We have moved in the past few years and I truly can't tell if my care issues are related to a new area of the country (SC/GA area) OR a general reflection of healthcare today. I am an admittedly burned out NP and I cannot tell you the grace I extend to providers and how much I try to reduce their administrative burdens: I don't send MyChart messages excessively, I am an extremely compliant patient, I am up to date on ALL of my wellness and screening items without reminding and I keep a list on my phone and provided copies of everything when establishing care. I take excessively good care of myself and aside from a mild pandemic induced ADHD (helping to manage a small primary care office through the pandemic with no large resources and helping an almost 70 year old practice MD owner learn telemedicine just blew my concentration and focus abilities...but I digress) I have zero anxieties, depressions or psych issues. I am extremely fit, take personal responsibility, etc. etc. In my head I'm a dream patient. I know not to add on multiple complaints to a wellness visit and all that jazz. I expect no emotional handholding.

My two current groups use Epic if that helps. Here are just a few of what I have encountered:

- major imaging was completed and I was never contacted regarding the results except through the imaging center. I don't expect a lengthy phone call to review the results and contacted the ordering provider stating my willingness to come in to review the results. Nothing. Crickets. I self-referred to a specialist and got the issue taken care of via a specialist.

-new onset problem that required multiple urgent care visits within the same system. Never once a notification from the internist saying "wow, I see all the urgent care visits, please come in so we can review and coordinate care."

-specialist refusing to review prior films; waving them off. IDK about you guys but I think it's a dream when a patient has CDs and reports from prior imaging and brings them with to an appointment. Saves me and my staff hours of tracking down and requesting. Most patients are all "I don't know when, who or where did all of that."

-Established care with a cardiologist at a large practice in Atlanta, tests completed as ordered. It's been a month. No contact, no update, no MyChart message with a summary, NO phone call stating "hey let's set up an appointment to review the results." Nada. Thankfully all are normal, I can see the results in the portal and have no ongoing questions.

Admittedly these are the things that burned me out as a provider because I always circled back, made sure patients knew to come in for reviewing films and results.

Do I need to just admit that concierge care is what I need to switch to? OR I have a frank talk with the internist in a few weeks? I *have* intervened for myself and advocated when it needed to be done....or else I would've been no doubt admitted for sepsis. But my god how is the normal patient with no medical background not slipping through the cracks? And damnit...I would love to be just....taken care of. I mean I know I have to stay checked in to my own care but please for the love of god don't make ME do all the work.

Thanks for reading. I feel better already.

I am respectful of my patient’s time. The only time I have run late in my practice was when a patient showed up late. With that said, I try to cover as much as possible, but it is sometimes unsafe to start exploring a new problem with 2 minutes left in the visit. I have tried agenda setting “what would you like to discuss? (note: I also verbalize that I have a plan to address it a follow up so I ensure that people feel heard/validated). “Okay, we will do X, Y, and Z” but it has not decreased the frequency of “can I just ask you about one more thing?” “Unfortunately we do not have enough time” will be met with a spectrum of “that’s fine” to “no, I’m here for my appointment and I expect this to be addressed.” I have even heard my colleague’s patients screaming at nurses because they didn’t do everything - no one deserves that.

Is there a better way?

How realistic is it to find jobs with 60/90 minute appointments in geriatrics? The clinic I rotate through does this and it’s been a dream. I keep thinking about the fellowship but I don’t know if this clinic is just special.

I’m currently waiting to hear back after interviewing for a Locum position via Locum Tenens. Took a year off after finishing residency and got married, so no work history.

College student health center. Mon-Wed, 8-5 pm. 10 PPD. $110/hr. Malpractice covered. 1 hour drive.

EDIT: “Doctor of the day” to sign off on NP consults. 3 NPs currently work there. Only one other physician currently works multiple half-days.

Reconsidering this offer in favor of a permanent position but having a difficult time finding a perm offer that covers malpractice within driving distance in Southern California..

Been looking hard and starting to apply in these 2 PNW cities. They seem overpriced for their size but I assume because they are the capitals of their respective states.

Any that folks here use beyond reddit? esp those with a clinical focus.

I am a 3rd year DO student torn between IM & FM. I like IM because of the complexity and acuity. I like FM because of the flow and relationships I can build with my patients.

Any advice or personal experience that helped you make your decision would be greatly appreciated.

I turned down a locum tenens position. 6 month contract. 30 day out clause. M to F, 9 to 5. 120$/hr. Housing not included. 2 year non compete.

Am I stupid for turning this down? Currently unemployed but I declined because I felt so pressured to sign the contract fast. They gave me the contract on Friday and expected me to start on Monday. I also think I’d prefer a permanent job and I’m still applying to places, so working 9 to 5 would’ve had me cut back on that. Thoughts ?

I had a patient who had a severe hypoglycemia response to a GLP-1 I started and I feel like garbage. Looking for tips on how to be better for the next patient.

50s, Female. She had been on insulin (124 units of glargine split twice a day and some mealtime insulin usually 10-20 units depending on her mood apparently since she wasn’t following a sliding scale or any instructions) and metformin, and refused to check her sugars regularly or try a continuous glucose monitor. She has skin problems and also complained of reactions to the 4 insulin injections per day she was getting. She would only check her sugars if she felt poorly and for that reason I thought she would be safer on a GLP-1 and metformin alone. She is also obese. He A1C was actually good, 6.5, but I was getting increasingly concerned about her refusal to monitor and her regular self-adjustments of insulin. I completely stopped the mealtime insulin and reduced the glargine by 20% from the dose she told me she was taking (which was more than prescribed) which I have seen in literature and my clinic pharmacist has recommended for patients with A1C <8. I started her on the lowest dose Mounjaro and she agreed to check her sugars at least twice a day until we got her med regimen situated. I prescribed oral glucose and educated about appetite/weight loss and also keeping sugar like juice on hand. I did not change her metformin. I told her to contact me if she has any highs or lows. I did not hear anything until she ended up in the hospital a couple of weeks later with severe hypoglycemia. She had apparently not followed the glargine instructions exactly and was taking slightly more but only by a couple of units each dose. I’m guessing she initially had highs and just adjusted on her own. She had been experiencing lows and stopped her glargine, but days later was still hypoglycemic. Literally sugars in the 30s. She apparently had stopped eating because she lost appetite on the med, even took her oral glucose at one point and instead of calling she took a second dose of Mounjaro and got worse. She said at the hospital she didn’t know it could cause loss of appetite, but we discussed that.

I’ve done the switch with the 20% reduction before and it’s gone fine, they usually run a little high. What would you have done differently? Is there something else I should be looking out for to predict who might be super insulin resistant generally but over respond to a GLP-1? Is the 20% guideline not conservative enough to prevent hypoglycemia? Should I just be referring patients who refuse to check sugars on insulin to endocrine instead of trying to manage? If a patient is not checking sugars should I just refuse to prescribe them insulin?

I’m not sure this has come up before, but I’m wondering what you all do for the amount of time for AWE visit. I am on a 15/30 schedule but I’m allowed /grandfathered in for 45 minutes for AWE. My system is trying to take that away saying that I should be able to do it in 30 minutes and a lot of doctors do do it in 30 minutes. The reasoning is twofold. They’re trying to create more access in general by reducing the time of the visit. they’re also saying that they’re not able to collect much billing, sometimes, beyond the simple awe code. EG picking up a 99214 , or a 99397 if they have Medicare advantage. I’m not sure why and they haven’t given me details about the billing issue. Like probably most of you, I usually combine my wellness visit with a chronic issue/new problem visit. Why make them come in twice? A lot of my patients are complicated and their usual follow-ups would be 30 minutes, so adding another 15 for the wellness to me is reasonable. Yes there are some easy patients who obviously don’t need the 45 minutes. But combining the fact that sometimes patients come late, and it takes longer to room a wellness because of all the questions, and the time I may take to do, for example, advance care planning discussion, or anything that comes up positive on the wellness screen, etc. can really make that plus chronic care new issue management very difficult in the allotted time especially 30 minutes. What do you guys do/how do you manage it? Thanks. Edit: I don’t have a lot of extra timeslots to make them come for a separate visit

I’m a newly graduated IM doc practicing primary care for a major medical system in a somewhat rural area. I inherited a large panel of patients that were on inappropriate controlled rx from a retiring doctor (no documented indication, early refills, no UDS monitoring, etc). I’ve begun tapering a lot of these patients, and as you can imagine, have had a lot of push back.

I was pulled into senior managements office last week for a monthly new provider meeting, and was lambasted for tapering these meds (clinic had received complaints from pts not agreeing with care). I was told that it was an expectation to continue these meds and it was poor judgement to consider tapering/discontinuing medicines as I have.

Have you ever experienced this before? I feel incredibly unsupported and don’t see how I can have a future in this job.

Addendum- after discussing this with other new docs in the same office - they all have been lectured the same thing.

 What are some great resources for myself- a primary care NP- to present to my supervising phsyician - a physician that offers “prayer, meditation and referral to my daughter, the nutritionist” to pts with LDL in upper 200s and CAC scores in 1200s- regarding the etiology of coronary atherosclerotic disease? He has reprimanded me several times for advising statins ("they do not prolong life and give pts diabetes") and referring to cardiology for stress testing (as recommended by CAC scores). Thanks in advance.

A patient had an abnormal finding on MRCP in 2021 and has had cyclical vomiting. We messaged GI and asked them if they saw this report. They messaged us back and asked to refer to hepatology and order a repeat MRCP. We write back that we would like the patient seen with them sooner than their follow up. The provider wrote back that she doesn’t manage the liver even though she’s in GI. What am I missing? What would you do now?

Looking for any tips on how to manage the cases of mostly homebound patients with BMI 75+. Somehow in my little town I've got a handful of them. Some are otherwise "healthy" in terms of normal blood sugars, no HTN, heart failure, etc., while others have the associated list of co-morbidities.

Educating, providing community nutrition and exercise resources, chair yoga/workout videos on YouTube, simple diet changes (no more Mt. Dew, etc) and close follow up and telehealth are all in my wheel house but not moving the needle for most of these folks.

What has been effective in your experience? Some of these folks have limited resources and plenty of enablers, otherwise have work from home jobs and support themselves relatively well.

I have had a lot of patients ask for book recommendations for T2DM lifestyle self-management and there really seems to be so much nonsense out there.

Any recommendations for a good book for patients who really want to learn about diabetes self-managent and/or prevention?

Anyone have go to resource on birth control pills? I just never really took the time in residency to sort through different options, combined/mini pill, biphasic, etc.

I feel like my gut is trying to sprintec and go from there, but I know my care and counseling is lacking.

Basically just looking for reasons to choose one over another, side effect profiles, brands. Benefits, etc.

Would do CME for sure. Need to check for a KSA.

Definite weakness I want to improve. I’m ok with knowing when to consider nexplanon or IUDs. Rings, patches and pills I’m limited.

Hello all. I perform TRT (when indicated) usually with biweekly IM injections here in my clinic. Currently, these patients come in on their own every 2 weeks for a Nurse-Only visit which is listed under the MA's name. They'll document that the injection was given and route their encounter to me to sign off on the actual testosterone order. From what I read it seems like the only codes we should be using for these visits are the 96372 and J1080 (but not the 99211). My question is how exactly am I generating revenue with these nurse-only visits? It doesn't seem like there is anything in the encounter that identifies me as the provider and would result in the visit counting toward my RVU's. Should I be asking my front desk staff to create encounters under my name when these patients come in just for injections or is that not allowed? It seems wrong that I am managing these patients and might not be benefitting at all (other than my patients feeling better of course). Thanks in advance for any insight!

Awards and grants

Hello,

I am trying to enhance my CV (helps visa) with various things in residency including posters, case reports, research. Looking for some additional grants or awards or scholarships or quizzes I can apply for. I know about the AAFP ones on their page and AAFP foundation. Also saw a few on STFM.

Looking forward to reading some feathers in your caps during residency Thanks

Saw an older patient today who’s previous pcp recommended prevagen for memory loss. It’s literally jelly fish fat. Doesn’t cross the blood brain barrier. Does absolutely nothing except make the owners rich. I was genuinely shocked that a practicing physician recommended it

Hi all! I am currently in my intern year of FM residency and enjoying it so much. Intern year for my program is very inpatient heavy and I only get 1/2 day of clinic a week except weeks I am on night shift. I was wondering what you guys recommend for studying? Such as Amboss, Uworld old ITE or AAFP questions? I know it is early on intern year still but I feel like I have a lot of knowledge gaps and feel like I knew a lot more when I was a 3rd/4th year studying for step 2. I finished 4th year in September of last year so was off from Sept-July when I started residency and want to get back on track with my learning. Recently took ITE and know I bombed it (didn't really study and wanted to set the bar low lol). But now I want to start getting back on track with my knowledge. Any suggestions and tips would be appreciated!

I Have had a few patients lately that have gained significant weight despite eating well and exercising. Initial labs checked were cbc, cmp, tsh, lipid. Everything has come back normal. It’s the same story and song with these patients. One lady in her 30s has put on 40 lbs despite running 3 miles a day for 3-4 days a week and exercising the others while calorie counting etc. this has been in the last 5-6 months. Physical exam is normal. Both patients say just something doesn’t feel right. What other labs would you look for? I’m checking fasting insulin, am cortisol that I know but open to other ideas? Thanks!

Patients are on no medications including BC etc

Rural midwest: $237 base + $55/wRVU over 4300. 66k starting bonus, 100k in loan forgiveness over 5 years and 60k retention bonus (20k/yr). 1.0 FTE. NP supervision without compensation.

Opinions:

I have a patient, new to me, that presented after car accident. 35 years old. Admitted to falling asleep while driving. Hx and ROS do not point to epilepsy. Obtain sleep study and shows severe sleep apnea. CPAP ordered.

With insurance and DME company it is 4 weeks later and he is receiving a cpap later this week. I just got a portal message wanting a work note stating he was late “late for work on Monday,” and “woke up this morning not feeling good so didn’t go in.”

On one hand he has severe OSA that does cause extreme fatigue. I guess the being late I could have understood but on the other hand I can’t say I’ve ever written a work note for missing entire days d/t sleep apnea? I initially just responded no but then got a long portal message back asking why and sort of arguing (which aggravated me for different reasons. This is not your personal chat line.) Maybe I’m in the wrong.

What are you alls thoughts? I’m typically not a gate keeper to work notes if you want to be out for a week for your cold here ya go. But this one feels different for some reason.

How many of you recommend all of your menstruating patients supplement folic acid? It is a guideline I honestly ignore personally, but I just got dinged for it in an audit.

I’m getting close to signing a job in NY soon (2 hours from NYC). Just wanted to know if you think that this is fair/appropriate or whether I should negotiate more. Thanks in advance!

Urgent care, 30 to 40 patients a day, four x 10 hour shifts with plan to transition to 3 x 12 hour shifts within a year after starting.

275 k base + $20 per wRVU above threshold, 75k sign on, 8K relocation, no student loan repayment, only one percent 401(k) match. 4 weeks vacation, one week CME, 10 sick days, 10 holidays, 2 personal days.

There have been many instances of the GOP wanting to gut Medicare, Medicaid, and repeal the ACA. How will that affect us moving forward?

There should be screening stickers like “I got my colonoscopy in 2024” or “normal cytology, negative HPV 2021”. Just ones for normal results with the routine follow up interval because these seem to be the people that don’t know if they had their colonoscopy 7 months or 7 years ago.

I know I know, I’m just getting it out of my system here so my MA doesn’t have to listen to it.

If anyone got it can you please share it thanks

I want to transition my private practice to a DPC (direct primary care) model from insurance based. My plan is to start offering a DPC option and then slowly cut out the insurance plans that I accept. I know that I need a lawyer to look over my plans to make sure that I don't run afoul of anything legally. How do I find one that can help me in this area. The lawyers that I have dealt with in the past (malpractice, collections, real estate) were a mixed bag in competency. I don't know anyone near me with similar needs that I could ask. Is there any available database with lawyer expertise and satisfaction ratings?

Edit: I'm in Illinois. One of the St. Louis suburbs.