Weekly follow-up volume?

[roehriat]

Curious how many follow-ups y'all are seeing in an average week. Community folks vs academics?

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[TheWallnerus]

Used to never be (much of) a thing: the number of follow up visits outnumbering the number of times the patient came in for treatment

 

[OTN]

29 f/u appts this week in 4 days of clinic. Private practice. Seems about standard for my weeks. I usually run between 30-40 on tx with 3-4 SBRT tx's per day as well.

 

[Lamount]

~13 f/u appts a week with 3 clinic days/week. Academic, main hospital, mostly lung cancer. I usually have 15-20 on treatment with ~4 SBRTs a day. Usually have 5-7 new patients a week, and 6-9 sims a week.

 

[roehriat]

29 f/u appts this week in 4 days of clinic. Private practice. Seems about standard for my weeks. I usually run between 30-40 on tx with 3-4 SBRT tx's per day as well.

Wow. How do you structure your week to see 30 f/u's and have time to see all the new patients to keep 30-40 on beam?

 

[jondunn]

OTN - when do you contour?

Also do you find that these are all follow ups you really need to be continuing to see? Just curious.

 

[Mandelin Rain]

I feel like lungs are must see follow ups for a while. Discharge breast after 1 or maybe 2 visits. Prostates I follow forever if urologist isn't; I've seen PCP drop ball too many times with post-RP/XRT PSAs. Rectum and esophagus I follow through 1 post surgery visit. Head and necks typically for 2 years. Brain mets/primary usually q3 months for life.

 

[deleted941485]

I used to keep it pretty low make room for new patients. Most not following for greater than a year if that. Covid forget it it was telehealth if it was working or nurses. Follow ups I would defer to whomever was willing to follow them PCP or a referring. EM coding is changing too according to my paymasters. Now I’m following more frequently and for longer. Helps justify my existence $.

 

[OTN]

OTN - when do you contour?

Also do you find that these are all follow ups you really need to be continuing to see? Just curious.

H+N follow ups are crucial, as medoncs and ENT docs aren't as good as we are at dealing with post-tx complications. I also follow my lung ca patients into the future to help with tx decisions if recurrence occurs. Prostate I also follow indefinitely, given the late recurrences we can see. Breast I start to spread out pretty aggressively after acute toxicity is done with, but I still follow them to 5 years out.

Most patients I treat with SBRT for oligomets I see back after every round of imaging to see if they would benefit from more SBRTing. I would strongly encourage everyone to do this. It's been a critical part of my building a large SBRT for oligomets practice.

I don't follow rectal cancer patients after their surgery, as most of what we treat gets removed. I also don't follow GBM patients that long, as we have neuro-oncologists in our practice, so I'll let them handle that pain. I was following them long-term after treatment, but it was just too depressing to have to hear about progression without being able to do much for it.

I think following patients for awhile has been great for me professionally. Not only can we actually help with small stuff from time to time, it helps me educate my patients better on what to expect for the long term, and I do enjoy the patient-doctor relationship that longer follow up creates.

Lots of my days start with 7 am SBRTs, but my clinic doesn't start until 9. So, I have a good two hours to catch up on dosimetry, and I also contour throughout the day when I have time.

 

[Mandelin Rain]

I also don't follow GBM patients that long, as we have neuro-oncologists in our practice, so I'll let them handle that pain. I was following them long-term after treatment, but it was just too depressing to have to hear about progression without being able to do much for it.

This is true, but I'm the Optune prescriber and the one most willing to have the hospice discussion, which I'm pretty liberal about if progressive symptoms/scans.

 

[RO28]

I follow all prostates, a handful of breast patients who dont get AI (most discharge at completion of treatment), HN. I definitely follow all my brain met SRS and all lung SBRT, I'm less picky about following for SBRT of random adrenal mets. I think it really helps to follow brain/lung imaging over time so you get a sense of what is radiation treatment effect and what is true progression. I'll also follow a patient if I did something weird fractionation wise.

 

[evilbooyaa]

H+N follow ups are crucial, as medoncs and ENT docs aren't as good as we are at dealing with post-tx complications. I also follow my lung ca patients into the future to help with tx decisions if recurrence occurs. Prostate I also follow indefinitely, given the late recurrences we can see. Breast I start to spread out pretty aggressively after acute toxicity is done with, but I still follow them to 5 years out.

Most patients I treat with SBRT for oligomets I see back after every round of imaging to see if they would benefit from more SBRTing. I would strongly encourage everyone to do this. It's been a critical part of my building a large SBRT for oligomets practice.

I don't follow rectal cancer patients after their surgery, as most of what we treat gets removed. I also don't follow GBM patients that long, as we have neuro-oncologists in our practice, so I'll let them handle that pain. I was following them long-term after treatment, but it was just too depressing to have to hear about progression without being able to do much for it.

I think following patients for awhile has been great for me professionally. Not only can we actually help with small stuff from time to time, it helps me educate my patients better on what to expect for the long term, and I do enjoy the patient-doctor relationship that longer follow up creates.

Lots of my days start with 7 am SBRTs, but my clinic doesn't start until 9. So, I have a good two hours to catch up on dosimetry, and I also contour throughout the day when I have time.

That's great. Honestly it's what I wanted to do in residency. More so than from my side, is the desire for patients to minimize their doctors visits in the post-treatment period.
Most of my early breasts are getting seen by Surgeon and Med Onc routinely so I let them go. Even H&N the academic ENTs end up wanting to do a lot of the scopes and not alternating, so if they have minimal RT toxicity then what am I doing... lots of questions about whether a co-pay to see me vs someone actively treating/surveilling them from patients.
I do encourage patient to kick Med Onc f/u out of say a H&N who didn't get chemo (if looking to minimize visits), or the weird sarcoma patient who I give RT to but never got chemo, prob doesn't need to f/u with med onc anymore. Gyn is pretty permanent though which will build f/u volume.

 

[medgator]

H+N follow ups are crucial, as medoncs and ENT docs aren't as good as we are at dealing with post-tx complications. I also follow my lung ca patients into the future to help with tx decisions if recurrence occurs. Prostate I also follow indefinitely, given the late recurrences we can see. Breast I start to spread out pretty aggressively after acute toxicity is done with, but I still follow them to 5 years out.

Most patients I treat with SBRT for oligomets I see back after every round of imaging to see if they would benefit from more SBRTing. I would strongly encourage everyone to do this. It's been a critical part of my building a large SBRT for oligomets practice.

I don't follow rectal cancer patients after their surgery, as most of what we treat gets removed. I also don't follow GBM patients that long, as we have neuro-oncologists in our practice, so I'll let them handle that pain. I was following them long-term after treatment, but it was just too depressing to have to hear about progression without being able to do much for it.

I think following patients for awhile has been great for me professionally. Not only can we actually help with small stuff from time to time, it helps me educate my patients better on what to expect for the long term, and I do enjoy the patient-doctor relationship that longer follow up creates.

Lots of my days start with 7 am SBRTs, but my clinic doesn't start until 9. So, I have a good two hours to catch up on dosimetry, and I also contour throughout the day when I have time.

Similar to my practice, i don't follow breasts unless they aren't following with anyone else, but if med onc is managing AI and pcp/surgeon ordering mammo and doing annual exam, i usually get myself out of the picture after a year or so.

How do you manage to see all these patients? I find it difficult to follow everyone and still keep room for several new patient consults every week

 

[RadOncMegatron]

Similar to my practice, i don't follow breasts unless they aren't following with anyone else, but if med onc is managing AI and pcp/surgeon ordering mammo and doing annual exam, i usually get myself out of the picture after a year or so.

How do you manage to see all these patients? I find it difficult to follow everyone and still keep room for several new patient consults every week

I feel the same way and have started to really slim my follow up clinic.

 

[OTN]

Similar to my practice, i don't follow breasts unless they aren't following with anyone else, but if med onc is managing AI and pcp/surgeon ordering mammo and doing annual exam, i usually get myself out of the picture after a year or so.

How do you manage to see all these patients? I find it difficult to follow everyone and still keep room for several new patient consults every week

Sometimes there's hustling that has to happen if things get busy, and cutting down significantly on my breast follow ups helped a ton. I'm very good at being efficient and only documenting what needs to be documented. I've still been able to keep a "yes to everything right away" consult policy, which obviously is critical to success.

 

[RadOncMegatron]

Sometimes there's hustling that has to happen if things get busy, and cutting down significantly on my breast follow ups helped a ton. I'm very good at being efficient and only documenting what needs to be documented. I've still been able to keep a "yes to everything right away" consult policy, which obviously is critical to success.

I find that my mouth automatically says “yes, I can see this consult right away” like a reflex when my brain says “NO YOU FOOL YOU ARE TOO BUSY!!!!”

 

[RadOncDoc21]

29 f/u appts this week in 4 days of clinic. Private practice. Seems about standard for my weeks. I usually run between 30-40 on tx with 3-4 SBRT tx's per day as well.

Googly moogly…$$$! Chi Ching…

 

[jondunn]

if i followed my breast patients i would have to quit my job.

 

[RSAOaky]

4 days of clinic a week, I see about 8-10 follow ups a week on one day a week primarily. Have to see all patients once within 3 months, which makes it non billable, per ACR rules so I see all patients 6 weeks post op. Breast I see 1 year later then never again. Prostate if they see urology I try to turf after a year. SBRT lungs I follow forever. ChemoRT lungs I usually see every 6-12 months because they see medonc often. Any CNS I’ll follow at whatever their imaging intervals are. Any GI I see annually. Palliative I get rid of after first follow up and have medonc refer back with any issues. H&N I see at 6 weeks, 12 week, 6 months, then annually.

A year’s worth of follow ups nets me 700 RVUs. 25% of my clinical time is spent seeing follow ups that are worth $35k a year. I do it if I add value, otherwise it’s a waste of everyone’s time.

 

[GapCalc]

29 f/u appts this week in 4 days of clinic. Private practice. Seems about standard for my weeks. I usually run between 30-40 on tx with 3-4 SBRT tx's per day as well.

When I grow up, I want to be like OTN.

 

[radoncftw]

When I grow up, I want to be like OTN.

I dream of this efficiency.

 

[grenz]

Sometimes there's hustling that has to happen if things get busy, and cutting down significantly on my breast follow ups helped a ton. I'm very good at being efficient and only documenting what needs to be documented. I've still been able to keep a "yes to everything right away" consult policy, which obviously is critical to success.

What sections do you include in your consult note? I’ve thought about cutting all but HPI, P/E, and A/P now that we can bill by time, but it feels weird to do it.

Also, f/u clinic is a great use of some of your APP’s time. The rest of their time can be spend prepping and seeing your consults. I pretty much only see consults and follow ups that need to be treated.

 

[ramsesthenice]

Googly moogly…$$$! Chi Ching…View attachment 352591

I couldn’t resist using a blast from the past as a retort. Swimming in money sounds like a great idea on paper but…

 

[ramsesthenice]

When I grow up, I want to be like OTN.

I hate to break it to you, but you won’t ☹️. Dude is a freak (and I mean that with nothing but respect 🙂). Pretty much everyone wants to be a pro athlete at some point in their childhood but unless you have an underlying glandular issue that makes you freakishly tall or strong, hard work alone ain’t gonna cut it. I consider myself fairly high energy and busy. I’m only 40% clinical, I carry about 15 on treats per day, see around 10 consults and 10-15 f/u per week, have a lab, and write grants. Still, no amount of coffee could keep me going long term OTN numbers. I’d have to do a bump of coke around breakfast and lunch everyday just to keep pace. I hope that’s not your secret @OTN…

 

[RadOncDoc21]

I hate to break it to you, but you won’t ☹️. Dude is a freak (and I mean that with nothing but respect 🙂). Pretty much everyone wants to be a pro athlete at some point in their childhood but unless you have an underlying glandular issue that makes you freakishly tall or strong, hard work alone ain’t gonna cut it. I consider myself fairly high energy and busy. I’m only 40% clinical, I carry about 15 on treats per day, see around 10 consults and 10-15 f/u per week, have a lab, and write grants. Still, no amount of coffee could keep me going long term OTN numbers. I’d have to do a bump of coke around breakfast and lunch everyday just to keep pace. I hope that’s not your secret @OTN…

What kind of coke you use?

 

[RSAOaky]

I hate to break it to you, but you won’t ☹️. Dude is a freak (and I mean that with nothing but respect 🙂). Pretty much everyone wants to be a pro athlete at some point in their childhood but unless you have an underlying glandular issue that makes you freakishly tall or strong, hard work alone ain’t gonna cut it. I consider myself fairly high energy and busy. I’m only 40% clinical, I carry about 15 on treats per day, see around 10 consults and 10-15 f/u per week, have a lab, and write grants. Still, no amount of coffee could keep me going long term OTN numbers. I’d have to do a bump of coke around breakfast and lunch everyday just to keep pace. I hope that’s not your secret @OTN…

You have to have an efficient setup, good support staff, and a strong drive to consistently handle this volume, particularly as a generalist. Kudos to OTN, man's a beast.

 

[ramsesthenice]

What kind of coke you use?

When I imbibe, I drink Cherry Coke (the real stuff, not the sugar free crap). Of course, I was referencing the Whitney Houston kind of coke (RIP). Such talent, reduced to a cautionary tale.

 

[jondunn]

I hate to break it to you, but you won’t ☹️. Dude is a freak (and I mean that with nothing but respect 🙂). Pretty much everyone wants to be a pro athlete at some point in their childhood but unless you have an underlying glandular issue that makes you freakishly tall or strong, hard work alone ain’t gonna cut it. I consider myself fairly high energy and busy. I’m only 40% clinical, I carry about 15 on treats per day, see around 10 consults and 10-15 f/u per week, have a lab, and write grants. Still, no amount of coffee could keep me going long term OTN numbers. I’d have to do a bump of coke around breakfast and lunch everyday just to keep pace. I hope that’s not your secret @OTN…

Sounds like you’re also quite busy. You may be ‘40 percent clinical’ but you have the volume of a full time person for academics from what I know/see friends of mine doing

 

[RadOncDoc21]

When I imbibe, I drink Cherry Coke (the real stuff, not the sugar free crap). Of course, I was referencing the Whitney Houston kind of coke (RIP). Such talent, reduced to a cautionary tale.

View attachment 352607

In my area, the drug of choice is meth… we have evolved!

 

[evilbooyaa]

I hate to break it to you, but you won’t ☹️. Dude is a freak (and I mean that with nothing but respect 🙂). Pretty much everyone wants to be a pro athlete at some point in their childhood but unless you have an underlying glandular issue that makes you freakishly tall or strong, hard work alone ain’t gonna cut it. I consider myself fairly high energy and busy. I’m only 40% clinical, I carry about 15 on treats per day, see around 10 consults and 10-15 f/u per week, have a lab, and write grants. Still, no amount of coffee could keep me going long term OTN numbers. I’d have to do a bump of coke around breakfast and lunch everyday just to keep pace. I hope that’s not your secret @OTN…

40% clinical with 15 on treats and 10 consults a week?

My dude/dudette, that is insanely busy. Suggests if you were 100% clinical 5 days a week you'd have 37-38 on treat and see 25 consults a week. Obviously not a 1:1 comparison

Doing that plus having a lab and writing grants... I would need coke for your job. Hope you're making @OTN money with that schedule.

 

[CaesarRO]

I find that my mouth automatically says “yes, I can see this consult right away” like a reflex when my brain says “NO YOU FOOL YOU ARE TOO BUSY!!!!”

I'm curious when y'all say "yes I can see them right away" aside from those scenarios where the patient walks down from med onc office same day, how quickly are you actually getting them in? Same week?

 

[ramsesthenice]

40% clinical with 15 on treats and 10 consults a week?

My dude/dudette, that is insanely busy. Suggests if you were 100% clinical 5 days a week you'd have 37-38 on treat and see 25 consults a week. Obviously not a 1:1 comparison

Doing that plus having a lab and writing grants... I would need coke for your job. Hope you're making @OTN money with that schedule.

I doubt I make OTN money but between base and bonus I am north of 450 so doing very well for a physician scientist.

Its not as bad as it looks on paper and most of it comes down to 2 issues. First, There are 2 of us who treat prostate and I just happen to be the one with a clinic on the same day as 2 of our busier urologists. So for scheduling reasons, I end up with the lions share of prostates. And lets be honest, having 10 prostates is probably about as much work as having 3 H&N patients. My other problem is that I am the only one who does a few things including pancreas SBRT, prostate HDR or any gyn interstitial HDR. Whenever you are the only one who does something it is going to translate into numbers.

I don't want to downplay it, I am a busy guy, but its not as bad as it looks on paper. Unless I have a grant deadline approaching I almost never work nights and weekends. Its just a hard stop for me and a decision I made a long time ago. I spent too much of my 20s and 30s doing nothing but working. All that said, perceptions matter. If you want to get support from your chair and cancer center for your research and trials, nothing gits r' done like RVUs. Im happy to play up my comparative productivity when I need to, even though I know its strategically inflated to some extent

 

[Bequerel]

Support staff is key to efficiency. I have similar numbers to OTN, with 450-500 new starts per year and average 32-40 on treat. Use to be about 40 on treat, but now that I’ve been doing more apbi it’s dropped. I use to see 30-40 follow-ups per week but now have an NP who does more than half. I can’t overstate how much a competent NP can improve your QOL! Also have 2 RN’s an MA and 2 dosimetrists who are amazing. Place almost runs itself if you have the right staff. Took years and a supportive hospital to get it set up. 4 day work week.

 

[RSAOaky]

I'm curious when y'all say "yes I can see them right away" aside from those scenarios where the patient walks down from med onc office same day, how quickly are you actually getting them in? Same week?

I speak to my front desk and nursing staff and we go back and forth about where we can squeeze the patient in before calling them to let them know I'll skip lunch to see them only to be told they can't do that time because they're playing shuffleboard at noon and can we do next Friday?

In all seriousness though, if a referring physician feels a patient needs to be seen urgently I will typically see them within 24-48 hours, definitely same week unless they call on a Friday. I have 4 free lunch hours a week which means I can see 1-4 urgent consults a week. The more willing you are to see a patient urgently, the more likely you are to get the call when a patient needs to be seen urgently. It's a blessing and a curse.

 

[OTN]

Being in a true private practice, rather than being a hospital employee, means I can dial things in to a significant degree. The decisions our practice makes are made with MD efficiency and QOL in mind as well, which goes a long way. Additionally, I think the four day work week helps. I can put in 4 super-hard 10 or 11 hour days, then use the three days off to recharge so I have the energy to work hard for the next four.

Finally, I think my staff is incredible. From my MA to RN to dosimetry, therapy, and physics, we've been fortunate to be able to build up a fantastic team, so I can rely on them rather heavily to do what needs to be done. Without them it wouldn't be possible.

No coke, though- it's not like I'm the creator of the modern residency system or anything.

 

[RSAOaky]

Being in a true private practice, rather than being a hospital employee, means I can dial things in to a significant degree. The decisions our practice makes are made with MD efficiency and QOL in mind as well, which goes a long way. Additionally, I think the four day work week helps. I can put in 4 super-hard 10 or 11 hour days, then use the three days off to recharge so I have the energy to work hard for the next four.

Finally, I think my staff is incredible. From my MA to RN to dosimetry, therapy, and physics, we've been fortunate to be able to build up a fantastic team, so I can rely on them rather heavily to do what needs to be done. Without them it wouldn't be possible.

No coke, though- it's not like I'm the creator of the modern residency system or anything.

Kudos. I don't know you personally but this kind of thing always starts from the top. It's why hellpits remain hellpits. There's no way to retain this kind of talent when people don't like working for/with you.

 

[CaesarRO]

I speak to my front desk and nursing staff and we go back and forth about where we can squeeze the patient in before calling them to let them know I'll skip lunch to see them only to be told they can't do that time because they're playing shuffleboard at noon and can we do next Friday?

In all seriousness though, if a referring physician feels a patient needs to be seen urgently I will typically see them within 24-48 hours, definitely same week unless they call on a Friday. I have 4 free lunch hours a week which means I can see 1-4 urgent consults a week. The more willing you are to see a patient urgently, the more likely you are to get the call when a patient needs to be seen urgently. It's a blessing and a curse.

Oh definitely, if referring says "please see urgently" I'll squeeze em in same day or next.

I'm in a situation where I'm building up a new practice and trying to figure out the sweet spot for seeing "routine" referrals promptly. 3/4 of the time the patient wants to be seen later or clinically they are too close to post-op for anything to be done quickly in any case. I feel like we see patients quickly, but not sure what the referring docs think.

 

[CaesarRO]

Support staff is key to efficiency. I have similar numbers to OTN, with 450-500 new starts per year and average 32-40 on treat. Use to be about 40 on treat, but now that I’ve been doing more apbi it’s dropped. I use to see 30-40 follow-ups per week but now have an NP who does more than half. I can’t overstate how much a competent NP can improve your QOL! Also have 2 RN’s an MA and 2 dosimetrists who are amazing. Place almost runs itself if you have the right staff. Took years and a supportive hospital to get it set up. 4 day work week.

These set ups require a partner right? Can't do 4 work weeks as a solo doc because of "supervision"

 

[RadOncDoc21]

Kudos. I don't know you personally but this kind of thing always starts from the top. It's why hellpits remain hellpits. There's no way to retain this kind of talent when people don't like working for/with you.

Also if admin is willing to help out in the hospital setting, but agree kudos for the strong work and developing a great system.

 

[TheWallnerus]

These set ups require a partner right? Can't do 4 work weeks as a solo doc because of "supervision"

You can if hospital based (do we not recall ASTRO et al “losing it” over making radiation being no physical presence required)

Medicare looking at making virtual supervision long term but impossible to predict if they will or won’t

 

[temujim]

Would like to see some research into how often do we really need to see follow-ups. NCCN recommendations are vague. For example, seem recall a canadian study that compared oncology follow up vs GP follow up with no difference in outcomes.

My bias is that if it's ok for a NP/PA to see the follow up... do they really need to be seen at all?

 

[RadOncMegatron]

I'm curious when y'all say "yes I can see them right away" aside from those scenarios where the patient walks down from med onc office same day, how quickly are you actually getting them in? Same week?

Yea it all depends, but if they usually call for a special I see them the same week. There is always the "patient lives far away / very busy can you see them today" kind of thing.

 

[OTN]

These set ups require a partner right? Can't do 4 work weeks as a solo doc because of "supervision"

Correct, I have a partner.

Also, re: follow ups...I've treated 50ish arthritis patients, all of them seen in follow up.

 

[evilbooyaa]

Oh definitely, if referring says "please see urgently" I'll squeeze em in same day or next.

I'm in a situation where I'm building up a new practice and trying to figure out the sweet spot for seeing "routine" referrals promptly. 3/4 of the time the patient wants to be seen later or clinically they are too close to post-op for anything to be done quickly in any case. I feel like we see patients quickly, but not sure what the referring docs think.

If possible, I like to do a quick chart review when I get specifically asked by my schedulers. Usually folks get scheduled for me in open slots in 1-2 weeks. For example, someone who is 1-2 week from lumpectomy, that can be scheduled 2-3 weeks out. Someone who just received their last cycle of chemo with a planned 4-6 week wash out can be seen in 2-3 weeks as well. Not saying they have to (this is dependent on your volume) wait that long, but it's not a 'bad' thing. If I get a call/e-mail from a referring about somebody I try to be involved with date/time that patient is scheduled, although that is relatively rare.

I do usually take a peek at my schedule say on Mondays for the next 1-2 weeks - if there are any consults out that far that I can access records (internal referral) I do a quick chart check to see if the timing is appropriate. Somebody scheduled 2-3 weeks out for vaginal cuff brachytherapy who got surgery 1-2 weeks ago? Sure, leave it. Someone who is ready to get going with RT? I let my schedulers know options (we have blocked consult times but can add patients on if doc approves) that week that I can see the patient.

 

[Palex80]

It's quite possible that many of these follow-ups will be substituted by apps in the future.

 

[theradiator]

Would like to see some research into how often do we really need to see follow-ups. NCCN recommendations are vague. For example, seem recall a canadian study that compared oncology follow up vs GP follow up with no difference in outcomes.

My bias is that if it's ok for a NP/PA to see the follow up... do they really need to be seen at all?

I would be interested in a randomized trial looking at litigation risk with or without follow-ups