What is important to look for in General IM jobs?

[Dr. Puffs]

Hello,
I've decided to pursue outpatient IM. There is a lot of questions on hospitalist jobs here, but I haven't seen many for general IM.

I've spoken with a lot of recruiters, and definitely decided on things I DON'T want to do. For instance one system I spoke with mentioned they wanted me to see minimum of 20 patients per day for $220k/year with only a "quality" bonus that was already predetermined. I'm also not interested in any value based jobs either and there aren't any true private practice jobs in my area.

What are some things I should look out for in contracts etc? What signals a job is "good"?

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[obiwan]

I'm not outpatient but general things to ask about include if you get any "admin" time during an afternoon or morning, frequency of having to take call for your partners if there are any, is there a non-compete clause

 

[collegestud2013]

Hello,
I've decided to pursue outpatient IM. There is a lot of questions on hospitalist jobs here, but I haven't seen many for general IM.

I've spoken with a lot of recruiters, and definitely decided on things I DON'T want to do. For instance one system I spoke with mentioned they wanted me to see minimum of 20 patients per day for $220k/year with only a "quality" bonus that was already predetermined. I'm also not interested in any value based jobs either and there aren't any true private practice jobs in my area.

What are some things I should look out for in contracts etc? What signals a job is "good"?

Not outpatient either, but I would not take an employed job without an RVU portion to your pay (on top of the base salary). This is especially the case if you're at a job with already a lot of volume. Quality bonuses can be very arbitrary and criteria changed at any time by your employer, and they do no account for patient volume the same way RVU pay does so you could end up seeing a lot more patients without extra pay. For RVU based pay, it's easier to roughly estimate how much you would make based on the patient volumes quoted. $220k base is pretty low for outpatient IM, especially if you're doing clinic for 5 days a week; if it's 4 days per week that may be more reasonable, but I still wouldn't take it if there's no RVU part of the pay. Would keep looking, but if you're in a saturated city it may be difficult to find a really good deal right out of training and you would have to be geographically more flexible. If that's not possible and you plan to stay in your current location long-term, most would recommend starting your own practice. This obviously has its own challenges, but it seems like those who do outpatient IM long-term and don't burn out are more likely to be owners than employees.

 

[Dr. Puffs]

Not outpatient either, but I would not take an employed job without an RVU portion to your pay (on top of the base salary). This is especially the case if you're at a job with already a lot of volume. Quality bonuses can be very arbitrary and criteria changed at any time by your employer, and they do no account for patient volume the same way RVU pay does so you could end up seeing a lot more patients without extra pay. For RVU based pay, it's easier to roughly estimate how much you would make based on the patient volumes quoted. $220k base is pretty low for outpatient IM, especially if you're doing clinic for 5 days a week; if it's 4 days per week that may be more reasonable, but I still wouldn't take it if there's no RVU part of the pay. Would keep looking, but if you're in a saturated city it may be difficult to find a really good deal right out of training and you would have to be geographically more flexible. If that's not possible and you plan to stay in your current location long-term, most would recommend starting your own practice. This obviously has its own challenges, but it seems like those who do outpatient IM long-term and don't burn out are more likely to be owners than employees.

Thanks for answering. The place I'm currently interviewing with is employed with a base salary and you get a % of your RVU's on top of that, which from what I've been told can be a significant portion. Its 4.5 days with a half a day for admin work, but I don't think that day can be M or F. I'm in an underserved area so this seems to be pretty good? I haven't gotten the contract yet though, so most of my information comes from the hospital recruiter and a doc who works there that I know. I just don't want to be worked to death, ground down and forced to see tons of patients. I want to enjoy my life.

 

[collegestud2013]

Thanks for answering. The place I'm currently interviewing with is employed with a base salary and you get a % of your RVU's on top of that, which from what I've been told can be a significant portion. Its 4.5 days with a half a day for admin work, but I don't think that day can be M or F. I'm in an underserved area so this seems to be pretty good? I haven't gotten the contract yet though, so most of my information comes from the hospital recruiter and a doc who works there that I know. I just don't want to be worked to death, ground down and forced to see tons of patients. I want to enjoy my life.

Is the extra pay based on RVU or a percentage of collections? Would need to find out concrete numbers before anyone could say if it's a good offer. If it's based on percentage of collections, pay will depend largely on insurance payer mix. And you're in an underserved area, that probably won't work in your favor (presumably there will be more patients with Medicaid or other low-paying safety net insurance). Better way is to ask your friend how much bonus they're getting, as $220k base salary otherwise seems very low. 20 patients per full clinic day seems pretty busy, and keep in mind in an underserved area they're probably more complicated patients as well each require a bit more work. Doing that for 4.5 days each week can lead to some burnout down the line. Would also find out how good and what amount of ancillary staffing the office has, as that will indirectly determine your overall workload.

 

[NotAProgDirector]

Ancillary staff is key. If you have several MA's and 3 rooms, you can see patients without wasting time. A nurse that answers patient questions and manages refills. An EMR that's decent.

 

[gutonc]

Ancillary staff is key. If you have several MA's and 3 rooms, you can see patients without wasting time. A nurse that answers patient questions and manages refills. An EMR that's decent.

These are probably more important than the pay structure. Or at least as important. If you have any portion of your compensation that is production based (and you should), an efficient clinic team and decent EMR will make you scads of money.

About 3 years ago, my clinic finally got RN coordinators AND 1:1 MA staffing. Within 3 months, my productivity increased by 25% without me actually working any harder.

 

[NewYorkDoctors]

20 patients a day?
Let's just do some napkin math. Let's just say you see 20 99213s a year (as PMD you will see annual physicals 99395-7, post discharge visits 99495-99496, phone calls 99441-99443, order some EKGs 93000, vaccine administrations 90471, quality codes for screening etc... but let's just keep the math simple). yes the payer mix varies. But i'm just doing napkin math here.

If you owned your own PMD practice, then Medicare allows $107.46 per 99213 billed
Unless the patient also has medicaid, the patient pays the 20% coinsurance and insurance pays you like $81.80 or something like that.

For the purpsoes of napkin math, let's just use $100 per patient.

20 patients per day = $2000 per day.
Let's say you work 300 days a year.

That means you are generating in the ballpark of $600,000 seeing that many patients.

While not everyone is able to start his/her own practice off the bat and working in this kind of job also ensures you do not need to deal with the billing and administrative side of things, you would want to make certain there is a good ancillary staff as mentioned above for vital signs, patient navigation, prior authorizations, point of care testing, vaccine admin, blood draw, etc... If the admins are going to make a buck off of you like this, you better get home on time and not take any night duties.

 

[cards67]

Lack of turnover can be a positive sign.

 

[collegestud2013]

20 patients a day?
Let's just do some napkin math. Let's just say you see 20 99213s a year (as PMD you will see annual physicals 99395-7, post discharge visits 99495-99496, phone calls 99441-99443, order some EKGs 93000, vaccine administrations 90471, quality codes for screening etc... but let's just keep the math simple). yes the payer mix varies. But i'm just doing napkin math here.

If you owned your own PMD practice, then Medicare allows $107.46 per 99213 billed
Unless the patient also has medicaid, the patient pays the 20% coinsurance and insurance pays you like $81.80 or something like that.

For the purpsoes of napkin math, let's just use $100 per patient.

20 patients per day = $2000 per day.
Let's say you work 300 days a year.

That means you are generating in the ballpark of $600,000 seeing that many patients.

While not everyone is able to start his/her own practice off the bat and working in this kind of job also ensures you do not need to deal with the billing and administrative side of things, you would want to make certain there is a good ancillary staff as mentioned above for vital signs, patient navigation, prior authorizations, point of care testing, vaccine admin, blood draw, etc... If the admins are going to make a buck off of you like this, you better get home on time and not take any night duties.

Working 300 days per year is crazy high assumption. If assuming something a bit more reasonable like 4.5 clinic days per week and standard 4 weeks of vacation, than 48 x 4.5= 216 clinic days a year. Assuming 20 patients and 100% medicare patients at $107 each as above, then it comes out to about $462k in revenue just from E&M. Of course this also has to cover your overhead practice costs which can be is often 30-50% of your revenue. So it comes down to more like $231-323k to cover all of your pay and benefits. Of course this is assuming all medicare patients, and medicare generally pays a lot less than commercial insurance. That's why most smaller PP primary care groups taking insurance would want to get as much patients with commercial insurance and won't be able to survive with mostly medicare patients (unless they have other significant sources of ancillary, non-E&M revenue). In a large health system setting, their outpatient PCP may have to be subsidized partially by revenue generated elsewhere in the system. They will do this since all the referrals and downstream tests that PCP order are vital to keeping the more profitable parts of the system profitable.

 

[tylerb1800]

Agree. 300 work days per year is crazy high. Math would be more accurate around at 230 to 240 work days per year unless your working weekends as a PCP. Many private practice PCPs are joining IPAs (independent physician alliance) to negotiate better rates and quality payments from your MA companies. Value based payments can be nice depending on how you practice and the number of MA patients on your panel.

Working 300 days per year is crazy high assumption. If assuming something a bit more reasonable like 4.5 clinic days per week and standard 4 weeks of vacation, than 48 x 4.5= 216 clinic days a year. Assuming 20 patients and 100% medicare patients at $107 each as above, then it comes out to about $462k in revenue just from E&M. Of course this also has to cover your overhead practice costs which can be is often 30-50% of your revenue. So it comes down to more like $231-323k to cover all of your pay and benefits. Of course this is assuming all medicare patients, and medicare generally pays a lot less than commercial insurance. That's why most smaller PP primary care groups taking insurance would want to get as much patients with commercial insurance and won't be able to survive with mostly medicare patients (unless they have other significant sources of ancillary, non-E&M revenue). In a large health system setting, their outpatient PCP may have to be subsidized partially by revenue generated elsewhere in the system. They will do this since all the referrals and downstream tests that PCP order are vital to keeping the more profitable parts of the system profitable.

 

[surfnsnow]

I'm not IM (FM) but 220k is low . It's rare for a city to be "saturated" with PCPs. Most healthcare systems do not have enough. Keep looking

 

[NewYorkDoctors]

while I agree with you that the OP should keep looking elsewhere for a better job offer ("greener" pastures? okay ill stop), I will comment and say primary care jobs for health system are fairly saturated in NYC. the health systems would much rather prefer hiring a DNP to be the primary care provider at a lower price than hire an MD/DO physician for a higher price. After all, the goal of PCP is to hit those "quality metrics" with the screening, BP goals, A1c goals and you hit those metrics by consulting more specialists and creating more revenue. This is more "cost effective" for the system

On the other hand, many PCPS in NYC who are part of a good IPA and get the best insurance rates open up a 99213 mill and can collect quite the windfall... 7 figures of revenue for some PCP offices. good quality care? that's subjective. just hit the metrics, "give the patient what they want," and panconsult.

Hey I didnt say it was "good medicine." It is what the system has created.

 

[sloh]

while I agree with you that the OP should keep looking elsewhere for a better job offer ("greener" pastures? okay ill stop), I will comment and say primary care jobs for health system are fairly saturated in NYC. the health systems would much rather prefer hiring a DNP to be the primary care provider at a lower price than hire an MD/DO physician for a higher price. After all, the goal of PCP is to hit those "quality metrics" with the screening, BP goals, A1c goals and you hit those metrics by consulting more specialists and creating more revenue. This is more "cost effective" for the system

On the other hand, many PCPS in NYC who are part of a good IPA and get the best insurance rates open up a 99213 mill and can collect quite the windfall... 7 figures of revenue for some PCP offices. good quality care? that's subjective. just hit the metrics, "give the patient what they want," and panconsult.

Hey I didnt say it was "good medicine." It is what the system has created.

Can you elaborate more on this? What do the patient visits specifically entail?

 

[NewYorkDoctors]

think of what your attendings in IM clinic told you about being thorough, communicating, closing the loop, not taking shortcuts, and not giving the patient antibiotics willy nilly.

now picture a PCP in a private practice 99213 mill not doing any of those things, giving the patients z-paks galore (to get them to be quiet and get out quickly) without even TRYING to address the other URI symptoms, panconsulting for everything (which is far faster honestly), and so on so forth.

that is how the private PCPs make seven figures in NYC. spend 5 minutes per patient billing 99213 (justifying that another 15 minutes was us use to review labs, write note etc.. to reach 20 minutes for 99213) Patients also give very high satisfaction scores because they got what they wanted and did not listen to a lecture about improving their health.

hey i didnt say it was good medicine. i just notice this from all the patients who get referred to me.


Edit: I mean I prescribe a fair amount of antibiotics but only if the patient has clear evidence of lower respiratory tract infection symptoms (i.e. purulent sputum, pleuritic chest pain, dyspnea, fever) or a history of a chronic respiratory illness that frequently gets respiratory infections such as bronchiectasis or COPD.
Moreover, I always induce sputum with 7% saline in the office to get a culture result to guide management later on. I never use that "oh azithromycin has anti-inflammatory properties independent of its macrolide ribosomal 23S binding function" line that some doctors like to throw around for an acute cough...

basically whatever MKSAP tells you about cost conscious high value care does NOT get done in many private practice offices because those things require a lot of talking to the patient and a lot of "the hard way out" decisions.

and I am not just blaming private physicians. I am sure the health systems out there want you to make low value cost care decisions as long as they can still get the revenue from said medical decisions or procedures. But the moment that revenue dries up from a possible CPT code, you betcha the health care administration is all fire and brimstone about needing to stop doing certain things lol.

Edit #2: I put my money where my mouth is in that I also do some PCP for some very complex chronic lung and CKD patients.
It's a lot of heavy work making sure all specialist issues plus all PCP issues / psychosocial / screening quality items all get done... this is where I do a lot of work after hours for these patients.
But this is indeed compensated work. lets just say I make good use of the codes 99358, 99491, and 99487.

 

[dozitgetchahi]

think of what your attendings in IM clinic told you about being thorough, communicating, closing the loop, not taking shortcuts, and not giving the patient antibiotics willy nilly.

now picture a PCP in a private practice 99213 mill not doing any of those things, giving the patients z-paks galore (to get them to be quiet and get out quickly) without even TRYING to address the other URI symptoms, panconsulting for everything (which is far faster honestly), and so on so forth.

that is how the private PCPs make seven figures in NYC. spend 5 minutes per patient billing 99213 (justifying that another 15 minutes was us use to review labs, write note etc.. to reach 20 minutes for 99213) Patients also give very high satisfaction scores because they got what they wanted and did not listen to a lecture about improving their health.

hey i didnt say it was good medicine. i just notice this from all the patients who get referred to me.


Edit: I mean I prescribe a fair amount of antibiotics but only if the patient has clear evidence of lower respiratory tract infection symptoms (i.e. purulent sputum, pleuritic chest pain, dyspnea, fever) or a history of a chronic respiratory illness that frequently gets respiratory infections such as bronchiectasis or COPD.
Moreover, I always induce sputum with 7% saline in the office to get a culture result to guide management later on. I never use that "oh azithromycin has anti-inflammatory properties independent of its macrolide ribosomal 23S binding function" line that some doctors like to throw around for an acute cough...

basically whatever MKSAP tells you about cost conscious high value care does NOT get done in many private practice offices because those things require a lot of talking to the patient and a lot of "the hard way out" decisions.

and I am not just blaming private physicians. I am sure the health systems out there want you to make low value cost care decisions as long as they can still get the revenue from said medical decisions or procedures. But the moment that revenue dries up from a possible CPT code, you betcha the health care administration is all fire and brimstone about needing to stop doing certain things lol.

As a rheumatologist, I can tell you that this “strategy” is a lot more common out there than you might think. It’s also how complex patients end up in my office that have been seeing a PCP for 20 years yet somehow have 20 years worth of unresolved symptoms, including high risk issues like chest pain and obvious DVTs etc, that have never been sorted out.

It makes my job a hell of a lot harder when I have to spend several visits sorting through that sort of mess just to get to the rheumatology…and punt it? To whom? I send out a fair amount of consults, yes, but more often than not I do the workup because I can’t neglect these things. I’ve caught two patients having active MIs in my office in the last year. Both were blown off by their PCPs. I caught three LE DVTs in my office just this month - one was told by her PCP to just wear compression stockings for her swollen right leg, with no ultrasound or any other workup 🤦‍♂️. (At least I get the ancillaries for all of the workup now.)

And don’t even get me started on the midlevels. That said, when PCPs start doing this type of stupidity they’re basically indistinguishable from midlevels in terms of what I see coming in. Our profession needs to do better than this if we want to make the claim that we deliver better care than the NPs.

 

[NewYorkDoctors]

for most of my referrals, I often get nothing from the PCP's office. I'm lucky if I get a paper prescription with reason for referral.
I don't expect any awesome IM note with a DDx and suspicion for which pulmonary disease process is going on. that's my job.
Without some form of background information, then one may not be able to give a good consultation without the background labs, medlist, imaging, etc... unless the patient is an amazing historian (usually not)

Fortunately for me, I am able to get the medication dispensed list through Surescripts (built into my EMR), pull up the imaging reports and images from the local radiology center and hospital EMRs I have access to, and check up labs from the online lab portals (for instance, Quest labs has a feature where you can search patient labs and they just track your access). This saves me so much time per patient. The very act of asking "so did you have a recent CXR? or what are you meds" can go from a seemingly straightforward question to a 5 minute scenic route detour with a patient going off on wild tangents....

 

[AlbinoHawk DO]

Their willingness to be open about their books, ability to talk to other doctors at the practice, patient population and their willingness to negotiate. In general, people that meet these qualifications give me a good vibe

 

[dozitgetchahi]

for most of my referrals, I often get nothing from the PCP's office. I'm lucky if I get a paper prescription with reason for referral.
I don't expect any awesome IM note with a DDx and suspicion for which pulmonary disease process is going on. that's my job.
Without some form of background information, then one may not be able to give a good consultation without the background labs, medlist, imaging, etc... unless the patient is an amazing historian (usually not)

Fortunately for me, I am able to get the medication dispensed list through Surescripts (built into my EMR), pull up the imaging reports and images from the local radiology center and hospital EMRs I have access to, and check up labs from the online lab portals (for instance, Quest labs has a feature where you can search patient labs and they just track your access). This saves me so much time per patient. The very act of asking "so did you have a recent CXR? or what are you meds" can go from a seemingly straightforward question to a 5 minute scenic route detour with a patient going off on wild tangents....

I don’t expect any awesome IM note either discussing the rheumatology. But I DO expect the PCP to actually be a PCP and manage all the other general medicine issues they’re supposed to be dealing with, instead of sending me a patient whose BP is always 200/100, with rip roaring chest pain, and one swollen leg that’s been swollen for years which nobody has ever bothered to work up or address, women past the age of 65 with fragility fractures who have somehow never had a DEXA scan, etc etc etc. I’ve seen way more of that crap than I ever care to have to deal with as a rheumatologist. I think a good PCP is worth their weight in plutonium, while a bad one just doubles the amount of work I have to do as a specialist, and gives me the feeling that I’m a chump for having to do someone else’s homework on top of my own. It’s even more discouraging to hear that being a crap “rack em/pack em/crack em” PCP seeing 40 a day and doing a lousy job of it makes $$$, while specialists like me are left to clean up the mess.

(At least the osteoporosis is in the rheumatology wheelhouse. The rest isn’t.)

 

[Angler]

The last few posts are pretty toxic. It suggests that PCP's don't care about their patients. I praise the specialists (here, Rheumatologists) who decide to rule out MI's, get CT angio's, etc, to do the PCP's job. I was a PCP for 34 years, and I retired three years ago; in the system I worked in, we policed ourselves and a PCP who did this kind of crap would have been kindly (or not so kindly) asked to shape up or leave.

At the very least, a PCP requesting a consult should give a short summary of what they want from the specialist. Otherwise, too much is left to chance. You cannot depend on the patient to ask the question of the specialist! I've been accused of writing "War and Peace" in my consult request narrative, but I think it helps. Why else are you requesting the consult? You gotta help the patient!!! I cannot believe that a specialist gets no information from the PCP.

I just don't get it.

 

[rokshana]

The last few posts are pretty toxic. It suggests that PCP's don't care about their patients. I praise the specialists (here, Rheumatologists) who decide to rule out MI's, get CT angio's, etc, to do the PCP's job. I was a PCP for 34 years, and I retired three years ago; in the system I worked in, we policed ourselves and a PCP who did this kind of crap would have been kindly (or not so kindly) asked to shape up or leave.

At the very least, a PCP requesting a consult should give a short summary of what they want from the specialist. Otherwise, too much is left to chance. You cannot depend on the patient to ask the question of the specialist! I've been accused of writing "War and Peace" in my consult request narrative, but I think it helps. Why else are you requesting the consult? You gotta help the patient!!! I cannot believe that a specialist gets no information from the PCP.

I just don't get it.

I rarely get any information on why there is a consult, generally have to dig through the notes if they are accessible or just ask the Pt and hope they know.

The VA is actually quite good at this… they give a paragraph on why the consult is being sent and the relevant notes and labs!

 

[NewYorkDoctors]

The last few posts are pretty toxic. It suggests that PCP's don't care about their patients. I praise the specialists (here, Rheumatologists) who decide to rule out MI's, get CT angio's, etc, to do the PCP's job. I was a PCP for 34 years, and I retired three years ago; in the system I worked in, we policed ourselves and a PCP who did this kind of crap would have been kindly (or not so kindly) asked to shape up or leave.

At the very least, a PCP requesting a consult should give a short summary of what they want from the specialist. Otherwise, too much is left to chance. You cannot depend on the patient to ask the question of the specialist! I've been accused of writing "War and Peace" in my consult request narrative, but I think it helps. Why else are you requesting the consult? You gotta help the patient!!! I cannot believe that a specialist gets no information from the PCP.

I just don't get it.

I am sure you are a great PCP (I assume)

I hope you did not approach these posts like a twitter post and took the position of "oh those dang specialists keep talking smack about me. I work so hard. etc...' I am sure you do.

But I am merely stating that I have observed a lot of "bad medicine" done in the name of saving time to make more revenue. You can't deny that doesn't exist. I applaud and commend excellent PCPs like yourself ( I assume) and we need more individuals like yourself.

I hope you do not take any personal affront at that tangent I went on...


I will admit that there is a degree of selection bias / confirmation bias (whatever its called) for specialists to gripe about the "hard patients" because PCPs who get their job done take care of the basic cases and only refer the very hard cases.

I do want to thank the community PCPs who send me (usually their midlevels who see the patient independently... yes my patients have told me they ONLY see the midlevels sometimes... not even just seeing an NP but just seeing a PA without the physician....) the softball down the middle of the plate consults. Thank you for sending me easy cases

 

[NewYorkDoctors]

I rarely get any information on why there is a consult, generally have to dig through the notes if they are accessible or just ask the Pt and hope they know.

The VA is actually quite good at this… they give a paragraph on why the consult is being sent and the relevant notes and labs!

same. luckily I usually get by when I see the radiology reports/images on the radiology PACS portals (because those reports usually hav a reason for imaging on it) and the good old chief complaint(s) usually gets me to where I need to go to.

 

[Angler]

I am sure you are a great PCP (I assume)

were.

Maybe.