Is outpatient really that bad?

[Osteoth]

I saw a community hospital contract like that once.

Hit 90% MGMA, and they switched to some other RVU metric (that paid a lot less) to prevent “overcompensation” (whatever that means, LMAO).

Of course…

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[NewYorkDoctors]

I have to say there is a ton of "gaslighting" of patients by PCPs in the local community amongst the base that refers patient to me.

While by no means am I am "academic doctor," (this means I do not do original research and I do not have an academic title. I have faculty on a fellowship program but that is more "honorary" than anything else. I teach fellows with my cases at times. I do some lectures. but this does not make me an "academic doctor") I do try to run my practice as "academically as possible. What this means is I do not run a mill for my pulmonary (and select few renal) patients. All my new patients get one full hour visit. Follow up results are done by phone first (if normal done by midlevel) with the option of scheduling a follow up in person. (this helps expedite getting a CT result - hey you have a 0.3cm nodule. it's not cancer fear not. what could it be? schedule full visit let's look at the picture together!)

I do not take "shortcuts." A common condition I see is NTM-pulmonary disease. I rotated through the Mycobacterial rotation at national jewish health and learned from the experts. By no means am I an "expert" but I would like to think I do a far better job than most local community pulms out there. One thing I spend a lot of time on are the non-pharmacologic treatment options such as dietary/GERD management, sleeping head of bed elevated whether a bed wedge pillow (which i can order as DME) or a hospital bed, pulmonary hygiene with nebulized saline, flutter valves, and chest physiotherapy, exercise, and getting vitamin D in diet / supplementation. This is all before I even consider starting RIF / AZI / EMB. Even if I started these (usually smear positive disease or rapid growers as those are unlikely to clear with conservative management alone), I am doing full med recs, 12L EKG for QTc, Ishihara color screen, Snellen eye check, and Retinavue retinal photographs as baseline checks.

Then I am also working up their bronchiectasis. While most commonly it is due to reflux or post Tb, a full workup for collagen vascular disease, inflammatory bowel disease, immunodeficiencies, and cystic fibrosis (some of the less common mutations with delayed penetrance and all that jazz can present later on in life).

Anyway this is just one example of a "hard case that I try to do the full workup like an academic doctor would."

Doing all this takes a lot of time and hence I dedicate a lot of time per patient visit and have hired plenty of support staff.

I do not start a mill for specialty care because that compromises care for complex ill patients.
A mill can only be done for primary care honestly in which there is zero expectation you can figure out their complex issues and can always refer out.
Moreover, if I ended up trying to overstuff too many patients, these same histrionic borderline narcissistic dependent personality disorder patients end up complaining "the doctor did not spend enough time with me."

Given a choice between A) looking incomptent and B) being reviled, I would gladly take the latter every time.

yet I get flooded with angry new referrals (all of whom I have never met before and thus have no legal obligation to) walking into the front desk making a scene. Their PCP discovered a lung nodule (likely subcentimeter) and they are going to die if they dont get consultation from me. Lol such histrionics. only in NYC.

when I ultimately see these nothingburgers, I am being all empathetic and nice. I tease out that very often the PCPs have gaslit the patients into a frenzy in an attempt to 1) "get out of my office now. I have other patients i need to put until the 99213 mill" and 2) "i am too proud to say you are out of my league. so I am going to gaslight you into thinking it might be cancer"

another situation is a PCP has been following a patients subcentimeter nodule for 5 years now with annual CT scans (non smoker so Lung cancer screening does not apply). It is 0.8cm and not ground glass. has had consecutive annual CT scan for 5 years now. Fleischer has already said no need for surveillance a long time ago.
This year I am referred this patient. I discuss guidelines, review images, provide reassurance
but I tease out the issue was "the PCP was unable to get a prior auth and referred me here."
My staff looked into things and turns out the PCP was unable to get 71250 (CTC withotu contrast) approved because clinical notes sent foudn stable nodule since 5 years ago. This is correct. The PCP got approval for 71271 (which is low dose CT scanning for lungcancer screening) as that is an easy prior auth. Do the online survey and hit the right answers. But the radiology centers all ask patients their smoking history. This patient said "i dont smoke. " Radiology center rightfully said "nope wrong test you cannot do this then." This means the PCP tried to "backdoor a CT scan." So irresponsible of the PCP. I talk to the patient and ask if the PCP explained lung nodule guidelines? The patietn said PCP told him "it could be cancer and

I called the PCP and yelled at the PCP for this obvious irresponsible management and gaslighting of the patient. The PCP said "but it is 0.8cm and large!" This is a 75 year old PCP who is not maintaining IM boards (expired on checkabim.org) and is not grandfathered in. sad sad sad

The patient "trusts the experience of the elderly PCP."

I informed the patient you could see your PCP then.

Only this same PCP gaslights the patient to walk into my office to bother my front desk everyday for a prior auth for CT scan.

the general lesson for all patients should be "age and experience are overrated for non-procedural physicians. check board certification status instead."

seriously I am not kidding.


addendum: since I am on a rampage throwing shade at older PCPs who are "set in their ways," I have another anecdote from residency. I witnessed an older PCP (in his late 60s back then, I wonder if he is still alive now. quick google search - wow 45 years of experience! patients are impressed) pick up a phone call from his outpatient while rounding in teh hospital. Hello Mrs so and so. you have a cough? how long? 5 days? want me to prescribe a Z-pak for you? sure i'll send it once I get back to the office"

I am trying to view it from that older "experienced" PCPs perspective and realize that they simply "do not read MKSAP" like the current generation and feel no need to stay "up to date." Experience! lol. Good luck leveraging your experience on rendering that diagnosis of acute intermittent porphyria Dr house haha.

 

[dozitgetchahi]

I have to say there is a ton of "gaslighting" of patients by PCPs in the local community amongst the base that refers patient to me.

While by no means am I am "academic doctor," (this means I do not do original research and I do not have an academic title. I have faculty on a fellowship program but that is more "honorary" than anything else. I teach fellows with my cases at times. I do some lectures. but this does not make me an "academic doctor") I do try to run my practice as "academically as possible. What this means is I do not run a mill for my pulmonary (and select few renal) patients. All my new patients get one full hour visit. Follow up results are done by phone first (if normal done by midlevel) with the option of scheduling a follow up in person. (this helps expedite getting a CT result - hey you have a 0.3cm nodule. it's not cancer fear not. what could it be? schedule full visit let's look at the picture together!)

I do not take "shortcuts." A common condition I see is NTM-pulmonary disease. I rotated through the Mycobacterial rotation at national jewish health and learned from the experts. By no means am I an "expert" but I would like to think I do a far better job than most local community pulms out there. One thing I spend a lot of time on are the non-pharmacologic treatment options such as dietary/GERD management, sleeping head of bed elevated whether a bed wedge pillow (which i can order as DME) or a hospital bed, pulmonary hygiene with nebulized saline, flutter valves, and chest physiotherapy, exercise, and getting vitamin D in diet / supplementation. This is all before I even consider starting RIF / AZI / EMB. Even if I started these (usually smear positive disease or rapid growers as those are unlikely to clear with conservative management alone), I am doing full med recs, 12L EKG for QTc, Ishihara color screen, Snellen eye check, and Retinavue retinal photographs as baseline checks.

Then I am also working up their bronchiectasis. While most commonly it is due to reflux or post Tb, a full workup for collagen vascular disease, inflammatory bowel disease, immunodeficiencies, and cystic fibrosis (some of the less common mutations with delayed penetrance and all that jazz can present later on in life).

Anyway this is just one example of a "hard case that I try to do the full workup like an academic doctor would."

Doing all this takes a lot of time and hence I dedicate a lot of time per patient visit and have hired plenty of support staff.

I do not start a mill for specialty care because that compromises care for complex ill patients.
A mill can only be done for primary care honestly in which there is zero expectation you can figure out their complex issues and can always refer out.
Moreover, if I ended up trying to overstuff too many patients, these same histrionic borderline narcissistic dependent personality disorder patients end up complaining "the doctor did not spend enough time with me."

Given a choice between A) looking incomptent and B) being reviled, I would gladly take the latter every time.

yet I get flooded with angry new referrals (all of whom I have never met before and thus have no legal obligation to) walking into the front desk making a scene. Their PCP discovered a lung nodule (likely subcentimeter) and they are going to die if they dont get consultation from me. Lol such histrionics. only in NYC.

when I ultimately see these nothingburgers, I am being all empathetic and nice. I tease out that very often the PCPs have gaslit the patients into a frenzy in an attempt to 1) "get out of my office now. I have other patients i need to put until the 99213 mill" and 2) "i am too proud to say you are out of my league. so I am going to gaslight you into thinking it might be cancer"

another situation is a PCP has been following a patients subcentimeter nodule for 5 years now with annual CT scans (non smoker so Lung cancer screening does not apply). It is 0.8cm and not ground glass. has had consecutive annual CT scan for 5 years now. Fleischer has already said no need for surveillance a long time ago.
This year I am referred this patient. I discuss guidelines, review images, provide reassurance
but I tease out the issue was "the PCP was unable to get a prior auth and referred me here."
My staff looked into things and turns out the PCP was unable to get 71250 (CTC withotu contrast) approved because clinical notes sent foudn stable nodule since 5 years ago. This is correct. The PCP got approval for 71271 (which is low dose CT scanning for lungcancer screening) as that is an easy prior auth. Do the online survey and hit the right answers. But the radiology centers all ask patients their smoking history. This patient said "i dont smoke. " Radiology center rightfully said "nope wrong test you cannot do this then." This means the PCP tried to "backdoor a CT scan." So irresponsible of the PCP. I talk to the patient and ask if the PCP explained lung nodule guidelines? The patietn said PCP told him "it could be cancer and

I called the PCP and yelled at the PCP for this obvious irresponsible management and gaslighting of the patient. The PCP said "but it is 0.8cm and large!" This is a 75 year old PCP who is not maintaining IM boards (expired on checkabim.org) and is not grandfathered in. sad sad sad

The patient "trusts the experience of the elderly PCP."

I informed the patient you could see your PCP then.

Only this same PCP gaslights the patient to walk into my office to bother my front desk everyday for a prior auth for CT scan.

the general lesson for all patients should be "age and experience are overrated for non-procedural physicians. check board certification status instead."

seriously I am not kidding.


addendum: since I am on a rampage throwing shade at older PCPs who are "set in their ways," I have another anecdote from residency. I witnessed an older PCP (in his late 60s back then, I wonder if he is still alive now. quick google search - wow 45 years of experience! patients are impressed) pick up a phone call from his outpatient while rounding in teh hospital. Hello Mrs so and so. you have a cough? how long? 5 days? want me to prescribe a Z-pak for you? sure i'll send it once I get back to the office"

I am trying to view it from that older "experienced" PCPs perspective and realize that they simply "do not read MKSAP" like the current generation and feel no need to stay "up to date." Experience! lol. Good luck leveraging your experience on rendering that diagnosis of acute intermittent porphyria Dr house haha.

Your feelings about these nodules mimic my feelings about how PCPs whip patients up over a positive ANA…stop telling people they have lupus just because they have a 1:80 ANA…

Also, I do the same as you with regards to workups in the “academic” style…I go all out in situations where something obscure/rare is going on. I’m well trained and I’m good at diagnosing…if I can’t find it, it’s unlikely that tertiary care will unless it’s a situation where new manifestations or testing results suddenly appeared by the time people get there. The referral “center of last resort” near me is Mayo…so I like to keep a running tab of “Dr Dozitgetchahi Vs Mayo”. Out of a dozen of these situations or so, I have yet to miss something that Mayo caught. I have something like 9 cases where Mayo agreed with my dx or otherwise couldn’t come up with a better dx, 2 cases where I caught something they missed, and one case where both Mayo and I missed it initially, and then I caught it after they came back from Mayo (that was a long story, basically lymphoma masquerading as RA). I think that’s a pretty good record. So when I pull out the stops testing something and can’t get to a clear dx (which is not necessarily unheard of in rheumatology), pts often ask me if they should head to Mayo etc. I tell them “you can if you want, but I’m not sure it’s going to be worth the time and effort”. Sometimes in weird rheumatologic situations, there is no alternative to treating what appears to be there while also waiting for the illness to declare itself more fully.

 

[NewYorkDoctors]

honestly any internist who actually read MKSAP and can remember half of it is a pretty dang good internist.

The younger generation of doctors who actually studied and read in the modern era of training are usually great internists.

It's that older generation that has the mantra of "I was paid to LEAD , not to READ" that makes bad referrals.
As I have mentioned in other posts, I really don't mind helping an internist out with the bare basics as that is a "fastball down the middle for me." But I really don't need a half hearted approach and workup mixed with gaslighting and setting the wrong expectations for patients before coming to me as a form of "bail out referral."

I deride this as a form of "playing hero-ball." This is another sports analogy. You're not Lebron, Kobe, or MJ. (nor am I) Don't try it. You're the all important point guard. Get the assist title instead of the scoring title and we can win the title together

One internist is great. He sends me smokers with the referral reason for "evaluate COPD and lung cancer screening. I have done nothing so far."
My response: "thank you very much I promise to take good care of our mutual patients and manage all their pulmonary issues, tell them not to bother you about it, and send you all my notes."
The patients usually say "my PCP told me to come. I'm not sure why I feel normal."

 

[Splenda88]

One internist is great. He sends me smokers with the referral reason for "evaluate COPD and lung cancer screening. I have done nothing so far."
My response: "thank you very much I promise to take good care of our mutual patients and manage all their pulmonary issues, tell them not to bother you about it, and send you all my notes."
The patients usually say "my PCP told me to come. I'm not sure why I feel normal."

You dont really believe this is what PCPs tell these patients

I am hospitalist and I am gonna go out on a limb to say no PCP will tell a patient to see a specialist w/o telling that patient why.

You gotta give your colleagues a little bit more credit than that.

Healthcare/medicine is very complex and most patients have ZERO understanding of what going on with them even if you explain things in layman terms. It's not the fault of neither the patients or the clinicians.

 

[NewYorkDoctors]

You dont really believe this is what PCPs tell these patients

I am hospitalist and I am gonna go out on a limb to say no PCP will tell a patient to see a specialist w/o telling that patient why.

You gotta give your colleagues a little bit more credit than that.

Healthcare/medicine is very complex and most patients have ZERO understanding of what going on with them even if you explain things in layman terms. It's not the fault of neither the patients or the clinicians.

that was a bit tongue in cheek in this example
for this PCP (who sent the referral reason to me ahead of time and said "lung cancer screening and COPD check in a smoker"), I actually welcome this blank slate. It can paint a picasso on a blank canvas.
on delving more deeply and review the referral reason the patient said "oh sure yeah check my lungs out since I smoke yep."


anyway I have a more professional working relationship with the hospital based doctors (primarily thoracic surgery, interventional pulmonary, infectious diseases, and CHF/PH cardiology) with whom I can either call/chat or share updates in EPIC through patient messaging.

but those community "randos" who send me patients - thanks and I will do my part to help you and our new mutual patient. but gaslighting of your patient ahead of the visit is not appreciated. I will attempt to be empathetic and make the assumption that it was not a malicious intent on the part of the PCP but rather the patient is just a "nervous inconsolable wreck who has delusions of granduer and undiagnosed schizoaffective disorder." but in that case, some word of caution ahead of the visit would be appreciated.

another recent referral was "patient has lung nodule needs follow up CT scan but I tried to get prior auth and failed. please assist."
sure glad to help
review of workup - Right lower lobe 0.3cm nodule incidentally found on CTAP as part of kidney stone workup in a nonsmoker / no radon / no biomass fuel / no family history / no aerospace / etc....
yeah already its not indicated per Fleischner criteria. but in real life, some patients are scared to heck and would like a full CT to make sure nothing is wrong in the upper lung zones. CXR normal so at least nothing over 1cm most likely
in this individualized case , reasonable to do one time CTC

the patient comes - feels totally asymptomatic and no complaints. for this patient I do not put him through unnecessary PFT or other testing if he has no symptoms, abnormal findings, or potential for lung resection surgery

He brings in the insurance denial letter. He telsl me "the PCP told me only a specialist can get this approved."

I read the letter and denial reason to the patient (this patient is Caucasian and speaks English well. he works a poet in NYC. nice guy)
in the print I read - 71271 is denied because the patient does not have a smoking history. But 71250 will be approved if requested.

*facepalm*

For this situation, someone just has to reply to insurance (not even a phone call. just an efax with the plan referene # for the prior auth and a letter stating - yes I would like to get approval for 71250 as is offered) .

logically this means
1) the PCP did not bother to read because "i was paid to lead, not to read"
2) the PCP was under the impression a phone call was required? this would be even more egregious
3) the PCP wanted a specialist on board? if so the PCP should have gotten the CT done first.

I waived this guys copay and just billed the lowest 99202 and said let me know when its done and report is in.


It's not the fact that many local PCPs are sending me very basic cases that any internist shoudl be able to handle (as I have said before, I welcome these easy softball cases and am happy to help). It's the extra large helping of "gaslight" that I could do without.


I am brainstorming what possible reasons there are for a physician to gaslight a patient?
The only reasons I can come up with are
1) I do not know how to manage this but I am too proud to admit it so I will gaslight you instead
2) Because I feel bad I cannot manage everything for you, I will gaslight you into thinking I am a heroic figure on your side as I refer you out
3) The physician does not think there is anything wrong and he/she is trying to be helpful.

When I see patient as primary, if it's something I really don't know how to work up, I admit it
"Hey we did a basic workup. your liver workup is negative for viral hepatitis, mono, autoimmune, hemachromtoasis. Perhaps it is steatohepatitis based on the book diagnosis. but I do not have the training or confidence to make that diagnosis without missing something else. I would like you to see a specialist to ensure I am not missing anything."

 

[dozitgetchahi]

You dont really believe this is what PCPs tell these patients

I am hospitalist and I am gonna go out on a limb to say no PCP will tell a patient to see a specialist w/o telling that patient why.

You gotta give your colleagues a little bit more credit than that.

Healthcare/medicine is very complex and most patients have ZERO understanding of what going on with them even if you explain things in layman terms. It's not the fault of neither the patients or the clinicians.

Bro.

I have lost count of the number of times a PCP sends a patient and the patient has no idea why they’re coming. Sometimes the referral gets put in after the visit happens and the note is written - which means that often I don’t even get a NOTE that explains why the patient is being sent. I have literally had visits where I opened by saying “welp your PCP sent no note (or sent me something that says nothing about why you were sent), so what’s going on?” And the pt responds “I have no idea”. And I have no idea either. It makes for an awkward visit at best.

My staff have done a much more aggressive job of screening this lately…I’d say something like 20% of all referrals come with no details, and lead to my staff calling the PCPs office to be like “you guys didn’t send any documentation whatsoever…you need to send us that”.

I am not sure wtf is going on in some PCP offices out there (and not all PCPs do this stuff - some are great), but the docs that keep doing this need to pull their pants up and do better.

 

[MD46]

We also get quite a few referral where the patients say “something wrong with my blood” thats why they are seeing a Hematologist, go figure…..

 

[Splenda88]

We also get quite a few referral where the patients say “something wrong with my blood” thats why they are seeing a Hematologist, go figure…..

This is what I am saying. You can explain things in layman terms to these patients, but they still won't get it. I have seen that so many times.

 

[NewYorkDoctors]

lucky for me I can screen a chart ahead of a visit fairly easily without relying on the PCP to actually do anything or send anything
the local radiology portals are have physician web portals.
quest portal has a way to check labs (if they used quest)
the local pharmacies don't seem to have any HIPAA issues and send us med list on demand (they do know we are legit physician office)
the local hospital EMRs are also available to me through my affiliations

it's a lot of "homework"

if that patient shows up, this extensive prep work I did goes into billing 99205 and toss in a G2211, believe that!

 

[NewYorkDoctors]

This is what I am saying. You can explain things in layman terms to these patients, but they still won't get it. I have seen that so many times.

which is fine. the doctors job, our job, is to educate the patient.
I have no issues and I never put down the patient for this
I put down the referring doctor for not even trying to send me what i need to do a good consult.


other consultants just write in note

"will call PCP office for labwork"

i just don't want to deal with loose ends after the visit if Ican help it.

 

[dozitgetchahi]

This is what I am saying. You can explain things in layman terms to these patients, but they still won't get it. I have seen that so many times.

In my experience, many of these situations are where a PCP is trying to slip a referral through the filters “on the sly”. For instance…”I know Dr Dozitgetchahi won’t take this if I label it fibromyalgia, so maybe if I don’t send any info at all he’ll somehow end up seeing the patient.”

No. That’s not how this works.

 

[NewYorkDoctors]

whenever i get a referral for "no reason" and "self referred" or "PCP did not refer me but my insurance does not need a a PCP referral," I just have my front desk schedule a full one hour visit assuming its complex. because my schedule is rather full, if this prospective patient balks at the wait time then that automatically has deterred a potential train wreck

if they did come, i have full one hour to try to do as good a job as possible

if they did not come, I use that no show time to manage my other patients and do a little telehealth to make up for things.

until i actually see a patient, no contract has been established and I am under no obligation to this prospective patient

but once I see the patient, this it is my patient and I am morally, medically, ethnically, legally obligated to all the whole distance of the field (another sports metaphor). for complex cases, it is best to start with a full one hour visit on day 1.

plus if this wait time for a 1 hour visit slot deters the patient, the burden lies on the patient for not wanting to wait and the patient has the freedom to go wherever the patient wants otherwise

alternatively, if I have a known legit for pulmonary only diagnosis (i.e. interstitial lung disease, bronchiectasis, pulmonary hypertension, severe COPD etc) being referred with proper workup, i'll usually just slot them into my lunch hour to see them out of benevolence to the patient and courtesy to the PCP. so this is not a situation of my cherry picking "easy patients."

Rather it is meant to avoid "unwelcome surprises" that it seems some patients enjoy to drop onto doctors.

i have found that by adhering to a schedule and then by scheduling "blank slate" patients with no referral reason (and hence may turn out to be a nothingburger with a side of psychosomatic fries and lots of Diet Cope ) for a full one hour visit (which usually with my schedule is not for 2-3 months) this deters many of these patients from coming. I am not a hospital clinic and am under no obligation to "see all comers no matter what."

 

[dozitgetchahi]

whenever i get a referral for "no reason" and "self referred" or "PCP did not refer me but my insurance does not need a a PCP referral," I just have my front desk schedule a full one hour visit assuming its complex. because my schedule is rather full, if this prospective patient balks at the wait time then that automatically has deterred a potential train wreck

if they did come, i have full one hour to try to do as good a job as possible

if they did not come, I use that no show time to manage my other patients and do a little telehealth to make up for things.

until i actually see a patient, no contract has been established and I am under no obligation to this prospective patient

but once I see the patient, this it is my patient and I am morally, medically, ethnically, legally obligated to all the whole distance of the field (another sports metaphor). for complex cases, it is best to start with a full one hour visit on day 1.

plus if this wait time for a 1 hour visit slot deters the patient, the burden lies on the patient for not wanting to wait and the patient has the freedom to go wherever the patient wants otherwise

alternatively, if I have a known legit for pulmonary only diagnosis (i.e. interstitial lung disease, bronchiectasis, pulmonary hypertension, severe COPD etc) being referred with proper workup, i'll usually just slot them into my lunch hour to see them out of benevolence to the patient and courtesy to the PCP. so this is not a situation of my cherry picking "easy patients."

Rather it is meant to avoid "unwelcome surprises" that it seems some patients enjoy to drop onto doctors.

i have found that by adhering to a schedule and then by scheduling "blank slate" patients with no referral reason (and hence may turn out to be a nothingburger with a side of psychosomatic fries and lots of Diet Cope ) for a full one hour visit (which usually with my schedule is not for 2-3 months) this deters many of these patients from coming. I am not a hospital clinic and am under no obligation to "see all comers no matter what."

I agree with scheduling the visit way out, and I have also found that this seems to discourage some of these people from showing up.

In fact, my general feeling is that the urgency with which a patient wants to get seen for a first visit tends to be inversely proportional to the actual severity of their illness (of course, there are exceptions). A lot of the people who want to be seen right away tend to have psychosomatic issues, or illness that otherwise isn’t very serious. On the other hand, it pains me when a sick SLE, vasculitis, etc patient sits in the queue for months waiting behind a bunch of nonsense patients. Hell, I will happily see a nasty gout flare the same day. Bad gout is pure misery, and fortunately I have straightforward solutions for that. Not so much fibro.

 

[NewYorkDoctors]

the pulmonary "functional disorder" patients are the chronic cough patients.

to be fair, cough is usually not a psychosomatic disorder so I am using the term "functional disorder" rather loosely.

if it is post infectious cough, will get better afte without any treatment in the subacute period

if its asthma, easy to diagnose and treat
if it is upper airway cough syndrome
if it is bronchiectasis, easy to diagnose and maybe hard to treat
if it is interstitial lung disease, easy to diagnose and hard to heart
if it is lung cancer, easy to diagnose and complex to manage

if it is GERD Oh boy it is NOT easy to treat.
patients are supose to use PPIs STANDING for 1-2 months. many patients use it "PRN" and give up because "they don't have heartburn."
they are also suppose to do lifestyle and dietary modifications - I found usually no prior doctors have ever really talked about this other than a few sentences of lip service. I tend to go into more detail and use print outs and give specific examples.

if the reflux has led to cough hypersensitivity, it becomes a nightmare for the patients and a disaster for me because the patient is under the impression that I am a "cough specialist" and have the "magical instant cure." sorry gefapixant is only approved in Japan and some European countries.

this chronic cough hypersensitivity patients are struggling but I need to educate them on day one "it's like you have a leaking roof with multiple holes dripping water. not only do we have to identify all of the holes and plug them all up, but we have to deal with the water damage to the house as well, make sense?"

I usually do some full court press of
1) GERD education dietary (PCP and GI shoudl be doing this but comon now... lol GI just says EGD normal you got nothing wrong cya)
2) CTC (looking for that patulous esophagus like in my profile pic), barium esophagram (low sensitivty and specificity but GERD BY ITSELF but may be helpful in the setting of chronic cough for me to justify more intensive GERD treatment)
3) ENT referral for nasopharyngoscopy
4) emphasizing sleeping head of bed elevated. whether i order a bed wedge pillow through DME or a hospital bed for pateints who want one I use my anatomy doll to explain how if you never treat the (likely silent) reflux

5) for recalcitrant patients who refuse to take antacids or do dietary modifications I tend to see if they would be willing to see (more helpful GI colleagues - I just preface to the Gi doctor you can just do the procedure for me please and ill take care of the results thanks ) for EGD + bravo study. This could prove the issue and possibly open the door for fundoplication if medical management fails. for the patients who have agreed to this, Bravo study usually finds pretty severe "silent" reflux.

("because I do not have heartburn or sour taste in my mouth." My reply (in a much nicer way) is ****! who said anything acid?" The GI docs tend not to believe in non-acid reflux. Dunno why not. But there is plenty of pulmonary literature finding in patients with structural lung disease and chronic cough BAL has found pepsin and trypsin in the lungs. Maybe it's a case of "no RCTs proved it so it does not exist!"

6) offer central antitussives such as baclofen and gabapentin at high dosages
7) offer nebulized ipratropium (even in the absence of obstructive airway disease this has central cough suppression effects via the muscarinic cough receptors)
8) offer nebulized lidocaine (if insurance covers)


but these things take time. "even if the holes are plugged up in the leaking roof, you still need to heal your airways. this might take time."

some patients take to this well and are very appreciative.
others are mad because it is not an instant cure. these patients have had codeine which can help does not treat the issue. they get easily frustrated an lash out and do not want to stick with the program. these are the pulmonary equivalent of a "functional disorder patient."

now I am somewhat empathetic to patients. recently I had a URI leading to acute sinusitis mixed in with upper airway cough syndrome. boy was I coughing a bit. robutissin, flonase, Netipot, guaifenesin and nebulized 3% saline helped a bit
ultimately it just took time. but I can relate to the patients like this.
but they need to "get with the program and not expect an instant one pill cure."

dyspnea is not too hard because I can use CPET to rule out organic disease for deconditioned or anxious patients
but cough that does not have an easily treated etiology is the bane of a pulmonary doctors existence

if gefapixant were ever approved in the US by the FDA, you can bet this medication would be the hottest medication to be prescribed (if it gets past the prior auth) and will crash the US economy lol

 

[Osteoth]

The problem is that everyone is so demoralized by reimbursement, support by their masters, lack of autonomy. Nobody cares anymore, no one feels valued, no one takes pride in their work.

Honestly I can’t blame anyone. Literally no one gives two ****s but the patients and most of them are clueless…

 

[NewYorkDoctors]

The problem is that everyone is so demoralized by reimbursement, support by their masters, lack of autonomy. Nobody cares anymore, no one feels valued, no one takes pride in their work.

Honestly I can’t blame anyone. Literally no one gives two ****s but the patients and most of them are clueless…

Good points . But this only applies to employed physicians .

Purely private practice who still do full fee for service and eat what you hunt only have three explanations for suboptimal medical care that is not the full breadth of care
1) wanting to reduce time spent per patient to maximize revenue / effort ratio . I guess the best way to achieve this is to gaslight patients
2) being woefully out of date and not bothering to do something As simple as mksap for knowledge
3) just not caring anyone year later and wanting to go through the motions . I’d suggest going into administration and hiring other providers .

If 1,2,3 apply but said provider still wants the Money , then jeez …

 

[dozitgetchahi]

Good points . But this only applies to employed physicians .

Purely private practice who still do full fee for service and eat what you hunt only have three explanations for suboptimal medical care that is not the full breadth of care
1) wanting to reduce time spent per patient to maximize revenue / effort ratio . I guess the best way to achieve this is to gaslight patients
2) being woefully out of date and not bothering to do something As simple as mksap for knowledge
3) just not caring anyone year later and wanting to go through the motions . I’d suggest going into administration and hiring other providers .

If 1,2,3 apply but said provider still wants the Money , then jeez …

I see all three among the PP docs out there (especially the ones who own their own practices). In fact, I see option #3 a lot. The doc who founded the practice starts hating medicine and finds a way to gradually shift themselves out of day to day practice as much as possible…usually this involves hiring a ****load of staff and other providers under them in an exploitative manner, so that the fruit of their labor largely flows to the kingpin of the practice (while he/she in fact applies less and less day to day effort to everything). This usually makes the “kingpin doc” rich - but usually they also become lazy with regards to medicine. They generally make less and less effort to keep up with the literature and take care of their remaining patients properly.

I interviewed at a rheum job like this. Small multispecialty PP where the sole rheum doc in the practice was the highest biller by far. He had something like 8 staff working under him - an NP, several nurses, several other staff doing infusion auths etc - and despite all these staff he was clearing around $850k a year. I didn’t end up going there because rather than just front my starting salary through the practice (they had plenty of money to do this), the guy wanted me to sign a 4 year obligation with both the town and the local hospital where they would front my (mediocre starting) salary under the condition that if things didn’t work out at that PP, I was on the hook to practice in that town for 4 years (or I had to repay every dollar of salary given to me). No bueno, guys.

Option 3 docs tend to be greedy, if you haven’t noticed.

 

[NewYorkDoctors]

Option 3 could be acceptable.. if the doc sees the "legit hard cases relevant to specialty" while the midlevels or other less experienced doctors see the more bread and butter.
But then the senior doc should be "driving the management" in the background and making sure the midlevels or junior doctors are doing guideline management

 

[dozitgetchahi]

Option 3 could be acceptable.. if the doc sees the "legit hard cases relevant to specialty" while the midlevels or other less experienced doctors see the more bread and butter.
But then the senior doc should be "driving the management" in the background and making sure the midlevels or junior doctors are doing guideline management

My experience with most of these older “option 3” docs is that their clinical skills…leave a lot to be desired.

Personally I’d rather see a younger doc any day.

 

[NewYorkDoctors]

Yep . Never trust an older doctor unless an academic doctor who has a professor title or is a procedural / surgeon (even then those skills erode at a certain age )

I’ll be old and useless one day too I’ll admit up front

 

[Osteoth]

I see all three among the PP docs out there (especially the ones who own their own practices). In fact, I see option #3 a lot. The doc who founded the practice starts hating medicine and finds a way to gradually shift themselves out of day to day practice as much as possible…usually this involves hiring a ****load of staff and other providers under them in an exploitative manner, so that the fruit of their labor largely flows to the kingpin of the practice (while he/she in fact applies less and less day to day effort to everything). This usually makes the “kingpin doc” rich - but usually they also become lazy with regards to medicine. They generally make less and less effort to keep up with the literature and take care of their remaining patients properly.

I interviewed at a rheum job like this. Small multispecialty PP where the sole rheum doc in the practice was the highest biller by far. He had something like 8 staff working under him - an NP, several nurses, several other staff doing infusion auths etc - and despite all these staff he was clearing around $850k a year. I didn’t end up going there because rather than just front my starting salary through the practice (they had plenty of money to do this), the guy wanted me to sign a 4 year obligation with both the town and the local hospital where they would front my (mediocre starting) salary under the condition that if things didn’t work out at that PP, I was on the hook to practice in that town for 4 years (or I had to repay every dollar of salary given to me). No bueno, guys.

Option 3 docs tend to be greedy, if you haven’t noticed.

I’m considering an employment option like the one you mentioned and can’t tell if it’s a bad deal or not. The practice doesn’t seem predatory but my salary is going to be structured as a forgivable loan 2 year forgiveness. It’s in an area I definitely see myself in long term so it seems reasonable but the liability is scary….I’ve talked to one guy who did it and was happy though.

 

[dozitgetchahi]

I’m considering an employment option like the one you mentioned and can’t tell if it’s a bad deal or not. The practice doesn’t seem predatory but my salary is going to be structured as a forgivable loan 2 year forgiveness. It’s in an area I definitely see myself in long term so it seems reasonable but the liability is scary….I’ve talked to one guy who did it and was happy though.

Don’t. I avoided several jobs like this while interviewing. They’re a ripoff. I’ve also had several jobs so far that were worse than advertised. You need to be able to leave a bad job and move on, without being stuck somewhere for years “paying them back”.

 

[Osteoth]

Don’t. I avoided several jobs like this while interviewing. They’re a ripoff. I’ve also had several jobs so far that were worse than advertised. You need to be able to leave a bad job and move on, without being stuck somewhere for years “paying them back”.

The problem is most jobs aren’t going to pay you to build a private practice. Obviously most employed jobs you’re building their practice, so making the move from employed to private seems like it would be difficult. Are you employed and are you trying to go private?

 

[dozitgetchahi]

The problem is most jobs aren’t going to pay you to build a private practice. Obviously most employed jobs you’re building their practice, so making the move from employed to private seems like it would be difficult. Are you employed and are you trying to go private?

I work in a multispecialty PP that started me with a salary and then went to “eat what you kill”. They fronted my salary in the beginning. I can leave when and if I want to without paying anything back, but I’m very happy with my job at the moment. I’m referring to my last round of interviews about 2 years ago.

Large multispecialty PPs are where it’s at IMHO. They give you a fair amount of that PP “flavor” while having enough size and resources to grease the wheels and have all ancillaries. You get PP autonomy and can take leadership roles to have a say in how it’s run. Smaller PPs are not so good in comparison. They tend to not have enough resources to make things happen.

 

[Osteoth]

I work in a multispecialty PP that started me with a salary and then went to “eat what you kill”. They fronted my salary in the beginning. I can leave when and if I want to without paying anything back, but I’m very happy with my job at the moment. I’m referring to my last round of interviews about 2 years ago.

Large multispecialty PPs are where it’s at IMHO. They give you a fair amount of that PP “flavor” while having enough size and resources to grease the wheels and have all ancillaries. You get PP autonomy and can take leadership roles to have a say in how it’s run. Smaller PPs are not so good in comparison. They tend to not have enough resources to make things happen.

Are you a partner?
If so, what percent of the practice do you own? What was the structure of your ownership buy in?
What percent are ancillaries of your total pay?

 

[dozitgetchahi]

Are you a partner?
If so, what percent of the practice do you own? What was the structure of your ownership buy in?
What percent are ancillaries of your total pay?

1) yes
2) The way the current practice is set up, everyone has “titular shares”. The buy-in is $100. You start getting your ancillaries 6 months in. All of this is beneficial because I feel big buy ins are basically exploiting the newcomers. My previous job was at a PP that imploded shortly after I left; everyone’s “shares” became worthless and nobody was paid out (thankfully I hadn’t paid in by the time I left). Even if you own “shares” in their real estate or something, it’s usually not clear what the real value of those shares actually is.
3) about 1/3 of my pay is ancillaries

 

[Osteoth]

1) yes
2) The way the current practice is set up, everyone has “titular shares”. The buy-in is $100. You start getting your ancillaries 6 months in. All of this is beneficial because I feel big buy ins are basically exploiting the newcomers. My previous job was at a PP that imploded shortly after I left; everyone’s “shares” became worthless and nobody was paid out (thankfully I hadn’t paid in by the time I left). Even if you own “shares” in their real estate or something, it’s usually not clear what the real value of those shares actually is.
3) about 1/3 of my pay is ancillaries

I see, that seems reasonable. Everyone gets equal shares of ancillaries? Proceduralists don’t get mad at that?

 

[dozitgetchahi]

I see, that seems reasonable. Everyone gets equal shares of ancillaries? Proceduralists don’t get mad at that?

You get your own ancillaries (actually it’s more complicated than that, you get your own CMS ancillaries back but for private insurance patients, the ancillaries are pooled by department and split equally among the members of the department).

The facility fees (we have an ASC) are split evenly among all partners. As are annual CMS bonuses for hitting metrics. Last year, the bonus for facility fees + CMS metrics amounted to about $50-60k for all partners.

Trust me, the proceduralists make plenty of money. The rest of us do also. Average salary here among all partners last year was about $650k.

 

[sloh]

You get your own ancillaries (actually it’s more complicated than that, you get your own CMS ancillaries back but for private insurance patients, the ancillaries are pooled by department and split equally among the members of the department).

The facility fees (we have an ASC) are split evenly among all partners. As are annual CMS bonuses for hitting metrics. Last year, the bonus for facility fees + CMS metrics amounted to about $50-60k for all partners.

Trust me, the proceduralists make plenty of money. The rest of us do also. Average salary here among all partners last year was about $650k.

Man this sounds like a unicorn gig. Kudos to you for finding it

 

[Osteoth]

Man this sounds like a unicorn gig. Kudos to you for finding it

I actually knew of a clinic like this where I trained. Sold right as I started and probably 50% of the docs left immediately lol. Partners too, just didn’t want to be slaves.

 

[dozitgetchahi]

Man this sounds like a unicorn gig. Kudos to you for finding it

It is. It took a hell of a lot of digging around and a lot of interviews where I sifted through PP gigs that weren’t nearly this good (many were frankly exploitative). So far, it’s lived up to everything they promised at the interview. I plan to ride the wave as long as I can - hopefully it’ll stay like this indefinitely. They’ve sold once already, but nothing changed about the compensation structure and our partners retained majority ownership of the practice, so we still have most of the power with regards to deciding what the practice does going forward. If they sell again, I’m in line for the payout. Each partner took home something like $400k in the last sale.

The upside to a $100 buy-in is that if **** ever hits the fan, I just leave. I don’t worry about getting my buy-in money back or whatever. I’ve been through two other ****show PP jobs already (one imploded) so I know how sideways these situations can go. These people seem legit so far.

 

[dozitgetchahi]

I actually knew of a clinic like this where I trained. Sold right as I started and probably 50% of the docs left immediately lol. Partners too, just didn’t want to be slaves.

If it sold again and it was obviously not going to be a desirable place to be in the future, I’d probably leave too. And then I’d dig around for another job like this. Because once you’ve been in a job like this, you’ll never work for a hospital system again.

 

[Osteoth]

If it sold again and it was obviously not going to be a desirable place to be in the future, I’d probably leave too. And then I’d dig around for another job like this. Because once you’ve been in a job like this, you’ll never work for a hospital system again.

Dying breed though eh?

 

[bronx43]

1) yes
2) The way the current practice is set up, everyone has “titular shares”. The buy-in is $100. You start getting your ancillaries 6 months in. All of this is beneficial because I feel big buy ins are basically exploiting the newcomers. My previous job was at a PP that imploded shortly after I left; everyone’s “shares” became worthless and nobody was paid out (thankfully I hadn’t paid in by the time I left). Even if you own “shares” in their real estate or something, it’s usually not clear what the real value of those shares actually is.
3) about 1/3 of my pay is ancillaries

What's the overhead % for the whole group? Is it the same as your individual overhead?
My previous big multispecialty group (60 docs) had a shared overhead then a personal overhead. By the time I paid everything, it was about 55% which made it impossible to get a high take home income.

 

[dozitgetchahi]

What's the overhead % for the whole group? Is it the same as your individual overhead?
My previous big multispecialty group (60 docs) had a shared overhead then a personal overhead. By the time I paid everything, it was about 55% which made it impossible to get a high take home income.

Mine is about 40% in total (my shared overhead is around 25-30% or so), which is part of why everyone is able to do as well as they do. Things are pretty lean and efficient.

I think a lot of this is the fact that we are in a LCOL area. We don’t have to pay out the ass for the buildings and labor costs are relatively low.

 

[dozitgetchahi]

Dying breed though eh?

There’s plenty of choices out there. If I didn’t end up at this PP, I would have chosen another PP. My first hospital job was so bad that I absolutely refuse to do that again. I’d rather start my own solo practice tbh. Or leave medicine. (And I’m only half joking.)

 

[bronx43]

Mine is about 40% in total (my shared overhead is around 25-30% or so), which is part of why everyone is able to do as well as they do. Things are pretty lean and efficient.

I think a lot of this is the fact that we are in a LCOL area. We don’t have to pay out the ass for the buildings and labor costs are relatively low.

40% is legit. It's also amazing that you get a cut of the ASC profits. My previous group didn't have an ASC (only an endoscopy suite) and the non-GI guys did not see a dime of it.

How much are the purely clinical people making? Like the PCPs, endocrinologists, etc? They won't have infusions to add to their ancillaries.

 

[dozitgetchahi]

40% is legit. It's also amazing that you get a cut of the ASC profits. My previous group didn't have an ASC (only an endoscopy suite) and the non-GI guys did not see a dime of it.

How much are the purely clinical people making? Like the PCPs, endocrinologists, etc? They won't have infusions to add to their ancillaries.

I donno exactly, but by outward appearances everyone seems to be doing well. Several of our PCPs own some of the biggest and most expensive houses in town, for what that’s worth.

 

[NewYorkDoctors]

I donno exactly, but by outward appearances everyone seems to be doing well. Several of our PCPs own some of the biggest and most expensive houses in town, for what that’s worth.

im sure the renovated basement was paid for by ANA < 1:320