Febrifuge

I am constantly looking stuff up, right there in front of the patient. Have been doing so for 11 years of practice. We even have a big flatscreen LCD on the wall that shows my screen to the patient. It doesn’t make you look dumb. Excusing yourself every few minutes like Clark Kent on a college football Saturday looks weird, though. I just click the UpToDate link right there in Epic and say, “hey, so what you have is ____, and the last time I dealt with a case of this, it all turned out great. I just want to check real quick and make sure nobody changed a guideline, or did a study that changes the recommendations.” Then I scan for what I need, and say something like, “okay, it’s still Cipro plus Flagyl,” or “aha, see, when I went to school they were still saying you needed to finish 14 days of treatment, but 7 should be plenty,” or depending on the patient I could crack a joke, like “yeah, okay, former head of the American College of Endocrinology, if that’s your *opinion* then I guess we can go with that.” Mostly though, as a new grad you just need to read. Set aside half an hour after dinner 4 days a week, and read up on what you didn’t know that day. Don’t obsess, and don’t berate yourself, but build up your knowledge base because that builds your confidence. And you need both.

Our org is back in the mostly-okay range too, in terms of revenue and margin, so as of the paycheck coming end of the month, we will be back to 100% of salary, up from 70% during June-August. And apparently in January the plan is to pay us a lump to get back almost all of the rest. It’s nice to be in MN, where HMO’s legally need to put profit into patient care.

Mostly Allen Edmonds lately. The key is to never wear the same pair two days in a row. Primary care work means I rotate between about 4-6 pairs, if you count the dress boots. Being at home two days a week makes those slipper days unless I have to run errands later.

We rotate, and lately the 8-12 Saturday in clinic has morphed into 8-noon both days of the weekend, but from home doing phone and video. It’s similar to being on call, in a way. And yes, we get the time back. For me, that’s an 8-hour Monday I don’t have to do, those times when I’ve just done the weekend.

I’ve been mostly ordering Td, except I’ve also been finding that families with babies on the way often need pertussis boosters anyway so for the past year or so I’ve done TDaP when the patient is about to be, or is likely to be soon, a grandparent/ parent/ aunt or uncle.

Sounds like Professor Doctor needs to speak with someone in the legal department of his university. This is an employment law question, really.

You should have a patient message/ email template ready to go, with your own summaries of a few key points, and links to your state Dept of Health page and the CDC page. That helps when people have email, or when your EMR system has a patient portal. It can also be a little like a talking points summary for when you call people — get used to figuring out the best, clearest, most succinct way to deliver the key points. Wouldn’t hurt to have a letter version you can mail to the patient’s home, after the conversation. Specifically what kinds of concerns have you run across, that you need help with explaining? It’s a big subject.

Yeah, personally I consider the RVU system to be way too easy to abuse and manipulate, plus I feel like being salaried allows me to make better and more appropriate clinical decisions. But that’s a different discussion, for another time. Right now, my organization has had everyone salaried see a 30% pay cut. Meanwhile, the RVU-based clinicians are being paid 70% of whatever their average monthly collections were during 2019. And we’re pretty lucky, compared to some other health systems in our area .

Yeah, 70% of previous for us too, starting May 1 and due to be re-assessed at the end of August. To be fair, even with all the telehealth going on, volumes are down a bit and I am actually leaving on time more often lately.

Spam aside, it’s interesting to see this old thread come up. How is everyone feeling NOW about telemedicine? Me, I’ve had a few recently where it’s clearly not the best option, but for example this morning my patient either has biceps tendinitis or maybe some shoulder arthropathy. In the clinic, I could do some passive ROM maneuvers and feel for the crepitus or any clunking, sure. But video is good enough for checking some key active ROM and ruling out quite a few possibilities. And the plan is the plan regardless, at least for now. I rather doubt that we will ever get back to seeing 100% of these issues in the clinic, and there will be at least a few patients asking “can we just do this by video?” at least to start with. And I do believe I’m okay with that.

Yeah, I am not at all interested in leaving. When the world isn’t upside-down, this is the best team I’ve ever been part of. It’s just, nowhere is safe, y’know? It was naive to assume that being salaried would insulate us from the revenue/ RVU bullshit, but I had been hanging on to a little of that feeling.

I’m finding myself struggling with some unexpected, complicated emotions. Our group is nominally a not-for-profit, and we’re both a health system and a health insurance plan. The effect is that since revenue is way down, it sounds like we’re at serious risk. The CEO announced that she is (and presumably others in the C-suite are) taking a 40% pay cut. They announced that first. 15 minutes later, I learned that everyone in our division will be asked to take a 30% pay cut. Our MDs and PAs are salaried, so the math is easy. People elsewhere in our part of the org who are on RVUs will be paid at 70% of their 2019 average. This will be in place for 4 months, and then we’ll see. I mean, I guess it *sounds* fair, and it’s better than a lot of what I’m reading here. But, ouch. I spent a lot of years poor, and took out all the loans to change careers. I’m nearly as old as friends who have been practicing for twice as long. I never thought of myself as being obsessed with money, but not gonna lie, this sucks. Feels that the only choices are a) to go along with the idea that my labor is now worth less than it would be if the rest of the org were doing elective surgeries and over-ordering tests, or whatever, or b) accept that I’m being under-paid but there’s no option other than grin and bear it, or get furloughed with no idea of a return date.

I'm on Humira - when I had my cancer scare, I was taken off it, and within a few months I had one of my severe flares, the kind I've had just a few times in the 30-ish years since I was diagnosed, and in the 18 or so years I've been on biologics. So stopping is arguably my least favorite option. But my health system has done some re-organizing and planning, and I feel pretty well protected. Patients are assessed on the phone first, and in the past week or so we have done everything possible to move scheduled office visits over to phone visits. Visitors and patients entering the building are asked all the screening questions first. People with respiratory symptoms are directed to a specific subset of our Urgent Cares, for either scheduled or walk-in visits. People with no respiratory symptoms can use the rest of the UC locations. Last week on Monday, I saw 8 patients in the office plus 12 on the phone. Yesterday it was just one pre-op, for a surgery that can't be postponed, and the rest were phone. We still have the option of asking a patient to come in if there's something we need to assess in person, and if they have no respiratory symptoms, but even those are being treated as high-risk. I know there's debate and sometimes strong opinions about telemedicine, but right now is a good time to lean on your history-taking skills and clinical judgment. As a good Oslerian, I consider the physical exam a way to confirm what I think I know, or find out what I know I definitely don't know yet, based on the history. If something needs to be done in person, I have a process for getting it done. But yeah, in a situation where I was seeing undifferentiated patients, some of whom had obvious COVID-19 symptoms, hell no I wouldn't accept that without a lot of discussion and planning.

Some observations, point by points starting with your opening line: This really doesn’t seem like a general question. This seems very specific. 1. If you’re saying you are not familiar with how research about admissions criteria compared to academic performance is done, and you’re wondering how a program director can design and implement a study about which measures best predict student performance in an academic setting, there are qualified people who participate on these boards who can help break it down. But I don’t think you’re asking that. It sounds like you’re starting from the premise that something inappropriate is happening and you’re asking for validation of that. 2. This doesn’t sound to me like an ethics question. So I think the most constructive and useful way to go forward would be to ask you this: please describe what you see as the ethical problems, and why you consider them to be so, and then the group can weigh in on some specific questions. Thanks. Looking forward to a good discussion.

Show me someone who claims they never make mistakes, and I'll show you someone who is lousy at recognizing their own mistakes. The trick is to embrace your mistakes. There are few more effective or memorable lessons. Do what you can to make them small, make them correctable, and make them once each. I only worry about people who keep making the same kind of mistake repeatedly; that's a failure to learn, and that's less okay.