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  1. I use Dragon too. I have my dot phrases and the exam pops up on my screen. I made my own exams up to be how I usually dictate. I can plug in the ROS and exam with a quick command. I use it all the time for annual well exams and quick visits for UTI, URI, sinus, back pain.
  2. My employer will offer PHYSICIANs 20 hours a week and keep full benefits. Advanced Practice Clinicians must work no less than .9 to keep full benefits. I am working on getting clarification of what my costs would be for health insurance, if I still qualify for 401K, disability and other fringe benefits at 20-24 hours per week. We had our CME cut in half at the beginning of the year and if working part time less than 20 hours there is no CME. So much has changed that finding the information from my employer is nearly impossible as most managers were fired and it is all centralized to Kansas or someplace in outer space. I do not even know anymore who to ask and those who I do ask don't get back to me. I've been researching the difference in the SS at age 62 vs. 66yrs and 4 months. Not sure I can hang in there with my current employer till my full benefits kick in. I could with another employer (depending on who it is!!!! Jobs here are limited and so far NPs are starting to get preferentially hired). I've been a PA for 13 years and it's been great. It is a good profession and I hope it continues to survive and advance.
  3. I'm strongly considering my exit plan from full time PA profession and maybe the profession all together. I am 61. Several things have been starting to break the camel's back. 1. Spouse with progressive dementia at an early age (60) and the need to be more available to manage his needs. I have help coming in 2x a week and he attends a dementia day program 2 days a week, and I have one day a week off, plus weekends. I travel 27 miles one way to my job, easy commute. 2. My employer was recently taken over by a very large non-profit religious organization that has caused severe demoralization with all practitioners, staff and managers. Previously we were a very small non-profit religious organization that held to its founding values. The large one not so much. While I am a person of faith, I decry the double speak of "show justice, mercy, and compassion" to your patients by the daily emails we receive when the staff is treated like slaves. 3. Recent news that our state DHS regulations will now require co-sig for all orders from PA/NP for medicaid patients. This was a surprise to all parties involved and currently we are getting clarification on the regulation. If it is in fact true the rural practice I am in will not have enough physicians who are willing to co-sign every single order. Every order. One of our well respected IM physicians told me with our new EHR and management he does not have time or desire to collaborate with either profession. He is supportive of changing our state laws to collaboration and for all professions to be responsible for their own actions and medical care of patients. 4. My previous SP retired from full time family practice in February and transferred to a part time nursing home practice. Therefore, the new physician who is our department VP is my SP. Very nice person....but does not read EKG's which I just found out yesterday...... Traditionally I have read my own EKG's and am privileged to do so...BUT....my state law says I cannot practice outside of the SOP of the SP......it now begs the question.....can I still read my own EKG's and what else does she NOT do? I need to have the discussion with her. Our state is in the process of attempting to change the PA SOP laws to being determined at the practice level based on experience and credentialing. Only time will tell if we are successful. 5. Speaking of EHR's. We were forced to change to a new EHR. The hospital, clinic and ER now have 3 different EHR's which do not communicate with each other. I am exhausted trying to find the records of what was done at each section of our hospital (my clinic is located in a wing of the hospital campus) when my patients come in for follow up or for transitional care management. The greatest pitfall is medication reconciliation and none of the 3 EHRs can help me verify meds and patients do not know what to stop and what to start and they THINK I know what happened at their hospitalization. Nope, I didn't have a clue and I have no idea what medications they are on in actuality. The pharmacies are no help either. 6. I will turn 62 in August 2018 and am considering triggering social security and maybe working enough to have some income so I will be able to pay for health insurance for myself. My husband will be able to get on Medicare fully if I no longer carry the health insurance. 7. One decision I made this week is I will be taking a one year sabbatical from being a preceptor starting Oct 1st after my current PA student finishes the rotation with me that ends Sept 28th. 8. The good news: We have no debt and can live frugally and may consider selling our home and downsizing to a small 2 bedroom condo closer to one of our children who lives in a larger city . This would be so I can get more services for my husband and the medical services include many more options for specialist, etc. I love rural but as we age the needs for us are increasing and finding it in small communities is quite a challenge. 9. Mostly, my post is to just help me vent and to see my thoughts on the screen. It may help me clarify the next steps.
  4. My state will be advocating for MSL and FPR. We have a great lobbyist who has advised physicians and other stakeholders that the PAs are not satisfied with the status quo. We will be shaking up the physicians a bit.
  5. All turned out ok. The patient went to the Saturday clinic and no abscess, infection nicely clearing up. Plus I did not hang up the phone, the ortho surgeon did. In fact I was so shocked since I worked with this surgeon on a Quality Improvement committee in the past. That particular group has a history of not responding to calls from outlying clinics and have been discussed at the QI meetings, of which he is the chair. Ok, Ok, I will try to be more open minded and not prejudice a specialty. It's the person, not the specialty, gotta remember that!
  6. The ortho office closes at noon on Fridays. I failed to mention my CP was fully aware of my treatment plan. I will find out tomorrow if said patient went to the ED.
  7. I had a patient scheduled to be seen for follow up of a cat bite to her wrist. The pt. was hospitalized overnight due to the infection and to get IV abx. She was sent home on Augmentin. All good care. She had an ortho consult with Dr. X while in the hospital just to make sure there wasn't a hand infection starting. When I see her 24 hrs after discharge, she had a fever and increasing swelling at the puncture wound (on the dorm of the central wrist), with what looked like as abscess starting. So I'm concerned of a deeper infection starting. No knavel signs....but still the fever and pain and getting worse. So......I call the ortho who is on call. It is Friday afternoon about 2 pm. I go ahead and describe the issue, happened to mention the patient saw his fellow ortho colleague in the hospital. Right then the ortho on call stopped me from speaking and said... "I'm going to have you break protocol right now and have you call Dr. X who saw the patient . That way there is continuity of care. Dr. X is working at the outreach clinic 30 miles away. You can call him instead." Then he hung up. Of course, I could not for the life of me get a hold of Dr. X. Nope, he was done with his outreach clinic at noon, and who knows where he is...he is not on call....why would he answer any page???? In the end I just managed it on my own, gave the pt another dose of IV ABX in the clinic , arranged for follow up at Sat. clinic and told her if she got worse overnight to go immediately to the ER. Then I documented the crap out of my note to the detail that the ortho on call wouldn't take my call and the other ortho was nowhere to be found. I sure hope I don't get scorched on this one.....
  8. My current compensation is $100,969 per year guaranteed for 2 years, started February 2015. The contract states that when I exceed 50%ile then I have the option to convert to the base guarantee and then get paid per RVU above the 50%ile before the 2 years are up. I have exceeded the 50%ile per my last metrics I just received yesterday. The new compensation plan for PAs starting Jan 2016 is base guaranteed pay of $106,325, plus RVU bonus above 50%ile. BUT: the company is now saying that I will stay at the $100,969 base pay plus RVU since that was my contracted base pay and I do not qualify for the 2016 base pay, but I can still convert to the RVU bonus system whenever I am ready, since I exceed the 50%ile. The reason for the turn about is we are now completely acquired by the largest catholic organization in the US, and they are deciding to make all compensation plans organizational wide to be consistent. Other PA/NPs in the eastern regions/states make far less than us in rural midwestern states, and some, so I hear, are used as scribes (at least the NPs are scribes). I have started the conversation that I believe that my base pay should be $106,325 starting 2016. I have asked for equity and also to discuss with an administrator (who frankly I do not know at all as they have changed and my medical director just resigned due to severe medical reasons, and actually quit practicing all together). I just found this information out today. What is a good way to go about making my point and advocating for myself? An NP was hired at the same time that I was and she is in the same boat, although I do not know if she has hit 50%ile yet. She has already taken on a part-time administration position as a "fire -starter" (meaning that she counsels practitioners who are not producing to help them become efficient, etc, and is doing this in our region, so she is not seeing patients as much). I will not be speaking for her at all and plan on not mentioning her if I can get an audience with the compensation administrator. Will it help that I saved the life of a patient today and they were having an evolving MI while in the office, and I got them appropriately cared for, and off to the ER with their abnormal EKG and elevated troponin at 2400? (I doubt it will make a difference to physician administrators as , again, this new organization believes NPs have higher credentials than PAs). "facetiously penned". I will have an answer on Monday of who next to contact. I have all my metrics as does the administrator. We also have been asked to see 20% more patients and an NP was fired this week. So I should have no problem as I am getting this NPs patients loaded onto my schedule. Needless to say, the very supportive FP/IM physicians are just as upset about all of this as the PAs/NPs and we all feel hamstrung and are short providers. A new PA starts early December. But one physician and and NP both are semi-retiring to part-time January 2016. We are remote/rural/7,000 population city so recruiting has been dismal.
  9. I'll let you know how it all works out. So far, my MA is still with me. In fact, the organization is trying to make clinicians more productive so a few months ago they started a project to hire MORE MAs and RNs so we can all do shared visits. A clinician will have 2 support staff, one to room, document meds vitals, order tests needed, start immunizations and the other to scribe, educate, close the visit and follow up on any needs the patient has. The pilot starts as soon as the staff is hires and 3 physicians in my group are in the pilot. So, the organization future sizes at the same time they are up sizing. Doesn't make sense and I think they have no real strategic plan. Tomorrow I have the privilege on attending a 75 minute touchy feely session on "mapping". Not sure what that is but I know for sure it is not an airplane ticket to Costa Rica, which sounds like a great place to retire.
  10. Yesterday our region got a newsletter blast from one of the upper administrators. It talked about "Future Sizing" the organization and then proceeded to discuss the loss of revenue due to high deductible insurance and less patients seeking care, increased medicare and medicaid patients and falling reimbursements, cost of doing business is high..... Therefore the "Future Sizing" project of the system will be instituted by starting to "let go" employees starting October 19th and ending October 29th. 500 in the statewide regions are rumored to be pink-slipped and 100 in my particular region. I'm just waiting for some knucklehead to get the idea that PAs can room their own patients, etc. and my MA will be gone by the end of the week.........just saying....... I just hate politically correct speech....Future Sizing my A#$#$! I imagine some CEO is not going to get their bonus if the loss of revenue is not stopped. They asked for ideas on how to help the future sizing. I posted "Cut at the top"? I will probably be a target but I have my answer if anything comes back to bite me. Thus, posting as Incognito today.
  11. Update: I was offered a position with an Internal Medicine group with ability to take on some FP duties if the need arises. The clinic is part of a regional system and still in a rural area, closer to my home. I have given a tentative yes once I review their contract. The upside is I have the opportunity to leave my current position where I still do not have a renewed contract. I have been working at my current job for one month now without a contract. The new job is a decrease in pay....but they offer 401 plan, health, CME, 4 wk vacation a year, guaranteed salary for 2 years at $101,000 with ability to go off of guaranteed as soon as I meet the median criteria. I have talked privately to the other 2 PAs who work for this group and they tell me I should be off guaranteed in 6 months. One was at $130,00 within 6 months, and the other very experienced PA is above that up to $200,000. We have the ability to work flexible schedules with one day off a week. I like that. I will be walking into a ready-made practice as 2 physicians have retired and there is no one else who is taking a lot of new patients. I have the ability to set up my schedule template for how long I want to see patients, so can schedule 40 or 45 for new patients, 20 minutes for f/u visits, 15 minutes for "quick care" visits, etc. The collaborating physician and other physicians have said they do not hover over the PAs/NPs in the group and want us to work autonomously within our scope and experience. How do I leave my current employer when I have no contract and can't be unemployed for the 60-75 days it takes to get credentialed at the new palce? The contract is at the lawyers office for review of the parts I deleted that were unacceptable to me. I do not know how long it will take before I find out if they agree to the changes I want. The changes I requested is to extend the contract to 2 years, deleted the following clause: XXX clinic may terminate the Agreement immediately if such termination is in connection with two (2) or more, uncorrected substandard performance evaluations or issues. ( If you have read the whole thread I had one complaint that was brought up at my last negotiation session on 10/31/14 and the physician and clinic director struggled to name names of who else complained or even what the complaints were). I feel the termination clause sets me up for failure and it represents a hostile work environment. The last change was for a 60 day notice rather than a 90 day notice. Here are my thoughts: If they agree to my changes, sign the contract and once the higher ups have signed, give a 60 day notice. It gives me an opportunity to remain employed for 2 months, not lose my health insurance or benefits that are due me when I leave such as vacation time I have been unable to use and will roll over to the new year. It will also trigger my new vacation benefits of 4 weeks per year, which when I leave should be pro-rated and paid out. It might protect me from being walked out the door once I give notice. If they don't agree, not sign the contract. Ask to be changed to an hourly wage employee with current wage, benefits, health insurance and vacation. I would forego the CME pot of money and CME paid time off ( I think they would not let me have that benefit, also would not let me have the 4 weeks vacation). I would ask them to give me a one page signed agreement that I can work there until I find employment elsewhere. Once signed, give a 60 day notice (or less). My estimated time of starting at the new job is Mid-March. My current employer moves at a snails pace when making these decisions and if I did not send email reminders to the clinic director nothing will get done on a timely basis. Kind of tells me where I stand. Regardless, I am outta there mid-March. Just trying to preserve health insurance mostly for family members who are covered who have special needs and income for a few more month. I am primary earner in my family. Does this plan make sense?
  12. It takes at least 60 days to get credentialed by a new employer, sometimes longer. The paper work is enormous for credentialing. I will need to be credentialed in their whole system, plus CMS, insurance plans, etc. 60 days notice gives the old employer a chance to find a replacement and is standard for positions like this to give a longer notice. My unsigned contract says 90 days, but I am not beholden to any contract now. I do not want to burn bridges either. There is value in that and prevents anything from coming back to you years later.
  13. Update: After much discussion and trying to correct the situation without success I was able to interview at one position. It was a great interview and I have been informed I am one of the top candidates. I will know in a few weeks if I actually get an offer. If I do, I will take it. The physician who I collaborate with and I had another discussion today, civil, and he will absolutely give me a good reference. We have an agreement to let my current unsigned contract lay dormant until I know the outcome of the interview. I will give a 60 day notice, no hard feeling or ill will, and will continue to see patients until I secure a new job. If I am not offered the new position I will continue my job search and can stay at current place until I find appropriate employment. I really have the sense I will get the job offer as the Regional Medical director of the organization is a physician I worked with during my first job in 2004 and she has intimated I will get the offer. There are just 2 more interviewees left to screen. There are 2 positions open. There are opportunities for leadership positions, precepting, being involved in my own alma maters distance rural education program, and seems like there is great respect for PAs at the organization. I am hopeful!!!
  14. Interview is tomorrow. If I get offered a position and the salary is something I can live with, I'm outta here. Just found out the other contracted employees were offered 3 years and the CA and doc told me the council only wanted to offer one year to all contracted employees, so they are lying to me. I can only think it is their way of telling me I'm on probation without actually telling me that. Wish me well with the interview, I am nervous.
  15. Update: Negotiations resumed today after a few cancelations. Reviewed what we last hashed out. Dr. said I am an excellent clinician medically, technically, scientifically. The best he's worked with (He's worked with two NPs and now me). Then the shoe dropped....I was waiting for it as I knew it would drop from the outset. There is concern with bedside manner and some patients have complained. Who? I ask, I'd like to know. Well, um a few. um, um, who was that? DO you want a specific name the CA queries. YES! They outlined the person and ding ding ding.....I remembered the incident. I had full schedule, only practitioner there, walk-ins only and I was just finishing a patient visit, had another patient waiting for me in a room and the receptionist double booked me with this patient that walked in....wanted treatment for depression. I just couldn't do it.. I could not squeeze her in. I stepped in the room and said I couldn;t see her today, please make an appointment tomorrow. She stormed out of the room. I went on to the waiting patient who ended up being a train wreck who had a hgb of 5 or something like that and it consumed the rest of the day, BTW was already the end of the day. So, I could have said it more professional, not let the stress get to me, and should've walked her down to the behavioral health dept. But I didn't. She came back next day and sees the doc. He mentions NOTHING to me about this incident (2 months ago) until today. CA...incognito you are just not warm and fuzzzy. THe NP was warm and fuzzy and welcoming, the MD is gregarious and loud and people love him. I say...I cannot change my personality, just like you Doc, you can't change yours. I tell my patients the truth ( I am kind, actually, they are jumping to wrong conclusion from one event). Then the question/statement: We are a family here, it's a small clinic and we all have a good time together. Do you like being part of a family? My response: Huh? What do you mean? Sure I like being part of a family, even a dysfunctional one, like this family, I've learned to live within the dysfunction. Eyes were bugged out by then. Doc says 'I really want you here, you are an awesome clinician." We need you here. But staff is still saying you are hard to work with". WHAT? WHO? We hashed this out one month ago and I thought it was all settled. WHO? IS IT YOUR NURSE? (his eyes beadily narrowed so I know that's a yes). I have not refused to fulfill any requests she has had since we hammered out the issue. I stated that it is the nurse's problem and she is the one who is hard to work with, since I have bent backwards to be receptive to her when she brings it med refill requests the doc doesn't want to do or is not present to do. So I got offered a one year contract, same salary, same benefits, same CME and license fees. I'm way above the top salary for FP in rural clinic so I can live with that. My interview for the other opportunity is Nov. 6th. I'm definitely going to it. The oddest and (somewhat scary thing )is I kind of enjoyed the exchange in a macabre sort of way. After all when the whole staff dressed up for Halloween and I was looking at the CA who was dressed as a nerd with black glasses on with duck tape holding them together, plaid shirt and suspenders, and high water pants, and the doc sat there with his COWBOY outfit on and elephant skin cowboy boots and bandana....I could only think are they for real? I dressed up as a PA. Lab coat, nice set of scrubs. You know, my usual dress.
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