Primary Care Jobs

[Bendamustine]

Hii Guys,

Just a question, why there is so much demand for primary care providers, but no one want's to take them?
Is it because of pay, coz after searching, I found both PCP jobs and Hospitalist Jobs with similar pay?

I'm searching for Hospitalist, but honestly, I'm able to find more PCP jobs.

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[NewYorkDoctors]

On the PCP side, the expectations of each visit are to
1) Update all screening - follow up on BIRADS3 that have been forgotten and villous adenomas that haven't been followed up on for the past 5 years
2) Reconcile all medications and confirm which medications the patient is actually swallowing
3) Review all consultant notes and hospital charts and get everything synchronized and updated.
4) Obtain prior authorization on DME equipment and meds the patient needs
5) Try to get vaccinations updated including COVID vaccines
6) Trying to tell patients a PA for Nexium is not going through because it is OTC and patients can pay some money for it.
7) Getting all SBIRT / depression / fall risk / goals of care done for patients

On the patient side, the expectations of each visit are to
1) fix all chronic pains and aches without the need for medications, weight loss, surgery, or other inventions.
2) have the doctor endorse holistic or non-proven therapies they read online in an attempt to feel empowered
3) not bring in the medication bottles and not know the medication names and just say "the blue pill the red pill."
4) try to get the PMD to do everything like the "classical doctor of old" and NOT go to see specialists.
5) Try to get the doctor to tell you natural immunity and HCQ + AZI is better than COVID vaccines.
6) Try to get the doctor to get PA on unnecessary medications that you want because you think name brand is better.
7) Not paying attention to the doctor (even if the doctor is using 6th grade level lay term like the doctor is supposed to) and repeating the same questions over and over.

just to name a few


You have 15 - 20 minutes for this (not including note charting time)

Get ready, set GO!


Hospitalists - admit, round, consult, talk to the discharge planning team, go home.
Patient in hospital - I have this chronic thing that just won't go away and I want you to fix me while im in the hospital
Hospitalist - discharge and follow up PCP

 

[Bendamustine]

Sounds horrible, lol

 

[NewYorkDoctors]

I do some primary care for my CKD and COPD/ILD patients. It's mostly not this dramatic. But there are these kind of patients out there lol.
It's a bit easier when you are their long term provider and you see them fairly frequently. You end up "dispersing" these annoying issues over each visit.

But when you are the salaried employee PCP and the system wants to crank out more revenue but getting more patients in and patients do not want to pay as much copay and they end up coming like q3-6 months per visit, each visit becomes condensed like this and becomes hard to get everything done effectively.

 

[VA Hopeful Dr]

On the PCP side, the expectations of each visit are to
1) Update all screening - follow up on BIRADS3 that have been forgotten and villous adenomas that haven't been followed up on for the past 5 years
2) Reconcile all medications and confirm which medications the patient is actually swallowing
3) Review all consultant notes and hospital charts and get everything synchronized and updated.
4) Obtain prior authorization on DME equipment and meds the patient needs
5) Try to get vaccinations updated including COVID vaccines
6) Trying to tell patients a PA for Nexium is not going through because it is OTC and patients can pay some money for it.
7) Getting all SBIRT / depression / fall risk / goals of care done for patients

On the patient side, the expectations of each visit are to
1) fix all chronic pains and aches without the need for medications, weight loss, surgery, or other inventions.
2) have the doctor endorse holistic or non-proven therapies they read online in an attempt to feel empowered
3) not bring in the medication bottles and not know the medication names and just say "the blue pill the red pill."
4) try to get the PMD to do everything like the "classical doctor of old" and NOT go to see specialists.
5) Try to get the doctor to tell you natural immunity and HCQ + AZI is better than COVID vaccines.
6) Try to get the doctor to get PA on unnecessary medications that you want because you think name brand is better.
7) Not paying attention to the doctor (even if the doctor is using 6th grade level lay term like the doctor is supposed to) and repeating the same questions over and over.

just to name a few


You have 15 - 20 minutes for this (not including note charting time)

Get ready, set GO!


Hospitalists - admit, round, consult, talk to the discharge planning team, go home.
Patient in hospital - I have this chronic thing that just won't go away and I want you to fix me while im in the hospital
Hospitalist - discharge and follow up PCP

I think primary care in NYC is different from some other places. My days are almost entirely unlike what you described.

 

[dozitgetchahi]

7) Not paying attention to the doctor (even if the doctor is using 6th grade level lay term like the doctor is supposed to) and repeating the same questions over and over.

I’m rheumatology, and dear god does this ever drive me bonkers. And it happens a lot, too. I can’t tell you the number of times I’ve gone through someone’s labs in depth, with them participating in the convo and nodding and seemingly understanding what I’m saying, and then I get to the end of the visit and pt goes “so what did my labs show?” Or the number of times I make a diagnosis and tell the pt what it is in depth and how we’re going to start to treat it, and I get to the end of the visit and pt goes “but doc, so what do you really think I have?”

It’s like, are you kidding me?

(I’ve also lost count of the number of times I’ve d/c’d a medication, making it abundantly clear to the patient that I was doing so, only to find out months later that the pt is still taking it…or I get a call from a pharmacy about a patient “angry that I cancelled their medication script” when it was a medication they were supposed to have stopped taking eons ago…)

I used to think it was something I was doing wrong in terms of communication, and so I tried a number of different ways of explaining things and nothing seemed to change lol. My conclusion is that there are absolutely a fraction of patients who just don’t listen, at all…

 

[Osteoth]

I’m rheumatology, and dear god does this ever drive me bonkers. And it happens a lot, too. I can’t tell you the number of times I’ve gone through someone’s labs in depth, with them participating in the convo and nodding and seemingly understanding what I’m saying, and then I get to the end of the visit and pt goes “so what did my labs show?” Or the number of times I make a diagnosis and tell the pt what it is in depth and how we’re going to start to treat it, and I get to the end of the visit and pt goes “but doc, so what do you really think I have?”

It’s like, are you kidding me?

(I’ve also lost count of the number of times I’ve d/c’d a medication, making it abundantly clear to the patient that I was doing so, only to find out months later that the pt is still taking it…or I get a call from a pharmacy about a patient “angry that I cancelled their medication script” when it was a medication they were supposed to have stopped taking eons ago…)

I used to think it was something I was doing wrong in terms of communication, and so I tried a number of different ways of explaining things and nothing seemed to change lol. My conclusion is that there are absolutely a fraction of patients who just don’t listen, at all…

Luckily you can fire these patients

 

[NewYorkDoctors]

Some additional ones

PMD
8) try to practice cost conscious medical care by discussing against the need for unnecessary imaging tests based on performing physical exam , using existing medical test results , and teasing out there have been no changes in the clinical history (other than patient read something online and has felt empowered by it )
9) trying to do a full and proper physical exam for a patient
10 ) trying to limit unnecessary blood testing
11) trying to do the best evidence based primary care for your patients and communicate openly and effectively
12) trying to fill out dme , work forms , disability forms , home health forms , etc in a timely fashion
13) trying to prescribe generic meds and economical options . For commercial patients trying to find copay assistance cards
14) trying to make sense of which meds the patient is actually dispensed . Patient accuses you of not prescribing specific medication . You show the patient proof of prescription from the EMR on said date and then call pharmacy in front of them to talk to pharmacist and ask for proof of dispensing on said date in from of patient . Asks pharmacist to help handle this issue with a patient who has cognitive difficulties or secondary gain
15) trying to reduce poly pharmacy but finds it difficult as certain chronic conditions has certain meds by default for their mortality benefit .
16) try to empathize with these patients and try To provide education via up to date basics , YouTube videos for animations , and other patient friendly sources


Patient
8) read something online and wants CT scans and MRIs but does not want to pay out of pocket for it and wants you to do a PA for them .
9) patients finding changing into a gown is too cumbersome for them and find it annoying . They also do not trust your exam skills and want to see a specialist or want an echo cxr or ultrasound
10) patients read about tumor markers for cancer screening and want their blood type checked becuase “they never knew what their blood type was” (and want to use the information to predict their covid19 risk , check their horoscope , or share at the dinner table with family like some kind of feat ) even if it were a female who has given birth before and seen obgyn .
11) wanting the pmd to be your in demand concierge PMD on retainer without paying for concierge services . Probably by trying to circumvent coinsurance copay by doing telephone medicine and demanding to speak to the doctor . I
12) giving a form to the doctor during the office visit and expecting it filled out right away
13) wanting the best meds read from advertisements on TV from those Happy healthy actors but bemoaning the donut hole (this is not really an issue for Medicare Medicaid and managed patients since their formularies are robust and have pretty much zero copay )
14) due to poly pharmacy and confusing medication names , patients get confused and flustered and misplace medications . Rather than speak with the pharmacist for clarification , goes to doctor to accuse doctor of not prescribing said medication . On hearing the pharmacist confirm it was given on said date , patient defiantly states no medications were received . Demands another course of medications covered by insurance
15) laments poly pharmacy but won’t give up their ambien belsomra or Xanax . Refuses to take trazodone, mirtazepine , or ramelteon
16) want to go to the social media of their political reference for medical education


Yeah this is a big city issue. There are lots of personalities .

I do see several kind elderly patients who remain self sufficient and come to see the doctor for a nice chat about their health and guidance on how best to treat their chronic illnesses . But that requires a degree of patient self sufficiency that is absent in many patients I see in the big city .

Also primary care is better when you are the sole provider (or maybe one NP or partner but you mainly see this patient ) for continuity of care

It devolves into madness in a clinic type of setting like many of these pmd jobs tend to be . Becuase the big corporations want to pay you 150K for the above . Whereas if you went full private practice and dealt with these issues head on (and mitigate these issues one by one over time and with more frequent visits ) , you can make so much more money in a 99213 mill than you every could in one of these corporate pmd mill jobs (and nephrology lol zing)

 

[Appellatelove]

Some additional ones

PMD
8) try to practice cost conscious medical care by discussing against the need for unnecessary imaging tests based on performing physical exam , using existing medical test results , and teasing out there have been no changes in the clinical history (other than patient read something online and has felt empowered by it )
9) trying to do a full and proper physical exam for a patient
10 ) trying to limit unnecessary blood testing
11) trying to do the best evidence based primary care for your patients and communicate openly and effectively
12) trying to fill out dme , work forms , disability forms , home health forms , etc in a timely fashion
13) trying to prescribe generic meds and economical options . For commercial patients trying to find copay assistance cards
14) trying to make sense of which meds the patient is actually dispensed . Patient accuses you of not prescribing specific medication . You show the patient proof of prescription from the EMR on said date and then call pharmacy in front of them to talk to pharmacist and ask for proof of dispensing on said date in from of patient . Asks pharmacist to help handle this issue with a patient who has cognitive difficulties or secondary gain
15) trying to reduce poly pharmacy but finds it difficult as certain chronic conditions has certain meds by default for their mortality benefit .
16) try to empathize with these patients and try To provide education via up to date basics , YouTube videos for animations , and other patient friendly sources


Patient
8) read something online and wants CT scans and MRIs but does not want to pay out of pocket for it and wants you to do a PA for them .
9) patients finding changing into a gown is too cumbersome for them and find it annoying . They also do not trust your exam skills and want to see a specialist or want an echo cxr or ultrasound
10) patients read about tumor markers for cancer screening and want their blood type checked becuase “they never knew what their blood type was” (and want to use the information to predict their covid19 risk , check their horoscope , or share at the dinner table with family like some kind of feat ) even if it were a female who has given birth before and seen obgyn .
11) wanting the pmd to be your in demand concierge PMD on retainer without paying for concierge services . Probably by trying to circumvent coinsurance copay by doing telephone medicine and demanding to speak to the doctor . I
12) giving a form to the doctor during the office visit and expecting it filled out right away
13) wanting the best meds read from advertisements on TV from those Happy healthy actors but bemoaning the donut hole (this is not really an issue for Medicare Medicaid and managed patients since their formularies are robust and have pretty much zero copay )
14) due to poly pharmacy and confusing medication names , patients get confused and flustered and misplace medications . Rather than speak with the pharmacist for clarification , goes to doctor to accuse doctor of not prescribing said medication . On hearing the pharmacist confirm it was given on said date , patient defiantly states no medications were received . Demands another course of medications covered by insurance
15) laments poly pharmacy but won’t give up their ambien belsomra or Xanax . Refuses to take trazodone, mirtazepine , or ramelteon
16) want to go to the social media of their political reference for medical education


Yeah this is a big city issue. There are lots of personalities .

I do see several kind elderly patients who remain self sufficient and come to see the doctor for a nice chat about their health and guidance on how best to treat their chronic illnesses . But that requires a degree of patient self sufficiency that is absent in many patients I see in the big city .

Also primary care is better when you are the sole provider (or maybe one NP or partner but you mainly see this patient ) for continuity of care

It devolves into madness in a clinic type of setting like many of these pmd jobs tend to be . Becuase the big corporations want to pay you 150K for the above . Whereas if you went full private practice and dealt with these issues head on (and mitigate these issues one by one over time and with more frequent visits ) , you can make so much more money in a 99213 mill than you every could in one of these corporate pmd mill jobs (and nephrology lol zing)

What does pmd stand for?

 

[Osteoth]

What does pmd stand for?

Primary medical doctor I believe

 

[Appellatelove]

Primary medical doctor I believe

Gotcha. I’ve been researching this and it seems to be that if you can find a well established private practice that’s the way to go. More flexibility, more money, less corporate headaches and ability to make your work more tailored to preferences.

 

[Osteoth]

Gotcha. I’ve been researching this and it seems to be that if you can find a well established private practice that’s the way to go. More flexibility, more money, less corporate headaches and ability to make your work more tailored to preferences.

Hard to find, generally underpay, less benefits like loan forgiveness, PSLF eligibility if you have a high loan burden.

 

[NewYorkDoctors]

Opening a private practice solo primary care practice is the best escape option for nephrologists (who are not in the academic sphere ) . You can also practice nephrology on the side and call yourself a hypertension and diabetic kidney disease specialist if you wish . You can do as much or as little nephrology as you wish (skip in center HD - get into in office Pd and home HD if you’d like as procedures ) and have the primary care carry you financially .

I digress but I am going to keep harping in the don’t do (non academic ) nephrology unless you have a clear cut plan .

 

[Bendamustine]

Did anyone consider the traditional practice? (Both Hospitalist and PCP job)

 

[Appellatelove]

Hard to find, generally underpay, less benefits like loan forgiveness, PSLF eligibility if you have a high loan burden.

I think this is how corporations get you. On average you make significantly more in private practice which will overtime make up for any of those benefits. Corporations can provide high base salaries to get you in the door and then suck your life out of you while private practices can’t give you as high of a base but you can exceed corporate salaries greatly overtime. I think the crazy part is how Medicare increased rvus for primary care. Many hospital systems didn’t pass down this increase to their primary care doctors to keep it “balanced” with specialty salaries (aka lower and not to disrupt the ecosystem). If you are in private practice you reap all of these increases without having a corporation steal it.

 

[Osteoth]

Did anyone consider the traditional practice? (Both Hospitalist and PCP job)

Very hard to do from a time stand point and you’ll make more $ just seeing more pts in clinic and contracting with a hospitalist.

 

[Osteoth]

I think this is how corporations get you. On average you make significantly more in private practice which will overtime make up for any of those benefits. Corporations can provide high base salaries to get you in the door and then suck your life out of you while private practices can’t give you as high of a base but you can exceed corporate salaries greatly overtime. I think the crazy part is how Medicare increased rvus for primary care. Many hospital systems didn’t pass down this increase to their primary care doctors to keep it “balanced” with specialty salaries (aka lower and not to disrupt the ecosystem). If you are in private practice you reap all of these increases without having a corporation steal it.

There are positives and negatives to both private practice and corporations.

I definitely advocate for physician ownership but you probably don’t make more money until IF you make partner then WHEN you pay down your buy in, can take 2-5 years then you have to hope the old guys don’t try to sell the practice from under you in that time.

 

[dozitgetchahi]

Some additional ones

PMD
8) try to practice cost conscious medical care by discussing against the need for unnecessary imaging tests based on performing physical exam , using existing medical test results , and teasing out there have been no changes in the clinical history (other than patient read something online and has felt empowered by it )
9) trying to do a full and proper physical exam for a patient
10 ) trying to limit unnecessary blood testing
11) trying to do the best evidence based primary care for your patients and communicate openly and effectively
12) trying to fill out dme , work forms , disability forms , home health forms , etc in a timely fashion
13) trying to prescribe generic meds and economical options . For commercial patients trying to find copay assistance cards
14) trying to make sense of which meds the patient is actually dispensed . Patient accuses you of not prescribing specific medication . You show the patient proof of prescription from the EMR on said date and then call pharmacy in front of them to talk to pharmacist and ask for proof of dispensing on said date in from of patient . Asks pharmacist to help handle this issue with a patient who has cognitive difficulties or secondary gain
15) trying to reduce poly pharmacy but finds it difficult as certain chronic conditions has certain meds by default for their mortality benefit .
16) try to empathize with these patients and try To provide education via up to date basics , YouTube videos for animations , and other patient friendly sources


Patient
8) read something online and wants CT scans and MRIs but does not want to pay out of pocket for it and wants you to do a PA for them .
9) patients finding changing into a gown is too cumbersome for them and find it annoying . They also do not trust your exam skills and want to see a specialist or want an echo cxr or ultrasound
10) patients read about tumor markers for cancer screening and want their blood type checked becuase “they never knew what their blood type was” (and want to use the information to predict their covid19 risk , check their horoscope , or share at the dinner table with family like some kind of feat ) even if it were a female who has given birth before and seen obgyn .
11) wanting the pmd to be your in demand concierge PMD on retainer without paying for concierge services . Probably by trying to circumvent coinsurance copay by doing telephone medicine and demanding to speak to the doctor . I
12) giving a form to the doctor during the office visit and expecting it filled out right away
13) wanting the best meds read from advertisements on TV from those Happy healthy actors but bemoaning the donut hole (this is not really an issue for Medicare Medicaid and managed patients since their formularies are robust and have pretty much zero copay )
14) due to poly pharmacy and confusing medication names , patients get confused and flustered and misplace medications . Rather than speak with the pharmacist for clarification , goes to doctor to accuse doctor of not prescribing said medication . On hearing the pharmacist confirm it was given on said date , patient defiantly states no medications were received . Demands another course of medications covered by insurance
15) laments poly pharmacy but won’t give up their ambien belsomra or Xanax . Refuses to take trazodone, mirtazepine , or ramelteon
16) want to go to the social media of their political reference for medical education


Yeah this is a big city issue. There are lots of personalities .

I do see several kind elderly patients who remain self sufficient and come to see the doctor for a nice chat about their health and guidance on how best to treat their chronic illnesses . But that requires a degree of patient self sufficiency that is absent in many patients I see in the big city .

Also primary care is better when you are the sole provider (or maybe one NP or partner but you mainly see this patient ) for continuity of care

It devolves into madness in a clinic type of setting like many of these pmd jobs tend to be . Becuase the big corporations want to pay you 150K for the above . Whereas if you went full private practice and dealt with these issues head on (and mitigate these issues one by one over time and with more frequent visits ) , you can make so much more money in a 99213 mill than you every could in one of these corporate pmd mill jobs (and nephrology lol zing)

I’m in the semi rural south and I see the exact same issues you speak of, and more. It’s not just a city issue. It’s an “America” issue. “Patient self sufficiency”? Hahahaha. Look, I have a huge contingent of patients who call my office every. Single. Month. asking for refills on a script in which they have 6 refills remaining…they do not go to the pharmacy, they just call us. And blame us if the pharmacy doesn’t already have it ready, or something.

Lately the big thing for new patients who “don’t have the money to come for an appointment” (read: “I don’t want to pay a co pay”) is to come for a new patient visit, get a workup, cancel the follow up appointment, and then call our office and demand and scream at my nurse and office manager that they should get a free phone call from me reviewing their labs and such. Not a telehealth phone visit, which I would bill for…but a free phone call. I fire these patients, and many others who are obnoxious and demanding and drug seeking and never come to follow up appointments and so many other things, but my goodness it seems like there are so many more of these people than there used to be…did Covid give everyone brain damage or something?

 

[dozitgetchahi]

There are positives and negatives to both private practice and corporations.

I definitely advocate for physician ownership but you probably don’t make more money until IF you make partner then WHEN you pay down your buy in, can take 2-5 years then you have to hope the old guys don’t try to sell the practice from under you in that time.

This is a huge topic, but having been in both corporate medicine and now private practice, I can tell you that I have a massive preference for private practice. I’m making better money, I actually have a say in my own office environment and how things happen, and my schedule is better in ways that my last health system adamantly refused to allow me to change to (now I have a half day of admin time, whereas I didn’t before). My office staff actually respect me here because they know who’s signing the paychecks…whereas at the last corporate hospital job I had I dealt with a disrespectful, lazy, argumentative, and all around awful MA who the hospital refused to move or replace for almost 3 years, and who made the job unbelievably painful during that timeframe. There’s just no comparison wrt how much better this has been.

The buy in issue is simply a matter of choosing a practice with low buyins…the trend is for low buyins and faster partnership tracks now. I'm a partner after just 1 year here. The buyin here is $20k. I saw places where the buyin was as low as $5k, or nothing. I was paid $50k better salary right off the bat to start here. Financially, this was a no brainer. Even if the practice was sold out tomorrow, I’m still coming out ahead of where I was at my previous crap hospital job.

 

[Appellatelove]

This is a huge topic, but having been in both corporate medicine and now private practice, I can tell you that I have a massive preference for private practice. I’m making better money, I actually have a say in my own office environment and how things happen, and my schedule is better in ways that my last health system adamantly refused to allow me to change to (now I have a half day of admin time, whereas I didn’t before). My office staff actually respect me here because they know who’s signing the paychecks…whereas at the last corporate hospital job I had I dealt with a disrespectful, lazy, argumentative, and all around awful MA who the hospital refused to move or replace for almost 3 years, and who made the job unbelievably painful during that timeframe. There’s just no comparison wrt how much better this has been.

The buy in issue is simply a matter of choosing a practice with low buyins…the trend is for low buyins and faster partnership tracks now. I'm a partner after just 1 year here. The buyin here is $20k. I saw places where the buyin was as low as $5k, or nothing. I was paid $50k better salary right off the bat to start here. Financially, this was a no brainer. Even if the practice was sold out tomorrow, I’m still coming out ahead of where I was at my previous crap hospital job.

Studies show that once a doctor gives private they can’t really go back to a corporate setting- the autonomy is key. How is your partnership structured? Is it rvu based?

 

[Osteoth]

This is a huge topic, but having been in both corporate medicine and now private practice, I can tell you that I have a massive preference for private practice. I’m making better money, I actually have a say in my own office environment and how things happen, and my schedule is better in ways that my last health system adamantly refused to allow me to change to (now I have a half day of admin time, whereas I didn’t before). My office staff actually respect me here because they know who’s signing the paychecks…whereas at the last corporate hospital job I had I dealt with a disrespectful, lazy, argumentative, and all around awful MA who the hospital refused to move or replace for almost 3 years, and who made the job unbelievably painful during that timeframe. There’s just no comparison wrt how much better this has been.

The buy in issue is simply a matter of choosing a practice with low buyins…the trend is for low buyins and faster partnership tracks now. I'm a partner after just 1 year here. The buyin here is $20k. I saw places where the buyin was as low as $5k, or nothing. I was paid $50k better salary right off the bat to start here. Financially, this was a no brainer. Even if the practice was sold out tomorrow, I’m still coming out ahead of where I was at my previous crap hospital job.

That sounds great how did you find your job? The private practices I’ve talked too seem kind of predatory and the buy ins high…

 

[VA Hopeful Dr]

Alright then, gather around and listen to Uncle VA Hopeful's "Ways to not hate outpatient primary care"...

Pick your battles. This is paramount and something I had trouble with for quite awhile. Yes, we know that ordering unnecessary and stupid lab tests isn't going to find the cause for "vague possibly made up symptom X". But is it worth arguing about? Generally speaking, I don't think so. I will warn patients that their insurance might not cover <insert test here> but if they're OK with that risk then I'm OK ordering the lab. Just this week I had a guy come in the STI testing. Was insistent on HSV testing despite being completely asymptomatic. I told him that the tests were pretty inaccurate without symptoms but he still wanted it so I ordered it. Easy. We also all know that antibiotics aren't good for 95+% of URIs. People still expect them. Fine by me, I'll write a just-in-case prescription to be filled if no better in X days and document as such. If they take it early (and we all know they will), that's on them. Referral to specialist X for stupidly easy to manage condition (usually endo for hypothyroid)? I offer to manage, if they still want it then I do it. You have to find your comfort zone of things that you will stand firm on and things you won't. Mine is starting benzos/opioids, continuing opioids if more than 30 pills are required every 3 months, and ever prescribing xanax. I have a partner that refuses to manage testosterone. Another that doesn't treat adults with ADHD.

Train your staff. Every refill request should be screened by them to make sure they don't have refills left at the pharmacy before it reaches you. If patients want to discuss labs, they should be told they have to make an appointment (many people order labs before scheduled visits to avoid this which can be nice as well). Meanwhile I have several buttons in Epic that send certain responses back to my nurses. Those are "Needs appointment", "OK to place order for what patient is asking for" mainly for things like mammogram order, refill if they have a visit scheduled in a week or two and don't have meds to last that long, or referrals that we already talked about.

Find the right job. This can take several attempts. Everyone has things that are important to them. There are hospital employed jobs that offer much of what PP jobs do. For example: my contract basically says that as long as I'm earning at least as much as I'm being paid, I can take as many days off as I want. Now sure if I tried to take 3 months (and I earn enough with bonuses that I could cover my base salary during that time) they'd probably have words with me. But the contract says we have 30 days no questions asked. I'm likely to hit 40 this year or close to it. But I work hard so I don't hear about it. My schedule is my own. As long as I work 4.5 days per week, I don't hear anything about it. Technically my contract says 36 hours, but given my long lunch I end up only having around 33 patient hours. And that's OK. I'm paid well. Admin is present but generally stays out of the way, though they are big on CMS quality measures but PP isn't exempt from that either. Oh, and despite around 33 patient hours per week and roughly 40 days off (not including major holidays) I expect to hit 400k this year same as last year.

You build the practice you want. Practice how you want to practice, eventually you'll end up with patients that do well with how you do things. I'm not super warm with patients. The doctor I took over for was. Very chatty, remembered everything about their lives, that sort of person. His patients loved him. However, since he left and I took over a bunch of them talk about how they love knowing that from check in to check out including labs/x-rays they are rarely there over an hour. They used to have to budget 2-3 hours with him since he ran so behind because of said chattiness. Did I lose some because I wasn't that way? Of course. But the ones that stayed really love the efficiency. Don't like lots of back-and-forth on the portal? Then outside of very basic questions or things related to a recent visit/labs, train your patients that they need an appointment. Will you lose some who feel like they should be able to message you every day with a new issue? Yep. But the ones that stay will be OK with how you do things. Don't want to deal with alternative medicine, fads, or other nonsense? Then don't. Tell patients firmly that you don't do X, Y, and Z. They will either go elsewhere or shut up about it. I don't start anyone on cytomel/armour thyroid, if that's what they insist on I will suggest they find another doctor.

Efficiency. This is important. If you're spending an extra 2 hours every day charting you're going to be miserable. My IM wife charts while talking to the patient. Jots down the history and puts in orders will they're talking. Several of my partners dictate and have very streamlined templates they've created. I have a dozen or so dot phrases that have 2-3 blank spaces I fill in so a stable chronic disease visit usually takes me around 60 seconds to complete. Less if its only 1-2 issues. Train your nurses to do as much as they can. They can be taught to check what preventative stuff is needed, offer it to the patient, and if the patient is good for it they can go ahead and put in the order. They can go ahead and enter meds to be refilled. Your nurses should also be doing 99% of your prior auths.

That hits the big stuff. Figure out where you want to be in each of those areas, make it happen, and while I can't guarantee that you'll love primary care that will hopefully keep you from hating it.

 

[Osteoth]

Alright then, gather around and listen to Uncle VA Hopeful's "Ways to not hate outpatient primary care"...

Pick your battles. This is paramount and something I had trouble with for quite awhile. Yes, we know that ordering unnecessary and stupid lab tests isn't going to find the cause for "vague possibly made up symptom X". But is it worth arguing about? Generally speaking, I don't think so. I will warn patients that their insurance might not cover but if they're OK with that risk then I'm OK ordering the lab. Just this week I had a guy come in the STI testing. Was insistent on HSV testing despite being completely asymptomatic. I told him that the tests were pretty inaccurate without symptoms but he still wanted it so I ordered it. Easy. We also all know that antibiotics aren't good for 95+% of URIs. People still expect them. Fine by me, I'll write a just-in-case prescription to be filled if no better in X days and document as such. If they take it early (and we all know they will), that's on them. Referral to specialist X for stupidly easy to manage condition (usually endo for hypothyroid)? I offer to manage, if they still want it then I do it. You have to find your comfort zone of things that you will stand firm on and things you won't. Mine is starting benzos/opioids, continuing opioids if more than 30 pills are required every 3 months, and ever prescribing xanax. I have a partner that refuses to manage testosterone. Another that doesn't treat adults with ADHD.

Train your staff. Every refill request should be screened by them to make sure they don't have refills left at the pharmacy before it reaches you. If patients want to discuss labs, they should be told they have to make an appointment (many people order labs before scheduled visits to avoid this which can be nice as well). Meanwhile I have several buttons in Epic that send certain responses back to my nurses. Those are "Needs appointment", "OK to place order for what patient is asking for" mainly for things like mammogram order, refill if they have a visit scheduled in a week or two and don't have meds to last that long, or referrals that we already talked about.

Find the right job. This can take several attempts. Everyone has things that are important to them. There are hospital employed jobs that offer much of what PP jobs do. For example: my contract basically says that as long as I'm earning at least as much as I'm being paid, I can take as many days off as I want. Now sure if I tried to take 3 months (and I earn enough with bonuses that I could cover my base salary during that time) they'd probably have words with me. But the contract says we have 30 days no questions asked. I'm likely to hit 40 this year or close to it. But I work hard so I don't hear about it. My schedule is my own. As long as I work 4.5 days per week, I don't hear anything about it. Technically my contract says 36 hours, but given my long lunch I end up only having around 33 patient hours. And that's OK. I'm paid well. Admin is present but generally stays out of the way, though they are big on CMS quality measures but PP isn't exempt from that either. Oh, and despite around 33 patient hours per week and roughly 40 days off (not including major holidays) I expect to hit 400k this year same as last year.

You build the practice you want. Practice how you want to practice, eventually you'll end up with patients that do well with how you do things. I'm not super warm with patients. The doctor I took over for was. Very chatty, remembered everything about their lives, that sort of person. His patients loved him. However, since he left and I took over a bunch of them talk about how they love knowing that from check in to check out including labs/x-rays they are rarely there over an hour. They used to have to budget 2-3 hours with him since he ran so behind because of said chattiness. Did I lose some because I wasn't that way? Of course. But the ones that stayed really love the efficiency. Don't like lots of back-and-forth on the portal? Then outside of very basic questions or things related to a recent visit/labs, train your patients that they need an appointment. Will you lose some who feel like they should be able to message you every day with a new issue? Yep. But the ones that stay will be OK with how you do things. Don't want to deal with alternative medicine, fads, or other nonsense? Then don't. Tell patients firmly that you don't do X, Y, and Z. They will either go elsewhere or shut up about it. I don't start anyone on cytomel/armour thyroid, if that's what they insist on I will suggest they find another doctor.

Efficiency. This is important. If you're spending an extra 2 hours every day charting you're going to be miserable. My IM wife charts while talking to the patient. Jots down the history and puts in orders will they're talking. Several of my partners dictate and have very streamlined templates they've created. I have a dozen or so dot phrases that have 2-3 blank spaces I fill in so a stable chronic disease visit usually takes me around 60 seconds to complete. Less if its only 1-2 issues. Train your nurses to do as much as they can. They can be taught to check what preventative stuff is needed, offer it to the patient, and if the patient is good for it they can go ahead and put in the order. They can go ahead and enter meds to be refilled. Your nurses should also be doing 99% of your prior auths.

That hits the big stuff. Figure out where you want to be in each of those areas, make it happen, and while I can't guarantee that you'll love primary care that will hopefully keep you from hating it.

Hey this is good thanks

 

[dozitgetchahi]

Studies show that once a doctor gives private they can’t really go back to a corporate setting- the autonomy is key. How is your partnership structured? Is it rvu based?

Not RVU based. PPs usually aren’t. After the first 2 years, AR - overhead + ancellaries = what you make each month. No mysterious RVU black magic. Don’t get me wrong, there are certainly ways that can go off the rails too (if your practice doesn’t aggressively collect, its docs can end up with huge ARs that don’t get collected etc) but in terms of transparency this is much, much better that dealing with the RVU BS.

 

[VA Hopeful Dr]

Not RVU based. PPs usually aren’t. After the first 2 years, AR - overhead + ancellaries = what you make each month. No mysterious RVU black magic. Don’t get me wrong, there are certainly ways that can go off the rails too (if your practice doesn’t aggressively collect, its docs can end up with huge ARs that don’t get collected etc) but in terms of transparency this is much, much better that dealing with the RVU BS.

Eh, RVUs have their uses. There are lots of PP doctors that don't see Medicaid because it pays poorly. Me, I make the same for a 99214 whether its Medicaid, Blue Cross, Medicare, or hospital charity.

This may not be the case everywhere, but I can request my billing information at any time and see what each code I billed on each patient paid the office.

Don't get me wrong, I think PP is great and I support it (usually) but let's not pretend that being employed is this terrible awful thing.

For background, I owned my own practice awhile back. Hated it.

 

[dozitgetchahi]

That sounds great how did you find your job? The private practices I’ve talked too seem kind of predatory and the buy ins high…

You have to shop around. During my job search I absolutely encountered private practices trying to exploit new associates (one talked about a buy-in of $125-150k after 2 years for just a rheumatology practice, not even including the building-lol. One wanted to offer me $180k to start with zero signing bonus - which is way below MGMA for rheumatology. Yeah, no. They eventually gave up trying to fleece a rheumatologist into taking the job and hired an NP instead.) But my current job started me at $300k with a $25k signon bonus and $50k loan repayment.

Here’s a secret: you might need to leave the Great Big Cities Doctors Love and look out in the country a bit. I’m in the semi rural south. The pay and respect get much, much better when they know they won’t be able to attract new docs to town very easily. In more urban areas, hospitals and private practices alike tend to be willing to burn through doctors as they have a belief that they can just pick another one up easily if you leave. Not so out in rural areas.

 

[dozitgetchahi]

Eh, RVUs have their uses. There are lots of PP doctors that don't see Medicaid because it pays poorly. Me, I make the same for a 99214 whether its Medicaid, Blue Cross, Medicare, or hospital charity.

This may not be the case everywhere, but I can request my billing information at any time and see what each code I billed on each patient paid the office.

Don't get me wrong, I think PP is great and I support it (usually) but let's not pretend that being employed is this terrible awful thing.

For background, I owned my own practice awhile back. Hated it.

When I was an employed doctor, I was absolutely miserable - for me, it really was this “terrible, awful thing”. I will never, ever work in a health system ever again. Any “benefits” were offset by massive issues of all sorts, and a strong sensation that the management (all of whom were MBAs who knew diddly squat about medicine) saw me as little more than chattel to be exploited to the maximum possible extent. Many other doctors share my opinion on this. I don’t necessarily want to run my own solo practice, either - but I am much happier in a multispecialty private practice than I ever was at a hospital system, and I am paid a lot better to boot.

 

[Prehealth1011]

Eh, RVUs have their uses. There are lots of PP doctors that don't see Medicaid because it pays poorly. Me, I make the same for a 99214 whether its Medicaid, Blue Cross, Medicare, or hospital charity.

This may not be the case everywhere, but I can request my billing information at any time and see what each code I billed on each patient paid the office.

Don't get me wrong, I think PP is great and I support it (usually) but let's not pretend that being employed is this terrible awful thing.

For background, I owned my own practice awhile back. Hated it.

Did you hate having private practice itself or the “DPC being on call all the time”nature of it?

 

[VA Hopeful Dr]

Did you hate having private practice itself or the “DPC being on call all the time”nature of it?

Both. The always on call wasn't too bad, I would usually get like 2-3 emails/texts between 5-8, almost nothing after 8.

But I was always thinking about the rent payment, managing my days off, keeping my supplies well stocked, and so on.

 

[VA Hopeful Dr]

When I was an employed doctor, I was absolutely miserable - for me, it really was this “terrible, awful thing”. I will never, ever work in a health system ever again. Any “benefits” were offset by massive issues of all sorts, and a strong sensation that the management (all of whom were MBAs who knew diddly squat about medicine) saw me as little more than chattel to be exploited to the maximum possible extent. Many other doctors share my opinion on this. I don’t necessarily want to run my own solo practice, either - but I am much happier in a multispecialty private practice than I ever was at a hospital system, and I am paid a lot better to boot.

And that's absolutely fair. Its unfortunate that there is such variation in hospital systems on that regard. In mine, the 2 levels of admin above me are both physicians who still actively see patients. Admittedly only 2 days/week usually but it does make a difference.

 

[NewYorkDoctors]

Both. The always on call wasn't too bad, I would usually get like 2-3 emails/texts between 5-8, almost nothing after 8.

But I was always thinking about the rent payment, managing my days off, keeping my supplies well stocked, and so on.

I love it when patients can email me . I pay for a hipaa secure email when I need to share results . This means they are usually functional enough to have a good conversation . Sharing thoughts Uptodate educational videos , etc … helps them and cuts down on the actual upcoming office visit

 

[Bendamustine]

I love it when patients can email me . I pay for a hipaa secure email when I need to share results . This means they are usually functional enough to have a good conversation . Sharing thoughts Uptodate educational videos , etc … helps them and cuts down on the actual upcoming office visit

But wouldn't you spend more time on one patient? I mean you are not being paid for chatting online with them right??

 

[VA Hopeful Dr]

I love it when patients can email me . I pay for a hipaa secure email when I need to share results . This means they are usually functional enough to have a good conversation . Sharing thoughts Uptodate educational videos , etc … helps them and cuts down on the actual upcoming office visit

Ah, so you're DPC or concierge then

 

[NewYorkDoctors]

Ah, so you're DPC or concierge then

well not really concierge. i dont take any cash outside of copay/coinsurance. i see a lot of medi/medi patients (they don't have to pay anything either). some commercial too. also in NYS, a lot of undocumented people end up getting Managed Medicaid (lol .. no comment .. and its all kinds of people from many countries of backgrounds not just those of Latin descent) and have zero copay and zero deductible. i just work to keep these people out of the hospital at all costs by seeing them more. and seeing them more equals more revenue. like not abusive seeing them. but if their BP is 180/100 but no stroke or MI, then I would do the hypertension workup, do 24 hour ABPM (only if I think its white coat - nonMedicare insurances tend not to pay this), set up remote BP monitoring eventually, titrate meds, see them at q-1-4 week interval until I see they are on the right track before I extend to a 3 month follow up out of safety. just for example.

I also see all the straight Medicaids - because these individuals eventually get a Managed MEdicaid insurance (in NYC it would be UHC, Healthfirst, Fidelis, Emblem, etc...) and the payment becomes close to what Medicare pays.

i just have several highly functional and well educated individuals who range from young to as old as 87 who communicate very well via email. because the more elderly tend to have a lot of more questions, I just like to handle these things with email and use the actual visit to see what is physically going on and doing something physical (exam, test, etc) for the patient. because when they try to ask these educational questions in the actual visit, it bogs the whole visit down and causes serious delays. yet I want to help keep them apprised of their health if they desire it.

 

[NewYorkDoctors]

But wouldn't you spend more time on one patient? I mean you are not being paid for chatting online with them right??

nope. cant bill for email. but if this helps me keep my workflow going, im all for it. im a Gen Yer so being online at all times is a given
sometimes if they email me about a concerning symptom (doc i think my something is acting up!) I would just call them and do an assessment and plan accordingly for a next visit if necessary or give reassurance. then bill the telephone codes. (99441, 99442 , 99443) but no billing just for emails.

 

[NewYorkDoctors]

Doctor:
17) Patient has brought up concerns about bubbles in the urine and some ankle edema. Assure patient the patient has recently had urine testing without proteinuria. Also reviewed prior lab tests with BNP and CMP as well as review prior imaging tests showing normal cardiac function. Informed patient that air bubbles will enter the urine toilet bowl due to the turbulence of urine entering the toilet bowl. Show patient a stock photo of nephrotic urine and how it looks like beer foam. Also reviewed with patient about the fact that patient's edema is probably related to the dihydropyridine CCB being used or venous insufficiency (after eliciting history of no edema in the morning and worse at night after standing all day long)

Suggest to patient to leave the urine in the toilet bowl without flushing the toilet for 30 minutes and return later to see if the bubbles are still present. It probably will not.

Tries to show empathy and want to provide education for the patient. But this is the 15th time the same patient has brought this same issue up. Performed a MMSE and no cognitive impairment is screened. Reminds self that water is wet.

Patient:
17) Patient has read something online about how edema in the legs might signify kidney disease. This fear is compounded by the fact that the patient notices bubbles in the toilet bowl. Comes to tell doctor he/she has kidney disease now. Expresses understanding at what doctor is saying but can't shake the feeling that social media is probably right and the doctor is not telling the whole truth. Will forget everything said this visit and ask again.

 

[Appellatelove]

well not really concierge. i dont take any cash outside of copay/coinsurance. i see a lot of medi/medi patients (they don't have to pay anything either). some commercial too. also in NYS, a lot of undocumented people end up getting Managed Medicaid (lol .. no comment .. and its all kinds of people from many countries of backgrounds not just those of Latin descent) and have zero copay and zero deductible. i just work to keep these people out of the hospital at all costs by seeing them more. and seeing them more equals more revenue. like not abusive seeing them. but if their BP is 180/100 but no stroke or MI, then I would do the hypertension workup, do 24 hour ABPM (only if I think its white coat - nonMedicare insurances tend not to pay this), set up remote BP monitoring eventually, titrate meds, see them at q-1-4 week interval until I see they are on the right track before I extend to a 3 month follow up out of safety. just for example.

I also see all the straight Medicaids - because these individuals eventually get a Managed MEdicaid insurance (in NYC it would be UHC, Healthfirst, Fidelis, Emblem, etc...) and the payment becomes close to what Medicare pays.

i just have several highly functional and well educated individuals who range from young to as old as 87 who communicate very well via email. because the more elderly tend to have a lot of more questions, I just like to handle these things with email and use the actual visit to see what is physically going on and doing something physical (exam, test, etc) for the patient. because when they try to ask these educational questions in the actual visit, it bogs the whole visit down and causes serious delays. yet I want to help keep them apprised of their health if they desire it.

Can you talk more about remote patient monitoring? I’d like to incorporate it into my own practice one day.

 

[NewYorkDoctors]

Doctor
18) Informs patient about the need for certain tests or referrals or next steps. In an attempt to make things as smooth as possible, the front desk staff will get the PA (if applicable) and then help the patient schedule and provide instructions. After the patient does not leave to the front desk and asks the doctor again for instructions on how to walk to a radiology center two blocks away, the doctor informs the patient to go to the front desk and that the doctor is not a secretary. Patient does not relent for some reason. Trying to show some empathy, doctor opens up google maps street view. the patient is more confused than before.
19) The front desk staff has helped the patient secure an appointment at another consultant's office. All paperwork is done. The patient did not have to lift one finger to trouble himself/herself to call as some patients just cannot manage IADLs anymore. Appointment info is written down on a large piece of paper.
20) Attempt to have another open dialogue with the patient for shared decision making. Expresses empathy to patient about the frustration of navigating the health care system and also the fear of his/her potential diagnosis. Informs patient whether the patient was able to understand my 6th grade level lay persons explanation of what is going on. Silence and no response from the patient. This goes on for a while without resolution... a long documentation session follows the visit.
21) schedule a quick follow up visit to re-explore the patient's thoughts without waiting too long. the patient no shows and long documentation session follows again. Family is attempted to be reached (or else incur the wrath of the children who were not informed) and unable to be reached. another long documentation session follows.

Patient
18) Despite hearing what the doctor said, the patient does not leave the room to the front desk. The patient thinks that the patient would rather ask the doctor about these patient navigation instructions. The doctor is the master of all things remotely related to my health care. He/she will solve everything with the snap of a finger.
19) On the day of a scheduled appointment to another referral physician or radiology (or whatever), the patient is a no show. The other office asks us does the patient still need to come? The patient walks into initial doctors office and complains "no one called me to remind me."
20) Patient loses interest in the whole deal and decides he finds seeing thoracic surgery to go for resection of a PET avid nodule too "troublesome" and wants to not do it.
21) patient no shows the quick follow up visit and does not answer the phone.

 

[rokshana]

Doctor
18) Informs patient about the need for certain tests or referrals or next steps. In an attempt to make things as smooth as possible, the front desk staff will get the PA (if applicable) and then help the patient schedule and provide instructions. After the patient does not leave to the front desk and asks the doctor again for instructions on how to walk to a radiology center two blocks away, the doctor informs the patient to go to the front desk and that the doctor is not a secretary. Patient does not relent for some reason. Trying to show some empathy, doctor opens up google maps street view. the patient is more confused than before.
19) The front desk staff has helped the patient secure an appointment at another consultant's office. All paperwork is done. The patient did not have to lift one finger to trouble himself/herself to call as some patients just cannot manage IADLs anymore. Appointment info is written down on a large piece of paper.
20) Attempt to have another open dialogue with the patient for shared decision making. Expresses empathy to patient about the frustration of navigating the health care system and also the fear of his/her potential diagnosis. Informs patient whether the patient was able to understand my 6th grade level lay persons explanation of what is going on. Silence and no response from the patient. This goes on for a while without resolution... a long documentation session follows the visit.
21) schedule a quick follow up visit to re-explore the patient's thoughts without waiting too long. the patient no shows and long documentation session follows again. Family is attempted to be reached (or else incur the wrath of the children who were not informed) and unable to be reached. another long documentation session follows.

Patient
18) Despite hearing what the doctor said, the patient does not leave the room to the front desk. The patient thinks that the patient would rather ask the doctor about these patient navigation instructions. The doctor is the master of all things remotely related to my health care. He/she will solve everything with the snap of a finger.
19) On the day of a scheduled appointment to another referral physician or radiology (or whatever), the patient is a no show. The other office asks us does the patient still need to come? The patient walks into initial doctors office and complains "no one called me to remind me."
20) Patient loses interest in the whole deal and decides he finds seeing thoracic surgery to go for resection of a PET avid nodule too "troublesome" and wants to not do it.
21) patient no shows the quick follow up visit and does not answer the phone.

eh…at least you won’t have to deal with pt in #20 for too long…

 

[NewYorkDoctors]

meh. these things are routine now and just happens fairly often. these things are more about outpatient medicine in general and not unique to primary care. i used to get frustrated (internally) but now I just realize this is the norm and not the exception. I just remind myself internally to "remember your training" and "do things by the book." In these difficult situations, I just take all the by the book steps and also "get the ball into the patient's court" as soon as possible. This doesn't mean I ignore an issue. It just means I take all the steps needed to communicate (including having my staff keep on calling until the patient responds) and then I keep documenting patient did not pick up.

when you expect disappointment everyday, you will never be disappointed.

 

[NewYorkDoctors]

Patient:
22) Walks into doctors office asking for a prior authorization for DAW Nexium 40mg because "it is better." Won't take no for an answer. Refuse to pay for it OTC or even buy it on Amazon or some other wholesale site for cheap prices. Will not listen to the doctors advice that PPI are not meant for long term use unless the indication is for gastric ulcers/gastric disease or if GI protection from DAPT/AC use. Won't leave the office and keeps harassing the doctor about it. Refuses to listen to doctors advice that "name brand Dexliant" is on the formulary. Insists on Nexium because the purple pill is better. May have ulterior motive to send to other family members.

Doctor
22) Tries to educate patient about how PPIs are not meant for chronic use without a clear cut indication. Shares how it can cause hypomagnesemia (and therefore leg cramps which all elderly complain about), C diff, osteoporosis, chronic interstitial nephritis, just to name a few. Tries to offer alternatives such as the modifying diet and eating habits ( the GERD rules), offering a DME prescription for hospital bed to sleep head of bed 30-45 degrees, try to discuss alternatives such as PRN H2 blockers
Ultimately, agrees to just go to the PA website (CoverMyMeds, Surescripts, etc) and answer the questions with the explanation of "the patient wants it because the purple pill is better" and then getting the PA rejected. When patient gets the letter and comes back to negotiate, doctor informs patient should using all of this effort talking to the insurance company and not to the doctor or should be using all of this effort to improve HTN, DM2, etc...

 

[Prehealth1011]

You have 15 - 20 minutes for this (not including note charting time)

Get ready, set GO!

This is exactly how I feel as a resident in clinic. When I'm on floors, after 2-3 hours of work, I don't really have to stay "on" for rest of the day

Clinic feels like a grind from the moment patient has been roomed. It's literally 1000 things to do in a short time frame and if one of my patients is a talker, I'm behind for rest of the day

 

[VA Hopeful Dr]

Patient:
22) Walks into doctors office asking for a prior authorization for DAW Nexium 40mg because "it is better." Won't take no for an answer. Refuse to pay for it OTC or even buy it on Amazon or some other wholesale site for cheap prices. Will not listen to the doctors advice that PPI are not meant for long term use unless the indication is for gastric ulcers/gastric disease or if GI protection from DAPT/AC use. Won't leave the office and keeps harassing the doctor about it. Refuses to listen to doctors advice that "name brand Dexliant" is on the formulary. Insists on Nexium because the purple pill is better. May have ulterior motive to send to other family members.

Doctor
22) Tries to educate patient about how PPIs are not meant for chronic use without a clear cut indication. Shares how it can cause hypomagnesemia (and therefore leg cramps which all elderly complain about), C diff, osteoporosis, chronic interstitial nephritis, just to name a few. Tries to offer alternatives such as the modifying diet and eating habits ( the GERD rules), offering a DME prescription for hospital bed to sleep head of bed 30-45 degrees, try to discuss alternatives such as PRN H2 blockers
Ultimately, agrees to just go to the PA website (CoverMyMeds, Surescripts, etc) and answer the questions with the explanation of "the patient wants it because the purple pill is better" and then getting the PA rejected. When patient gets the letter and comes back to negotiate, doctor informs patient should using all of this effort talking to the insurance company and not to the doctor or should be using all of this effort to improve HTN, DM2, etc...

After 5 minutes this is when you say "I am not doing that, I think it's best if you find another doctor" and walk out.

 

[NewYorkDoctors]

This is exactly how I feel as a resident in clinic. When I'm on floors, after 2-3 hours of work, I don't really have to stay "on" for rest of the day

Clinic feels like a grind from the moment patient has been roomed. It's literally 1000 things to do in a short time frame and if one of my patients is a talker, I'm behind for rest of the day

in real life it gets a little better once you get to know this patient after several visits. you already have addressed and documented the things you need to do (screening and SBIRT and stuff) so you can listen to some fluff and then tackle the follow up or acute issues. in general if a screening item has been addressed and documented in my note (like the LDCT is done for the year next one in one year or colonoscopy no issues within the last 10 years or something) then I am NOT spending any breath talking about it again on a subsequent visit.

but in residents clinic, there is no real continuity (despite attempts by the program to have patients only see the same resident). However, patients cannot always follow the resident's 4+1 or 5+2 or whatever schedule. Then comes the eternal constant question of "why can't I see the same doctor every time?"

Well you could... if you have insurance you could see a private practice doctor out there...

 

[rokshana]

Patient:
22) Walks into doctors office asking for a prior authorization for DAW Nexium 40mg because "it is better." Won't take no for an answer. Refuse to pay for it OTC or even buy it on Amazon or some other wholesale site for cheap prices. Will not listen to the doctors advice that PPI are not meant for long term use unless the indication is for gastric ulcers/gastric disease or if GI protection from DAPT/AC use. Won't leave the office and keeps harassing the doctor about it. Refuses to listen to doctors advice that "name brand Dexliant" is on the formulary. Insists on Nexium because the purple pill is better. May have ulterior motive to send to other family members.

Doctor
22) Tries to educate patient about how PPIs are not meant for chronic use without a clear cut indication. Shares how it can cause hypomagnesemia (and therefore leg cramps which all elderly complain about), C diff, osteoporosis, chronic interstitial nephritis, just to name a few. Tries to offer alternatives such as the modifying diet and eating habits ( the GERD rules), offering a DME prescription for hospital bed to sleep head of bed 30-45 degrees, try to discuss alternatives such as PRN H2 blockers
Ultimately, agrees to just go to the PA website (CoverMyMeds, Surescripts, etc) and answer the questions with the explanation of "the patient wants it because the purple pill is better" and then getting the PA rejected. When patient gets the letter and comes back to negotiate, doctor informs patient should using all of this effort talking to the insurance company and not to the doctor or should be using all of this effort to improve HTN, DM2, etc...

No is a complete sentence.

 

[dozitgetchahi]

After 5 minutes this is when you say "I am not doing that, I think it's best if you find another doctor" and walk out.

Yeah, I call it quits on that crap way before that point. I’ve straight up told patients “this isn’t going to go through if I do this, and it’s not a good use of my/staff time to do that”.

 

[dozitgetchahi]

This is exactly how I feel as a resident in clinic. When I'm on floors, after 2-3 hours of work, I don't really have to stay "on" for rest of the day

Clinic feels like a grind from the moment patient has been roomed. It's literally 1000 things to do in a short time frame and if one of my patients is a talker, I'm behind for rest of the day

I feel the exact opposite…

In the clinic (I am rheumatology) the visits are controlled, times are set, the day moves. I can (and do) tell patients “I gotta run”. Your staff sets up your clinic the way you want it and you can move your workflow along.

In the hospital, everything is chaos. Nothing is set up to be efficient. You burn time walking around to rooms…if you have to do a procedure, you burn time finding the equipment, waiting for the pharmacy to send up lidocaine, whatever. Patient XYZ went to surgery? Well…now I guess we have to wait around several hours to figure that problem out. Pager goes off - hey doc, now you have another consult. ****ing wonderful. Someone codes, unexpectedly. One or two super sick patients can totally monopolize your time, and crowd out all the other patients who also need your attention. You don’t have office staff to help you chase records or do drudgework. Hospital work sucks and I am blissfully happy to be able to do exactly zero inpatient consults as a rheumatologist.

 

[NewYorkDoctors]

23) Patients who want to confront the doctor to discuss copay / coinsurance charges on the EOB. A patient feels like it is good idea to have the doctor take care of this issue. The patient feels entitled that healthcare is a right and healthcare should be free. The patient laments that he/she has commercial insurance, straight Medicare, or managed Medicare (all without the Medicaid component) and has to pay for the premium and perform cost sharing. Laments how people in poverty (i.e. with Managed Medicaid or Medi/Medi) have zero copay, zero coinsurance, zero deductible. Laments how undocumented patients in New York City can get "free health care." Wants the doctor to call the insurance company to find some way of waving the copay/coinsurance. Patient also cries angrily about the copay on the unnecessary test that the patient demanded to do (maybe a Lyme disease Antibody or a rheumatologic arthritis panel for chronic fatigue) that the doctor did warn the patient about. Patient angrily asks why the doctor doesn't know all these prices?

23) Doctor asks patient to discuss this with the front desk and billing department. The patient won't leave the room. Doctor reluctantly looks at the EOB and finds nothing is amiss and it is a standard 20% coinsurance or patient just has a high deductible and has not met it yet. Regarding the special lab tests, the doctor informs patient that the patient was warned that there is likely going to be an out of pocket cost to these tests. The doctor even documented this into the note. The doctor gets a blank stare from the patient who is trying to be poker faced and not wanting to reveal his/her hand regarding this situation. Doctor tells the patient the doctor does not set these prices and the laboratory does not give a flyer or tutorial to doctors about the specific costs. While one can search CPT codes and charges to be a rough idea how much will be charged, that is the job of the billing department which the patient was advised to ask but did not bother to do so.

Time Wasted: too much

 

[VA Hopeful Dr]

The fact that you address any of this yourself for more than 15 seconds is your own fault. But it does help explain why you feel the way you do about primary care.

 

[NewYorkDoctors]

The fact that you address any of this yourself for more than 15 seconds is your own fault. But it does help explain why you feel the way you do about primary care.

I suppose it does lol . However This whole thread was mostly tongue in cheek about the bad behavior that many patients exhibit. See all those likes and reactions my posts got?

Yet my approach is not “five minutes are up find yourself a new doctor .” Mine is okay let me sift through this crap for the (potential) benefit of my patient .