Questions about Primary Care

[FranticFrancis]

Hello all.

I'm a second-year IM resident. I always thought I wanted to do Hospital Medicine. Studied really hard (still do), got praised extensively in my program by staff, nurses, PD, and colleagues. But recently I've been developing a subtle case of the surreptitious little bastard adequately named "burn out." Not all bad things have bad outcomes, though. It made me revisit my decisions and introspect quite significantly. I've come to realize that having a regular schedule, enjoying my time with my family, and pursuing several other hobbies I have are all things I value more than Hospital Medicine. Also, the "acuteness" of Hospital Medicine was causing me some quite intense anxiety (well, still is).

This brings me to Primary Care (I'm not here to talk about fellowship just yet, my particular situation with visa would be best handled by delaying any future specialization for now). Also, I am not at all concerned about salary, in fact, residency salary is more than sufficient for me at this point in time (wife also IM resident btw).

So, a few questions:

1. Is it feasible to secure jobs with a 4 day work week that do not try to push down my throat excessive patient encounters to meet quotas?

2. My program does not really train us for outpatient procedures, but I am quite interested. How often do PCP jobs offer training and have opportunities to perform outpatient procedures? By this, I mean Urgent Care stuff, joint injections, etc.

3. What is the average workload of patients per day? And how often notes have to be finished at home. I understand this varies greatly, but I truly have no sense of what the average is (while I have a good sense of what the average of patient encounters is for Hospital medicine).


These are only small details that are not particularly going to change my decision to now pursue Primary Care, but it may change the way I go about looking for jobs and dealing with contracts.

Any help would be greatly appreciated.

Thank y'all!

---

Members don't see this ad.

 

[AlbinoHawk DO]

Doesn't your program have clinic time built into it? I think that's where you should start asking

Procedures can be learned through elective time. I would recommend a sports medicine rotation or one with an outpatient ortho group. Overall, lack of providing procedures shouldn't stop you from having a healthy clinic

In terms of job arrangement, anything is possible as long as you're willing to deal with the pay cut for it

 

[fooli_doc]

I've been out of IM residency a couple years and have been doing primary care. There are a lot of misconceptions I read on here and other places in general. I hope I can help provide some insight.

First, I picked IM because I didn't want to see children/do any OB, plus it gave me an option to specialize if I wanted to. I knew I was probably going to do primary care after intern year. I liked inpatient medicine and of course was much better trained for it, but the thought of working every other weekend, nights, holidays made my decision really easy. Also, I saw the kind of work our private hospitalists were doing and it was so impersonal, consult heavy, paper pushing etc.

I also really think residency clinic does such a huge disservice for primary care. I bet you won't find 10 IM residents in the country that love their continuity clinic. I think getting past this as your impression of your future career is one of the biggest hurdles. Staff turnover, very sick chronic patients, more onus on the residents to do tasks you won't do in practice (PAs, call every single patient with results, update histories in the chart etc), waiting in a line to check out to an attending; all these things are way better in my experience in practice.

I'll try to highlight some things about my job that I think are important. I cannot emphasize this enough: Always remember you have all the leverage when looking for a job in primary care as a physician. This was very apparent to me when I started looking for a job. Do not be afraid to ask for things you want in the job. I work in a mid-sized city in the SE so it may vary some accordingly. I work for a large healthcare corporation, so I don't worry about overhead, hiring etc. I do have a ton of say in the basic operations of our clinic on a local level. Our manager is very responsive and our staff is efficient. My medical assistant is very good and pretty much knew how I like to do things after the first 6 months. I work 4 days per week (off Friday, this is something I was looking for). I see patients from 8-5 with an hour lunch. I am still building my practice but on average see 15-16 a day at this point, plan to get to 18-20, which is what other more tenured providers in our system are seeing. We don't do pure RVU base compensation but it turns out similar. If I bill efficiently (make sure to do medicare wellness visits when those patients come in for follow up), I can easily do about $260k per year seeing 15-16 a day, 4 days per week. I mix in probably a procedure or two per week (joint injection, minor skin stuff, I&D), but there is no pressure for me to do that. I supervise an NP as well, which my employer pays me 1k a month for to add on top of that.

Ultimately, I have great work life balance and I make plenty of money for what I want to do. I always finish notes and results before I go home. I usually get in around 7:30 to do results and I'm usually home by 5:45 (15 minute commute home). I have always been fairly efficient charting but I do feel I document pretty well compared to what I'm seeing in the community (its horrible).

Hope this helps, let me know if you have any Qs

 

[VA Hopeful Dr]

Hello all.

I'm a second-year IM resident. I always thought I wanted to do Hospital Medicine. Studied really hard (still do), got praised extensively in my program by staff, nurses, PD, and colleagues. But recently I've been developing a subtle case of the surreptitious little bastard adequately named "burn out." Not all bad things have bad outcomes, though. It made me revisit my decisions and introspect quite significantly. I've come to realize that having a regular schedule, enjoying my time with my family, and pursuing several other hobbies I have are all things I value more than Hospital Medicine. Also, the "acuteness" of Hospital Medicine was causing me some quite intense anxiety (well, still is).

This brings me to Primary Care (I'm not here to talk about fellowship just yet, my particular situation with visa would be best handled by delaying any future specialization for now). Also, I am not at all concerned about salary, in fact, residency salary is more than sufficient for me at this point in time (wife also IM resident btw).

So, a few questions:

1. Is it feasible to secure jobs with a 4 day work week that do not try to push down my throat excessive patient encounters to meet quotas?

2. My program does not really train us for outpatient procedures, but I am quite interested. How often do PCP jobs offer training and have opportunities to perform outpatient procedures? By this, I mean Urgent Care stuff, joint injections, etc.

3. What is the average workload of patients per day? And how often notes have to be finished at home. I understand this varies greatly, but I truly have no sense of what the average is (while I have a good sense of what the average of patient encounters is for Hospital medicine).


These are only small details that are not particularly going to change my decision to now pursue Primary Care, but it may change the way I go about looking for jobs and dealing with contracts.

Any help would be greatly appreciated.

Thank y'all!

1. Yes. My wife is IM and works 4 days per week 8-5. She sees 18-20 patients/day. No pushback to see more.

2. Formal on the job training for procedures is pretty rare. Your partners might be willing to help you learn to do things if you want. I'm FP and precepted my wife on her first carpal tunnel injection, she's been comfortable on her own since then.

3. My wife's numbers from point 1 per her in the top 10 of internists in our group. That's out of about 30.

 

[diesel2101]

I've been out of IM residency a couple years and have been doing primary care. There are a lot of misconceptions I read on here and other places in general. I hope I can help provide some insight.

First, I picked IM because I didn't want to see children/do any OB, plus it gave me an option to specialize if I wanted to. I knew I was probably going to do primary care after intern year. I liked inpatient medicine and of course was much better trained for it, but the thought of working every other weekend, nights, holidays made my decision really easy. Also, I saw the kind of work our private hospitalists were doing and it was so impersonal, consult heavy, paper pushing etc.

I also really think residency clinic does such a huge disservice for primary care. I bet you won't find 10 IM residents in the country that love their continuity clinic. I think getting past this as your impression of your future career is one of the biggest hurdles. Staff turnover, very sick chronic patients, more onus on the residents to do tasks you won't do in practice (PAs, call every single patient with results, update histories in the chart etc), waiting in a line to check out to an attending; all these things are way better in my experience in practice.

I'll try to highlight some things about my job that I think are important. I cannot emphasize this enough: Always remember you have all the leverage when looking for a job in primary care as a physician. This was very apparent to me when I started looking for a job. Do not be afraid to ask for things you want in the job. I work in a mid-sized city in the SE so it may vary some accordingly. I work for a large healthcare corporation, so I don't worry about overhead, hiring etc. I do have a ton of say in the basic operations of our clinic on a local level. Our manager is very responsive and our staff is efficient. My medical assistant is very good and pretty much knew how I like to do things after the first 6 months. I work 4 days per week (off Friday, this is something I was looking for). I see patients from 8-5 with an hour lunch. I am still building my practice but on average see 15-16 a day at this point, plan to get to 18-20, which is what other more tenured providers in our system are seeing. We don't do pure RVU base compensation but it turns out similar. If I bill efficiently (make sure to do medicare wellness visits when those patients come in for follow up), I can easily do about $260k per year seeing 15-16 a day, 4 days per week. I mix in probably a procedure or two per week (joint injection, minor skin stuff, I&D), but there is no pressure for me to do that. I supervise an NP as well, which my employer pays me 1k a month for to add on top of that.

Ultimately, I have great work life balance and I make plenty of money for what I want to do. I always finish notes and results before I go home. I usually get in around 7:30 to do results and I'm usually home by 5:45 (15 minute commute home). I have always been fairly efficient charting but I do feel I document pretty well compared to what I'm seeing in the community (its horrible).

Hope this helps, let me know if you have any Qs

That sounds like a phenomenal setup. Out of curiosity, where are you geographically located? I'm IM as well, and definitely feel like my outpatient experience is lacking, but have become fed-up with the inpatient grind.

 

[fooli_doc]

I am in the Southeast. By no means rural, metro area somewhere around 600k.

There is a lot of learning curve when you start, but its manageable. My very first patient I saw in practice post-training was on Trintellix, chronic Adderall (fortunately they came with neuropsychologist eval and a consistent history of controlled fills), and a few meds chronically for dermatology. I had never even heard of Trintellix, my attendings in training would have had a stroke if I prescribed someone a stimulant, and the last thing on your mind for a residency clinic patient with 10 chronic conditions is their skin. You learn fairly quickly. One thing I think is important is I may not always know what to do for a patient at the time I see them, but I always know what not to do and that is OK. I have been able to mold my practice to my comfort but am always looking to expand my skillset. I keep my controlled meds very tight and minimal, but I will say it is very hard to completely eliminate from community practice. As far as procedures go, I was able to do a few I&Ds, minor skin stuff, joint injection (knees, subacromial bursa, trochanteric bursa) in training and have rolled with it in practice with great results.

Edit: Underrated part of my job is frequent free drug rep lunch if you can tolerate it. It does actually help catch you up to speed on some of the branded meds, but I still incorporate them as I am comfortable.