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  • Avatar mainah 
    Participant
    Status: Advanced Practice Provider
    Posts: 39
    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.

    in reply to: New patients #220887 Reply
    Avatar mainah 
    Participant
    Status: Advanced Practice Provider
    Posts: 39
    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.

    in reply to: New patients #220857 Reply
    Avatar mainah 
    Participant
    Status: Advanced Practice Provider
    Posts: 39
    Joined: 10/04/2018

    Sorry to add to your to do list, but he must look for a new job like yesterday. Sounds like the writing is on the wall with the current one, you don’t want to be caught with the pants down with no job and looking while everyone else is looking.

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    He had been, but thankfully we just found out he has a contract + housing for next year (phew)

    in reply to: debt free vs knee surgery vs fertility workup #210497 Reply
    Liked by Lordosis
    Avatar mainah 
    Participant
    Status: Advanced Practice Provider
    Posts: 39
    Joined: 10/04/2018

    I suggested trying to get him seen earlier and he quickly panicked and said no. He teaches for a private school and they hammer not scheduling “routine” medical appointments during the school year. They actually gave him a hard time about having a lithotripsy scheduled this past Dec, and he taught with significant pain for 2 weeks. The school is undergoing financial hardship and cut 9 teaching positions last year, and he just hard there is a $1M deficit this year. He is afraid of rocking the boat and and wants to wait until school is out.

     

    I’ll look into the fertility stuff in 2 weeks once I know for sure if we failed again. Thank you for your help!

    in reply to: debt free vs knee surgery vs fertility workup #209482 Reply
    Avatar mainah 
    Participant
    Status: Advanced Practice Provider
    Posts: 39
    Joined: 10/04/2018

    Please do not worry so much about being in debt. The reason to get rid of debt is to improve your quality of life.  Sometimes there are other ways to improve your quality of life by spending money and not paying your debt. If this isn’t one of them, I don’t know what is.

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    This is a really great way to put it, thank you

    in reply to: debt free vs knee surgery vs fertility workup #209420 Reply
    Avatar mainah 
    Participant
    Status: Advanced Practice Provider
    Posts: 39
    Joined: 10/04/2018

    Agree with others

    1. Your surgery first and his surgery soon afterwards.

    2. Continue to put into retirement plans.

    3. Most likely you would have maxed the deductible after these surgeries and the insurance covers everything 100%, consider tests for infertility that can be done strictly within this year and you don’t have to pay additional money for it. I am not disputing hatton1 and SLC OB  advice on not needing work up till the 3rd fetal loss but you don’t want to have that next year and starting the work up then and having another 5K deductible payment. This is more of looking at it from financial standpoint and not medical standpoint. Unfortunately the current 5 and 10K deductibles make us plan things more around it than from what we would do strictly from a medical point of view. JMHO

    Good luck

    Click to expand…

    Thank you for your help! Looking from a deductible standpoint, my husband’s deductible year goes July 1 to July 1. He doesn’t have his consult until June 19th and I already confirmed with his surgeon’s office he most likely wouldn’t have his surgery until after July 1, unless the PA gods are on our side. So we would pay $5k for his deductible in July. My deductible year is the regular calendar year. Let’s say I theoretically have my scope this summer, that’s 5k for me.

    In other 10 or so days, we will know if we were able to conceive this cycle. Let’s say it’s favorable. My estimated due date would mid January, so another 5k deductible for me. Plus the baby would then have their own deductible. Theoretically we could be looking at $18k+ in deductibles in less than a year!

    My employer covers 100% of my insurance. His job is year to year at this point so we haven’t wanted to do a family plan on his in case he loses his job. I think Radonlake and other posters are right, we need to look into optimizing our insurance coverage, HSAs, and building a “deductible fund” for now.

     

     

    in reply to: debt free vs knee surgery vs fertility workup #209419 Reply
    Avatar mainah 
    Participant
    Status: Advanced Practice Provider
    Posts: 39
    Joined: 10/04/2018

    You have gotten pregnant twice since the beginning of the year? No need for work up yet. We don’t work up RPL (recurrent pregnancy loss) until after 3 SABs. You are young (especially in my area! We have tons of 40+ year old Moms) with regular cycles, tubes open (since you have gotten pregnant) and must have pretty good sperm to have done it’s job twice. Just make sure you are Rh positive, since you have not been seen for your SABs. Enjoy the process and don’t worry about this expense at this time.

    You are so close with the loan pay off…. I understand your desire to keep going. But could you get the stuff done for yourselves and finish the loans by January, instead of October? When does the free housing possibly go away? End of school year? Calendar year?

    Good luck, either way you go, you will be fine.

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    Thank you for the encouragement and advice! Free housing could potentially go away in July. He will know in another couple weeks if we will still have it or not. I know it’s so doable to have kids in your 40s, we are just so rural that if I have a baby at AMA with complications, our specialists would be 2+ hours away. We’ll cross that bridge when we get there though.

    in reply to: debt free vs knee surgery vs fertility workup #209036 Reply
    Avatar mainah 
    Participant
    Status: Advanced Practice Provider
    Posts: 39
    Joined: 10/04/2018

    Can’t you get on your husband’s health insurance to be double covered? And why the obsession with paying off the student loans when you have other important ongoing needs? I also personally think it is generally a big mistake to prioritize student loans over retirement contributions. Your income is decent, have decent jobs (well you do, he doesn’t), have subsidized housing, it feels like you are causing more stress than needed for yourself by setting an unattainable goal for the student loans payoff schedule.

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    Because when we got married 1.5 years ago with 160k in debt and no financial knowledge between the two of us, someone handed me a Dave Ramsey book which said you can put retirement contributions on hold as long as you would be debt free by 18 months. We fell into that category and wanted to take advantage of the free housing. Heaven forbid I was unable to work and we were stuck with his income (I didn’t know about disability insurance at the time, which I am currently undergoing the underwriting process for). We have been set back 6 months with some other medical expenses

    We hadn’t looked into double coverage, so thank you.

    in reply to: debt free vs knee surgery vs fertility workup #209035 Reply
    Avatar mainah 
    Participant
    Status: Advanced Practice Provider
    Posts: 39
    Joined: 10/04/2018

    Are you attached to your location? Fifteen states mandate some coverage for fertility; a few for IVF. Your salaries are on the low end for your fields- many states would pay more. The free housing is nice, but it’s not guaranteed.

    I think you need better jobs, better insurance, and a new location. You need to look for jobs with insurance with lower deductibles and more comprehensive coverage. I just don’t think you are going to get where you need to be earning what you earn with crappy insurance that doesn’t cover infertility.

    Click to expand…

    My husband is incredibly close to his family (they are quite awesome) and I don’t see us ever moving.

    Interesting you say that my salary is on the lower end. For my first 5 years I worked my way up from 70k to 75k at an FQHC (average for my state according to AAPA salary report), but when I got married and moved and got this job, I was elated with the 33% salary increase to 100k. We are in a LCOL area. His salary is low but his contract lists his benefits (which includes all meals free during school year in addition to housing) and it’s over 70k, so we are trying not to complain. Starting salary for teachers in our state is 31k. Plus he really likes his job and is very good at what he does.

    in reply to: debt free vs knee surgery vs fertility workup #209004 Reply
    Avatar mainah 
    Participant
    Status: Advanced Practice Provider
    Posts: 39
    Joined: 10/04/2018
    I’m sure (actually I know) the other physicians and APPs, who are all 25+ years my senior, roll their eyes when I discuss ways to make things more efficient in the office so I can get out at a reasonable hour. 

    Click to expand…

    Do the other physicians and APPs have a similar patient load and get out at a reasonable hour?

    Click to expand…

    They all see more patients than I do on a daily average. 2/4 have retired to a 4 day work week and spend the 5th day as an administrative day catching up.

    The other are probably our most productive and work slightly longer hours. They also have billing and our referrals coordinator on their backs constantly for incomplete charts that are up to 2-3 months old, and literally hundreds of labs/consult notes/hospital visits that haven’t been signed off on. I prefer to be in the clean plate club by Sunday and I know our support staff greatly appreciates it. My turnaround time for pt phone calls/PAs/PT orders/MA clarifications etc etc is pretty quick.

    in reply to: Fatlittlepig vs. Lazy Millennials ? #208231 Reply
    Avatar mainah 
    Participant
    Status: Advanced Practice Provider
    Posts: 39
    Joined: 10/04/2018

    Born in 85. I’m in a different situation than you all, being a family practice APP married to a teacher. I’m at work by 6:30A, out between 4:30-5:30P. After work it’s running to get to the bank, grocery store, dishes, laundry, Walmart, making supper etc, in addition to needing to find 1-2 hours in the evening to complete charts. My husband coaches and takes on residential duties at his school, 25-35 hours a week in the evenings on top of his normal teaching hours to qualify for school provided housing, so a lot of the activities pertaining to running and maintaining a household fall on my shoulders. It’s 7:30p by the time we’re both home eating supper together on a good night. We are hustling to pay off student loans and can’t afford to eat out all the time or pay others to do household tasks for us. I’m not going to stay an extra hour seeing patients and I’m not going to stay an hour later to accommodate patients who are late; they can reschedule even if it means I didn’t carry a full schedule for the day. My husband and I would never see each other and it’s not worth the mental drain or sacrificing my marriage putting the extra time in. I’m sure (actually I know) the other physicians and APPs, who are all 25+ years my senior, roll their eyes when I discuss ways to make things more efficient in the office so I can get out at a reasonable hour. If I’m the lazy millennial who doesn’t understand what the life in family practice is “supposed to be,” then so be it. 4/4 of them have been divorced and 2/4 are doing the bare minimum clinically and have checked out. My husband and I have a wonderful marriage and overall I’m pretty happy. I go above and beyond for my patients trying to give them the best care possible.

    I’m impressed with those of you who can swing the extra shifts and I don’t want to be callus and say that you’re sacrificing your family in order to make it work, but I’m sure I’m not alone. I can’t imagine what it’s like for those with kids.

    in reply to: Fatlittlepig vs. Lazy Millennials ? #208219 Reply
    Avatar mainah 
    Participant
    Status: Advanced Practice Provider
    Posts: 39
    Joined: 10/04/2018

    The other sad aspect of this story is all the comments siding with the woman placing the suit, complaining about money hungry family members and financial advisors

    in reply to: Powerball winner sues son, says money invested poorly #208215 Reply
    Avatar mainah 
    Participant
    Status: Advanced Practice Provider
    Posts: 39
    Joined: 10/04/2018
    Splash Refinancing Bonus

    Rural family practice PA, 7 years into practice. 18-24 per 7 hour day depending on how many annual exams, procedures, and new patients which get 30 min appts, and of course no-shows. Some days I don’t have an MA so I don’t know if I could handle much more than that.

    in reply to: Daily volumes #202405 Reply
    Avatar mainah 
    Participant
    Status: Advanced Practice Provider
    Posts: 39
    Joined: 10/04/2018

    I used to get $600/6 week rotation for a PA program associated with a med school, plus access to their library and UpToDate (at my current clinic the stipend goes into a general fund and gets split between the providers). I’m in a different income bracket than most here but doing 4 students a year paid for my travel/vacation expenses for the year so it was worth it to me.

    in reply to: Teaching stipend to host med students in the office? #196245 Reply
    Liked by Tim
    Avatar mainah 
    Participant
    Status: Advanced Practice Provider
    Posts: 39
    Joined: 10/04/2018

    Both medical and recreational THC are legal in my state. There is a NP in our clinic who is certified to rx it and from what I hear from other patients, it’s pretty easy to get if you say you are anxious, and I don’t think I’ve ever heard of anyone applying for a card being denied. I haven’t talked with him about this aspect of his practice at all though. I just saw an epilepsy patient today who is going to see him tomorrow, and I asked her what her neurologist thought about the appt, and it sounds like he was against it. There is another doctor who travels around the state doing certification clinics for cash ($125 for initial certification) but I imagine followup is quite poor for the stuff in between yearly certifications. My policy is to say “you need to follow up with the person who prescribed this to you about it” when patients ask me questions, and if they are just considering it but haven’t started it, I say what has already been echoed above, there isn’t a ton of evidence to support it just yet.  I have had an increase in patients with medical cards coming in with cannabis hyperemesis after starting it, and they usually aren’t pleased to hear me say their sx are caused by the THC. Our state board has also made it clear, though disciplinary hearings, that they don’t feel that rx medical THC with benzos or opiates is appropriate ever, which sometimes is an issue for patients on chronic opiates or benzos for pain/anxiety with THC coming up in their drug screens.

    in reply to: Medical Marijuana #184633 Reply
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