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Guidance please (WARNING: LONG)

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  • Guidance please (WARNING: LONG)

    Guidance please, and please be honest. I'm struggling at my current position but don't know if it's a case of sucking it up vs finding a new environment.

    As a background, I am a PA who spent the first 5 years of my career at a rural FQHC in family med. By the time I left, I was working with a full schedule. Pt appts were 20 and 30 mins and I was typically seeing 16-22 a day, depending on the amount of physicals and procedures I had and the weather. I was putting 50-60 hours in a week depending on the amount of off hours house calls I did. We had great support from our MAs, who would get the patients in early, and a lot of data entry and screenings done, helping with the EHR burden. It was busy but manageable. I had my own patient panel and knew my patients well. However, I was working for 70-73k/year and our clinic was never in a sound place financially, half our patients were Medicaid or uninsured.

    I got married and moved to my current position at a private practice rural primary care clinic where I've been for just over a year. I'm the newest provider out of 2 physicians and 2 NPs and am still building up my patient panel. Initially, depending on the weather,  I could start with 6-8 pts a day in my schedule and stay there, or end up seeing 22-24 a day. I'm probably averaging 20 patients a day at this point. The other providers are seeing on average 24-32 a day, sometimes up to 40 pts/day. Appts are every 15 mins or 30 mins for procedures/physicals. However, I'm struggling to keep up with this pace. I'm finding that when we are short on MAs, which happens 1-2x/week, I'm the one that is often scheduled to work on my own, relying on the kindness of another MA who can help room my patients, or I actually have to room on my own even stay remotely on schedule. Patients aren't required to show up early and can show up 10 mins late for their 15 min appointments and I am expected to see them. New patients are thrown into my schedule all the time and I will often have no records. Or the opposite, two days ago 500! pages of a new patient's medical records with a significant psych and surgical history were placed on my desk and the pt was scheduled less than 24 hours later, not having time to adequately prepare for the appointment or preload some of the history. Sometimes the MA will update the med list, most of the time it's my job update if they are an existing patient, or enter in everything entirely if they are a new patient (meds/surgical history/family history etc). I'm easily spending all my allotted time per patient on basic data entry and rooming patients, let alone trying to actually practice medicine. I'm spending a ton of after hours time trying to catch up on charting and the basic data entry.

    I've been thinking about suggesting some changes, largely having a contingency plan when we are understaffed and asking patients to come 10-15 mins early so MAs have time to get the basic data entry and screenings (PHQ-9s, etc) done. I feel like I have no leg to stand on though where I am the least productive. Then I read this article from KevinMD  about how advance practice providers are more inefficient and I am really doubting myself. I get frustrated because I see the shortcuts the other providers are making that I'm not ok with. Med lists are never up to date, if meds are even entered at all (seriously--I wish I was joking). Our most productive providers are also the leading prescribers of z-packs and prednisone for coughs and sniffles and I'm not willing to do that in order to save 3 mins of time spent educating pts about abx stewardship. Don't get me started on the amount of opiates rx for acute back pain or indeterminate abd pain. Basic histories aren't being entered into charts and sometimes I have a hard time following what is going on with patients. Patient followup on abnormal labs or imaging is delayed by weeks or there is no followup at all. We're talking stuff like labs showing new liver/kidney failure or with moderate to severe electrolyte abnormalities, abnormal stress tests, lung nodules without appropriate f/u, etc, and patients are ending up in the ER for things that might have been prevented if someone was paying attention. Visit notes from the other providers are usually 1-2 sentence HPIs with a generic ROS/PE clicked away and I have a hard time following care at times.  I know this stuff is happening because like I said, I'm seeing largely acute visits from other providers.

    The practice owner is my SP and is pretty reasonable. Can I go to him with my concerns, or is this just what primary care has amounted to? Was my first clinic an anomaly or is this a bad environment? I [thankfully] don't carry the financial burden of maintaining a private practice and can't imagine the stress of doing so while somehow meeting all the ACA guidelines with charting and EMRs. I don't want to come across as a snotty, goody two shoes, especially like I said where I'm seeing the least amount of patients.

    As a side note, I recently had my annual review, got perfect scores on the 20 different measures I was evaluated in, and my SP said he has no clinical concerns with the care I provide (and he reviews every chart I write). I believe I am a halfway decent provider and with good support could be successful.

    Thank you!

  • #2
    sounds like you need a new job. start looking.

    suggest changes.

    if nothing happens, you hopefully have found somewhere else to go.


    • #3
      Suggest the changes.

      If brushed aside or not implemented, I would recommend applying for another job. Your current working conditions put you at risk for a malpractice case should things really fall through the cracks.


      • #4
        Is hiring hard there or are they cheap?

        In the Army positions like Doctor and Dentist are what are referred to as a "force mulitplier".  Meaning that while we don't shoot guns, we keep attrition of troops and combat effectiveness high.  For instance, my time overseas I saw what amount to 5-10 patients per week that would have needed evac to remain combat effective.  Average evac time was anywhere from 1 week to 1 month return depending if they needed to go to Baghdad or Germany.

        Why is that relevant?

        If they are not fully utilizing the productive assets of the clinic, ie providers, then they are losing money.  Medical assistant costs (I'm guessing) ~25k per year, but allows you to see 4 patients more per day at $100 per patient.  $400 per day times 200-250 work days (50 weeks @ 4-5 days per week) means the office profits no less than $55,000.  My office we actually try to have at least one surplus person per day.  There is always a benefit to having someone available to perform a task, but the real payoff is when we are out two people we are simply at our need, versus the massive stressful and expensive (reduced production) days when we are truly short.

        For Want of a Nail, The Shoe Was Lost

        For want of a nail, the shoe was lost;
        For want of the shoe, the horse was lost;
        For want of the horse, the rider was lost;
        For want of the rider, the battle was lost;
        For want of the battle, the kingdom was lost;
        And all from the want of a horseshoe nail.


        • #5
          What you're describing is, sadly, the nature of primary care nowadays, and APPs are going to have to do ever more of it as becomes less appealing to doctors. When I used to have primary care clinic as a resident, I'd have to review charts the day before and start pre-writing my notes, otherwise it was impossible to finish during the course of a visit (granted, these were VA pts with a lot of comorbidities).

          If it helps, you're not the only one. I see what I consider to be substandard care/downright stupidity by other doctors every day of the week. I'm sure some of them feel the same way when they look over my work.

          But, it's very hard to get other people to change their behavior/practice. You'd probably go crazy if you let it bother you too much.

          I suggest you take pride in the good care for your own patients. You should let your supervisor know about your thoughts, but emphasize more concern for your own pts rather than criticizing others (unless there is some truly egregious practice). If they don't at least seem receptive, you should think about leaving.


          • #6
            You are talking about 2 separate issues--efficiency of practice and quality of care.  If the issue was just efficiency, I would look at both internal and external ways to improve that (i.e. things you can do and things others can do).  But since you are talking about poor quality of care too, I would be doubtful that is going to change, at least from what you have the ability to enact.  I would not want to stay at a place where my coworkers are failing to follow up on significant findings.  It seems doubtful that that behavior will change.  I would look for a new job while you have the good review from this job.  It sounds like you are a very thorough and caring PA and this is not the right workplace for you.


            • #7
              Agree w/above.  You need to talk with the medical person running the practice about quality of care concerns and efficiency.  My guess is they are  unaware of your own concerns but also condoning much of the current practice.  If THEY are making a substantial profit they may not be the type of doc/corporation/whatever who is going to invest in quality of care or happiness of their providers.

              If they are willing to provide you a dedicated MA, compensate you based on providing a high level of care etc, then give them some time to show it.

              That won't fix your co-workers, but the question also is if YOU get what you need, can you put up with a work environment filled with others providing subpar care?

              I think exploring a new job needs to happen WHILE you talk with the powers above.  Make sure your significant other is on board from the get-go so if you need to walk-away you can do so with support at home.  If you don't have it saved now, make sure you pack away $ so you can walk away and even go without a job for a few months if needed so you can save your sanity if things don't improve and a new job isn't waiting.
              An alt-brown look at medicine, money, faith, & family


              • #8
                A lot of good suggestions above.  Mine would be to focus your concerns when you talk to your boss, and think about what are the individual problems with your practice, what are systems problems, and what are problems of other people.  You then need to prioritize.  Personally I would not focus much on the problems of others (which largely amounts to practice style) as you are not likely to change them much.  If you can't tolerate the way the providers practice then you should think about working somewhere else.  Your boss should be able to help with systems problems if you convince him, especially if you can find a solution to make everyone's job easier, like having pts show up 15 minutes early.

                Not having a MA is really inexcusable except in emergencies, and I would definitely mention that.

                I doubt anybody expects you to review 500 pages of records, so make sure you are not putting unnecessary pressure on yourself.   Most of medical records today are crap, you just have to pull out the nuggets.


                • #9
                  I find that a lot of providers who have efficiency issues related to charting often miss the forest for the trees or struggle with some internal compulsions.

                  The EMR is a state of entropy, esp for complex patients. There are infrequent but important clinical encounters when you need to spend the time to delve deep and understand things and/or spend some time cleaning up the record but these are relatively rare.

                  Your own notes are not candidates for the the Mann Booker prize, the likelihood is that they are at best going to skimmed once by one other person.

                  I'm not advocating sloppiness, I'm advocating that you focus on what's important.

                  All of that said, it sounds like you need a new job. Both hospitals where I have worked have had excellent and robust primary care provider networks (admittedly few APPs in those places). As a non primary care provider I am not resigned to the idea that it's a losing game.


                  • #10
                    Yikes.  Not all primary care is that dysfunctional.  Sounds like you can do better.  Start looking.


                    • #11
                      So much good advice, thank you.

                      My husband was the first one to suggest I start looking elsewhere, probably after seeing how much sleep I'm losing over it, so he is supportive. The tricky thing is that we just started the family planning process and my OB has told me he doesn't want me putting it off much longer (I'm 33) so the thought of possibly being pregnant with a lapse in health insurance coverage is daunting. We have a modest emergency fund that just decreased by 1/3 with a medical issue my husband just had with his high deductible plan and even back at full strength wouldn't last long if I were unemployed and pregnant. The other issue is being rural, there aren't an abundance of jobs around, and I don't know if moving would be the best option. My husband has a good job, he is good at it, he likes it, and though it doesn't pay well (2k/month), his employer provides housing and utilities for free, and he can eat free whenever, which has helped us pay off debt tremendously. In the 16 months we've been married we have paid off over 100k in student loan/car debt and should be debt free by Sept.

                      I think the plan, based on everyone's help, is to bring up suggestions regarding efficiency and not quality issues at our next provider meeting which should be next week. If things go well, then great! If things don't go well, start job hunting, preparing for a longer commute, holding off on the family planning process, and slowing down student loan payments (I'm paying 4x the monthly amount right now) and putting more away as a bridge if needed.

                      Thank you! I am appreciative of the collective wisdom


                      • #12
                        Don't quit that job before you find a new one.


                        • #13
                          Meh forced vacation is nice too...


                          • #14

                            Meh forced vacation is nice too…
                            Click to expand...

                            Not if you're concerned about being pregnant without health insurance.


                            • #15
                              I think you are young.  Your efficiency in seeing patients and procedures will improve with time.  I also agree with the above comment that no one expects you to read 500 pages of medical records.  Look for the most recent summary, problem list, meds etc.  If you need something specific you can hunt for it.  Have patients come early to fill out paperwork is great or even better mail it to them.  Hang in there.