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Role Reversal - Could this really be true?


Guest Paula

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Guest Paula

It looks like I'm in for a role reversal of sorts.  My clinic has 3 full-time providers and one is retiring end of May.  She will stay on to fill in for vacations, sick leave, etc.  Her position has been walk-in clinic and she is an NP.  When she leaves we are not hiring another full-time provider (we don't need one....I only had one patient today...).

 

The MD in the clinic is going to be the walk-in provider starting June 1st and will be selecting a few of his chronic patients and keep them on as a panel.  I will be doing ALL chronic care and will be considered THE primary care provider of the clinic.  The plan is for the MD to start talking to his patients and transferring the majority of his patients to me, plus from now forward I am the only one taking new patients. 

 

Currently I am a primary care provider plus fill-in for walk-ins.  The NP has all the walk-in patients follow up with me or the MD.  She sees a lot of coughs, colds, flu, UTIs, injuries, etc., med refills, orders some labs as appropriate as sees workman's comp.  Usually she would follow through on all of her own WC cases.

 

I am not sure how this will all pan out.  It seems like a role-reversal where the MD is not doing chronic care (except for a select few of his patients he wants to keep) and is seeing usually straightforward cases.  He will now manage all the emergency walk-ins too, which the NP and I usually have done. 

 

I already know which patients he will not want............and the select few he will keep (mostly his friends who he trades favors with....golf, scripts called in on weekends, treating them outside of work.....you know the score). 

 

Should I consider this a challenge or am I being dumped on?   It may not last and end up being a disaster as I can't see him doing walk-ins for a long period of time.

 

Currently I see scheduled patients, do H&Ps, well baby, well child, sports physicals, see lots of diabetes patients, do most of the pre-ops, ADD/ADHD patients, HTN, CKD, etc.  The whole gamut of care.  I dunno, maybe patients will now walk-in for a sports physical, well baby and child exams or his patients will just walk-in to see him. 

 

What do you all think?

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I look at it in a different way--They trust you enough to manage those chronic diseases and that you have done an excellent job in the past.  My feeling is that I am going to be at work anyway for a set amount of time and I will do the best I know how with the patient in front of me and as long as I am not working too much past my scheduled work time, I would be okay with that.  I know it can be frustrating when you have to deal with the non-compliant patients but you will keep getting challenged for sure.  Now, if he is going to dump certain types of patients your way e.g. pain pts, and say you do not feel comfortable prescribing Methadone for headaches, so you don't.  Do what you think is ethical/legal/proper medical treatment.  That patient will more than likely just walk-in to see him anyway because the patient knows s/he will not get that med from you.  

Glass is half-full.

(To the grammar police:  Yes, I know that was a lot of run on sentences and fragments :)

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This days everyone seem to be changing their practice model. The truth is, there's more money in UC/Walk-in clinic than in primary care and almost every practice seem to be chasing after the $$. Walk-in clinic/UC are lucrative in rural, suburban or area that are less attractive/less competition/ or areas where no one wants to work. No competition and you set your fees with insurance companies. Your SP is just been lazy or gearing towards retirement and doesn't want to work. Given the description of your current responsibilities, clearly it's an added workload. I will ask for more steak. My 2c

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I guess it is possible the clinic is dumping on you ..... but it sounds like a dump I would like .... especially if in a year I negotiated for more money given added responsibility and that you are essentially the reason people are coming back. at that point I doubt the clinic would want to make ANOTHER change in PCP for patients .... the pt's would likely get turned off. I would much rather treat chronic disease most of the day instead of urgent care issues. I respect the profession of urgent care and they find out serious things all the time and either manage or transfer to ER. At the end of the day however urgent care in a primary care setting can be awfully repetitive and boring. Do you feel organized enough for the change in schedule pace ?  do you have a game plan ?  sounds like this could be a lot of fun and a new challenge.

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....boring & repetitive? I think every specialty of medicine is repetitive. I've worked in FM/IM and still do and I found it boring & chasing paperwork/filling forms/ lots of TLC (not to offend the FM folks. I currently work flexible PT as a primary care PA). I must say that primary care can be rewarding and there's a lot of folks that finds it a true calling. I will shot myself in the head if I was to go back doing strictly primary care again. Furthermore, a mixture of UC cases; the unschedule pts and not knowing what will walk in IMO makes primary care or IM more interesting especially in setting where there's XR, CT and lab on site. In the setting where the OP is referring to, it appears the SP/admin are dumping the more complicated cases/pt load, the less reimbursable cases on the OP, freeing up the SP time to see the easy cases/ the better reimbursable case load/generating more revenue for the practice/himself. Is like working for a spine surgeon who have you 4days in clinic while he operate 4days a week and dumping all the post-op complicated patients/ the pain patients and the failed back surgical pt for you to manage/deal it. By freeing the surgeon time so he can operate more, the surgeon generate more revenue. The same idea applies here. I've seen this kinds of attitude so many times in my years as a PA and it's very upsetting to say the least. We are not here to do all the work while they go out playing golf and vacationing with their children. Enough said!

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Guest Paula

It will be  a work in progress.  I work at a tribal clinic and we are also an FQHC.....so reimbursement is the same for both of us...at 100%.  However, I am asking for a meeting with the new health director and the MD to hash out what this really means for me and the MD.  We are in the midst of implementing our 2nd EMR starting to go live end of May.  It will be interesting and I expect stressful as we go from paper to EMR to brand new practice model all within a 2 week period.

 

If I end up seeing much more chronic complicated patients and it extends my days and end up getting dumped on by doing any of his lab f/u's , or all the WC's, pain patients, etc.  I will be asking for a huge raise when contract negotiation comes up in September.  I should have at least 3 months of the new schedule by then to be able to advocate for a raise.  My compensation now is really good and  I'm at the top of the scale for FP, much better than most others.

 

Plus I will be the sole provider on Fridays as that is the MD day off   (he consults elsewhere 2-3 days a month to sign off charts at another tribal clinic in a mental health department....big bucks for 1/2 day work...sweet deal.).

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^^ Then you could turn the table around to your advantage. A tribal clinic, an FQHC designated and being compensated at > 90 percentile for FP PA. I do not see why you would complain. I would learn to adapt to the new role.

 

If you're already at the top of the scale as you said, I wouldn't push it any further at next review/meeting. Instead, track your #s, bar chart or graph it and discuss your figure at your meeting. You could do a power point presentation on it. Use that figures/information as ground for asking for more steak, preferably, quarterly or annual bonus whatever works.

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Guest Paula

The NP who is retiring has agreed to come back prn for vacations,etc.  Otherwise each of us will be sole provider if she is unable to come in and the other on vacation.  This new system might be ok once it settles down.  Will be interesting.  I will attempt to track my numbers and hopefully our office manager has learned how to do that. 

 

I must say the new director has whipped this place into shape.  She is all about the bottom line but the clinic has been bleeding money for years because of lack of an administrator that knew anything about being profitable.  So in the end may be all good.  It's just that change is hard but I've decided to go with the flow.  Just need clarifications and still plan on a joint meeting.

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So he's gone and the walk in is closed, and you're gone and the fp office is closed? I'm sure if one of either of your longer term pt need to be seen acutely and the provider is away, the other can get them in to be seen? This system you describe can work, it just has to be air tight. What if's need to be answered before they happen (can't expect all the unexpected though, right?). Good luck! Keep us posted..

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Guest Paula

Actually the walk- in and FP clinic are one and the same.  It's just that patients can  walk in and get service.  When I do walk-in I treat my patients like FP patients and cover most of their issues. (the nurses hate that).  After all, it is weird to say "Follow Up with your PCP and schedule an appointment".  Oh, yeah, that's me!   Patients will walk in and say "I need my A1C checked".  Then the lab tech chases me or one of the others down for an order.   I tell the patient to stay for the results, discuss them, alter meds if needed and count it as their DM follow-up.

 

I draw the line for a walk-in pap test.  Now that I think of it I have done a walk-in pap. My motto..never waste an opportunity.

 

We have walk-in emergencies, too. This past winter we had a drag-in emergency.  One of our COPD patients got his oxygen tank cords tangled around his feet getting in his car...right next door to the clinic.  Hit his head, passed out.  Found unconscious in the snowbank next to his car. We literally dragged him in, warmed him up, hooked up the O2, no cpr needed, just knocked out.  He was quite blue and off he went to the ER.  Life is interesting on the rez to say the least.

 

We practice frontier medicine.  Never, ever a dull moment. 

 

Yes, we are a dysfunctional clinic.  Very small.  The tribal patients are entitled to come in and be seen whenever they want for whatever reason and we cannot turn them down.  

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Yes, we are a dysfunctional clinic.  Very small.  The tribal patients are entitled to come in and be seen whenever they want for whatever reason and we cannot turn them down.  

sounds like every ER in the country...working a slow shift today taking care of "emergent" finger strains, chronic pain, runny noses x 1 hr, etc.

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Guest Paula

Paula, do you soak your instruments in bourbon whiskey before usage? Sounds like Doc off "Gunsmoke". I know. I just lost 95% of the readers with that one.

 

Heck no, we drink it all day long!!!! 

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It looks like I'm in for a role reversal of sorts.  My clinic has 3 full-time providers and one is retiring end of May.  She will stay on to fill in for vacations, sick leave, etc.  Her position has been walk-in clinic and she is an NP.  When she leaves we are not hiring another full-time provider (we don't need one....I only had one patient today...).

 

The MD in the clinic is going to be the walk-in provider starting June 1st and will be selecting a few of his chronic patients and keep them on as a panel.  I will be doing ALL chronic care and will be considered THE primary care provider of the clinic.  The plan is for the MD to start talking to his patients and transferring the majority of his patients to me, plus from now forward I am the only one taking new patients. 

 

Currently I am a primary care provider plus fill-in for walk-ins.  The NP has all the walk-in patients follow up with me or the MD.  She sees a lot of coughs, colds, flu, UTIs, injuries, etc., med refills, orders some labs as appropriate as sees workman's comp.  Usually she would follow through on all of her own WC cases.

 

I am not sure how this will all pan out.  It seems like a role-reversal where the MD is not doing chronic care (except for a select few of his patients he wants to keep) and is seeing usually straightforward cases.  He will now manage all the emergency walk-ins too, which the NP and I usually have done. 

 

I already know which patients he will not want............and the select few he will keep (mostly his friends who he trades favors with....golf, scripts called in on weekends, treating them outside of work.....you know the score). 

 

Should I consider this a challenge or am I being dumped on?   It may not last and end up being a disaster as I can't see him doing walk-ins for a long period of time.

 

Currently I see scheduled patients, do H&Ps, well baby, well child, sports physicals, see lots of diabetes patients, do most of the pre-ops, ADD/ADHD patients, HTN, CKD, etc.  The whole gamut of care.  I dunno, maybe patients will now walk-in for a sports physical, well baby and child exams or his patients will just walk-in to see him. 

 

What do you all think?

 

make sure you get a HUUUUGE raise. if you are good enough to do what you describe, you are the one with the power in this negotiation. If the SP won't pony up, take your (excellent) experience elsewhere :)

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....boring & repetitive? I think every specialty of medicine is repetitive. I've worked in FM/IM and still do and I found it boring & chasing paperwork/filling forms/ lots of TLC (not to offend the FM folks. I currently work flexible PT as a primary care PA). I must say that primary care can be rewarding and there's a lot of folks that finds it a true calling. I will shot myself in the head if I was to go back doing strictly primary care again. Furthermore, a mixture of UC cases; the unschedule pts and not knowing what will walk in IMO makes primary care or IM more interesting especially in setting where there's XR, CT and lab on site. In the setting where the OP is referring to, it appears the SP/admin are dumping the more complicated cases/pt load, the less reimbursable cases on the OP, freeing up the SP time to see the easy cases/ the better reimbursable case load/generating more revenue for the practice/himself. Is like working for a spine surgeon who have you 4days in clinic while he operate 4days a week and dumping all the post-op complicated patients/ the pain patients and the failed back surgical pt for you to manage/deal it. By freeing the surgeon time so he can operate more, the surgeon generate more revenue. The same idea applies here. I've seen this kinds of attitude so many times in my years as a PA and it's very upsetting to say the least. We are not here to do all the work while they go out playing golf and vacationing with their children. Enough said!

 

I feel the same way. It's soured me on the profession as a whole. I experience it time and time again, how they get us on the cheap and then basically leave us working (unpaid) late hours doing all the work, and they take off for the beach or a weekend in london. or just leave to live a normal life. I have been fired for choosing to go home on time and not work for free. it sucks.

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