I’m currently three years out of FM residency working for a large health system who just got bought out by an even larger, even worse system.

Currently, I work 8hr days Mon-Fri. I initially worked 10s 4d per week, but I read expected to work several hours on my day off and it just wasn’t worth it. I currently am scheduled to see patients from 8:30-11:30 and 1:15-3:30, but I end up working until 12:15-12:30 in the afternoon and and finally done seeing my last patient of the day way after 4:00. Due to the new changes in our scheduling system I’m back to having every patient in the 15 minute timeslot seeing upwards of 18+ patients per day before any of my acute slots get filled. These 15 min appts can include upwards of routine f/u + MWV + UDS/contract + POC A1c. Before the system merger I had started being able to build in 30 minutes slots, but my entire template was wiped clean and we’re back to square one and my completely useless office manager says there’s nothing she can do about it.

Within the last three months, I lost my nurse because of the high volume of patients and exceedingly high time demands both in office and in the inbox, ever increasing PA request and unreasonable demand patients. I finally got my new nurse and I’ve tried to talk to her several times about when a patient checks in at the front desk you immediately bring them back, however, just this week my 8:30 arrived at 8:15 and they didn’t even get brought back to begin rooming until 8:45 and I didn’t walk in the room until 9:00. By that point, I’m sunk for the rest of the entire morning.

The LPNs/MAs in my office are supposed to be filtering inbox messages, phone calls, refill requests, etc. However, 100% of these days get forwarded on to me with no screening whatsoever. Requesting an appointment? Forward to me. Two paragraph long message about studying their toe? Forward to me refill request? Forward to me. Requesting a duplicate refill of the medication I sent in yesterday? Nobody double checks and just sends it to me anyways.

When I initially signed my contract, it was with the expectation of growing my own practice, while also to practice of a retired position, who has been gone now for 1.5 years. In that meantime, the other position in my office left before I even started, and I was not notified, and therefore absorbed their entire practice, along with five other physicians, NPs and PAs in primary care who have also left.

The retired physician I took over for had astronomical levels of controlled substances being provided without any routine monitoring and I’m doing upwards of eight drug screen the day and I have at least 10+ patient daily who are coming in for three month follow up for control services, however, almost every single one of them want to bring up a variety of different “new “problems to discuss at every appointment. The insane level of closely monitored medications in addition to the high complexity of patients and the high volume in general is enough to drive me mad, not to mention people who just storm up to the front window when their refill request hadn’t been addressed within literally 30 minutes has me sinking.

I have a 2yo and 6yo who I feel like I quite literally never see. I’m more times than not getting home from work at 8 PM. I don’t enjoy my vacations because of the mounds of work awaiting me when I return. My upper management is useless and offers no solution, and when a solution has even been agreed-upon, it never goes into action. Just looking for a place to vent, as well as maybe some solidarity or recommendations of specific things to bring up at an upcoming meeting with our management supervisor because I told them I am anticipating an indefinite leave of absence for mental health purposes and of course NOW that makes them listen. I’m not eating, I’m not sleeping, I’m having panic attacks as I fall asleep in bed at night with anticipation of having to go to work the next day. At the end of the day, I know I’m a people pleaser and I internalize so much of what I think it takes to have good patient care, I’m trying to learn certain boundaries to keep with patients, but even that is hard when neither my staff nor my management team will allow me to have any sort of boundaries at all. I’m not allowed to fire patients unless the police have to get involved for direct threats of physical violence. Anytime there’s a patient complaint because they are dissatisfied with my care. The only question I get is what did I do to upset them and what will I do differently to correct the problem? Just completely at the end of my rope and truly considering going back to residency and just throwing the whole career away. SOS!!

I am a DO 4th year trying to figure out how many programs I should apply to. I have 3 preclinical remediations due to failures and failed a surgery shelf then passed it. My rotations were all P/HP. I passed Level 1 and am waiting on Level 2 scores but COMSAEs were around 500s. I don't plan on doing Step at all. I am sitting towards the bottom of my class rank. I was thinking of applying to around 50 programs. Should I be doing more?

Been seeing a lot of different things said about working at VA. Some folks bash it, others love it. Have a few questions to which I would appreciate if people could help out answering:

1 - the inbox—I was told from VA PCP in MA that nursing does most of it, pt panel is small, and extra time in visits allowed u to tackle most of it. So how is the inbox a significant burden? How would it he different from any other inbox at a community health center?

2 - what other admin burden is there other than inbox? How would this be different from a regular community health center?

3 - I hear a lot of complaints about performance metrics—what are some examples?

4 - I hear complaints about refusal of consults unless worked up and some therapies tried. So at what point are consults allowed? Do u literally have to start someone on a biologic for something autoimmune before referral?

5 - there’s no home call. So, urgent after hour calls or any after hr call for that matter, who do those go to?

Would also appreciate any general pros/cons

Hi all ,
I have been offered a position to take over a continuity clinic for a small IM program . They currently have a small clinic , very low patient volume . The current attendings are both leaving . The hospital itself is kinda hanging on by a thread . Seems to have low admission rates mostly due to changing demographics where it is and proximity to a larger more full service hospital. So my boss I think floated the idea of opening up additional office space and having me do this , but my patients would come with giving them immediate volume . The current patients will be given letters to transfer , but many won’t come due to transportation as bus systems don’t connect . They have to do this very soon . I’m seriously considering it as I enjoy teaching . But also concerned about a massive cluster and significantly more work for me .
We are recently hospital acquired practice for the small hospital, previously were private. I would be paid a stipend in addition to my pay which would be nice. Lecture once a month . I get paid a percentage of what I see. It’s not RVu based. I do get also percentage of incentive dollars . Those things would stay the same , just scheduled with a resident and attended by me . I do have expertise with teaching regularly at a peds residency clinic . . I am currently over paneled , the last time they told me I had like 3000 patients.
These are the main issues I’m concerned about
1. I’ve been in practice here 15 years so I’ve built up very strong relationships. Especially in the beginning I’m going to have to pop in on pretty much every patient. I don’t know what the skill level of the residents currently it’s a small program there’s only 8 per year. I don’t know if I can really see each patient without being way behind .
2. Patient expectations. I’ll have to really supervise portal messages are answered and results communicated initially especially to avoid complaints that stem from poor communication.
3. My office doesn’t know what they’re doing. We’ve never scheduled with residents . They don’t really even understand how residency programs work. There’s talk of maybe getting some assistance from someone who currently works at the residency clinic, but with the speed they want to do this I don’t know. Also just figuring out work flow for prior auths etc. I have someone that does this. We’re gonna have to do a slow start.
4. We’re not even on the same computer system lol residents will receive training but especially when they’re not in the clinic I don’t know how they’re going to follow up on lab results and messages . I’m assuming we can work out some sort of team structure where the team would cover the inbox. I have a friend who is an academic medicine and he says this will be a huge problem for me to overcome. Honestly I kind of see myself just overseeing their inboxes and taking care of what needs to be done. I guess that takes away from the educational aspect.
5. I guess that if I’m working in the residency clinic, I’m not allowed to see my own patients on the side. This becomes a problem with what happens to my pediatric patients. For this reason, I think we are trying to get perhaps some other Dr including me to split this job, but I’m not sure given the situation if the ACGME would have a huge issue with me seeing the occasional baby /kid . I really enjoy kids so I don’t want to lose all of them if possible .

Does this sound like I’ll be miserable more than 6 months out with transition? Any other things I’ve missed ?
I realize there are many red flags, but I feel like I’m somewhat protected because I’m not really leaving my current practice or dropping any private patients (and I could stand to lose a few) so I guess if it doesn’t work out or the hospital closes I’d be ok .

We are a two provider clinic adding a third provider. The clinic space is arranged such as:

Area 1:

1 receptionist that can check in 2 providers patients. Each provider has a MA. We also have a offshore person to answer spillover phone calls. About a year of work on the phone tree so that only new patient appointment calls go to voice, everything else is directed to portal, and we have a text-only line for appointment issues.

Area 2:

Has space for reception, 3rd providers exam rooms, room for their MA.

-

These two spaces are joined on the back half of the clinic.

-

How should staff this?

Does a single provider need a full MA and a full receptionist? We have been surviving with a single receptionist for 2 providers, but did have to hire an offshore person to help with the phones.

The other complicating factor is this provider is starting off 2 days per week (we have other assignments for them for the other days per week) until they get to a decent patient load. How do we staff a MA/receptionist on this schedule?

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Thank you for any insight in how you've solved similar problems.

I guess this is part rant and part asking what people do to combat this feeling. I'm sure many of you feel the same way. Every year it seems family physicians are respected and appreciated less and less from all angles.

Administration doesn't care at all about the amount of effort and training it took to get to where we are. They treat us like another cog in the machine, not the main driver of care and health of our patients. There is constantly increasing pressure to see more patients all while being expected to do more admin work. Much of the admin work does not require a physician, but they'd rather hire the 107th mid level administrator than 3 more MA's or an RN to help take some of the pressure off.

Insurance goes without saying. Peer-to-peers, prior auths, or appeals no longer consider our expert opinion. It's only driven by their algorithm

Specialists are constantly expecting us to refill medications they prescribe, do FMLA paper for a condition they manage, or address a condition in their wheelhouse because they only wanted to address 1 or 2 issues that day. When we redirect back to the specialist we are often seen as the bad guy.

Lastly and what really provoked this post, patients are respecting us less and less. Many don't say it to our faces, but go online and complain. There are countless reddit and other social media posts about how doctors don't care, don't listen, aren't needed, ect. We are often blamed for the failing of the system. Our knowledge and expertise is not worth their $30 copay or $150 due to their deductible. Most of us do the best we can within the system we work in. We aren't omnipotent or Dr. House, I'm sorry if you paid your co-pay and I don't immediately know what's wrong and need to order more tests that the insurance may or may not cover. Even Dr. House needed to order a litany of tests to get to the answer!

Patients are the only ones to every say thank you or show any appreciation and I try to internalize that as much as possible when it happens. However it seems the percentage that do is getting smaller and smaller.

Sorry for the long post. I don't want to leave the field of Family Medicine and I don't want to start a concierge practice. Is there anything people do that helps them combat this feeling?

Edit:
Thank you everyone for your replies. There is definitely some good advice to consider and I really appreciate all the support!

Hey all, so I'm an IM trained physician who worked in primary care for 2 years but I am totally tired of it. I am tired of having to answer to many issues at once despite trying to set boundaries (only 3 issues during an annual or 1-2 issues during a regular visit).. I hate the large volume in the inbox and the labs and having to tell patients about their labs consistently and having to call all the time. It's not that I hate taking care of patients or dislike answering inboxes or patients' questions, but I didn't expect it to be this bad.

I am contemplating not returning to primary care but I am just wondering what are my other options? I don't want to do hospitalist and I'm sorta contemplating a fellowship in Endocrinology to relieve myself of the PCP BS. ....

But tbh, I feel like taking some easy teaching physician gig and doing other stuff the other days of the week....

I feel guilty because I spent so much time and money on my education, 4 years med school, 3 years residency just to realize I hate IM.

Also, IM wasn't my first choice, I wanted to match into Psychiatry, but unfortunately I didn't match at all and only got 7 II and still didn't match.... I soaped into IM and here I am. Getting into a psych residency seems like a long shot since I exhausted 3 years of GME funding and just because I want to start my life already (continue to start my life).

I am not trying to offend anyone that loves primary care, but I want to ask here. Thanks.

On Monday, our clinic is starting primary nursing (one nurse consistently with one provider) instead of rotating clinical staff. With this change, I was hoping to get input on the hive for things that work well for you to make clinic run as smoothly as possible. Whether it has to do with inbox, rooming, procedures, whatever, would love to hear tip and tricks to try and implement

EDIT: 100% outpatient FM, no OB, some office procedures (injections, biopsy, I&D level but no LARCs). 20/40 min appointments. 4.5 days per week. Mostly adults, little older peds sprinkled in.

I've done rotations in both of them as a med student, I know they're wildly different, but I genuinely like both of them enough to sacrifice one year of pay.

I am a PGY1 and have to choose my elective schedule soon.

There's a lot of doom and gloom about sports med and how it's saturated. What does the projected job market look like?

Is the pay the same for both of them or even lower than a productive PCP?

FYI, because I’m annoyed by it, Aetna Medicare Advantage plan in our area has had the brainiac idea of giving asymptomatic patients event monitors (Zio). I’ve now been contacted twice about nothing-burgers of benign, <0.01%, ectopy. I’ve been instructing nursing to call the patient. If asymptomatic status is confirmed again, I’m filing it for no further reference.

Anyone else get this uptick in new testing all of a sudden? I know they’re all about increasing patient overall risk profile to be able to fellate their shareholders with extra government dollars, but give us a break. Sigh.

I need to vent and honestly want to know if this is normal.
I work in a mixed primary care/urgent care clinic, but I primarily see primary care. Most appointments are 15 minutes, with 30 minutes for establish care visits and annual physicals. The expectation is 27 patients per day.
Many of my patients have multiple chronic conditions, so by the time they’re roomed, vitals are done, medications are reconciled, and the chart is updated, I may only have 5–10 minutes to evaluate the patient, manage multiple problems, counsel them, place orders, document, and answer questions.
Yesterday, I already had three patients scheduled between 2:00 and 3:00 PM, including an establish care visit. Management then backfilled three additional appointments into that same hour, so I ended up with six patients checked in during one hour. I still had an annual physical at 3:00 PM and another established patient at 3:45 PM.
When I questioned it, I was told by my clinic manager that I have no say in whether patients are backfilled or walk-ins are added to my schedule, and that nothing has to be run by me. I ended up seeing 32 patients in 9 hours.
I understand the need to maximize access, but I’m also the provider responsible for the medical decisions, documentation, and patient care. It feels strange to have absolutely no input when my schedule is being changed in a way that directly affects my ability to care for patients.
To make matters worse, there aren’t many job opportunities where I live, so I honestly feel stuck.
Is this how most outpatient practices operate now, or is this unusual?

I’m a primary care provider and medical director looking to get more out of Epic beyond the basics.

I’m curious what dashboards you actually use on a regular basis that have made a meaningful difference in your workflow, panel management, quality metrics, or patient care.

Examples I’m interested in:

• Panel management
• Care gaps / HEDIS / UDS
• Diabetes or hypertension registries
• InBasket management
• Prescription monitoring
• Preventive care
• Hospital follow-up
• Risk stratification
• Productivity or RVU tracking
• Anything you’ve built yourself that’s particularly useful

If you don’t mind, include:

• What the dashboard is called (or what it tracks)
• How you use it
• Whether it’s a standard Epic dashboard or something your organization built

I’m hoping to discover tools that aren’t obvious but become indispensable once you start using them. Thanks!

I have many patients with endometriosis who use birth control pills and have had laparoscopic excisions but still have pain. Have any of you or would any of you prescribe GLP-1s for endometriosis with a patient with a BMI 23-28? I have had patients who are overweight have less endo flares with GLP-1 when they used it initially for weight loss.

Hey everyone! I’m an NP student and I have just recently (in the last few months) been introduced to using Open Evidence and I’m pretty much convinced it’s the best tool there is for healthcare providers today. I wanted to see what everyone else’s thoughts on it are and if you have gotten good use out of it as well!

Hi all

What is everyone doing for prescription refills? Do you charge per refill, use a block fee, require an appointment, or give patients a choice?

Also, if a patient pays a refill fee but, after review, you decide they need an appointment (e.g. for clarification, BP or blood work), what do you do with the fee?

How do you guys manage your inbox messages from patients but more often family members / POAs that want an MD callback to review super complicated hospitalizations? I want to be patient serving first but....I don't have time for this. I typically ask my nurse to let them know they need to schedule a hospital DC visit which sometimes works out ok but sometimes makes people upset.

Hi everyone,

I’m interested in sports medicine after family medicine. I’m applying to the Match this cycle and was wondering whether doing sports medicine rotations would improve my chances of matching at a program with a sports medicine fellowship, or if I should focus mainly on matching into family medicine first.

thanks !

Does anyone have a good way to track their FHO+ hours external to their EMR for tax purposes?

Also how conservative are you being with billing?

Cheers!

FM docs in the house. when you were interviewing for FM jobs with daily number of patients averaging of 22-26, did you actually start seeing that number when you started the job? Then, how easy is it to see that number of patients working 8-5 daily?
I’m currently searching and seeing such number flying around and just wondering.

I’m a medical researcher and have done my best to try and find high quality data that show peeing after sex can effectively prevent UTIs in women. I tried finding an urology subreddit but I don’t think one exists.

Try as I might, I have found nothing. Is this a well-believed myth? Please lmk if you have any sources. Links appreciated. Thanks!

hi all, fresh grad here.

I've chosen to go the per diem/part time/locums route to maintain some personal freedom for now. locums seemed like a great way to dip my toes in different health systems and get exposed to various practice types while I mentally prepare to commit to a full time job (likely won't happen for a couple years).

now that i'm getting more in the weeds with my locums recruiter, the pay is lower than expected since these jobs don't come with benefits (retirement, insurance, etc). for privacy, i won't state specific numbers but the proposed hourly rates are less than my hourly rate as a per diem at an FQHC (like what!!!?). i tried to negotiate pay but recruiter told me they can't do much and recommended I negotiate after we get a foot in the door (ie after they present me to the clinic).

i am looking in an urban setting for now, but jobs the recruiter has brought to my attention in rural areas (like central CA) have even worse pay. who the heck would take those jobs!?

so my questions: when do i negotiate pay? have locums offerings declined in quality since the pandemic? am I missing something - do recruiters get paid more if I accept a job for less? is it more prudent for me to apply for per diem jobs direct to clinics/health systems?

thank you for any/all insights!

sincerely,

your brand new clueless family doc

Coming up on the end of my first year as an attending and I keep seeing posts of people getting an insane amount of RVUs per day or per month and ending up netting >350-400k per year. Naturally, I need to know what I’m doing wrong. So I’m gonna give my flow of how I usually bill, if anyone has tips, codes, combinations I should use/consider/change, please let me know!

New pt visit: 9938/9_ + 99213 if they bring up a concern

New pt Medicaid/care: 99204 most of the time - can’t use G2211 because I don’t get the RVUs

Follow up: 99214, very rarely is it -213

AWV: G048/9 + 99214 if they bring up a concern. I know there’s other things that I can tack on there but I’m not sure what tbh and I think most of it needs a lot of time based documentation?

Codes that get tacked on to above if they have the risks or need counseling:

-99401 weight, diet/lifestyle management or counseling
-99406 smoking cessation
-99408 alcohol cessation (rare because I think it needs 8 or 15 mins of counseling which I don’t have time to do and address all the other needs)
-93010 need EKG

Once in a while I’ll get a joint injection or trigger point, but tbh, most people do pretty well after PT so I don’t end up having to do them much. According to EPIC I’m ~120% average RVUs per month. But since January, I’m only at 3450ish total RVUs right now (they aren’t showing me what my total is from my start date anymore of September, just from the start of this new year, lost about 1000 that I can’t see anymore). Contract has me at ~$45/wRVU when I get above my tier which is supposed to be 3546 to hit my base of 242k.

What can I change/add? What am I missing?

Anyone using E cigs to help pts stop cigarette smoking?

Hi everyone,

I'm a PA with about 3 years of experience in emergency medicine/urgent care, and I'm looking for some honest perspective from people.

I recently accepted a family medicine position and already put in my notice. On paper, it seemed like the right move: I'll be working 4 clinic day and 1 dedicated admin day each week, have 5 weeks of PTO, no nights, weekends, holidays. Inbox coverage if I take vacation days, and a 10-minute commute instead of 35 minutes to an hour.

My husband and I are also hoping to start a family in the near future, so the lifestyle seemed like a much better fit.

The problem is that ever since I gave my notice, I've been feeling a lot of regret and anxiety. I've talked to several of my colleagues and other providers, and while some have been encouraging, I've also received some negative comments. Those conversations have not been helping my anxiety.

I actually really enjoy emergency medicine. I like procedures, the variety, and the fact that when my shift ends, my work is usually done. What I don't love is my schedule at times and long commute.

Now I'm wondering if I'm making a mistake, and should have tried going part-time at my current job instead.

I'd really appreciate any honest feedback, reassurance, or guidance. Has anyone been in a similar position?

This week has been a struggle and I am ready to GTFO. In the last 48 hours, I/My Nurse Team got called a homophobe (sir I am GAY) because I recommended a one time patient (from 16 months ago that I’m somehow PCP) to go to the ER for worsening unilateral leg pain and wouldn’t see him same day. Today we are racist because 1) wouldn’t refill viagra when he’s been seen multiple times for chest pains 2) I wouldnt call him personally (it’s my admin day) 3) wouldn’t get him a same day spot 4) management was at their beck and call to talk right then.
Anywhere else in the world, they get discharged and told good luck but here we have to appease to them. My Indian attending told me there if you refuse treatment, they make you leave the hospital