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  • Lordosis Lordosis 
    Participant
    Status: Physician
    Posts: 1681
    Joined: 02/11/2019

    @ Lordosis – you have a traditional access balance problem.  Sounds like over pannelled and under staffed.  All acutes going elsewhere anyways since 6 months wait.

    What the heck do you do for post hospitalization?

    Not really panel management at all unless you count only chronic disease management into that equation.

     

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    I think you misunderstand.  I can see established patients same day.  Follow ups and physicals can be booked later this week if needed.  I see post hosp 2-7 days.

    The only people waiting 6 months are new patients coming in.

    “Never let your sense of morals prevent you from doing what is right.”

    #220788 Reply
    abds abds 
    Participant
    Status: Physician
    Posts: 239
    Joined: 01/16/2017

    I’m in the same boat as ACN and the other specialists, especially surgeons. New patients are how I get more surgeries scheduled. Unless I’m actively managing a problem that may lead to a surgery, follow ups are a waste of my time from an efficiency standpoint. I (me +PAs) see 60-70 patients a day, 20 new, more if I had call recently. I see all the new patients by myself.

    I know that’s not necessarily helpful to you from a numbers standpoint, but it sounds like you need to figure out how to see more new patients.

    #220796 Reply
    Liked by Tim, HandFellow, ACN
    Avatar wideopenspaces 
    Participant
    Status: Physician
    Posts: 1096
    Joined: 01/12/2016

    Lordosis, it sounds like you actually have things humming along nicely if you can get your current patients in quickly. It sounds like you just feel bad new people wait so long? I personally have loyalty to my current patients. When I got to the point I could not work them in acutely or schedule a routine follow up for 8 weeks, I realized I was in trouble. So I stopped seeing anyone new for 6 months, created several acute slots for each week and didn’t resume taking new patients until I was only booked out 4 weeks for follow ups. I’m not sure there is anything you personally can do to change your current situation. My institution has started hiring APRNs to do new evals and then transferring them to us as follow ups. Personally I don’t like this because the new eval is when I have more time to really get to know someone and establish rapport. So there’s no perfect solution here. My PCP never sees me acutely, I wish you were my doc! 🙂

    #220802 Reply
    Avatar Anne 
    Participant
    Status: Physician
    Posts: 1119
    Joined: 11/07/2017

    Lordosis, do you care more because it is affecting your own practice (you prefer news to follow-ups, you want more variety of patients, want more income) or is it more that you feel bad that patients have to wait so long?

    In my area, it is also a sig wait to establish with a primary care physician.  Many of them are closed to new patients.  My solution was to wait until a new wave of residents graduated and I chose someone I didnt know personally but I knew people who had precepted her as a resident and recommended her.  Now her panel is full too but I am on it–I have only ever gone for my yearly visit but at least I know I can get in if I need to.

    Have you ever considered a direct primary care model?

    #220805 Reply
    Avatar StarTrekDoc 
    Participant
    Status: Physician
    Posts: 1966
    Joined: 01/15/2017

    Yeah, so a bit confused — you’re concerned on the New Patient wait times?   That’s a system level issue of really not having enough docs.

    Sounds like the existing panel of patients that you’re managing is sufficient and in a pretty good spot.   you CAN increase your new patients per session if you wish, but if your clinic manager isn’t, it’s probably because you’re doing a pretty good job with the current panel access.

    This is a spot if you’re finding yourself BORED, you can negotiate a higher panel and workload if you wish — I’d be careful and cautious broaching that though and talk with your immediate report before going down that rabbit hole.

     

    #220809 Reply
    Liked by Anne
    Avatar Tuxedo 
    Participant
    Status: Physician
    Posts: 38
    Joined: 02/20/2017
    Click to expand…

    I think you misunderstand.  I can see established patients same day.  Follow ups and physicals can be booked later this week if needed.  I see post hosp 2-7 days.

    The only people waiting 6 months are new patients coming in.

    Click to expand…

    If you’re able to see established same patients same day I don’t think there are any adjustments to be made.

    Many practices would close to new patients once they are unable to meet demand from current patients and then re-open as space permits.  But it sounds like you have reached a homeostasis and if patients are willing to wait 6 months and seeing 1 per day keeps you exactly full.

    #220820 Reply
    Avatar GraceisOTL 
    Participant
    Status: Physician
    Posts: 14
    Joined: 04/19/2019

    You are a PCP, right? It sounds as if you are appropriately portioned to the new patients. You only have 24 hours in the day. If you are providing good service to your current patients, you may just need to say the serenity prayer and let go of guilty. You can’t fix everyone.

    #220845 Reply
    Avatar mainah 
    Participant
    Status: Advanced Practice Provider
    Posts: 40
    Joined: 10/04/2018

    Lordosis–family practice PA. I’m the newest (to the clinic) of 2 physicians and 3 APPs, averaging 18-24 pts a day the past month, mostly acutes, new patients, and yearly physicals. That’s mostly because I have the smallest patient panel, not necessarily because that’s how the clinic utilizes APPs. Our physicians see 22-28/day. New patients can call for a same day appointment with me but I usually don’t get records ahead of time because they are trying to keep my scheduled filled. Our physicians see about 1 new pt per week but I don’t think there is any formula on how often they are scheduled. You can usually get an acute visit with our physicians specifically within 2-7 days, same day or next day with an APP. Hospital followups usually within the week with our physicians, and theoretically depending on the complexity of the patient, sooner with an APP. The office tries to avoid scheduling our most complicated patients for hospital followups with anyone but their primary because 15 mins isn’t enough time to review a history, do the med rec, etc, but our physicians have been okaying them being put in my schedule if they can’t get them in. Our physicians’ schedules are pretty full when the week starts, I’d say around 90% full, but 2-3 weeks out there are plenty of openings.

    I do most of the office’s well woman checks because we are male provider heavy, and get most of the newborns as well. I’d say my day is 40% new patient visits/well child checks/yearly physicals, 40% acute visits, and 20% routine f/us. My preference would be to do more chronic care because I do have some experience under my belt, but it’s been an asset to our clinic to have some breathing room for the acutes. We are at a sweet spot in having lots of same day flexibility but ending up with full schedules. However I am not a fan of not having records ahead of time (that includes hospital f/u in addition to new patients).

    When I see complicated patients whom I know need to be seeing a physician, I’ll spend extra time with them and do as much of the grunt work as I can, then touch base with their physician at the end of the day and review the case to make sure nothing extra needs to be done. Whatever I can do to make their lives easier with the patients that can really consume a lot of time. I usually make sure they have an appointment within the next 1-4 weeks with a physician.

    #220857 Reply
    Lordosis Lordosis 
    Participant
    Status: Physician
    Posts: 1681
    Joined: 02/11/2019

    I’m in the same boat as ACN and the other specialists, especially surgeons. New patients are how I get more surgeries scheduled. Unless I’m actively managing a problem that may lead to a surgery, follow ups are a waste of my time from an efficiency standpoint. I (me +PAs) see 60-70 patients a day, 20 new, more if I had call recently. I see all the new patients by myself.

    I know that’s not necessarily helpful to you from a numbers standpoint, but it sounds like you need to figure out how to see more new patients.

    Click to expand…

    It is a little different for us PCPs.  Surgeons tent to fix an issue and move on.  Rarely is there a long term relationship.  All my patients are presumed to be for life.  Obviously people move or die or transfer but so far that is a very low number.

    Lordosis, it sounds like you actually have things humming along nicely if you can get your current patients in quickly. It sounds like you just feel bad new people wait so long? I personally have loyalty to my current patients. When I got to the point I could not work them in acutely or schedule a routine follow up for 8 weeks, I realized I was in trouble. So I stopped seeing anyone new for 6 months, created several acute slots for each week and didn’t resume taking new patients until I was only booked out 4 weeks for follow ups. I’m not sure there is anything you personally can do to change your current situation. My institution has started hiring APRNs to do new evals and then transferring them to us as follow ups. Personally I don’t like this because the new eval is when I have more time to really get to know someone and establish rapport. So there’s no perfect solution here. My PCP never sees me acutely, I wish you were my doc!

    Click to expand…

    I think I am going to try that.  However turning off the new patient switch is somewhat of a hassle since I would need to get the higher ups to approve it.  I know they would but I would have to make it a priority.    I try not to rock the boat more then needed.

    Lordosis, do you care more because it is affecting your own practice (you prefer news to follow-ups, you want more variety of patients, want more income) or is it more that you feel bad that patients have to wait so long?

    In my area, it is also a sig wait to establish with a primary care physician.  Many of them are closed to new patients.  My solution was to wait until a new wave of residents graduated and I chose someone I didnt know personally but I knew people who had precepted her as a resident and recommended her.  Now her panel is full too but I am on it–I have only ever gone for my yearly visit but at least I know I can get in if I need to.

    Have you ever considered a direct primary care model?

    Click to expand…

    Ugh I do not want more new patients.  I am so glad the days of 6-8 news a day are over.  They are a pain with twice the mental work and thrice the documentation.    I have a good amount of variety at least consistent with my area.  I would love more income but that is not what this is about.  I just want to be able to deliver good care.  I have made it a priority to do so for my established patients but I still feel bad for the folks who need to wait 6 months.

    I am in a small community.  I do not think it would support that model.

    Yeah, so a bit confused — you’re concerned on the New Patient wait times?   That’s a system level issue of really not having enough docs.

    Sounds like the existing panel of patients that you’re managing is sufficient and in a pretty good spot.   you CAN increase your new patients per session if you wish, but if your clinic manager isn’t, it’s probably because you’re doing a pretty good job with the current panel access.

    This is a spot if you’re finding yourself BORED, you can negotiate a higher panel and workload if you wish — I’d be careful and cautious broaching that though and talk with your immediate report before going down that rabbit hole.

     

    Click to expand…

    Exactly.  We need more docs in this community.  There is revenue ripe for the picking.  Any takers?!?!

    I surprisingly do not have an office manager.  It is an odd way they run it here.  I basically had to make my own schedule and see as many as I like.  I get paid completely on collections so it is in my best interest financially to see more.  There is some quality metric stuff as well but mostly just I get a portion of the billing.  They are actually not that pushy with us about how much because those who see less get paid less.  I am young and do not mind the hard work so I rank about #2 out of a group of 20 docs.  #1 has alimony issues so I think that is why he works so hard.

    I have been slowly ramping up the past 4 years.

    If you’re able to see established same patients same day I don’t think there are any adjustments to be made.

    Many practices would close to new patients once they are unable to meet demand from current patients and then re-open as space permits.  But it sounds like you have reached a homeostasis and if patients are willing to wait 6 months and seeing 1 per day keeps you exactly full.

    Click to expand…

    Even if I close I would always take family members.  I also work the nursery and snatch a few babies as well.  I think that might be enough to keep me full.  Most of the other new patients are people just pissed at their old doc and changing to me because I am the only other choice.  Then they learn that I will not give them ABX over the phone, opiates for silly reasons, Test for vitamin crazy levels, balance chronic benzos and stimulants, etc.  But since I am the end of the line for now they are stuck with me.

    You are a PCP, right? It sounds as if you are appropriately portioned to the new patients. You only have 24 hours in the day. If you are providing good service to your current patients, you may just need to say the serenity prayer and let go of guilty. You can’t fix everyone.

    Click to expand…

    Serenity now, Insanity later!

    Image result for serenity now

     

    Thanks everyone I think I just needed a rant.

    Also thank you for not calling me a troll when I went away from keyboard for the past few hours 😉

    “Never let your sense of morals prevent you from doing what is right.”

    #220860 Reply
    Lordosis Lordosis 
    Participant
    Status: Physician
    Posts: 1681
    Joined: 02/11/2019

    Lordosis–family practice PA. I’m the newest (to the clinic) of 2 physicians and 3 APPs, averaging 18-24 pts a day the past month, mostly acutes, new patients, and yearly physicals. That’s mostly because I have the smallest patient panel, not necessarily because that’s how the clinic utilizes APPs. Our physicians see 22-28/day. New patients can call for a same day appointment with me but I usually don’t get records ahead of time because they are trying to keep my scheduled filled. Our physicians see about 1 new pt per week but I don’t think there is any formula on how often they are scheduled. You can usually get an acute visit with our physicians specifically within 2-7 days, same day or next day with an APP. Hospital followups usually within the week with our physicians, and theoretically depending on the complexity of the patient, sooner with an APP. The office tries to avoid scheduling our most complicated patients for hospital followups with anyone but their primary because 15 mins isn’t enough time to review a history, do the med rec, etc, but our physicians have been okaying them being put in my schedule if they can’t get them in. Our physicians’ schedules are pretty full when the week starts, I’d say around 90% full, but 2-3 weeks out there are plenty of openings.

    I do most of the office’s well woman checks because we are male provider heavy, and get most of the newborns as well. I’d say my day is 40% new patient visits/well child checks/yearly physicals, 40% acute visits, and 20% routine f/us. My preference would be to do more chronic care because I do have some experience under my belt, but it’s been an asset to our clinic to have some breathing room for the acutes. We are at a sweet spot in having lots of same day flexibility but ending up with full schedules. However I am not a fan of not having records ahead of time (that includes hospital f/u in addition to new patients).

    When I see complicated patients whom I know need to be seeing a physician, I’ll spend extra time with them and do as much of the grunt work as I can, then touch base with their physician at the end of the day and review the case to make sure nothing extra needs to be done. Whatever I can do to make their lives easier with the patients that can really consume a lot of time. I usually make sure they have an appointment within the next 1-4 weeks with a physician.

    Click to expand…

    Even patients who wait six months to see me more often then not arrive before their records 😛

    When ever I mention this issue at work everyone wants our NP to help establish the new patients.  I put my foot down here because I need that chance to get to know them and set things right from the start.  Also you never know how complex someone is before they show up.

    “Never let your sense of morals prevent you from doing what is right.”

    #220862 Reply
    Avatar mainah 
    Participant
    Status: Advanced Practice Provider
    Posts: 40
    Joined: 10/04/2018

    As an APP I’m going to objectively say that YMMV when it comes to APPs. Honestly as a new grad working rurally at an FQHC with only one other physician, I wished the clinic had been more selective in assigning patients based on complexity. I made it work because I studied all the time and was paranoid about making a mistake. My SP and I were both early birds and in the clinic by 6a for an 8a start, and I would review all my patients for the day, and ask questions as necessary. I was single and had the extra time but not everyone has that luxury. He loved to teach and we got along well, so it was a good fit. I can easily see how that situation could have been very different for the patients.

    After 7 years of chronic disease management I don’t think I’m properly being utilized in my current clinic. There is an NP who has been there longer but has less experience. They see mostly chronic patients and I’m mostly the acutes and well visits, but from a care quality (and the NP’s sanity because they struggle) the roles really should be reversed. New grads should not be seeing moderately complex patients every 15 mins and really need to be in an environment conducive to developing the training which is hard to swing for a lot of clinics.

    New grad APPs can easily handle the easy acutes (UTIs, URTIs, cellulitis, etc) and preventative visits, but if I were a physician I’d probably appreciate a few of those sprinkled in my schedule for a mental break. I can’t imagine seeing only the most complicated patients all day would be fun unless you had unlimited time with them. An experienced APP could really work well for a practice though for the routine chronic care, more complex acute visits, and as a catchall for the physicians they work with, but ideally as a physician I’d need to be very confident in how they practiced, their attention to detail, their drive to improve their knowledge, and how well they knew their limitations, especially since there is liability attached. I wish administrators cut physicians more slack in terms of being able to have the flexibility to develop that relationship with an APP without financial penalty/lost productivity. It would really optimize quality and access to patient care with some financial benefit to the practice. I wish I had the financial smarts to come up with the numbers to find the magic formula to support the best mixture of APPs/physicians.

    #220887 Reply
    Avatar SLC OB 
    Participant
    Status: Physician
    Posts: 533
    Joined: 06/23/2018

    I have a 6 week wait list but my partners can see new patients the same day. It is too bad for my surgical case volume, as those that need surgery often can’t wait. I have been established in the community for 15 years, so people will wait. If they have an urgent need, have seen me before or a doctor is calling specifically for me, I will squeeze them in. I also squeeze the acute/urgent patients in same day (like UTI, yeast, etc.).

    Our system had a long wait list for PCP but modified the number of physicians and increase to 7 day availability and now we can accommodate much much better. Our ED visits are dropping, as the simple stuff is now going to the 7 day a week clinic instead.

    #220905 Reply
    Lordosis Lordosis 
    Participant
    Status: Physician
    Posts: 1681
    Joined: 02/11/2019

    As an APP I’m going to objectively say that YMMV when it comes to APPs. Honestly as a new grad working rurally at an FQHC with only one other physician, I wished the clinic had been more selective in assigning patients based on complexity. I made it work because I studied all the time and was paranoid about making a mistake. My SP and I were both early birds and in the clinic by 6a for an 8a start, and I would review all my patients for the day, and ask questions as necessary. I was single and had the extra time but not everyone has that luxury. He loved to teach and we got along well, so it was a good fit. I can easily see how that situation could have been very different for the patients.

    After 7 years of chronic disease management I don’t think I’m properly being utilized in my current clinic. There is an NP who has been there longer but has less experience. They see mostly chronic patients and I’m mostly the acutes and well visits, but from a care quality (and the NP’s sanity because they struggle) the roles really should be reversed. New grads should not be seeing moderately complex patients every 15 mins and really need to be in an environment conducive to developing the training which is hard to swing for a lot of clinics.

    New grad APPs can easily handle the easy acutes (UTIs, URTIs, cellulitis, etc) and preventative visits, but if I were a physician I’d probably appreciate a few of those sprinkled in my schedule for a mental break. I can’t imagine seeing only the most complicated patients all day would be fun unless you had unlimited time with them. An experienced APP could really work well for a practice though for the routine chronic care, more complex acute visits, and as a catchall for the physicians they work with, but ideally as a physician I’d need to be very confident in how they practiced, their attention to detail, their drive to improve their knowledge, and how well they knew their limitations, especially since there is liability attached. I wish administrators cut physicians more slack in terms of being able to have the flexibility to develop that relationship with an APP without financial penalty/lost productivity. It would really optimize quality and access to patient care with some financial benefit to the practice. I wish I had the financial smarts to come up with the numbers to find the magic formula to support the best mixture of APPs/physicians.

    Click to expand…

    Just like there are good and bad physicians I am sure there are good and bad APPs.  Maybe good and bad is not the right way to put it.  Well trained and less so.

    You seem to be of the well trained variety.  I am lucky to also have a well trained NP in my office.  However the way it is run here the NP has his own patient load.  All of his patients are assigned to one of the MDs but there are enough that follow just with him that it gives him his own panel of sorts.  I do not really care for this model but it was here when I got here and inertia has kept it.

    The next system over does things differently.  The APPs only see the overflow.  When not busy they are handling the prior auths and MDs inboxes.

     

    I do like the sprinkle of acutes in my day.  It is nice to help people when they are sick. I can adjust BP and DM meds like a pro but it does get monotonous.   Usually though it is extra work because they are put between follow ups.  But I get paid for the extra work so it does not matter if it is reasonable.

    “Never let your sense of morals prevent you from doing what is right.”

    #220913 Reply
    Lordosis Lordosis 
    Participant
    Status: Physician
    Posts: 1681
    Joined: 02/11/2019

    I have a 6 week wait list but my partners can see new patients the same day. It is too bad for my surgical case volume, as those that need surgery often can’t wait. I have been established in the community for 15 years, so people will wait. If they have an urgent need, have seen me before or a doctor is calling specifically for me, I will squeeze them in. I also squeeze the acute/urgent patients in same day (like UTI, yeast, etc.).

    Our system had a long wait list for PCP but modified the number of physicians and increase to 7 day availability and now we can accommodate much much better. Our ED visits are dropping, as the simple stuff is now going to the 7 day a week clinic instead.

    Click to expand…

    Wow a 7 day a week clinic.  I would never sign up to work that but it is good for the patients.

    My office staff does not like how accommodating I am to squeeze in acutes.  I feel it someone calls in with a URI/UTI/stubbed toe/ etc those should be easy visits that can be worked in rather quickly.  The patient is happy because they can see their doc for the problem.  I am happy because I can tell them it is a cold and Urgent care does not put them on a zpak.  I am also happy because I get paid rather then losing the revenue to urgent care or the ER.  I have room built into the schedule for acutes but some days you get more and others you get less.  It is hard to predict.    The office staff only gets the added work and nothing else.  This has been a struggle.  Especially since the other docs in the office are more apt to send extras off to urgent care.

    I know this is an issue with my staff and I am trying to figure out a way to address it.

    “Never let your sense of morals prevent you from doing what is right.”

    #220916 Reply
    Avatar SLC OB 
    Participant
    Status: Physician
    Posts: 533
    Joined: 06/23/2018
    Wow a 7 day a week clinic.  I would never sign up to work that but it is good for the patients.

    Click to expand…

    I live in a ski community, so working Sat/Sun when the ski resorts are super busy and being off on Tuesday/Wednesday/Thursday (our docs work 4 days a week) is actually nice for those without kiddos.

    I know this is an issue with my staff and I am trying to figure out a way to address it.

    Click to expand…

    Is the Urgent Care part of your system? If not, then maybe management can help by rewarding the MAs and Front office staff when they help you with this extra work. Maybe they get their names put in a hat for a monthly massage drawing, Starbucks card, etc. I know it goes a long way for me to just say “Wow, you guys really hustled today, not only do I appreciate it but the patient really appreciate it, thank you!”

    On occasion, I am the only doc in the office and get completely hammered (20+ patients in a half day). I have had our management buy bouquets of flowers, place a sign in lobby saying “Dr. XXX is the only one in the office today. Due to the demand of our community, she is completely overbooked. We apologize in advance if you have to wait. Please have your questions ready so that she can answer them for you.  Please take a flower as our token of appreciation for your understanding.”  At the end of the day (which usually is amazing because the patients understand and are efficient in the visit!) I have my office staff take home the rest of the flowers as appreciation. Just another thought…

    #221415 Reply

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