Resident Continuity Clinic vs "Real World" Outpatient

[BillBill1219]

A vast majority of my colleagues go into hospital medicine upon graduating. Even those thinking of doing outpatient end up taking hospitalist jobs. My program is very inpatient heavy and the only exposure we get to primary care is our continuity clinic where we commonly see low-functioning, uninsured, uneducated, chronically co-morbid, often drug addicted patients. We get a taste of insurance company denials, mountainous levels of paperwork, and an outdated EMR (eCW). Could this lack of exposure to a properly run outpatient clinic be the reason so many choose to avoid clinic medicine? I am not terribly keen on the 7 on 7 off hospitalist schedule and would rather work more regular hours with no weekends or holidays but I can see the why my colleagues choose to stay 10,000 feet away from an outpatient clinic after graduation. So...is continuity clinic anything like the "real world"?

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[Angler]

So...is continuity clinic anything like the "real world"?

Sorry for the trite answer, but it depends. The fact is that most pure IM residencies emphasize inpatient medicine over outpatient. Obviously, there are 1° care IM residencies that don't. It's unfortunate, because there are a lot of outpatient situations which are not frustrating, like the poorly functioning clinics that you reference. Moreover, the "better" residencies which allow a lot of independence tend to be located in big cities with the type of demographics you describe. It's the nature of the beast.

If you search out outpatient primary care settings in areas with higher SES, there tend to be better functioning clinics/offices. Of course, you've still got the bureaucracy of hashing out how you get paid, but that is a fact of life of 21st century medicine wherever you work, unless you find a place where you don't have to manage your practice. But then, you're kinda at the mercy of your employer.

If your mission is to help the masses, and not just the middle (and up) class, then you will often run up against frustration. In that case, you'll have to balance that frustration with the satisfaction of provision of good health care to all.

Edit: typo due to user error.

 

[chessknt]

Honesty I love my outpt specialty clinic so much more than my fellow clinic. I had a patient who really annoyed me--spent all this time discussing hsi issue and ways we were going to address it--didnt do anything I said then would show up to the hospital then come whining back to clinic saying he needed xyz or he would die etc so I just fired him because it was dragging me and all the staff down. Could never do that in fellowship.

 

[BillBill1219]

So basically this just sucks for years and years until it gets better. But it might not get better depending on the practice setting. Not to sound overly cynical but that is the only concussion I am able to draw at this point.

 

[gutonc]

So basically this just sucks for years and years until it gets better. But it might not get better depending on the practice setting. Not to sound overly cynical but that is the only concussion I am able to draw at this point.

I would say that virtually any outpatient clinic is better as an attending than a resident/fellow. There will be various flavors of suck based on the clinic, but none of them will be as dysfunctional or annoying as even the best run resident clinic (assuming such a thing exists).

 

[NewYorkDoctors]

So basically this just sucks for years and years until it gets better. But it might not get better depending on the practice setting. Not to sound overly cynical but that is the only concussion I am able to draw at this point.

If you get paid for sucky work, then sign me up and drag me through the mud!

But also when you are an attending, all of these prior authorization tasks are all done online with your accounts / NPI. As a resident you have no such luxury of using the attending's NPI accounts and you must call and fill out forms.

Moreover, resident clinics tend to see the most destitute of destitute and patients tend to have more social issues

private practice GIM with more well off (not exactly rich but even "normal middle class") patients tend ot have fewer social hedache issues... usually

 

[dozitgetchahi]

I would say that virtually any outpatient clinic is better as an attending than a resident/fellow. There will be various flavors of suck based on the clinic, but none of them will be as dysfunctional or annoying as even the best run resident clinic (assuming such a thing exists).

Agree.

Resident/fellow clinics frankly suck. The support staff are either nonexistent or too few in number to help much, nothing really works well, you have no say in anything, trainees are expected to pick up the slack with a huge amount of scut work, everyone knows that you’re only passing through for a few years so nobody cares if it sucks for you, etc.

This is usually quite a bit different in your own clinic as an attending - but again, to different degrees.

That said, a ****ty day in my OP clinic as an attending is better than almost any day I worked in the hospital as a resident. I’m happy to be OP only.

 

[dgdg]

IM programs are probably always going to be inpt heavy, yet many in the past have gone into outpatient clinics over the decades and did fine.
Many of the outpt problems you'll see in clinic are simply less severe inpatient issues you managed all the time. Simple outpatient ortho may be one example where you don't manage much as inpt. Also, you might be surprised how much the outpatient clinics train you for non hospital work.
You'll still need to keep learning, but no doubt you could do well with it.

 

[BillBill1219]

One realization I had upon observing an OP rheumatologist recently was that a lot of the joy she experienced in her work was derived from her relationship she had with patients. She knew each of them as a person, knew details about their lives, saw them improve from a crippled mess to functioning human. A lot of visits were like catching up with old friends. This experience is all but absent from the resident clinic because we are there every 5th week and constantly see patients for the first (and often only) time. So if a key "ingredient" in finding satisfaction in OP work is building pt relationships, we simply do not have the opportunity to establish such.

 

[VA Hopeful Dr]

One realization I had upon observing an OP rheumatologist recently was that a lot of the joy she experienced in her work was derived from her relationship she had with patients. She knew each of them as a person, knew details about their lives, saw them improve from a crippled mess to functioning human. A lot of visits were like catching up with old friends. This experience is all but absent from the resident clinic because we are there every 5th week and constantly see patients for the first (and often only) time. So if a key "ingredient" in finding satisfaction in OP work is building pt relationships, we simply do not have the opportunity to establish such.

This is one of the best things about outpatient. Even ignoring the fact that you get to know your patients as actual people, once you've seen them enough times you know what's going on and so the visits get substantially easier. On a given day half my schedule is people there for stable chronic disease follow-up appointments. I ask a few questions, do a focused physical exam, order refills and labs.

 

[Angler]

once you've seen them enough times you know what's going on and so the visits get substantially easier.

Exactly. That gives you time for some therapeutic social banter. Therapy for you and your patient.

 

[NotAProgDirector]

One realization I had upon observing an OP rheumatologist recently was that a lot of the joy she experienced in her work was derived from her relationship she had with patients. She knew each of them as a person, knew details about their lives, saw them improve from a crippled mess to functioning human. A lot of visits were like catching up with old friends. This experience is all but absent from the resident clinic because we are there every 5th week and constantly see patients for the first (and often only) time. So if a key "ingredient" in finding satisfaction in OP work is building pt relationships, we simply do not have the opportunity to establish such.

This.

The real joy in an outpatient continuity clinic is the continuity. It's knowing your patients, getting to see and talk to them. Primary care naysayers will tell you that you manage the worried well all the time, and that you hardly have opportunities to make a difference. But they miss the whole point.

When I was a PCP, I had a couple under my care. Each of them was cheating on the other, and neither knew. I knew all about it. Was able to meet with each of them independently, help them address their issues, and watched their marriage come back together. That will never be some CMS metric.

If you go into primary care, the first 2 years is tough. You'll think you made a mistake. After the first 6 months, you'll know your sick cohort. After 2 years, you'll know everyone -- and then it's really great.

 

[BillBill1219]

This.

The real joy in an outpatient continuity clinic is the continuity. It's knowing your patients, getting to see and talk to them. Primary care naysayers will tell you that you manage the worried well all the time, and that you hardly have opportunities to make a difference. But they miss the whole point.

When I was a PCP, I had a couple under my care. Each of them was cheating on the other, and neither knew. I knew all about it. Was able to meet with each of them independently, help them address their issues, and watched their marriage come back together. That will never be some CMS metric.

If you go into primary care, the first 2 years is tough. You'll think you made a mistake. After the first 6 months, you'll know your sick cohort. After 2 years, you'll know everyone -- and then it's really great.

I am quite used to thinking that I have made a mistake by entering this field in the first place 🤣. Kidding aside, I am glad there are those who enjoy outpatient and see it as a viable career path.