Rheum - seeing consults in private practice

[konromellie]

IM PGY-1 here, just did a rheum rotation and I really enjoyed it, am now strongly considering rheum. We'd typically spend half the day in clinic and the other half of the day seeing consults. I liked this balance of inpatient and outpatient and I do enjoy seeing consults, even the silly ones. My understanding is that most private practice rheumatologists spend all or almost all of their time in clinic. I wanted to know if there are private practice jobs out there in which seeing consults is a good chunk of the job. It'd be nice to spend some half days or days seeing consults as it breaks up the monotony of being in clinic all the time. I have little to no interest in going academic. Would appreciate insight from any rheum fellows/attendings out there. Thanks!

---

Members don't see this ad.

 

[dozitgetchahi]

IM PGY-1 here, just did a rheum rotation and I really enjoyed it, am now strongly considering rheum. We'd typically spend half the day in clinic and the other half of the day seeing consults. I liked this balance of inpatient and outpatient and I do enjoy seeing consults, even the silly ones. My understanding is that most private practice rheumatologists spend all or almost all of their time in clinic. I wanted to know if there are private practice jobs out there in which seeing consults is a good chunk of the job. It'd be nice to spend some half days or days seeing consults as it breaks up the monotony of being in clinic all the time. I have little to no interest in going academic. Would appreciate insight from any rheum fellows/attendings out there. Thanks!

You can absolutely go see consults as a PP rheumatologist. It’s not hard to get a job set up that way.

However, as you get farther on in training, you may realize that there are very good reasons why you may not want to. (I am a PP rheumatologist who is 100% outpatient, and you would have to drag me kicking and screaming into the hospital to see a consult.) It’s time consuming, it feels like a major distraction from all the work that needs to be done in clinic, and it doesn’t reimburse well. Also, bear in mind that a lot of community hospital rheumatology consults are not nearly as interesting as what you might see at a tertiary care center. You’re not generally going to be called about AAV, sick lupus patients, etc. You’ll get called about gout flares (hospitalist should know how to manage these), “we don’t know what is wrong with this patient so let’s call rheumatology”, etc.

But if you want to do it, knock yourself out. It’s not hard to find a job like that.

 

[Residentdoc86]

Currently PGY-5 at a large academic center with high volume of inpatient consults ranging from gout, SLE, AAV, to really sick patients who we get called for "does this patient have one of your weird diseases?" We see very interesting cases but I can certainly say I'm not always excited to go from clinic to the hospital to see 4 new consults and rounding on olds (our census can be anywhere from 10-20 patients). I don't like having to think about pending consult while trying to take care of the patient in front of me.

Regardless, would say majority of those outpatient jobs with a little inpatient consult tend to be in an academic center where you'll likely have a resident to help versus doing the consult yourself. As @dozitgetchahi pointed out, unless you're in a big center with protected time for inpatient consult it's almost not even worth the headache doing inpatient consults. Also you'd have to work weekends.


Feel free to PM me if you have specific questions.

 

[bronx43]

IM PGY-1 here, just did a rheum rotation and I really enjoyed it, am now strongly considering rheum. We'd typically spend half the day in clinic and the other half of the day seeing consults. I liked this balance of inpatient and outpatient and I do enjoy seeing consults, even the silly ones. My understanding is that most private practice rheumatologists spend all or almost all of their time in clinic. I wanted to know if there are private practice jobs out there in which seeing consults is a good chunk of the job. It'd be nice to spend some half days or days seeing consults as it breaks up the monotony of being in clinic all the time. I have little to no interest in going academic. Would appreciate insight from any rheum fellows/attendings out there. Thanks!

Most hospitals simply don’t have many rheum consults so it would be very unlikely to find a job where it’s “a big chunk of the job.”

The only places that have such volume are big tertiary care centers and we’ve discussed here numerous times that rheum jobs in fakedemia is akin to indentured servitude. In fact, I would argue that rheum jobs in any metro area is not tenable in the long run.

If you want to do rheum AND want a good job, then you’ll need to work in rural/semi rural.

 

[NewYorkDoctors]

side note one rheumatologist whom I refer patients to is an associate professor of medicine at NYU.. big researcher academic etc...

but also a private practice for cash business seeing... osteoarthritis, psychosomatic stuff, ANA 1:80, gout uncomplicated, osteoporosis get some Evenity or Tymlos going ... for cash money no less no insurance allowed! anyone has a legit vasculitis or something gets fast tracked to NYU.

 

[bronx43]

side note one rheumatologist whom I refer patients to is an associate professor of medicine at NYU.. big researcher academic etc...

but also a private practice for cash business seeing... osteoarthritis, psychosomatic stuff, ANA 1:80, gout uncomplicated, osteoporosis get some Evenity or Tymlos going ... for cash money no less no insurance allowed! anyone has a legit vasculitis or something gets fast tracked to NYU.

Why would people pay cash when they can just see any rheum at one of the many hospital systems?

 

[NewYorkDoctors]

Why would people pay cash when they can just see any rheum at one of the many hospital systems?

"new yawhkas" lol. some people don't mind paying if it means getting to the front of the line.

 

[dozitgetchahi]

Why would people pay cash when they can just see any rheum at one of the many hospital systems?

Yeah I’m confused why any rheumatologist would want a side business solely composed of some of the most miserable consults in rheumatology (even if it was cash only).

These types of consults are usually even worse when it’s rich “worried well” types. This isn’t “easy money” by any means. It’s trying to get histrionic bored rich housewives to realize that there actually isn’t anything wrong with them. Take a deep breath, and get ready for 60-75 min visits where you review Ms. Wealthy Wife’s 5 previous workups with many of the most prestigious rheumatology departments in the country - and where they all have come to the same conclusion that she is actually OK. But there must be something wrong with me! I am fatigued.

I did a lot of that in fellowship. Hard pass.

 

[bronx43]

Yeah I’m confused why any rheumatologist would want a side business solely composed of some of the most miserable consults in rheumatology (even if it was cash only).

These types of consults are usually even worse when it’s rich “worried well” types. This isn’t “easy money” by any means. It’s trying to get histrionic bored rich housewives to realize that there actually isn’t anything wrong with them. Take a deep breath, and get ready for 60-75 min visits where you review Ms. Wealthy Wife’s 5 previous workups with many of the most prestigious rheumatology departments in the country - and where they all have come to the same conclusion that she is actually OK. But there must be something wrong with me! I am fatigued.

I did a lot of that in fellowship. Hard pass.

That was literally my job day in day out in fakedemia. True misery like no one could ever imagine.

 

[NewYorkDoctors]

Yeah I’m confused why any rheumatologist would want a side business solely composed of some of the most miserable consults in rheumatology (even if it was cash only).

These types of consults are usually even worse when it’s rich “worried well” types. This isn’t “easy money” by any means. It’s trying to get histrionic bored rich housewives to realize that there actually isn’t anything wrong with them. Take a deep breath, and get ready for 60-75 min visits where you review Ms. Wealthy Wife’s 5 previous workups with many of the most prestigious rheumatology departments in the country - and where they all have come to the same conclusion that she is actually OK. But there must be something wrong with me! I am fatigued.

I did a lot of that in fellowship. Hard pass.

yeah same thing when people with some end stage IPF with Class3 PH on Ofev, supplemental oxygen, and Tyvaso and need palliative care see my google high reviews and decide to come to me and I tell them yeah no that's not how it works. If you saw the leaders of the field at tertiary care center of excellent, what makes you think I the lowly but friendly (hence a lot of 5 stars) community doctor has any other answers for you?
these patients grumble .. hmphm hmph now you're going to charge my insurance.
nope sir or maam... I waive copay and I waive this visit and charge nothing. Good luck and good bye.


anyway addendum:

Conversations with 4 Dual-Certified Rheumatologists - The Rheumatologist

Dual certification is neither a conventional nor a low-stress career path in medicine. But choosing to train in specialties complementary to rheumatology, such as pulmonary/critical care or allergy/immunology, can offer more expansive career and research opportunities. This career choice can...

www.the-rheumatologist.org

dual cert rheumatologists. this is usually for super academics doing super duper research

but still these things are complrementary enough and could help craete a niche to avoid seeing those ANA 1:80 consults

 

[bronx43]

yeah same thing when people with some end stage IPF with Class3 PH on Ofev, supplemental oxygen, and Tyvaso and need palliative care see my google high reviews and decide to come to me and I tell them yeah no that's not how it works. If you saw the leaders of the field at tertiary care center of excellent, what makes you think I the lowly but friendly (hence a lot of 5 stars) community doctor has any other answers for you?
these patients grumble .. hmphm hmph now you're going to charge my insurance.
nope sir or maam... I waive copay and I waive this visit and charge nothing. Good luck and good bye.


anyway addendum:

Conversations with 4 Dual-Certified Rheumatologists - The Rheumatologist

Dual certification is neither a conventional nor a low-stress career path in medicine. But choosing to train in specialties complementary to rheumatology, such as pulmonary/critical care or allergy/immunology, can offer more expansive career and research opportunities. This career choice can...

www.the-rheumatologist.org

dual cert rheumatologists. this is usually for super academics doing super duper research

but still these things are complrementary enough and could help craete a niche to avoid seeing those ANA 1:80 consults

There’s actually a huge need in rheum-pulm, since the understanding of ILD and its relation to serological testing is quite limited.

I tossed around the idea of doing a pulm fellowship (non CC) but I couldn’t justify 2 years of lost income.

Alot of people do allergy-rheum but honestly I don’t see the value add there… immunology is the self proclaimed link but it’s quite meaningless from a practical standpoint - not more meaningful than saying physiology is the link between rheum and pulm.

 

[sloh]

"new yawhkas" lol. some people don't mind paying if it means getting to the front of the line.

How much does he charge?

 

[Ubba]

Come to think of it, maybe concierge Rheum is a good way to go if there's an abundance of rich people who like killing time at the doctor's office. 400-500/hr cash? Why let Psych have all the fun?

 

[dozitgetchahi]

Come to think of it, maybe concierge Rheum is a good way to go if there's an abundance of rich people who like killing time at the doctor's office. 400-500/hr cash? Why let Psych have all the fun?

There are a few rheums out there who have done this.

Problem is, yet again, that the clientele is likely going to wear you down. The kind of person who wants cash only wide open access to a rheumatologist (and who has the means to pay for it) is often going to be “a certain kind of patient”, so to speak.

Wealthy people who actually have serious rheumatologic disease are often going to take themselves to prestigious academic centers and stay there. A lot of high prestige rheum departments have a “fast track” for these types of patients, and they basically get a concierge experience anyway.

 

[NewYorkDoctors]

Still this kind of patient tends to be more educated and as long as you do your due diligence this person will keep giving you cash

Many Medicaid people I serve demand instant access , are distrustful of western medicine , and also balk when I discuss lifestyle modifications like walking on a pedometer to lose weight over time to improve OSA or to order an automated bed to sleep head of head 45 degrees to prevent reflux and aspiration … wane some magic cough pill . Gefapixant notbapproved in us sorry

 

[bronx43]

Come to think of it, maybe concierge Rheum is a good way to go if there's an abundance of rich people who like killing time at the doctor's office. 400-500/hr cash? Why let Psych have all the fun?

I wouldn’t see these patients for $1000 an hour. No amount of money is worth it.

 

[konromellie]

Thanks a lot for your input everyone - I can see why most rheums in PP don't want to see consults now. Being expected to see them on top of clinic without any protected time is a big yikes. Would make much more sense to knock out a follow-up in the time it takes to see a consult.

Most hospitals simply don’t have many rheum consults so it would be very unlikely to find a job where it’s “a big chunk of the job.”

The only places that have such volume are big tertiary care centers and we’ve discussed here numerous times that rheum jobs in fakedemia is akin to indentured servitude. In fact, I would argue that rheum jobs in any metro area is not tenable in the long run.

If you want to do rheum AND want a good job, then you’ll need to work in rural/semi rural.

Interesting. Is it because the academic centers in the big metros snatch up all the interesting cases? Leaving OA/RA/etc for the PP groups?

One more thing I wanted to ask is how big of thing is MSKUS in PP? One day a week during my rotation, we had ultrasound clinic in which we did diagnostic ultrasound and ultrasound guided injections. I really enjoyed this but can see it not being as big of a thing in PP due to reimbursement/the logistics of setting it up.

 

[gutonc]

Thanks a lot for your input everyone - I can see why most rheums in PP don't want to see consults now. Being expected to see them on top of clinic without any protected time is a big yikes. Would make much more sense to knock out a 4-6 follow-ups in the time it takes to see a consult.

FTFY.

I'm onc, not rheum, but I suspect that the amount of work required for a complex new inpatient consult is similar.

In my prior job, just walking to and from the clinic to the patient's room was at least the amount of time it took me to see one outpatient follow up. Talking to the patient (and inevitable family members "in healthcare" at the bedside) took the same time as seeing 1-2 outpatient follow ups...3-4 if the patient said "hang on a second, let me call my cousin Charlene who's a radiologist (aka X-ray tech) because she's gonna have questions". Chart biopsy and note writing was another follow up at a minimum and then whatever time it took to talk to other consultants, the requesting doc, etc, easily ate up at least one more follow up visit's worth of time. So that's at least 4 outpatient follow ups, probably 5 or 6, that I could have seen in the same amount of time. That inpatient consult pays me 3.5 wRVU. The 4-6 outpatients I could see in the same time period pays me 8-12 wRVU.

 

[dozitgetchahi]

FTFY.

I'm onc, not rheum, but I suspect that the amount of work required for a complex new inpatient consult is similar.

In my prior job, just walking to and from the clinic to the patient's room was at least the amount of time it took me to see one outpatient follow up. Talking to the patient (and inevitable family members "in healthcare" at the bedside) took the same time as seeing 1-2 outpatient follow ups...3-4 if the patient said "hang on a second, let me call my cousin Charlene who's a radiologist (aka X-ray tech) because she's gonna have questions". Chart biopsy and note writing was another follow up at a minimum and then whatever time it took to talk to other consultants, the requesting doc, etc, easily ate up at least one more follow up visit's worth of time. So that's at least 4 outpatient follow ups, probably 5 or 6, that I could have seen in the same amount of time. That inpatient consult pays me 3.5 wRVU. The 4-6 outpatients I could see in the same time period pays me 8-12 wRVU.

Yeah exactly.

It’s not a 1:1 exchange for hospital consult:clinic followup, it’s more like at least 1:3 or 1:4, with a healthy serving of distraction along with it.

In my current situation, my PP uses epic but the local hospital uses Allscripts, which is godawfully slow and isn’t nearly as easy to use. Trying to figure out how to be efficient with an EMR you use 1/10th of the time you use the other one really sucks.

Never mind that your clinic will still be full, so you’ll be seeing these consults either before or after clinic. Getting there at like 6am (or staying way past clinic into the evening) to see the consult followups gets way less appealing the longer you’re in practice (especially when, as a rheumatologist, you don’t have to).

 

[dozitgetchahi]

Thanks a lot for your input everyone - I can see why most rheums in PP don't want to see consults now. Being expected to see them on top of clinic without any protected time is a big yikes. Would make much more sense to knock out a follow-up in the time it takes to see a consult.


Interesting. Is it because the academic centers in the big metros snatch up all the interesting cases? Leaving OA/RA/etc for the PP groups?

One more thing I wanted to ask is how big of thing is MSKUS in PP? One day a week during my rotation, we had ultrasound clinic in which we did diagnostic ultrasound and ultrasound guided injections. I really enjoyed this but can see it not being as big of a thing in PP due to reimbursement/the logistics of setting it up.

You can do the ultrasound guided stuff if you want to.

At my last two PPs, no ultrasound was available - so I would have to front the cost of that if I wanted one. Then, the time it takes to roll in the ultrasound machine in the midst of a busy clinic isn’t always worth the (often modest) benefits you get in terms of diagnosis. And I already try to avoid doing procedures as much as possible just because it bogs down clinic and isn’t worth it from a collections standpoint unless you have a well oiled workflow with staff who know exactly how to help (I don’t).

Also, I see plenty of complex, legit rheumatology in my PP clinic. One little secret you won’t hear in tertiary medical centers: most really sick people are actually taken care of in the community. Tertiary care doesn’t have nearly the capacity to see all of these people.

 

[NewYorkDoctors]

As mentioned in the other post get a butterfly IQ (I don’t work for them I just like their product ) . Even if you aren’t allowed to use your own product at your workplace for billing / quality reasons , it’s still super fast to look at an obese persons knee to see if there is an effusion or not .

 

[gutonc]

Also, I see plenty of complex, legit rheumatology in my PP clinic. One little secret you won’t hear in tertiary medical centers: most really sick people are actually taken care of in the community. Tertiary care doesn’t have nearly the capacity to see all of these people.

This is true in oncology too, and I suspect across most/all IM specialties except possibly procedural ones where the really weird/complex stuff sometimes can't be managed in the community. I saw more of that stuff in my first year as a community oncologist than I did all throughout fellowship.

 

[NewYorkDoctors]

same here. I never saw a case of Anti MDA5 antisynthetase syndrome (to keep the rheum pulm connection in residency or fellowship (saw the EJs, OJs, SRP etc...) but saw two cases as attending in the community. Both had RPILD and both required "yeomans work" by all involved. one survived and is doing great on MMF + CS without the need for third agent
the other one is no longer with us now.

 

[hotsaws]

Most of the happier docs I know are ones that don't ever step foot in the hospital anymore. This includes surgeons and non-procedural specialties. Hospital culture kind of sucks and, as was mentioned above, the going from clinic to hospital in a given day just doesn't make any sense time wise. I could see it as a temporary thing if you are trying to build a practice and maybe you want to offer inpatient consults. You could allow consults to be called to you during the day and just briefly take down info and then go see them after you finish clinic. This would make days long depending on volume but it could help build a practice and "legitimize" your practice. I know people that have done this in allergy. This only makes sense to me if you're breaking into a saturated market where you don't have full clinics already. If you are in a market where your outpatient clinic is flush with patients, then there wouldn't be much benefit from this.

If you really want consults as part of your weekly routine, you're probably better off going academic, so at least you have residents or fellows to do some of the grunt work and you'd probably have the protected time and generally lower volume. I think as you progress in training, you will realize that PP clinic is not really all that monotonous and you may not want to see the "cool" or "interesting" stuff all that often. I see a wide variety of disease in PP and I can do as much as I want to, or refer as much as I want out. My lane is what I make it and what I'm comfortable with. I'm not a slave to hospital formularies and policies (eg only certain biologics, HAE drugs, biologics available...or having to deal with BS about getting imaging or procedures scheduled). In PP, I see EGPA, ABPA, HAE, primary immunodeficiencies, fungal sinus disease, and some other random stuff and plenty of new rashes. I also see tons of bread and butter. I would take a monotonous clinic full of bread and butter allergy and asthma all day.

 

[NewYorkDoctors]

certain private practices who have sufficient number of partners (maybe even two) can both decide who is on inpatient duty and who is on clinic and set up work rotations.

but as an individual solo practitioner, it makes little sense to travel back and forth unless you are in walking distance to the office and as hotsaws mentions you need to get new patients for your office. this might still be the case for certain primary care providers or if it is a very saturated market (nephrology lol .. go schmooze some consults)

 

[sloh]

I also see tons of bread and butter. I would take a monotonous clinic full of bread and butter allergy and asthma all day.

Quick visits, probably pays you better as well

 

[hotsaws]

Quick visits, probably pays you better as well

Yeah, it does. They also are generally nice people with reasonable expectations who I can help significantly. That never gets boring to me. Sure, it's cool to see something more complex or rare but I'm perfectly content just seeing the simple stuff and knowing that it's gonna be an easy win.

 

[Legend of Link]

Yeah, it does. They also are generally nice people with reasonable expectations who I can help significantly. That never gets boring to me. Sure, it's cool to see something more complex or rare but I'm perfectly content just seeing the simple stuff and knowing that it's gonna be an easy win.

Nothing beats quick and easy patients and easy and fast clinic days.
Currently doing a rheuma rotation and I love those easy RA follow ups. Done in 5 minutes. Short notes