Unhappy in FM - advice appreciated

[hikerPA]

Hello,

I am looking for some advice about my current unhappiness in my FM position. I work at a large health care organization. I’m still a newish grad, having been in practice for a bit over a year. I see 20 patients/day in a family medicine clinic. My schedule is mainly same day appointments. I basically function as an urgent care provider in an FM setting. I get my fair share of URI’s, kids with a temp of “99F,” but a good deal are shortness of breath, injury requiring x-ray, dizzy, chest pain, acute abdominal pain patients. These patients are often poorly controlled with their chronic health issues, since they never see their PCP’s and can just make a same day appointment. So I am also addressing chronic health issues, htn, A1c, depression, along with whatever issues the patient wants to bring up. I do try to draw boundaries about how many issues can be addressed. A lot are interpreter visits as well. I am feeling very burnt out and exhausted, to say the least. I’m looking for a new position currently, and wondering if I should just leave FM or if straight urgent care would be a better fit. I feel like the expectations of this job are unreasonable, but I also feel like a failure in some ways as this is my first job out of school. I would appreciate your advice. 

Thank you!

HikerPA 

[marktheshark89]

Honestly 20 patients per day in family med isn’t unreasonable. 20 patients in an urgent care day is slow. It is definitely important to not try to solve 10 problems in a single visit though, thats an easy way to burn out and also not really do a good job on any problem because none receive the attention they need. For these urgent care visits with multiple chronic issues, treat anything life threatening and their major complaint, have them schedule an appointment with you to go over their other issues. If they won’t come in, that’s not your fault. Since interpreter visits take longer, have them give you longer timeslots for those visits if possible. 

[EMEDPA]

urgent care might be a better fit as it releases you from some of the responsibility of managing their primary care issues. you can just suture a laceration and write " discuss your blood pressure/depression/thyroid/etc with your pcp at your next visit.

[mgriffiths]

I would talk with your superiors about expectations.  I know several PAs who function in a similar fashion as you, but they are told very clearly they should not be spending any significant amounts of time on chronic issues.  They are basically an UC.  Now, they will start a BP or oral DM med in some cases, but otherwise the goal is to have that patient return for a true PCP appointment in 1-2 weeks.  This tends to be very lucrative, because the patient sees you and the hopeful result is that they becomes a regular patient of the clinic.  It is possible you are are doing more than your superiors would like, which could take some stress off of you.  I know that may be frustrating in that you want to help someone now, but I work FM and take same-days...I do not discuss chronic issues during same day appointments, unless it's something like they came in with dizziness or elevated BP and they have HTN.

[ALC0313]

Good advice above.

It's very common that your first job out of school is not a good long term fit. I think anyone could struggle with this set up, so don't feel like a failure if you decide to move on.

You should not be in a situation where you're already feeling burned out a year out of school.

 

[LT_Oneal_PAC]

My job can be similar to yours. Not quite as bad, except on the weekend coverage when my job is exactly this. Been doing it three years minus some deployments. 

Not a failure. This model sucks. 3 years in and I’m finally able to get out, but it literally blackened my soul a bit. Fixing everyone’s problems during acute visits sucks. Not doing it, for me, doesn’t make me feel any better because then I didn’t feel I gave full and appropriate care regardless if it’s the patient’s fault for not seeing their PCM.

[south]

I agree strongly with mgriffiths and the LT.  Get your (and your patients') expectations straightened out.  The problem may be your attitude.  Your heart is definitely in the right place and, by the way, I would be proud to be your co-worker or patient.  But you are trying to do too much and fit a square peg into a round hole.  

I wouldn't start looking around yet unless this goes very badly for some reason. 

[sas5814]

Practice this saying..." that is a long term problem and needs to be addressed with your primary care provider." We get people in UC every day that want us to manage their blood pressure, diabetes, long term pain problems etc. This is my polite way of saying " we don't do that here."

You have to politely set boundries and expectations. I worked in FP for years and years. The other thing I had to deal with was people that wanted all 15 of their problems fixed in 1 visit...usually to avoid another co-pay. I'd say "we only have time for 2 things at this visit so I'm going to choose the one I think is most important medically and you choose the one that is most important to you. The rest will have to be sorted out at another visit."

[PA-SGuy]

18 minutes ago, sas5814 said:

Practice this saying..." that is a long term problem and needs to be addressed with your primary care provider." We get people in UC every day that want us to manage their blood pressure, diabetes, long term pain problems etc. This is my polite way of saying " we don't do that here."

You have to politely set boundries and expectations. I worked in FP for years and years. The other thing I had to deal with was people that wanted all 15 of their problems fixed in 1 visit...usually to avoid another co-pay. I'd say "we only have time for 2 things at this visit so I'm going to choose the one I think is most important medically and you choose the one that is most important to you. The rest will have to be sorted out at another visit."

Another thing to add would be "we don't want to make too many changes today because then we won't know what worked" is a good line when they come in with their back pain, insomnia, diabetes and HTN all bothering them

[WeBuyAndSellJunk]

Easier said than done to set boundaries when you are not a stand alone urgent care. I agree, it will help, to set the expectation, but as someone said above this is a flawed system and you are an income generator for them. A place like this will likely put whatever on your schedule, acute or not, to simply fill in time slots. I’m a bit jaded at the moment though, my experience is a bit too much like yours.

[sas5814]

Setting boundries is done with the patient AND the clinic.Start with the patient. If the organization can't be fixed they have to be hoisted on their own petard.

My organization is a vast machine with most all of the decisions being made echelons above the actual clinics by people who have very little understanding of how they function. During the peak of cold and flu season we were just getting crushed. Admin didn't want to hear anything about the maximum number of patients we could each safely see so we collectively decided to hit them where they live...in patient satisfaction surveys and Press Ganey scores. We simply stopped killing ourselves and slowed down. Patient cycle times went from the expected 1 hour average to 3. Each of our 7 clinics had 10-15 people leave without being seen each day. We would often still be seeing patients (assuming they didn't leave) 2-3 hours after closing which put everyone in every clinic on OT. 2 providers quit and more threatened the same. You could hear the loud "POP" as their collective heads popped from their collective butts.

We finally set an general number of patients at 45 but provider discretion as to when you were too mentally fatigued to safely continue became the order of the day. Some days it might be 35 because you were on your 4th 12 hour shift. Some days you might be feeling good and go to 50 or more but they finally listened.

Several months ago we had a water main break and none of the bathrooms would flush so the clinic smelled like a Calcutta outhouse. I was told "vice president Important Ass says we never close the urgent cares" so everyone who came in and mentioned the smell...I gave them his name and office number and told them he made the decision not me. We closed shortly after until the water line was fixed.

If the organization can't or won't behave then your only real choice is to move on. This sad story is all too common these days when bean counters and administrators are making all the decision based on reports and graphs and haven't a clue what is actually happening on the ground.

[BruceBanner]

On 1/22/2018 at 9:01 PM, hikerPA said:

Hello,

I am looking for some advice about my current unhappiness in my FM position. I work at a large health care organization. I’m still a newish grad, having been in practice for a bit over a year. I see 20 patients/day in a family medicine clinic. My schedule is mainly same day appointments. I basically function as an urgent care provider in an FM setting. I get my fair share of URI’s, kids with a temp of “99F,” but a good deal are shortness of breath, injury requiring x-ray, dizzy, chest pain, acute abdominal pain patients. These patients are often poorly controlled with their chronic health issues, since they never see their PCP’s and can just make a same day appointment. So I am also addressing chronic health issues, htn, A1c, depression, along with whatever issues the patient wants to bring up. I do try to draw boundaries about how many issues can be addressed. A lot are interpreter visits as well. I am feeling very burnt out and exhausted, to say the least. I’m looking for a new position currently, and wondering if I should just leave FM or if straight urgent care would be a better fit. I feel like the expectations of this job are unreasonable, but I also feel like a failure in some ways as this is my first job out of school. I would appreciate your advice. 

Thank you!

HikerPA 

Been there, all of it. The great dumping grounds of medicine. And 20 ppd in this setting is near max if you ask me. 

Some people have a lower tolerance for this type of work and will burnout more quickly. I think most of it comes down to personality and the mitigating factors you have in your life to offset the suck.

From my experience I would suggest looking for an urgent care type gig where the expectation is you only manage the most acute problems. That's if you want to stay in the FM spectrum. Trying to change things from the "inside out" is good motivational talk but I think you'll end up banging your head against the wall, because the folks making administrative decisions are not the ones seeing patients and they really dont give a flying f*ck how you feel. It's all about access and production. The best you can do in the meantime is manage patient-level expectations, which will cut down on some of the workload. Avoid big workups if you can and pass complex disasters to docs if you can do so diplomatically. Try to work with your MAs to divert certain patients (PCP, specialty, ER, etc) if you can do so without getting noticed.

These are just survival tactics though, you gotta get out.

[sas5814]

I can't argue with your logic about changing organizations but if nobody tries how will anything get changed? You have to try and change the currency to one admin understands. I often ask them how much money they will make if nobody wants to work here for longer than 6 months? What is the cost of recruiting and training new staff? What is the liability of having providers and staff that are burned out and unhappy?We just had 2 of our most experienced PAs leave for jobs with better quality of life. What is that going to cost us?

It is a Sysiphean task (if I spelled that right) but Sancho.....there are windmills to be tilted at.

[camoman1234]

17 hours ago, printer2100 said:

Easier said than done to set boundries when you are not a stand alone urgent care. I agree, it will help, to set the expectation, but as someone said above this is a flawed system and you are an income generator for them. A place like this will likely put whatever on your schedule, acute or not, to simply fill in time slots. I’m a bit jaded at the moment though, my experience is a bit too much like yours.

Set boundaries with office manager/CP. 

[WeBuyAndSellJunk]

I agree, it is worth trying, especially if you are happy otherwise. I guess my concern is that depending on what this clinic looks like, even the office manager may not actually have much power from the standpoint of scheduling. My office manager can make some changes day to day, but scheduling overall is under different management, in a different building, and has different expectations/rules to follow. I have no control over my schedule and it hasn't mattered how much I have complained, offered recommendations, or changed my perspective/outlook. Again, I would encourage you to have the difficult conversations the individuals above recommend, but be ready to hit the road because my suspicion is you work in a place that is running on a tenuous, rail-thin budget and is being forced to use every work around at the expensive of any person they can in the clinic.

The one thing I will take away from my current position is the understanding that a lot of the people above me are given equally cruddy options to make the boat float. It is really a systemic problem/failure in this sort of practice (i.e. really sick, uninsured panels). 

[sas5814]

Yup...my department manager and medical director have exactly zero power. They are water bearers for senior admin. I take the perspective we are in this together and we rail against the machine when we can.

[SHU-CH]

A wise family doc that was my preceptor used to start every encounter with something along the lines of "What can I best help you with today?" If the patient had a laundry list he would smile, talk about a future visit for those other problems, and keep laser focused on today's issue. 

It got patients in and out and usually helped establish a pattern of being seen with some regularity instead of just crashing in when they had a problem. 

Corporate med will never view us as professionals. Once the MBAs took over we all became little cogs on a big wheel.

[AlteredBeast]

My first job was a nearly identical set up.  I only lasted a year.  My advice is to stay away from all walk in/storefront/urgent care+ family medicine combo /fast track/same day/whatever clinician abusing machines are out there.  I still have to deal with this type of nonsense occasionally now, it seems like 85-90% of patients would have been better off if they hadn't come in in the first place.  Catching the 10-15%(generous) of patients that actually need treatment wasn't/isn't enough to stave off burnout for me.  Some providers' tolerance for this stuff is much higher than mine however, to me I assume this is what purgatory is.

TLDR: find a new specialty.

[GetMeOuttaThisMess]

My first job was a nearly identical set up.  I only lasted a year.  My advice is to stay away from all walk in/storefront/urgent care+ family medicine combo /fast track/same day/whatever clinician abusing machines are out there.  I still have to deal with this type of nonsense occasionally now, it seems like 85-90% of patients would have been better off if they hadn't come in in the first place.  Catching the 10-15%(generous) of patients that actually need treatment wasn't/isn't enough to stave off burnout for me.  Some providers' tolerance for this stuff is much higher than mine however, to me I assume this is what purgatory is.
TLDR: find a new specialty.

Not all are bad. My gig is pretty simple since I’m the king of snot/cough.

[KMD16]

What was the agreement when u joined the practice? Where u sign up to see strictly walk-in same day visit? Do u work M-F?

If u sign up to see strictly same day..bad idea. Can u mix things up like M or T u sees same day & W-F seeing own pt panel.

PM if want. Very familiar w ur settings ( none English speaking/working in medically underserved area).