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2 yrs of family med and feeling totally burnt out and afraid I’ll always be overworked

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I’m a relatively new PA. I graduated a little over 2 yrs ago and I have been working in family med for about that long. I get 30 min per patent which I know is quite generous compared to a lot of places. A large percentage of my patients are 50 + and I hardly ever see children. I am always behind. Patients are always late to their appointments which really messes up the flow. I feel like the 30 minute time slots are usually enough time to see the patient and write my notes (except for combined Medicare annual wellness visits and “physicals.”) However, I don’t feel that I have enough time to review labs, documents, telephone encounters, or refill meds. I use templates and other things to get things done faster. Still I’ve been coming in early, working through lunch, staying late, working at home during the week and on the weekends. And it’s not just because I’m a slow new PA. The other PA and the MD I work with do the same. I like family medicine but I feel like I can’t sustain this. And now I’m feeling very nervous that this is just how medicine is and I picked the wrong career path. I like being a PA but I really just want to work a more reasonable number of hours. I am going to start looking for a new job soon. Any thoughts and advice would be greatly appreciated. 

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Family medicine can be like that.  The good news is that with two years under your belt you can branch out into other things that are higher pay, fewer patients, and, honestly, more fun (for whatever you value as "fun").  My first 2-3 years in family medicine were pretty grueling too, but I left that behind.  Once you've got Malcolm Gladwell's 10,000 hours under your belt, you'll have a much better idea of what to sweat and what to NOT sweat, and it sounds you're really well on your way there.

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Rev,  2 patients per hour???   How does it get better than that?  8 hour work day is 16 patients per day in FM.

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Family medicine can be like that, for sure. The patients per day can be deceiving. 16 ppd doesnt sound too bad but it's all about the complexity and back-end work involved. Not to say there arent good FM gigs out there, but you will probably only find them in small private practices. 

The most stressful job I ever had was in FM. And every doc/PA in that practice worked part-time to stay somewhat sane. 

Now that you have 2 years under your belt I'd suggest finding a new job. Some suggestions: College health (PM me if in Michigan), urgent care (be VERY careful, most are meat-grinders), Occupational health for a corporation or local government (not commercial occ health), maybe a non-surgical specialty. 

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A full day in 9 hours is 14-16

this is to be going over a 9 hour day

 

IM and FP can be tough - I think it is one of the hardest specialities

you are truly functioning as a doc, and that can be tough

 

 

don't forget you don't need to answer all questions in one visit, and honestly sometimes you don't answer any

defend you time, address what is in front of you

insurance companies pay to manage 1-2 problems a visit, that's it - don't do more

 

 

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14 hours ago, TWR said:

Rev,  2 patients per hour???   How does it get better than that?  8 hour work day is 16 patients per day in FM.

I'm doing about 1 per hour in eating disorders.  2 per hour in sleep medicine is a LOT easier than 2 per hour in family med, as well.  I see 2 per hour in family/occ med, and that's sometimes I can keep up with that, but rarely.

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I work in cardiology. Usually see between 18-20 pts per day in the OP setting. I come in an hour early to write short notes/labs/imaging info on each patient. Makes for a very efficient day (for me anyway) and I can usually stay relatively on time. 

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I work FQHC rural family medicine.

Family Medicine is taxing and there are a lot of demands on your time. Whilst I somewhat enjoy the respect that patients think of me as "their provider", I find it challenging when they really make the "THEIR" possessive. It sounds like you may be using ECW (you mentioned "telephone encounters" which is why I wonder) which is not the most user friendly. Continue to use templates, avoid using the telephone encounters feature for extensive back-and-forth conversations with patients ("Ms. Smith, your cholesterol is mildly elevated and I would love to discuss a plan on how to address this further at a follow up appointment. See this link I've included for further information." or "Your labs came back NORMAL" or "Your iron level is improving. I want you to continue your supplement at the same dose for 2 more weeks and then return for a follow up appt.") Dont engage with them on "Hey doc, I got this sore throat....blah blah blah...paragraph...oh and i need refills...and about that pet letter......and unrelated nonsense etc." Keep it simple. If its not, encourage them to schedule an appt. We dont get the luxury of billing by the hour for every second that a patient uses of our time. So dont give away your time for free, as much as you reasonably can avoid it. 

-Dont worry about every little detail. Yes, details are important, but if you get lost in the weeds on every single thing, you'll lose sight of the big picture and lose your sanity with it. Your patients are (hopefully for the most part) fully functioning adults and can take care of things themselves. Just because they waited until TODAY to ask for a refill of their med that they let run out, doesnt make it immediately your emergency and ergo your immediate stressor. (I mean, please fill peoples insulin and practice good medicine) But what I mean is, work with your patients and change your prescribing habits to improve this workflow if you havent already. If a pt is doing well and stable on Lisinopril 40mg daily, just send a year's worth of it to their pharmacy. Dont short change them on their chronic stable meds. Then you dont get a refill request every 1-3 months. Encourage the patient to contact their pharmacy FIRST to generate the refill request. That way they dont come in thru phone messages, letters, and telephone encounters. In general, at least where I work, the system tends to be more efficient that way because the refill requests come thru official channels and into me e-refill tab on the EHR.

-Family med is a broad area of practice. Can you find something in it that you enjoy that your employer will support that you can focus on.? That may help keep you interested and engaged. For instance, I like procedures but hate OB. There are only 2 FT providers at the clinic. To keep us both happy (the MD loves OB) and to keep us both proficient in each area, she does all the OB and I am the procedurist who does most of the suturing, the joint injections, trigger point injections, casting, etc.

-Pre-chart. Not too much, but a 1-2 liner on the patient's chart for the day can help keep you on task. Its a benefit to scheduled vs. walk in patients. If you know that your 10:00 is a follow up visit on iron repletion...."26yoF w/ ongoing iron repletion in the setting of menorrhagia. Currently undergoing workup for uterine fibroids as an underlying cause. US scheduled Tues. Prior Hgb 1 week ago was 9.0." Of note, need to discuss OCPs today." If your EHR has a "Pre-planning" section like our ECW does, put it there. That way, when you open their chart you know exactly whats going on for that visit and this REALLY helps when you are running behind. Make sure to update anything you type and to remove it if the pt no-shows (unless if automatically deletes) Try not to pre-chart too much as it can bite you in the butt.

-I felt very similar to you when I started. I still show up and preview/pre-chart pts for 20 min in the AM and work thru my lunch. BUT, when I am done with my last pt., I spend 10-20 min finishing up loose ends (half the time I spend ZERO time) and then I'm out. I dont work from home at night or on weekends or on PTO. I truly credit my previewing of pts the day before/morning of and pre-charting 1-2 liners as reminders for this.

-That all being said (and I probably just rambled on and on due to too much coffee late at night).... I am just finishing 2 years in family medicine and am on the hunt for a different position in a different specialty. Ive cherished all the benefits to family medicine and the broad knowledge base that it has laid down for me during my first 2 years of practice, but I want to branch out to something different.

 

Feel free to PM me to chat further.

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4 hours ago, bike mike said:

I work in cardiology. Usually see between 18-20 pts per day in the OP setting. I come in an hour early to write short notes/labs/imaging info on each patient. Makes for a very efficient day (for me anyway) and I can usually stay relatively on time. 

I love the diversity of family medicine, but when I've tried to do that, I've found as much as 25% of my schedule will totally change--cancellations, work-ins, same-days--and I gave up.

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On 1/3/2020 at 9:09 AM, Mayamom said:

Have you talked to your SP About this?  Might be a place to start.

Yes I did. I was basically told that that's just how it is. My SP comes in early, works through lunch, stays late, works on the weekend. For some reason she thinks it is sustainable. I do not. 

On 1/4/2020 at 8:42 PM, Colorado said:

I work FQHC rural family medicine.

Family Medicine is taxing and there are a lot of demands on your time. Whilst I somewhat enjoy the respect that patients think of me as "their provider", I find it challenging when they really make the "THEIR" possessive. It sounds like you may be using ECW (you mentioned "telephone encounters" which is why I wonder) which is not the most user friendly. Continue to use templates, avoid using the telephone encounters feature for extensive back-and-forth conversations with patients ("Ms. Smith, your cholesterol is mildly elevated and I would love to discuss a plan on how to address this further at a follow up appointment. See this link I've included for further information." or "Your labs came back NORMAL" or "Your iron level is improving. I want you to continue your supplement at the same dose for 2 more weeks and then return for a follow up appt.") Dont engage with them on "Hey doc, I got this sore throat....blah blah blah...paragraph...oh and i need refills...and about that pet letter......and unrelated nonsense etc." Keep it simple. If its not, encourage them to schedule an appt. We dont get the luxury of billing by the hour for every second that a patient uses of our time. So dont give away your time for free, as much as you reasonably can avoid it. 

-Dont worry about every little detail. Yes, details are important, but if you get lost in the weeds on every single thing, you'll lose sight of the big picture and lose your sanity with it. Your patients are (hopefully for the most part) fully functioning adults and can take care of things themselves. Just because they waited until TODAY to ask for a refill of their med that they let run out, doesnt make it immediately your emergency and ergo your immediate stressor. (I mean, please fill peoples insulin and practice good medicine) But what I mean is, work with your patients and change your prescribing habits to improve this workflow if you havent already. If a pt is doing well and stable on Lisinopril 40mg daily, just send a year's worth of it to their pharmacy. Dont short change them on their chronic stable meds. Then you dont get a refill request every 1-3 months. Encourage the patient to contact their pharmacy FIRST to generate the refill request. That way they dont come in thru phone messages, letters, and telephone encounters. In general, at least where I work, the system tends to be more efficient that way because the refill requests come thru official channels and into me e-refill tab on the EHR.

-Family med is a broad area of practice. Can you find something in it that you enjoy that your employer will support that you can focus on.? That may help keep you interested and engaged. For instance, I like procedures but hate OB. There are only 2 FT providers at the clinic. To keep us both happy (the MD loves OB) and to keep us both proficient in each area, she does all the OB and I am the procedurist who does most of the suturing, the joint injections, trigger point injections, casting, etc.

-Pre-chart. Not too much, but a 1-2 liner on the patient's chart for the day can help keep you on task. Its a benefit to scheduled vs. walk in patients. If you know that your 10:00 is a follow up visit on iron repletion...."26yoF w/ ongoing iron repletion in the setting of menorrhagia. Currently undergoing workup for uterine fibroids as an underlying cause. US scheduled Tues. Prior Hgb 1 week ago was 9.0." Of note, need to discuss OCPs today." If your EHR has a "Pre-planning" section like our ECW does, put it there. That way, when you open their chart you know exactly whats going on for that visit and this REALLY helps when you are running behind. Make sure to update anything you type and to remove it if the pt no-shows (unless if automatically deletes) Try not to pre-chart too much as it can bite you in the butt.

-I felt very similar to you when I started. I still show up and preview/pre-chart pts for 20 min in the AM and work thru my lunch. BUT, when I am done with my last pt., I spend 10-20 min finishing up loose ends (half the time I spend ZERO time) and then I'm out. I dont work from home at night or on weekends or on PTO. I truly credit my previewing of pts the day before/morning of and pre-charting 1-2 liners as reminders for this.

-That all being said (and I probably just rambled on and on due to too much coffee late at night).... I am just finishing 2 years in family medicine and am on the hunt for a different position in a different specialty. Ive cherished all the benefits to family medicine and the broad knowledge base that it has laid down for me during my first 2 years of practice, but I want to branch out to something different.

 

Feel free to PM me to chat further.

Thank you for sharing your experience. We do have ECW at my clinic. I feel like there is a lot of clicking and closing and reopening windows. Things can take a lot of time. Even with my templates I feel like I can't fly through a note because I have to open and click on so many different things. I prechart as well and I do think it really helps me. I think my biggest downfall is that I struggle to chart in the room during certain visits. I can do so pretty easily when I'm doing something like a physical or a URI, but in other situations I find it pretty difficulty. For example, I recently saw a pt. who I thought was going to be just a simple URI, but actually he had been vomiting, fainted, went to the ER, was dx w/ vasovagal syncope, and is no longer vomiting, but now has bronchitis. It was challenging to sort through that whole story and while I'm in the room I can basically just write bullet points that make sense to me, but wouldn't really make sense if I didn't go back and reorganize things. I get stressed out by being responsible for every problem. In family medicine I cannot ignore anything. I also feel stressed by sticking to a schedule when patients are late, my MAs are slow to room, etc. Also sometimes crazy things happen and I feel like the whole day gets thrown off. Today my laptop stopped working and I couldn't print a patient's labs and I got behind. I regularly get 90 page documents and I feel like I can't just skim through them. I recently found out a patient had a fistula which needed to be repaired and it would have been missed if I didn't read his records because the ordering physician missed it. I think I am also rambling at this point. Bottom line is I'm burnt out. I'm hoping I can find something better, but I'm not sure what that would be. I've been thinking maybe inpatient work would be better. 

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Sure have been a lot of these posts lately.

 

Not sure what the answer is but more likely it's many answers and not just one.  The standard of perfection in this country for providers is as unpractical as it is unreasonable and it's quite literally killing us with stress.  Honestly, providers I know are some of the most unhealthy people I have met.  They have little time to take care of themselves and when they do get the rare few PTO days, it's almost impossible to really get away.  We are all still attached to our practices with a digital umbilical cord.  Gawd I miss the days of no cell phones.

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Sorry to hear your SP was not helpful/supportive.  I guess its time to try something new.  Maybe a 4 day work week would

help.  IDK.  I left clinical practice in August & hopefully will never have to return. 

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2 hours ago, Mayamom said:

Sorry to hear your SP was not helpful/supportive.  I guess its time to try something new.  Maybe a 4 day work week would

help.  IDK.  I left clinical practice in August & hopefully will never have to return. 

retire or change professions?

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OP, consider 4 day weeks if your employer would entertain the idea . I work 3 regular days and one long day in which I staff our extended hours clinic from 5-8pm with one ma and one front desk staff member. Not only is it extending access to care to patients who otherwise may not be able to come to clinic during normal business hours, but you’ll be getting all your required weekly hours in and make it more reasonable to the employer that they allow you to only be in clinic 4 days a week. Just a thought. 
 

since you stated you were a newer PA and unless your family or NHSC paid for your education.... I’m going to go out in a limb and assume you don’t have the financial luxury to retire or quit the profession entirely . If you have the student loan debt that most newer pas have, you’re in our boat where our work as PAs pays better than almost any alternative that we are qualified for without extra education (more expenses) and are more or less forced to put up with the crappier positions in order to pay that debt.

if you feel like you have to get out, look for other non clinical jobs you can use your background with. Research, public health. There’s a job near me paying PAs to assist with stem cell research for $75/hour .

you could go on an income plan for repayment allowing you to work a lower paying non pa job and afford payments. You’ll pay on those loans for twice as long.

 Good luck! 
 

sorry to be so verbose guys.... too much coffee.

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The PA profession offers you the opportunity to re-start in any specialty, usually by joining a hospital staff. There are so many needs out there at the moment such as geriatrics, nephrology, cardiology, rheumatology, and the list goes on. By 2030 there will be 157,000 less care givers in geriatrics nationwide . Lateral movement is far better than throwing away your education and experience.

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On 1/4/2020 at 8:42 PM, rev ronin said:

I love the diversity of family medicine, but when I've tried to do that, I've found as much as 25% of my schedule will totally change--cancellations, work-ins, same-days--and I gave up.

Yup. Tried the same. I would come in review the chart so if it’s a chronic thing I’m seeing then I’m quick on the ball, but I found a lot of wasted time trying to do anything other than a quick review.

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