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Young Attending- Neurohospitalist question- Am I just a lazy millennial?

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  • Young Attending- Neurohospitalist question- Am I just a lazy millennial?

    Hello,

    I have been employed for 11 months. I have seen ~1020 inpt new consults, ~1100 intpt follow ups [ Did about 100 new outpt consults and 100 outpt follow up, but shut down my clinic]. I am not sure what a high volume is but I work as hard as I can. I do not have typical 7-on-7off schedule either, I work on average 22 days/month. I am having trouble finding out averages for neuro-hospitalists specifically since the AAN publishes numbers for neurologists in general. Despite the volumes I am well under the median for neurologists. I am not sure I am capable of working much harder than I am now. I do not think I am a "lazy millennial," but I recognize that I may be blind to my own faults/laziness. I often put in 12-16 hour days when including documentation I just want to understand who to be the best advocate for myself. I may be just inefficient (I do spend a lot of time talking with families, reviewing their imaging with them, participating in family meetings) which is generally not billable work since I use E&M coding. I feel like I provide a ton of value, but I have no hope of extra compensation since my productivity numbers suck.

    Thank you.

  • #2
    U are probably a good doctor but do not work efficiently if you have 12-16 hr days... work smarter

    12-16 hr days are not sustainable. This will sound strange to hear but spend less time with your patients. U have to take care of yourself first. Spending your whole day and evening in the hospital is not healthy.

    Comment


    • #3
      I’m not sure what you are asking?

      are you asking how to grow your practice?  Are you asking whether you should be on salary?

      of course you are capable of working much harder.  It has the risk of leading to burnout.

      I wouldn’t worry about the volumes.  The first year effort is likely to be eclipsed by the second and third years in number of consults and follow ups.  Then you will have to choose, as everyone else has before you, on where to economize with your time.  You can’t have high volumes and spend a lot of time with families.  It’s every clinician’s dilemma.

      congrats on completing the first year of practice.

      did you decide to accept the medical directorship?

       

      Comment


      • #4


        work smarter
        Click to expand...


        Still trying to break that code!


        did you decide to accept the medical directorship?
        Click to expand...


        Yes. No pay bump though.


        I’m not sure what you are asking? are you asking how to grow your practice?  Are you asking whether you should be on salary?
        Click to expand...


        I am currently salary. My contract ends in a year and per my contract I have to give them 6 months warning if I am not going to renew so I am trying to gameplan for the fall when I renegotiate. Do I ask for higher base salary? Lower productivity thresholds? Do people only care about productivity numbers or is there any chance at people valuing the quality of my work (and paying me more )

        Comment


        • #5







          work smarter
          Click to expand…


          Still trying to break that code!




          did you decide to accept the medical directorship?
          Click to expand…


          Yes. No pay bump though.




          I’m not sure what you are asking? are you asking how to grow your practice?  Are you asking whether you should be on salary?
          Click to expand…


          I am currently salary. My contract ends in a year and per my contract I have to give them 6 months warning if I am not going to renew so I am trying to gameplan for the fall when I renegotiate. Do I ask for higher base salary? Lower productivity thresholds? Do people only care about productivity numbers or is there any chance at people valuing the quality of my work (and paying me more ? )
          Click to expand...


          Respectfully

          no pay bump for medical directorship-bad start to your relationship.  Now you set the precedent and the flight path for work expectations.  We warned you about that.  Also, you are too polite and nice, and so you will get fleeced by the administration.  You needed time to toughen up.  

          value the non-RVU work-of course administration appreciates your willingness to have good patient relationships.  Not enough to pay you significantly better, but they appreciate it.  See above comments.

          who is your 1 up leader?  What do they say about best way to achieve your professional goals?

          there is only a question of how much time you get if there is a persistent mismatch between income and professional measured productivity.  In that sense your decision for negotiation will be based on whether you think you will continue to under produce, in which case you should get salary with RVU kicker for production.  If you are going to get clinically busy, then production model is way to go.

          good luck

          Comment


          • #6


            We warned you about that.
            Click to expand...


            Yea, I did ask for more money but was quickly shut down and I did not put up much of a fight.


            who is your 1 up leader?  What do they say about best way to achieve your professional goals?
            Click to expand...


            I do not have anyone in my specialty to help. My 1+ boss is a neurosurgeon and I am planning to meet with him soon to discuss.


            get salary with RVU kicker for production
            Click to expand...


            Thankfully that is my current pay structure. I plan to ask for significantly more money but it is a hard sell if I am not productive. I guess I will have to highlight my other non-productivity related accomplishments.

             

            Thanks, as always

            Comment


            • #7


              I have been employed for 11 months. I have seen ~1020 inpt new consults, ~1100 intpt follow ups
              Click to expand...


              So you're seeing 4.2 new inpatients per day?  That shouldn't take you 12-16 hours.  What are your RVU numbers (assuming you are on such a contract and have them).

              Comment


              • #8
                I agree with @childay . You're seeing 4.2 new inpatient consults a day and a little more in inpatient follow ups. Efficiency seems to be your biggest issue.

                Comment


                • #9





                  I have been employed for 11 months. I have seen ~1020 inpt new consults, ~1100 intpt follow ups 
                  Click to expand…


                  So you’re seeing 4.2 new inpatients per day?  That shouldn’t take you 12-16 hours.  What are your RVU numbers (assuming you are on such a contract and have them).
                  Click to expand...


                  Assuming numbers are correct I think this is spot on. 2 hours for a consult is probably even excessive.

                  I'd want to know about your documentation. Many docs spend way too much time trying to craft the great american novel that no one will ever read, well it might be skimmed once by the primary service.

                  Frankly from the tone of this post I think you're headed for the rocks. You feel like you're working hard and not getting the comp you want. At the risk of sounding overly critical I think you should have looked at benchmarks like consult volume/rvu/compensation BEFORE you took this job especially given that it has an uncompensated leadership role.

                  Comment


                  • #10


                    Many docs spend way too much time trying to craft the great american novel that no one will ever read, well it might be skimmed once by the primary service.
                    Click to expand...


                    I firmly believe that documenting too much is definitely a thing and I'll make the case that it actually hurts you if a malpractice case comes up. It's a Goldilocks situation. Not too much, not too little, but just right.

                    Comment


                    • #11





                      Many docs spend way too much time trying to craft the great american novel that no one will ever read, well it might be skimmed once by the primary service. 
                      Click to expand…


                      I firmly believe that documenting too much is definitely a thing and I’ll make the case that it actually hurts you if a malpractice case comes up. It’s a Goldilocks situation. Not too much, not too little, but just right.
                      Click to expand...


                      Mostly true.

                      The big issue for me is excessive documentation that just doesn't do anything for you, it doesn't help care for the pt, doesn't protect you in litigation, and doesn't increase your billing capture. You see this with long meandering HPIs often written on the inpatient side. It's not hurting anyone and it's certainly consistent with a lot of the things we were told in med school it just kind of wastes time. The patient's story is critical to hear, I'm not sure it's critical or even necessary to reproduce.

                      The malpractice issue is interesting. In my experience inadequate documentation is 10:1 more common than the alternate problem.

                      I think all of us as we get older get much more tactical in our documentation which I think is what you are saying @Cord.

                      One thing I like to point out to residents is that if you are typing out a more than 2-3 lines to explain why you aren't doing something (ordering a test, calling a consult etc), maybe you should just do it?

                      Comment


                      • #12


                        Yea, I did ask for more money but was quickly shut down and I did not put up much of a fight.
                        Click to expand...


                        Now that you have an year under your belt it is time to toughen up. For the next pay negotiations make it clear you are no more a pushover - give me medical director's pay or find someone else to do it - maybe that neurosurgeon. You will not be doing it for free any more. It then becomes clear if you need them more than they need you. If you are the only neuro-hospitalist and they cannot recruit another one they will accede to your request.


                        I often put in 12-16 hour days when including documentation I just want to understand who to be the best advocate for myself. I may be just inefficient (I do spend a lot of time talking with families, reviewing their imaging with them, participating in family meetings) which is generally not billable work since I use E&M coding.
                        Click to expand...


                        I can understand that in a 1st year you are learning the ropes and making sure things are done well and everyone likes you, from staff to patient. Like my child learning to drive. But by year two you should be more efficient. Maybe use a NP. See more quickly. Allocate a set time for each consult and follow up and try to do within that time. If you find that you have done everything in 5-6 hours and there are no more patients to be seen then you have a problem. You cannot drum up more referrals unlike a outpatient neurologist. You are unlikely to get more money since there is no more production to be had. So you must decide if you want to stay or go to a busier hospital.

                        Comment


                        • #13
                          You are getting great advice about efficiency and standing up for yourself. That goes for admin, but also patients. Be nice to patients, but neurologist sitting in on family meetings? basically unheard of. Even as a psychiatrist, I almost never do that in the hospital. Only when I have time on a slow day, and I can bill for it (add on family therapy code 90847). You can't. Stop doing that. Long explanations about procedures, your PA or RN can do most of that. Two hour consults and narrative documentation, stop. Use bullet points and templates, it's easier to read anyway.

                          All this being said, commit to making change but also take solace in the fact that this was your first year. You can and will get faster, better, more efficient. My first year was also filled with very long days as I learned the art of medicine. I routinely worked til 8 pm. Within three years I was routinely done by six pm, and more productive. Now I routinely finish by 5 pm, and am more productive still. This improvement occurs naturally, but more quickly when you commit to the change. As with any change process, write down your goals. The steps you need to take to achieve them. A timeline. Accountability partner and mentors. Etc.

                          Comment


                          • #14
                            Really pretty simple.
                            You are putting in a lot of time.
                            Your compensation is tied to productivity.

                            You may enjoy the directorship, interaction with patients and staff, and documentation. But, you aren’t getting paid for it. If you really want to produce, then that needs to be your focus. If you find yourself standing but not generating the next wrvu as quickly as you can, fix it and move on. My supposition is that “that’s not your style”. It’s most likely a natural progression that you “style” is causing the long hours with lack of productivity. The obvious candidate for non-productive time is the directorship. Just even the original and subsequent discussions were uncompensated.
                            If the hospital wants to pay you for production, then that’s where you need to spend your time, working with patients or drumming up new ones. Get rid of the time wasters.

                            Comment


                            • #15
                              How many neurohospotalists are at your facility/in your practice? This is by no means a shot at you, but the fact that you’re working 22-23 days and was offered a medical director job less than one year in suggests it’s a pretty small group. If that’s the case, you have a huge upper hand in that they can’t afford to lose you unless you’re being insanely demanding (your posts suggest this would not be the case). More information, in general, about the practice and hospital situation and size would be somewhat helpful. Also, do they have a hard time recruiting neuro at your hospital (many hospitals do)? That would also give you some bargaining power.

                              Comment

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