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

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

  • childay childay 
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    At a minimum research how you should be coding these 2 hour visits. Critical care time?

    It sounds like you could use an assistant of some sort. Like a RN stroke coordinator. They could do all this calling families and discussing plan of care, coordinating transfers which would free you up some

    #230096 Reply
    Liked by wonka31, q-school
    Avatar Dusn 
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    Some of the dumbest doctors I know are also the fastest.  Having only 2 things on your differential because your brain doesn’t know the other 8 can really cut down on both the time spent working up the patients and on your stress level.

    Unfortunately that probably won’t help you. Are you easily mobile and would have an easy time switching to another job if this job doesn’t give you the resources that you need?     Also if you’re working in the midatlantic, do you have mostly very highly educated (and sometimes neurotic) patients and families that need very thorough explanations?

    #230101 Reply
    Liked by Anne
    Avatar Anne 
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    Consulting on a stroke patient should not take 2 hrs, you’re a neurologist that’s your bread and butter. History 15 minutes, exam 15 minutes (if that), dictate, done and move on. 

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    Scenario #1 (more common): Pt came in found down, aphasic, not moving R side, unclear last known well. Meet pt in ambo bay, quick assessment go to radiology with them. Do CT/CTA/CTP. I read imaging real time. Hunt down family to see if we can get last known normal. Find out that pt was seen 2 hours ago fine. Draw up IV tpa, give tpa. See large vessel occlusion on CTA when in radiology suite. Also calling academic center to come get patient to do thrombectomy. Informing family and getting their contact info to neuroIR team at academic center. Coordinating with ER doc if intubation is needed for L MCA stroke of complex carotid aortic arch anatomy etc. Dictate note. Edit note. Takes about 2 hours.

     

    Scenario #2: Pt comes in aphasic but no weakness. Woke up with symptoms, last known well before bed. I met in ambo bay quick eval, since aphasic concern for MCA clot. I got to CT, CTA. No large vessel blockage but still aphasic which is severely disabling. CT brain looks normal. I talk to family. No other contraindication beside times. I order MRI brain. Do it as STAT as a 1 MRI scanner hospital can. I read the MRI in real time if there is DWI-FLAIR mismatch, I consent and document the hell out of this since it is not yet standard of care, give tpa, talk to ICU team, dictate note, correct note and finalize.

     

    I would not say that these happen every day but these are scenarios that I deal with and it takes me 2 hours.

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    I edited it a little to show the tasks that you should not be doing–Scenario #1 (more common): Pt came in found down, aphasic, not moving R side, unclear last known well. Meet pt in ambo bay, quick assessment go to radiology with them. Do CT/CTA/CTP. I read imaging real time.

    While I am in rads with patient nurse hunts down family to see if we can get last known normal. Brings them to convenient area for me–Find out that pt was seen 2 hours ago fine. Briefly discuss findings and plan with them.  Draw up IV tpa, give tpa. See large vessel occlusion on CTA when in radiology suite. Also calling academic center to come get patient to do thrombectomy. Informing family of medical plan, nurse gets their contact info to neuroIR team at academic center and answers basic questions. Coordinating with ER doc if intubation is needed for L MCA stroke of complex carotid aortic arch anatomy etc. Dictate note. Edit note. Takes about 2 hours.

    I bet if you cut out the stuff that doesn’t require the MD to do–hunting down family, initial discussions (nurse can talk you up, Dr. Christopher is our stroke specialist, he is going to be in with you soon to discuss what’s going on and the plan–so you don’t have to spend time orienting them to the basics)–getting stuff like phone numbers (well this is my cell, but Jack’s cell works better if blah blah blah–those discussions can waste 5 min right there when you have WORK to do), you will find it much easier to be efficient and focus on the important areas where YOU add value.

    Some basic info sheets to give families can also be helpful with the stuff you find you/your nurse repeating over and over again.  You might have to write it at a certain grade level and get it passed through committee based on your hospital policy.

    You need some support.  Either they can pay for that support to free up your time to either be more productive or be at work less hours, or they can pay you $50-100k/more to be your own nurse.  Or you can take your services elsewhere and they can regress in their stoke care, which will add to days of stay etc. and hurt them in other ways.

     

    #230102 Reply
    Zaphod Zaphod 
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    Some of the dumbest doctors I know are also the fastest.  Having only 2 things on your differential because your brain doesn’t know the other 8 can really cut down on both the time spent working up the patients and on your stress level.

    Unfortunately that probably won’t help you. Are you easily mobile and would have an easy time switching to another job if this job doesn’t give you the resources that you need?     Also if you’re working in the midatlantic, do you have mostly very highly educated (and sometimes neurotic) patients and families that need very thorough explanations?

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    Its all a spectrum and distribution. There will be people at both tails and all combinations for good doctoring and time spent doing so. The trick is to find where you are spending a lot of time but not progressing in either management of the pts condition, educating, or the day in general. Thats what you cut out. Figure out whats of value and what isnt, cut what isnt from the day/routine.

    Eventually you end up seeing the same stuff and the differentials are basically the same as well, it adds no further time to drop them in your note/brain in the days of EMRs.

    #230103 Reply
    Liked by q-school, wonka31, Anne
    Avatar Kamban 
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    I honestly think I am being underpaid by $50-$100k per year based on the very comprehensive stroke care I provide and some of the leadership, quality review, risk management administrative stuff I do.

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    Christopher

    1. You are working as a highly trained sub-specialist more than half the time but being lowly paid as a generalist.

    2. The way they shut you down quickly for director pay makes me think they are unlikely to pay as much as you are worth. So time to explore other options.

    3. I would suggest that you start exploring other stroke centers which would value your services appropriately. You should start interviewing at other places that fit this mold. Preferably in places like the Midwest and Southeast where the pay is more. Maybe at at places which has high enough volumes, adequate support staff, an established coordinated plan in place than the solo uncoordinated approach you are taking now.

    4. By having another specialist to help you out you can have more professional satisfaction and avoid a burnout. This will also help you bounce off your ideas, help you keep up with the trends and lend support for any actions you take. And maybe advise caution if you are become a bit gung-ho in your actions.

    5. This place has been a good start for your career but maybe you need to move on for your further professional development.

    JMHO.

    #230112 Reply
    Avatar Jackmomma 
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    I think your main problem is you are trying to do too much at a time in a short period of time. your role is neuro-hospitalist and listen by all accounts you seem like a great doctor and I would probably have no problem letting you take care of my loved ones but wow, you are doing waaaay more than a hospitalist should do.

    your time would be better spent :

     

    1. developing a coordination of care with other services. get a cardiology group involved early on so you are not the one dealing with discussion of loop recorders and setting up outpt visits. let cards do that.

    2. discussing SSRI on CVA recovery – great, I love this being a PM and R doctor, but better off just developing ties with the local rehab unit/facility and PM and Rs there, let them do that/decide who’s a good candidate or not. Seen plenty of stroke pts we put SSRI on and they actually don’t tolerate well etc.

    3. Develop ties with local neurologist with clinic to let them take over ASAP. Do your part, stabilize, optimize and let someone else take care.

    4. You mentioned boundaries. OK, what are they? More importantly, ** will you listen to your own boundaries **? Or will you break down?

    Family discussions are the massive time sink in most people’s days. Start timing how long you spend talking to families. Learn to get things discussed in ways that are less verbose and easier to understand

    DO NOT be afraid to tell families “Ok thank you for meeting with me. I do need to move on to the next case. Thank you.”

    5. Any director ship should be paid at a reasonable rate with a contract. You need to negotiate the contract, the number of hours and the $/hour.

    EVERY SINGLE THING YOU DO needs to be documented on a time sheet. Photocopy it every month and save it. They don’t pay? you stop services.

    *** 6. GO interview at another facility/area and get a job offer. A nice job offer. That’s your hedge. Leverage yourself. And realize oftentimes you are vastly more appreciated by the outside than by your own group. You can decide to leave, or use this to get yourself a boost.

     

    I’ll finish off by saying realizing you have these inefficiencies and talking about them are great things for you. Getting feedback is hard to hear but important. Efficiency is oftentimes learned not something you are born with.

    #230131 Reply
    Avatar jm129 
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    agree with kamban on exploring different options.

    this place does not seem to appreciate the value you provide.

    the processes are not well coordinated and support staff has not been utilized efficiently.

    being the medical director will allow you to improve the workflows however it will require some level of assertiveness and ability to twist administrators’ arms once in a while.

    You seem to have less experience in working/collaborating with other specialties as an attending, you are working as a resident (which is different than living like a resident for the first 5 years).

    I would certainly look into other job opportunities with well-established workflows.

     

    #230158 Reply
    Liked by Kamban
    Avatar jacoavlu 
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    are the radiologists in your facility not competent? No offense meant and it’s great that you review images on exams you order but you could be getting other work done on same patient while letting them do their job. And you’re putting yourself at risk if not coordinated with them, assuming they’re making the official report.

    Also it sounds like a lot of scut work that is way below your pay grade. It sounds like you’re in a certified stroke center. Where is the rest of the stroke team? Who does that stuff when you’re not working?

    The Finance Buff's solo 401k contribution spreadsheet: https://goo.gl/6cZKVA

    #230171 Reply
    Liked by Zaphod, childay
    Avatar ChristopherMD20 
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    At a minimum research how you should be coding these 2 hour visits. Critical care time?

    Click to expand…

    I usually bill for it but get bumped when ER doc bills for critical care time at same time.

    do you have mostly very highly educated

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    Not where I work. Very working class.

    I bet if you cut out the stuff that doesn’t require the MD to do–hunting down family, initial discussions

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    It is amazing how often the EMS/RN give the wrong LKW. They do this when the patient is communicative, but hunting down collateral historian is not something that often gets done. However, I agree I can and should delegate that.

    You need some support.

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    My RN coordinating doesn’t do any clinical work, so has to do all the data collection.

    Figure out whats of value and what isnt, cut what isnt from the day/routine.

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    This will also be helpful for life as well, not just medicine!

    ristopher 1. You are working as a highly trained sub-specialist more than half the time but being lowly paid as a generalist. 2. The way they shut you down quickly for director pay makes me think they are unlikely to pay as much as you are worth. So time to explore other options.

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    You are probably right. I still have a year left on my contract. I would have to look into the details of the contract to figure out when the best time to do all these things are.

    More importantly, ** will you listen to your own boundaries **? Or will you break down?

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    I will probably break. I am assertive about clinical care stuff and patient management issues. However, when it comes to the money/business stuff I feel like I am ungrateful and being too “soft.”

    “Ok thank you for meeting with me. I do need to move on to the next case. Thank you.”

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    That is a much better closer than “do you have any other questions or concerns today?” which is what I have been closing with. Bad move on my part.

    5. Any director ship should be paid at a reasonable rate with a contract. You need to negotiate the contract, the number of hours and the $/hour. EVERY SINGLE THING YOU DO needs to be documented on a time sheet.

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    I was told that the culture at our hospital is that no one is paid for their medical directorship. I have verified with my colleagues that they are not being paid for being directors. Their wRVU thresholds have been decreased. My CMO has told me not to spend as much time on the directorship stuff.

    Getting feedback is hard to hear but important. Efficiency is oftentimes learned not something you are born with.

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    I am pretty receptive to feedback, but I do have trouble actually enacting some of the fantastic advice. Everyone has been very helpful and given me a ton to think about.

    this place does not seem to appreciate the value you provide.

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    My colleagues do, which helps a lot. I have developed fantastic professional relationships with colleagues both professional as well as friendships. When I have expressed frustation in the past, colleagues have said “please do not leave you make this place so much better.” I am not arrogant enough to believe that my leaving would really make any huge impact, but I know that other departments burnout and frustrations would significantly increase. My job security is that no one likes neuro patients and especially complicated stroke patients.

    you are working as a resident

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    This is very true.

    are the radiologists in your facility not competent?

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    Usually once a week I have to call someone to addend their read because they missed something. Sometimes little, sometimes clots in the basilar artery…

    Who does that stuff when you’re not working?

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    The on-call neurologist via the phone. ER team does the hands on stuff.

    And you’re putting yourself at risk if not coordinated with them, assuming they’re making the official report.

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    They are good at getting the dry CT brains back quickly, but I am not going to wait for that to start mixing tpa. The fact that they are mostly off-site and it takes a while for all the CTA images to be reconstructed and sent to their PACS remotely. I do not have time to wait for them. It is comical how many times I get called about a M1 clot and the patient is already on their way to the academic center to get the clot sucked out.

    No offense meant and it’s great that you review images on exams you order but you could be getting other work done on same patient

    Click to expand…

    For follow ups and non-emergent cases I do rely on their reads more.

    #230240 Reply
    Avatar Tim 
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    “The on-call neurologist via the phone. ER team does the hands on stuff.”

    Since you are the director (uncompensated) maybe that little time spent can be worked out between your CMO and the on-call neurologist and the ER team?

    Reminds me of a story of a 3rd year attending looking to trade a weekend call. How many times do you think she had previously rearranged things to swap out with a colleague because it’s the right thing to do for the partners? Sends out her request and not ONE response.
    Not everyone that “receives” is willing to “give”. As long as you give freely, you will find plenty of “takers”.

    The long hours need to stop, it will burn you out (literally chew you up and destroy you). You need to do your work within your “assigned time slots”. Then hit the door. Turn it over to the ER team and the on-call neurologist.
    Honestly, the job security is not worth sabotaging your career. You need to focus on delivering the skills you trained for efficiently. You will get paid for your skills in the right setting. This hospital seems a poor fit or your skills don’t match the position. That’s a professional choice you need to make.

    Short term and long term, one can be competent and pleasant and still require payment for services. Each hour needs to be paid. “Not too many?” Even one hour a week needs to be paid. That’s a week’s services! You need to be selfish with your time. Some of your time management is personal that you easily can continue to develop. The compensation is on you in some respects, you are the “giver”, learn some “taker” skills. When’s the last time you left early and turned it over to the on-call neurologist and ER team? You volunteer to stay late. Where is the give and take? The favors you are giving will never be repaid in kind or in money.
    Only you can say no and change that. Takers are plentiful. Many have suggested skillful ways of doing that. You might find it’s actually easy. Change your hours and simply don’t work for free.

    #230287 Reply
    Liked by Zaphod, wonka31
    Avatar Jackmomma 
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    “I was told that the culture at our hospital is that no one is paid for their medical directorship. I have verified with my colleagues that they are not being paid for being directors. Their wRVU thresholds have been decreased. My CMO has told me not to spend as much time on the directorship stuff.”

     

    Wow. What city is this? Where I live there’s competition to be directors, not just for the money but the prestige that it *may* bring.

    Keep in mind that as a Medical Director you have influence in medical policies. You are also at risk potentially based on policies you sign off on or advise on at the hospital, when it comes to malpractice. My malpractice policy covers medical director activities.

    I don’t know if your does or not. My point is : being a medical director is not just a fun volunteer a few hours at the Elementary school type thing. There are very real consequences to what you are deciding in those meetings.

    You should be getting paid for this. You mentioned above you feel ‘ungrateful’ if you ask for money. I completely disagree. Being a director is practicing medicine at a more Macro level. You can have a tremendous positive influence on the medical practice and culture as a director. You should be getting paid for this (at a rate CMS considers reasonable) provided this is a real directorship.

    #230309 Reply
    Liked by q-school, wonka31
    Avatar ChristopherMD20 
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    you are the “giver”, learn some “taker” skills.

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    I think I can translate my skills elsewhere to help with this. I am not nearly as passive as I sound in other aspects of life. I am very aggressive about clinical management and ensuring people actually follow my recommendations and hold them accountable. I do not back down on my clinical impression/recs when someone is trying to cut corners etc. I come from a background/culture where “people should be thankful to have a job and food on the table and not bite the hand that feeds [them].” I am capable of being a taker, but just have to psyche myself up. Everyone here on this forum has been amazing. I have requested an internal review of my coding/billing since there are a lot of oddities when I look at it. When I switched to billing myself (albeit coders continue to change stuff on the back-end because of Medicare rules for inpt consults etc.) if I saw the same volume my current trend would have yielded me 15-20% higher wRVU and a bonus. After that review, I plan to meet with my boss and express my frustrations and the things that I want corrected now. If they are willing to compensate me more I do have another year on my contract and time to find a new position.

    Wow. What city is this?

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    Somewhere in the Maryland-DC-Northern Virginia area.

    being a medical director is not just a fun volunteer a few hours at the Elementary school type thing.

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    That’s how the boss is portraying it.

    #230314 Reply
    Avatar Perry Ict 
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    It’s funny that you should say that you should get paid 50-100K more.  I was listening to a podcast where someone was citing a study stating that everybody thinks that their lives would be so much better if they got paid 30% more then what they currently get paid.   It’s interesting, because it doesn’t matter how much you get paid, whether it’s 50K or 500K, everybody thinks that if they only got 30% more, their lives would be that much improved.

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    I think there’s a lot of good advice on this thread.  I quoted the above because, while some of your frustrations might be due to being relatively underpaid, you also have to ask yourself whether you would be totally happy with the situation if you were just paid more.  When it comes down to it, you are still working 60-80 hour weeks, basically working like a resident, and I wonder how sustainable that is even if your employer obliges with any salary increases.

    #230319 Reply
    Avatar StateOfMyHead 
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    It’s funny that you should say that you should get paid 50-100K more.  I was listening to a podcast where someone was citing a study stating that everybody thinks that their lives would be so much better if they got paid 30% more then what they currently get paid.   It’s interesting, because it doesn’t matter how much you get paid, whether it’s 50K or 500K, everybody thinks that if they only got 30% more, their lives would be that much improved.

    Click to expand…

     

    I think there’s a lot of good advice on this thread.  I quoted the above because, while some of your frustrations might be due to being relatively underpaid, you also have to ask yourself whether you would be totally happy with the situation if you were just paid more.  When it comes down to it, you are still working 60-80 hour weeks, basically working like a resident, and I wonder how sustainable that is even if your employer obliges with any salary increases.

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    Excellent point @Perry Ict and probably the first thing I would determine.

    OP it can take practice and stones to recognize your value and graciously but firmly require the salary you deserve when negotiating. You are correct that while there are plenty of physicians in this general area there is also no shortage of facilities hiring specialists. Wages aren’t as high as in the rural parts but if your hospital is taking advantage of you whether you allowed it to happen or not doesn’t mean it has to stay that way. As trite as it sounds it would be beneficial to start networking with fellow neurohospitalists in this area if you aren’t already. The inside information I have gotten from colleagues regarding expectations and opportunities has been invaluable. Best wishes you sound like a good guy and conscientious doc.

    #230431 Reply
    Liked by Perry Ict
    Avatar Tim 
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    “That’s how the boss is portraying it.”
    Politely repeat, “How much for a few hours? Is that per week or month? How many hours per year and feel free to pay the on-call and ER department or ask them to donate. My feelings won’t be hurt, I promise.”

    Maybe the hospital from the “boss perspective” needs your skills only 1/2 the time. Nothing wrong with paying you full time, adjusting your targets and agreeing to flexibility in your schedule. Your needs and the hospital need to be aligned. You are assuming the “Boss’s needs”.
    He may need your skills on staff but not your production. You may have been killing your self for a target that is of low value to him. Somehow work to find your value to him. You may be extremely valuable just being on staff. Your need is burnout and fair compensation. Your worries about production may be extremely low priority to him. It sounds like your skills are unique. what a relief if he simply needs your skills and coverage. Give it some thought. Physicians might have suggestions about probing to find out. That’s a communication issue.

    #230433 Reply
    Liked by Zaphod, wonka31

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