink nudge nudge ) and health systems/pratices have and collect /track this data...last year's median clinic encounters for GI per month was in between the range from 180 to 190 per month

 

[hemosuccus]

When you are practicing, goal is 3 minutes or less till cecum, scope length 70-80 cm. Goal In pp is 100 encounters a week. 50/50 or 60:40 endo/clinic. That’s hard In covid with cancellations. This goes down when you are covering the hospital. Academic different game as there is no overhead and the academic center will take the loss. You can do as low as 5 cases a day.

3 min or less to cecum? Lol no. Sometimes, sure. 100 encounters a week means 10 clinic patients or 10 scopes each half day. Possible? Yes. Should you? Depends what you want out of it, and you will make money certainly, but this is a killer schedule. Know that people do half those numbers and still do very well financially.

 

[Scope guy]

50 scopes and 50 clinic patients(new plus follow ups) per week is doable. with cancellations and stuff, it will be 85-90. with cut in reimbursements, this volume will be required to maintain a private practice to cover overhead and still make some profits

 

[Scope 22]

3 min or less to cecum? Lol no. Sometimes, sure. 100 encounters a week means 10 clinic patients or 10 scopes each half day. Possible? Yes. Should you? Depends what you want out of it, and you will make money certainly, but this is a killer schedule. Know that people do half those numbers and still do very well financially.

I have seen practices booking 20 minutes for each procedure, 15 minutes for each clinic visit. Practices 7-4. You do the math. Again guaranteed you won’t perform 100 encounters a week with cancellations - you are likely ending with 80s. With Medicare cut 3%, I am curious to see how numbers will change. Also, practicing in Midwest or academic is different than practicing in northeast/west coast in community settings so you have to keep it in mind

 

[hemosuccus]

I have seen practices booking 20 minutes for each procedure, 15 minutes for each clinic visit. Practices 7-4. You do the math. Again guaranteed you won’t perform 100 encounters a week with cancellations - you are likely ending with 80s. With Medicare cut 3%, I am curious to see how numbers will change. Also, practicing in Midwest or academic is different than practicing in northeast/west coast in community settings so you have to keep it in mind

I have friends in private practice on both coasts who do this. It is not for everyone, that is the point. The math of course checks out. 5 min consent/ room-in, 5 min to cecum, 10 min withdrawal- possible, not a guarantee. Took an extra 5 min to the cecum reducing loops? Found a few extra polyps? So where will you cut time from? Your withdrawal, your ADR. Clinic is different, you can double book 15 min followups and still do fine.

 

[Elixir6]

Wow...is this real? I'm just a fellow, and obviously growing, but I cannot even imagine consistently getting to cecum in 3 min (like 80% of the time). How can adequate care be provided in such a time frame? Is it even possible to have a good ADR or find flat polyps if you are withdrawing fast because you needed a few minutes for a loopy colon?

 

[Scope 22]

I have friends in private practice on both coasts who do this. It is not for everyone, that is the point. The math of course checks out. 5 min consent/ room-in, 5 min to cecum, 10 min withdrawal- possible, not a guarantee. Took an extra 5 min to the cecum reducing loops? Found a few extra polyps? So where will you cut time from? Your withdrawal, your ADR. Clinic is different, you can double book 15 min followups and still do fine.

I agree with you. I think 20 minutes procedure is short. 30 minutes is optimum.

 

[hemosuccus]

Wow...is this real? I'm just a fellow, and obviously growing, but I cannot even imagine consistently getting to cecum in 3 min (like 80% of the time). How can adequate care be provided in such a time frame? Is it even possible to have a good ADR or find flat polyps if you are withdrawing fast because you needed a few minutes for a loopy colon?

Short answer, no. Quality benchmarks will only get more rigorous. ADR will likely be openly available and go up even as patients start younger etc. You need about 10 min to do a good withdrawal. AI will help with efficiency hopefully. 3 min to cecum is for seasoned attendings, and is an aspirational goal. Don't worry about it. Target getting there consistently with a short scope in any time in first year. 5-10 min consistently should be your 3rd year target.

 

[ChessMaster3000]

Short answer, no. Quality benchmarks will only get more rigorous. ADR will likely be openly available and go up even as patients start younger etc. You need about 10 min to do a good withdrawal. AI will help with efficiency hopefully. 3 min to cecum is for seasoned attendings, and is an aspirational goal. Don't worry about it. Target getting there consistently with a short scope in any time in first year. 5-10 min consistently should be your 3rd year target.

100% agree, but even 5-10 minutes to cecum in 3rd year consistently will be hard for a fair number of 3rd year fellows

 

[ChessMaster3000]

Wow...is this real? I'm just a fellow, and obviously growing, but I cannot even imagine consistently getting to cecum in 3 min (like 80% of the time). How can adequate care be provided in such a time frame? Is it even possible to have a good ADR or find flat polyps if you are withdrawing fast because you needed a few minutes for a loopy colon?

this is an unfortunate case of the SDN neurotics dominating. 3min cecum is not standard even for the best (I mean, maybe if youre doug rex). but the average GI attending within a first few years out of training will not, under any legitimate practice setting, be expected to make it to cecum in 3 min on a routine basis.

 

[Elixir6]

this is an unfortunate case of the SDN neurotics dominating. 3min cecum is not standard even for the best (I mean, maybe if youre doug rex). but the average GI attending within a first few years out of training will not, under any legitimate practice setting, be expected to make it to cecum in 3 min on a routine basis.

Thanks for calling out this BS. I'm at a very academic place, and I sometimes scope with folks that are ASGE master endoscopists. I don't remember a 3 min cecum as typical when I've watched them scope alone.

I thought maybe in PP they are ramming the scope to the cecum, and I've been too dainty in my exams, but turns out it's just the SDN exaggeration effect.

 

[Scope guy]

Thanks for calling out this BS. I'm at a very academic place, and I sometimes scope with folks that are ASGE master endoscopists. I don't remember a 3 min cecum as typical when I've watched them scope alone.

I thought maybe in PP they are ramming the scope to the cecum, and I've been too dainty in my exams, but turns out it's just the SDN exaggeration effect.

i know many PP use all peds scope and go ramming in, finish colon in 10 mins(I was told by a PP that they do 4 colons in 1 hour, you can figure out the math)

 

[ChessMaster3000]

they may *schedule* 4 colons in 1 hour, that doesnt mean they are getting in an out within 60 minutes. things run late, one or two poor preps so you cancel the case, one or two no shows over the course of a morning

i know many PP use all peds scope and go ramming in, finish colon in 10 mins(I was told by a PP that they do 4 colons in 1 hour, you can figure out the math)

 

[cabergoline2]

i know many PP use all peds scope and go ramming in, finish colon in 10 mins(I was told by a PP that they do 4 colons in 1 hour, you can figure out the math)

i have seen 2 cancers in patients after recent (within 2 years) scopes by a PP guy who has that reputation for 10 minute colons. schedules 3-4 colons and hour and supposedly goes ramming in. in both those cases photodocumentation of cecum was very questionable... I would not want 10 minute cursory colon done on me. so i won't do such a pathetic job on a patient..

 

[Scope guy]

i have seen 2 cancers in patients after recent (within 2 years) scopes by a PP guy who has that reputation for 10 minute colons. schedules 3-4 colons and hour and supposedly goes ramming in. in both those cases photodocumentation of cecum was very questionable... I would not want 10 minute cursory colon done on me. so i won't do such a pathetic job on a patient..

Interval CRC rate is so low that these guys are getting away with it unfortunately

 

[indonacious]

In general, are most private practice or hospital employed positions 5 days a week? The job I am signing averages 4.5 day weeks and when I compare to MGMA I’m curious if I should be accounting for this potential difference in work hours.

 

[1Cor1557]

In general, are most private practice or hospital employed positions 5 days a week? The job I am signing alternates 5 day weeks with 4 day weeks and when I compare to MGMA I’m curious if I should be accounting for this potential difference in work hours.

No your position should be considered 1.0 FTE when you add in call, administrative tasks, evening/ weekends, no one should try to sell you sub median over a typical work schedule, if they had the nerve to do so, be warned