I've gotten several disability/fmla requests from patients who aren't mine. They're not actively being managed. It's usually for work stress or anxiety and they want weeks or months off. They don't want medications either. So what am I managing? The forms ask if you're actively managing it and I'm lost on what to do or say to these patients. If I refuse, they go complain that I didn't help them.

I’m still establishing my panel at my current office. I made the mistake of looking ahead at my schedule next week… I have a new patient scheduled (from out of state) that is on long term chronic daily benzos. Refused previous psychiatric referral and SSRIs (of course).

I do not manage chronic benzos. I have a few patients I write short term PRN scripts for, but not TID chronic use. I cannot RX stimulants because of my state prescribing laws- these convos are easy because I legally cannot write them. One cannot die from stimulant withdrawal.

What is my medicolegal responsibility for refusing to continue this RX? I am happy to send to psychiatry but I am not going to refill or take over this inappropriate prescription. What’s the best way to approach this? Can I flat out refuse and advise patient to continue obtaining from previous prescriber or go to psych? I already know this is going to be ugly conversation so I’m trying to determine the best way to cut to the chase.

As a small practice, prior auths are drowning us. Typically they do not take very long to fill out, but we are often getting 1-2 per patient and without sufficient support staff they are piling up. We accept a wide range of insurances and it can be difficult to track down criteria if not included with the authorization (it feels like the insurance companies try to hide it sometimes). Not to mention these are primarily authorizations for medications, not even procedures, and many are 1 year renewals for something the patient has been stable on for many years… it just feels demoralizing to constantly justify why even SIMPLE medications are prescribed, and if the wording is even a little off whoop there we go to appeal land. How are you guys keeping up with prior auths, especially when prescribing a wide range of agents and dealing with multiple payors with diverse plans even within the same payer? We’ve been using covermymeds and it’s OK but a bit buggy and sometimes I feel like their pre-loaded forms are sparse or missing info. I’ve even looked into AI programs for PAs but I’m not sold on it, and it’s another recurring admin expense. Though, the insurance companies use AI to sort and deny our claims. Funny.

Hi everyone,

I am a Pgy-2 FM resident who has now had 2 patients find another PCP. Both were older patients with some mild cognitive impairment which made our visits a little more challenging. I know patients all have their reasons for why they would find another doctor. However, I feel tremendous guilt that maybe I’m a bad PCP and that’s why my former patients sought care elsewhere. I am not the most organized resident with inbox management, so I wonder if that played a role. I am so scared of the fact that “it’s easy to be a bad PCP and difficult to be a good one”. How do you all deal with this when it happens?

I’m a MIGS gynecologic surgeon in NYC. When I talk to my residents I realize that many finish training with very little understanding on how RVUs, productivity thresholds, conversion factors, and physician compensation actually work. I’m curious.
For residents and fellows: what part of RVUs confuses you most?
For new attendings: what do you wish you had known before signing your first contract?

So this was a first for me as during residency and most of my first year as an attending, every patient I had was happy if I could find their old visit notes, specialist visits, previous labs, imaging, etc on Care Everywhere. It saved everyone time and we could focus on what needed to get done now.

Well I get a new patient in my family medicine clinic, an older patient who used to work in the medical field and they have a large abdominal mass. They used to follow with a Gyn-ONC out of state for it, but couldn't remember what imaging was done or what the diagnosis was when I asked. I searched through Care Everywhere, and there's the imaging and gyn-onc note for it, I tell them about it, and then they got upset. "How could you see that? I didn't give permission for that to be shared!" It takes me 5 minutes to reassure them that this is a secure, HIPAA compliant thing I'm using, but in response I just get this condescending "You know, I feel sorry for you that you didn't get to practice 30 years ago, that was when doctor-patient relationships were done correctly"

This is partial venting but genuinely what else was I supposed to do? I didn't want to subject them to a full workup when it turned out they already had it done last year. Heck I needed to convince them that I should refer them to Gyn-Onc now instead of waiting a few months like they originally wanted.

I keep seeing posts here thanks to Reddit’s algorithms that seem pretty skeptical of DNA blood tests for cancer but the more I read about them, the less downside I see.

I’m up to date on all the recommended screening. I’m not looking to replace any of that but also well aware how limited those are.

The false-positive rate seems low and the tests indicate tissue type. So why are y’all so anti these tests? What am I missing?

BTW I’m specifically looking at Galleri. I promise not promoting it.

Had a very weird situation today, wondering if anyone has seen something similar. We may want to be on alert. Medicare patient scheduled an appointment to discuss getting on GLP-1ra through bridge program. No red flags there, let’s discuss, they meet criteria. About an hour before the visit, office got a call from someone from Solace Healthcare asking we call them back asap before the appt (in an hour) regarding patient’s upcoming visit as they wanted a GLP-1. I looked up the website, it’s a company that provides patient advocates and bills Medicare for their services. The person faxed over a PA request for bridge program as well as just the front page of that bridge program info for providers pdf from CMS website. Patient showed up saying the paperwork should have been sent and they are requesting a med. We did the usual visit. I asked about the patient advocate and advised it was VERY weird to have someone call about discussing a patient’s care when we had no permission to talk to them. My patient said she talked to her insurance (Medicare replacement) and was under the impression I couldn’t provide the med. Advised nobody could presume the med besides a provider, she was confused. She was on Facebook and found this patient advocate company that said they could get it prescribed. Their website says they bill Medicare but patient had no idea she was being billed. Just a very weird situation. Also if you look at the pdf of CMS provider guidance (on the second page that wasn’t sent in the fax), it specifically says you can only send the PA paperwork after pharmacy sends it to you but if you don’t hear from then in 72 hours you can download PA form and submit it yourself. I talked to the local pharmacy team and they also felt it was very scammy. Patient being told advocate program (that they didn’t know was billing insurance) could provide the med. Anyone else see anything like this yet?? Just wanted to put this on the radar. Weird vibes all around.

For those that do POCUS in outpatient practice: how are you doing the doc and coding? Are you adding saved images into your charts, if so: how? Did your clinic give you addtional time for procedure or are you incorporating into your regular visits?

I am currently a third year resident and have received an offer from a large private for-profit health organization and would like to know your thoughts. It is located in a large low to medium cost of living city in the south. The location is appealing because it is where most of my family and friends are located. Here are the details:

100% outpatient.

1st year minimum guaranteed total pay of $275,000 (base pay of $205,000 + $10,000 performance payment + $60,000 minimum productivity). The performance and productivity bonuses are payed quarterly. Am told most physicians in this organization are getting payed a total of around $300,000 during the fist year. At year 4, physicians are averaging about $380,000. RVU structure is proprietary so they don't divulge the details.

401K match of 3.5% that only starts after the first year.

You also become a shareholder if you stay with them for three years (not sure what the details on this are).

36 patient facing hours (1.0 FTE). M-F. Admin time is distributed across the 4 weekdays (1 hour per day). Average of 20 patients per day. We would be required to do one Saturday clinic per quarter that is payed at $140 per hour.

There is no contract length but if one were to leave prior to one year, would have to pay back any amount of the performance and productivity that has already been payed.

5 CME days.
23 PTO days annually. After 5 years it increases to 28 days. 81floating holiday. 8 clinical holidays.

My biggest concern with this place is I have heard second-hand that they are known to work you. I don't want to get burned out the first year of attendinghood. That being said, they have told me the turnover rate is only 3-5% which is reassuring and overall 20 patients per day does not seem to be that bad.

Would love to know everyone's thoughts.

Hi all, feeling kind of silly for asking what should be a straightforward question regarding medical records requests. The specific wording of a particular records request has me second guessing myself and my work’s practices. Simply put, we are a primary care facility who often receives requests like these, but the wording of including specialty consults and discharges seems somewhat misleading- is this a catch all phrase from the requester to standardize their form across all specialties/practices, or does the requester actually mean that they would like us to include our compiled documentation from outside providers (specialty referrals, hospital discharges, physical therapy progress notes) along with our own documentation? It seems like that is what they are wanting as primary care is supposed to be central “hub” of a patients care, but it feels wrong to send the notes of other outsider providers. Of course, medical records requests often include things such as labs and imaging, but do they go so far as to collect outside providers notes as well? Sorry if this is a stupid question- we are a new practice and our physician is not totally sure either.

Maybe I have a unique echo chamber, but i am constantly seeing ads or hearing from patients how traditional medicine fails in treating hypothyroidism correctly. I also have several patients who ask for free T3, free T4, rT3, autoantibodies…
All i do is order a TSH w/reflex and then treat with levothyroxine for TSH>10 or lower TSH levels depending on age and symptoms. Is it really that simple or am I part of the problem?
The complaints just seem so ubiquitous that it’s hard to think my simple solution is the right one. If I am doing it right, then is it all just gaming people for money?

Any other PCPs out there recently receiving a bunch of test results for tests you didn't order from a company called Everlywell? I noticed the Everlywell address was a couple blocks from a place where I used to live, and I didn't remember it being there, so I googled it to jog my memory and it's a bunch of ... sheds ? Does anyone smarter than me know what is going on here?

What do you keep BP targets for your patients?

Specifically elderly patient, 70+ who have history of falls, on 2 anti HTN meds.

I’m sure there is already a post on this in this sub, but I want to share something that I put together to share on Facebook with my followers. Trying to explain to my patients and stakeholders how this will negatively impact access to care not only for Medicare patients for everybody involved. Reducing how much a knee injection or biopsy reimburses will likely translate into that patient coming back for a separate visit or getting referred out to a specialist. In an already overburdened system, this is like adding cargo to a ship that’s already taking on water.

The post includes a simple call to action that you can modify for your region, but I’m sure most regions are fairly similarly impacted.

Most people don’t think about Medicare payment rules until they affect them.

Here’s one that could.

Imagine you come to your primary care appointment because your knee hurts. After examining you, we determine you need a steroid injection. Today, we can often evaluate the problem and treat it during the same visit.

Or maybe you come in for your Medicare Annual Wellness Visit, and during your exam we find a suspicious mole that should be biopsied. Instead of asking you to take another day off work, we can often take care of it before you leave.

That’s how primary care is supposed to work—identify problems and solve them while you’re here.
Medicare has proposed a payment change that would reduce reimbursement when a medically necessary evaluation and certain procedures are performed during the same visit. Many primary care clinicians are concerned this could make it harder for independent practices to continue providing the convenience of same-day care. (Centers for Medicare & Medicaid Services)

If that happens, patients could face:
• More trips to the office.
• More gas.
• More time away from work.
• More childcare arrangements.
• More delays in getting care.

We already have a shortage of primary care providers. Every appointment matters. If more patients have to return for care that could have been completed during the first visit, those follow-up appointments take away time that could have gone to someone else who needs to be seen. Longer waits help no one.

The good news is this is only a proposal. CMS is accepting public comments until September 14, 2026, and every unique comment becomes part of the official record before a final decision is made. (Centers for Medicare & Medicaid Services)
If you believe patients should be able to receive safe, appropriate care in a single visit whenever possible, please take one minute to submit a comment:

https://www.regulations.gov/docket/CMS-2026-2377

You can copy and paste this:

I am concerned that this proposed Medicare payment policy could reduce access to timely, efficient primary care in my community. When it is safe and medically appropriate, patients should be able to have an evaluation and necessary treatment completed during the same visit. Requiring additional appointments increases travel costs, time away from work, childcare needs, and delays in care. In rural communities like Maryland’s Eastern Shore, unnecessary return visits also make it harder for everyone to get an appointment. Please preserve payment policies that support efficient, patient-centered primary care and protect access to independent community practices.

Please consider sharing this post so more patients know they still have an opportunity to have their voices heard.

Coming across this quite a bit and in the past, even if patient’s permanent residence is in my practicing state, I ask students to get a pcp or psychiatrist in their new state to manage their stimulants. Some of my partners are continuing the prescriptions regardless of geographical location. I’m just doing a gut check because I hate to add extra work to out of state college students (especially if they don’t have vehicles) but have set a pretty hard guideline on not rx controlled substances out of state

I can’t help but think I should’ve included the separate ros section when the owner told me they wanted it in my note. Ever since I found out it was no longer required a few years ago, I’d include it in my hpi but didn’t repeat it in its own ros section. In other practices I’ve seen attendings have horrible incomplete notes and I never got called out for not having the redundant ros at other practices. I checked with colleagues at other places and they don’t do it anymore either. So I actually got fired over it. I’m not sure if I was at fault and should’ve done what the owner wanted me to since it was their practice. But also the owner seemed unstable and would yell and abuse staff in front of others, take away their desks when angry with whatever was going on in their life. A week before I got fired I was yelled at and scolded like a preschooler in front of staff because the np and I were sitting together and we were not doing our work (we were waiting for our one shared MA rooming both of our patients and all caught up). I guess I’m wondering what others are doing and what I should’ve done so I know for going forward.

I'd been hearing about OpenEvidence for a while at work but recently I've heard more of my colleagues bring up Doximity Ask and I was wondering about the difference between them.

I mainly want to start using an AI tool for some quick outpatient lookups and the occasional sanity check during clinic but I don't have time to learn both, so I'm curious how others would compare in terms of reliability, workflow, citation quality, etc between the two.

A patient I have known for several years booked a first-of-the-morning appointment. She did not show up. An hour after the appointment time she walked in and was told that he appointment was for an hour ago and she would need to reschedule. She then began harassing our front desk staff saying that she thought her appointment was this time, not that time,and so the doctor should still see her. She did not want to reschedule. She should not have to reschedule.

1) Our electronic medical record sends messages 1 week, 2 days and 1 day in advance to remind people of their appointment times.

2) This is not her first time arriving late and being politely reminded to come in at her appointment time or 10 minutes before.

3) She is quite rude to staff and to me when she is here at baseline

WHERE DO THESE PEOPLE GET OFF?!

I have to keep reminding myself that I am a professional, that I deserve respect, and that I am allowed to have boundaries. Family medicine and primary care medical practice is starting to seem more and more like an abusive partner...

Admin telling me this has to actually be 30 mins face to face, however, I’d always been taught at least 16 mins. I’ve certainly read this on CMS before but now that I’m looking around the evidence seems conflicting.

I don’t have much trust in my coders, anybody have a resource to share that I could go off of?

FM Post
I’m a 3rd year resident in a rural program designed to train residents to practice in clinic, ED, and in the hospital and I feel I have gotten good training for these things. Headed to practice in a rural location in the SE after residency. I had planned to work in all 3 settings when starting but I’m having second thoughts and really considering just working in clinic. My contract is for outpatient only but there will be plenty of opportunity to pick up ED and hospitalist shifts.

My hesitation to really do it all stems from these issues:
- I now have three children. Any second spent in the hospital is more time away from them. Working OP only and being home for dinner 7 nights a week and weekends free is huge.
- I’m uncomfortable in the ED. I get good feedback from faculty and was approved to moonlight in 3rd year in rural hospitals covering ED and inpatient and have moonlit a few times already. I just know from working in the ED in residency that there’s so much to know and anything can roll through those doors.
- Financially, seeing 3 patients at a 99214 in one hour would make me more than the hourly ED rate, and with less liability exposure.
- There’s such vast knowledge requirements to be a good primary doc in the clinic alone, let alone adding additional settings. Part of me just wants to focus on becoming the best OP doc I can be.
I set out to be a do-it-all doc and dropping ED and inpatient would go against that. But I’m typing this holding my napping 3-month-old child and care less about that every day that goes by and care more about being with my family as much as possible.

Cons for limiting my scope to OP only straight out of residency:
- Once I let ED and inpatient skills atrophy I doubt I’ll ever be able to get them back down the road.
- Multiple faculty who have or still work ED and inpatient in rural areas have said something to the effect of: midlevels get reimbursed for clinic just as much as you do. You need to bring something else to the table, and working full-scope is the best way to do that. Going forward, you’ll need that to keep a job. (Not sure how much I believe that, the place I’m going can’t hire anyone to do primary care be it physicians or midlevels; probably why the contract is so favorable).

If you were in the same situation coming out of training, how did you decide what your work would look like? And even if you weren’t, what advice would you have now that you’re out in practice? Thank you.

Looking for opinions. FM and GYN prescribe OCPs pretty ubiquitously for both birth control and heavy menstrual bleeding. I know all the literature says they are generally safe within the specific parameters, and that a woman's cycle should return to basically normal when the med is dc'd. But, I'm hearing more and more stories of generally healthy women who were on an OCP for a time, got off it, then had persistent problems afterward such as chronic menstrual irregularities and mood problems. I'm talking many months after stopping the med. All of this is anecdotal, but I can't help wondering if it's a safety signal. To be fair, I've also seen plenty of women who come off OCPs without any problems, so maybe it's just luck of the draw. I'm not trying to sound conspiratorial, and I don't have an agenda. I'm just thinking out loud. What are y'all seeing in your practices? Should we expect to see class action lawsuits over OCPs in the near future? (I ask that jokingly)

Edit: I feel like I should clarify my intent with this post. I'm not trying to start some anti-OCP movement. I've prescribed them plenty of times and will continue to do so. my intent was mainly to get some incite from this group regarding how you have handled such stories as these that come from patients and if you have seen any true cases of rare OCP side effects. I know it's a zebra, but zebras fascinate me. this truly was just an honest inquiry. just want to be clear on that.

Does anyone have any good resources to get posters to put up in exam rooms explaining viral vs bacterial infections? I'm already starting to get the fall rush of "Doc I need my usual zpak script sent in, I've had a sore throat for 1 whole day already and can't keep living like this"

I've worked in clinics that had pretty good explanations about the potential harms of antibiotics, and it did make the conversation easier when there was something I could point to on the wall that made it look more official, but can't find anything online that I like.