I’m fortunate enough to currently be averaging 18 a day full spectrum outpatient… I know others see much more. My network is trying to force my hand and increase that to 24ish a day. I’m currently billing out in the top decile and have the top patient satisfaction scores in my region.

My contract is up this year and I plan to try to negotiate a patient cap.

Has anyone been successful in leveraging these big corporations. From what they told me they are all focused on “encounters” now and going away from the revenue/RVU model.

A friend of mine suggested leveraging all the “inbox/messages” as encounters. I’m sure most of us spend hours on the inbox whether it’s answering questions, prescribing meds or managing refills and doses. Anyone successful in using this as leverage against increasing patient caps?

Thanks

The venom of a Gila monster forms the basis of GLP-1’s and now that this class of medications has become a generation defining medication even appearing in rap battles and pop culture, we should pay homage to the Gila monster.

Also with the caveat that it is derived from Venom which is a metaphor and a cautionary tale as we tread further into uncharted territory with medicine as well as a reminder that medications can always carry adverse effects and even lead to death.

It’s also funny how such a laid back lizard literally produces ozempic in its mouth to kill things with.

For my elective I can pretty much create the schedule I want so I am looking for elective ideas I can do while in my last year of residency that might help prepare me for being a new attending, i.e. billing course, etc. as well as being relatively light so I can get some downtime. Thanks!

Any suggestions on small gifts for colleagues? I expect to give something to our MAs, nurses, and reception…probably about 10-15 people all together…I’m sure they are sick of Starbucks gift cards, so looking for something meaningful or useful, that won’t break the bank!

Anyone else waiting for the CFPC fall 2024 results to come out? Previous years indicating next week to be a possible release window… 😔

Hello yall

I signed up for a private practice at the end of residency in July. Interview was great, and contract was okay (regretting not getting is seen by a contract lawyer).

At first it was going well, but then there seemed to be signs of financial stress- they did not pay on time, checks bounced, they did not use direct deposit. I made a bit of a fuss about getting payment on time, and to not give me a check that will knowingly bounce and they started to be better about it (baffling that I have to tell them).

We also were pregnant- my wife had MFM appointments and heme appointments. 2 days prior to delivery, we get a notification from one of the docs that insurance was not active. I found out that health insurance wasn't active for about a month. But they continued to take money out of my paycheck. Speaking with the insurance broker, I found out that the employers didn't pay the insurance premium.

I'm so done with this place. I've spoken to an employment lawyer and getting some more advice, but it's mentally draining. I want to quit, but I have to give a 90 day notice. Any advice how I can just leave.

Hello, would appreciate any advice/comments regarding a job offer for after residency. I have went and read through old posts and have a fair expectation on what most people will say (low all offer), but just wanted to see for myself.

Semi rural/suburban area with the closest major city about 2.5 hours away. hospital system based clinic.

Base 220k. $40/wrvu productivity after reaching that threshold (5500). Will be taking over a small panel of about 500-600, will have to build panel up.

Sign on 20k. Quality metric bonus of 40k - after speaking to other physicians, they get anywhere from 12k-36k of that.

$5k cme.

24 days PTO.

6% 401k match with 2 year vested period.

36 clinical hours, 4 admin hours per week with option for 4 day work week. 2 year initial contract.

So I figure I won't be getting much, if any, of the production bump due to small panel size with no real guarantee of volume. My approach would be to negotiate the base salary rather than wrvu rate for this contract due to likelihood of a lower volume. Most other physicians were able to get between 230-250k base after their negotiations.

Other factors - no state income tax, low cost of living.

Private equity calleth on my clinic and we aren’t sure what’s going to happen to it. Interested in hearing what you all would do if your clinic suddenly closed for example, with where you currently are in your career/financial spot.

I was wondering if anyone can quantify the months required during residency to consider to apply for hospitalist or ED post residency?

Thank you

I am a third year, planning on doing a fourth year, and my dream is to practice in Guatemala. Before I go for the long term I want to be financially secure because I really only plan on making enough to live off of when I’m there. I have a lot of loans, thinking of pslf, and I’m married with 0 kids and 0 kids planned at least for the foreseeable future.

I’ve spent three months in Guatemala spread out over six years but have little experience working in healthcare over here.

Honestly, I’m just hoping someone has some good advice as to how to work towards this dream. I am not looking to explain my reasons or talk about my experiences that have informed my desire.

Thanks for reading!

Edit: I’m a PGY-3

I have been out of residency for 2 years or so and I have been pretty burnt out from my job. I'm planning to transition to urgent care but I'm thinking of transitioning to do part time work and from my colleagues, it seems like they can make 200k+ even as a per diem. Urgent care full time - you do 12 or so shifts a month and you can make 310k+ in my area. Any regrets of those who are per diem? The thing I would love the most is the flexibility - work when I want. 100k in the grand scheme of things won't make me happier(even though almost half of it will go to taxes) but I would have to face reality of being in school debt, buying a house with a high mortgage monthly, etc. I'm also younger so sometimes I think it may be unwise to be working per diem. Would just like to hear some thoughts for those who are per diem and how it worked for you

Let's hypothetically say that you work at an FQHC in the US, and leadership suddenly shares, unexpectedly, that the budgetary situation is dire. They institute layoffs to avert closing shop in 2 months (!!!), and you are skeptical of the org pulling it together. You're thinking things could spiral as staff freak out and quit to make sure they can pay their rent at a more stable job elsewhere. If any providers go on extended leave or quit, the wrench thrown into the revenue picture might be big enough to tip the whole thing over. Maybe the org will have a brutal restructuring involving cancelling programs, and the primary care clinic will live on, being the main revenue source. Alternately, it will fail and you will find yourself out of a job and without access to your patient panel, who are suddenly left in the lurch.

At this stage, when you really do not know what will happen, do you start notifying some patients that they should consider finding a new PCP? Particularly people who are medically very complex, or on controlled prescriptions that take a while to get at another clinic, or just won't cope with a sudden closure due to mental illness. You know this will inspire some of them to spread rumors in the community and it will get around. Removing patients from the panel also decreases revenue in the long run due to wrap payments. You know that some of the clinic staff have already leaked this to some clients because they were feeling heated about the layoff announcement.

Anyway, maybe it's not hypothetical. I am also sorting out whether I should leave since I am on a HRSA contract and I can only work at few other clinics in town, and half of them are not hiring. I don't want to end up stuck with no work options within a 30 mile radius. Also credentialing takes time. But I think things are so tenuous that my exit would be a disaster. Our small group of providers is basically holding the whole agency on our back right now. Thanks for listening.

(meant to put weight management in title)

I have a patient in clinic with this (I’m a resident), and she’s really struggling with the weight part. She can’t afford GLPs. I’ve got her in to see nutritionist, but her weight has been stagnant at all of our visits.

Anyone have go to weight loss tips for these patients? I was considering talking qsymia vs contrave with her, but I know a lot of people don’t love these because the weight immediately comes back when you stop…my hope is that she can lose weight and achieve some steady state with lifestyle changes with the dietician she works with..

Happy Thanksgiving! There is a lot to be thankful for, but on a lighthearted note, I’ll go first:

When my MA calls out and her temp rooms my patients on time!

Homeless guy who got assaulted two weeks ago, presented with severe leg pain. The nurse manager which I do not get along with just put him on my schedule without asking. (I already have 30 pts sch) I told her I would not be seeing him and that she should send him to ER. He was placed on my nurse slot.

Today was my last day at this job and this dysfunctional office. She also had 0 mas scheduled with me this morning.

Just venting

I recently graduated from an inpatient-heavy rural program with 2 other co-residents. 2 of 3, including myself, became nocturnists, another became a PCP.

Two classes before me, there were 5 graduates, 2 became hospitalists. In the class before them, I think it was a class of 5 and only 2 of them became a PCP.

It made me wonder if there was any reported trends, or trends you all have subjectively noticed, about the career trajectories of recent FM graduates compared to 10-20 years ago. Since I graduated from a small program where FM hospitalists and ER doctors were the norm, I figured maybe it was just a rural medicine thing, but more and more I read about the burnout primary care doctors face. I certainly couldn't handle it.

What have you all noticed?

Patient insurance network changes

As a patient covered by an HMO, I get super angry at my insurer when they change the network they participate in. In my case I live one county, 30 miles away from a metro area. My HMO has decided to terminate their relationship with a major network in my county. My PCP for sure is not changing networks so I will need to start all over again with someone new assuming I find anyone taking new patients

As much as I'm angry and annoyed at my HMO, what is it like for you physicians?

Anyone think we should be seeing an EMR built from the ground up on AI? Not AI add ons like we see now.

Hi, I'm currently PGY1 FM resident in Canada, I did medical school in the US and completed the USMLEs. I'm also a Canadian citizen. Was wondering if anyone has any insights on how I would go about possibly practicing family medicine in the US after completing residency? And if I could be eligible for taking the ABFM exam.

Also, does anyone know if canadian FM grads are eligible for fellowships in the US, such as sports medicine, geriatrics, or addiction medicine?

Anyone else notice the criteria changed recently through cover my meds regarding Zepbound and needing a BMI greater than 35? It’s a lot of work to appeal these. Criteria used to be greater than 30 or 27 with a comorbidity.

This is a bit of an odd situation for me but would love some opinions. Sorry for the long read.

I am a PCP in my second year out of residency. My wife and I had our first child 2 months ago. Over the weekend from Friday night into Saturday, my wife developed evidence of mastitis with a low-grade fever.

Given it was weekend, and the OB on-call recommendation was urgent care or ED, I decided to call in some abx for her since there were no severe symptoms overall. It is not common at all for me to treat family members but given the situation just went ahead and did so.

So I decided to send in some Keflex 500mg QID. It’s been a little bit since I’d treated mastitis but previously in residency I had a couple patients that I tried to treat with the classic dicloxacillin but the pharmacy called back saying they didn’t have that so I used Keflex instead with good results.

Things were going fine with improvement in pain. However, yesterday afternoon the redness seemed to worsen a bit and I felt a bit of fluctuance, so being concerned for abscess, we went to ED. US showed some fluid but Radiology was noncommittal — can’t rule out abscess. Gen Surg tried aspiration without success.

The entire time we were there, the OB NP and later attending, chastised and derided us, saying Keflex is not first line treatment for mastitis. I told them I disagreed. Prior to my sending in the abx I did confirm with Up To Date, which listed either one as options for uncomplicated without risk factors for MRSA.

Today I checked with my cousin who is ID — they agreed and sent me guidelines from Johns Hopkins abx guide as well as Sanford Guide, both of which include Keflex as first line.

Ultimately the OB switched her to dicloxacillin and said to follow with Surgery if no improvement. We agreed, but I don’t see much of a change in spectrum of coverage…

What are everyone’s thoughts on whether I mismanaged the issue? Do you agree that dicloxacillin > Keflex?

TLDR; treated my wife for mastitis with Keflex and seemed to not respond. OB chastised us for this not being first line. Do you agree?

Hi everyone, i wanted to ask for some advice from family medicine trained physicians.

I’m currently in the process of interviewing with residency programs and I’ve had the opportunity to interview with both FM and IM programs.

I would love to know from FM trained physicians currently in the field;

1. would you choose family medicine all over again?
2. What type of practice do you do and is it fulfilling?
3. How is your compensation and do you feel like you’re well valued by your employer?

I’m leaning towards family medicine but just want to get an honest outlook from those in the field before I start making my rank order list! 🙏🏻 thank you so much for any insight and answers 🥹

So I’ve been an attending for a little over a year now, have a panel of ~1300 patients. Recently, 3 doctors from the clinic I work at left and 2 are retiring, leaving thousands of patients without a doctor. I said I would still be accepting patients, but not to funnel all of them my way - management took this as opening the floodgates and they’re throwing them all on my schedule even though I’m booked out through August for new patient visits.

I’m getting inundated with requests for med refills of benzos and narcotics from these patients who I’ve never seen - is it unreasonable for me to request to see them in office before refills? I used to really like my job and now that I’m effectively covering for my own panel and multiple other physicians’ panels, I’m feeling squeezed and starting to resent coming to work. I have a hard time getting my own patients in as it is, and now that I’m being forced to take on all these extra patients that leaves even fewer openings.

On top of this, they’re asking me to extend my work hours by an additional 2 hours/week (I currently work 4.5 clinic days).

Every time I see this on a forensic files or dateline episode, I can’t help but think I would miss a diagnosis like this. Maybe if they said “wow I get really sick every time I drink iced tea that my wife brings me”. Has anyone ever had a suspicion for poisoning that turned out to be correct?

We're looking at organizing in our academic center. Are there others on this forum who are working on doing the same? Would love to connect to others who are in the same or similar boat.

Feel free to DM if you're worried about getting doxed, you can look through my post history to see I'm a real person with dumb interests.

Also feel free to use this thread to discuss unionization in general.

Hey all, I work in a rural location where emergency and urgent care are staffed by separate physicians than the primary care clinics. At the clinic I work at, we have no proximal x ray facility and no casting supplies. The staff keep booking "Query fracture" patients with me and I keep pushing back on them saying these patients should go to the ED. I still see a lot of delayed fracture patients which are annoying to sort out calling ortho etc. So today a patient falls outside the clinic as I am about to go home and the staff ask if I will see him to see if "he needs an x ray". I say no, we are closing. I don't have time to sort him out. I used to work in rural emergency and elderly falls were often pseudo traumas. They have also booked confused head injuries with me before as a same day appointment and I have told them not to do this.

Main question is, is query acute fracture a thing you guys often see in the primary care clinic (without attached x ray facility)? Do you spend your evenings and weekends trying to manage these things as an outpatient? Do you just assess the patient and send to the ED if you are concerned there may be a fracture? Interested in different opinions.

Edit for spelling

Want to learn more (aging population). Would like this to be practical information. Have funds to burn- anyone have CME that teaches geriatrics they know of?

I was wondering is there a way to calculate your board score from the number of answers you got correct?

The 2024 ITE answers are out, not the official scores, and I wanted to calculate my score