Febrifuge

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.

I have several really well tuned, carefully written patient info sheets that give the big picture and then go into detail about how no, green doesn't mean bacteria (myeloperoxidase is cool!) or that if you've been sick for a day and a half and you're draining thin clear stuff, you don't have a bacterial sinus infection. But I get good mileage just saying "I mean, the thing is, if I gave you antibiotics today, then you'd have this cold, plus diarrhea, and no real benefit to show for it." Similar approach for people who think they need a chest x-ray: "today's Thursday. You've been sick since Monday. I think you sound just fine, you don't have a fever, and your saturation is 100%. If you roar back into your usual good health over the weekend, we would have done an x-ray today for no good reason. If you feel worse next week and it seems like a good idea to get an x-ray then, I'd really feel better about ordering it if it's not your second one in 10 days, y'know?" People appreciate knowing that I have a thought process. I cheerfully acknowledge that I'm open to the idea I might be wrong, and in fact it seems to disarm them to find I'm not just some a-hole insisting I must be right. That's followed with the idea that dammit I'm advocating for your health, even if you're not getting what you think you wanted. I'm not going to cause you problems with side effects or unnecessary radiation because I was being a chicken about it. People get confused. They sometimes pause, like they know they're supposed to be upset, but they feel cared for and listened to. They seem to kind of admire the way I just denied them without making them feel dumb (because they also suddenly understand they were being dumb). It's a cool thing to see, when it comes together.

Family history is not a risk factor under the ACC guidelines. Neither is low socioeconomic status. Are you trying to study actual practice patterns, or how well people know and follow the evidence-based recommendations?

If you want to be blunt, think of it this way: somewhere out there is someone who graduated the same year as you, maybe even someone from your program, who is WAY more stupid and unprepared than you are. And yet, this hypothetical person isn't tying him- or herself in knots and questioning everything. He/she is sailing along, doing their best, learning as they go, and gradually getting better. The question is, do you want to give up, and let this chucklehead actually become smarter and better than you, or do you want to figure out how to proceed? The impostor syndrome is real, and nobody is perfectly able to identify where they're at on the Dunning-Kruger curve. The fact that you're worried is probably good, but worrying isn't all that helpful. Talk to a mentor, and if you don't have one, please get one. Get a bunch, if you can.

We do a fair proportion of phone visits- but those are to check in with our established patients. If the entire purpose of a visit is to have a conversation about "so how is the losartan/ citalopram/ metoprolol working out?" then making the patient take half a day off from work and deal with our parking ramp is not only not indicated, it's bordering on mean. If they have anything whatsoever that we might feel should be looked at, listened to, or palpated, then we have no hesitation about asking patients to come in for an office visit. But 15 minutes on the phone is often actually a better way to learn about how it's going, when the patient is relaxed and receptive.

Functionally, our group works as a team, and we all sign for each other. We also question one another and verify or clarify as needed. If I get a request to refill something and I don't like what I think I'm seeing, I am expected to ask about it, consult with whoever else is there that day, and decide what to do based on my own judgement. If I told one of the docs, even my SP of record, "I just signed it because I thought you would expect me to," they would look at me funny. I'm not an extender or an assistant; I'm one of the clinicians on this team.

I just wish people wouldn't be sent to us because someone read a PPD as "positive" when there was less than 10mm of redness and no induration whatsoever. A truly positive skin test can literally be read with your eyes closed, right?

Okay, but the question - and the thing you need to plan around - is what do you do with the people you don't approve? Are you going to allow for "determination pending" and re-visits within 45 days? If you don't have support staff and a facility to be part of, mind your logistics and prepare for the unlikely weird stuff, is my advice.

I am also gradually working on a way to talk about this stuff with patients. Lately there's been some progress using the analogy of lawn care and gardening. I had someone tell me they "never use chemicals" on their lawn, and then turn around and suggest that for taking care of some weeds we have in ours, we use white vinegar. I said LOL that's acetic acid, which is a chemical you chucklehead, and we laughed about it, the friend agreeing with me, but saying you know, there's a difference. And I think that's it: there are chemicals we think we know well, and feel okay about, and don't think of as "chemicals," and then there's everything else. It's about comfort. It's not about effectiveness. My friend also said to be careful not to get the white vinegar on any plants I don't want to see dead. Compare that to some of the organic chem nonsense in the appropriate aisle at Home Depot, with long weird names and the ability to kill broad-leaf plants but have no effect on grass. Not sure yet how to put it all together, but if the goal is educating and getting people to think, I find the indirect approach is often good.

Good point: my group defines full-time as 35 hours a week of scheduled patient visits. It's understood there can be about an hour a day of random charting, dealing with emails, paperwork, etc. Sometimes more, sometimes less, averaging out to 5 hours a week so a work week is really about 40 hours. We don't get scheduled for 40 hours in front of patients and then told to just deal with the rest.

You said it yourself: your issue isn't what anyone else has, or gets, or is doing. Your issue is you took it upon yourself to work harder out of the goodness of your heart, to build up the practice, and didn't think about it. That's great if you're a part-owner of the practice, or if you get bonuses based on the overall performance of the group. Otherwise, I guess you can enjoy the satisfaction of a job well-done, because you now seem to have a healthy practice that's able to hire more salaried employees, and smart ones too since they have advocated for schedules that work out for them. You really need to talk with HR, or the practice owner/s, or whoever, and you needed to do it a long time ago. Second best time to get this done is today.

I work for a salary, which is great because my earnings are not tied to RVUs, and I get paid the same if I don't order unnecessary tests or do unnecessary procedures. I get paid the same if I spend 10 minutes reassuring someone their cough isn't pneumonia or if I spend 35 minutes sympathizing and coming up with a plan to handle a new cancer diagnosis. However, this works because my clinic doesn't believe in seeing 4 patients per hour either.

In the Minneapolis area, $55 to $60 is about right, but that's with benefits.

In my old job, i qualified for benefits at about 16 hours a week. PTO accrued based on hours worked, so like electric above I didn't have as much as FT people, but I had more than enough. Malpractice, CME, all the rest was the same as anyone who qualified for benefits.