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Today was my first day in practice


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Seems surreal. I'm in FM. Very supportive SP. saw 10 patients in 4 hours which I thought was good given it was all so new and the room is not set-up yet and the clinic is not completely familiar. I think I should be able to see 15-20 in that time in a couple of weeks. So weird to go from student to actual PA. Excited and numb at once! haha

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Seems surreal. I'm in FM. Very supportive SP. saw 10 patients in 4 hours which I thought was good given it was all so new and the room is not set-up yet and the clinic is not completely familiar. I think I should be able to see 15-20 in that time in a couple of weeks. So weird to go from student to actual PA. Excited and numb at once! haha

 

CONGRATS!!!

 

Dang 15-20 q 4h? Are your pts low complexity? At my practice (FP/HIV) I see 20-25 a DAY 30 if they are mostly urgents (one problem or two max) but I will be useless after and my charting will be backed up.

 

What's your secret?

 

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Perhaps my goal is unreasonable but that's what my SP does and he thinks I can do the same. We shall see; only time will tell.

CONGRATS!!!

 

Dang 15-20 q 4h? Are your pts low complexity? At my practice (FP/HIV) I see 20-25 a DAY 30 if they are mostly urgents (one problem or two max) but I will be useless after and my charting will be backed up.

 

What's your secret?

 

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I think I should be able to see 15-20 in that time in a couple of weeks. So weird to go from student to actual PA. Excited and numb at once! haha

 

 

 

WHHHOOOOOAAAA

 

slow down

20 patients a day is what an established season's PA see's in FP

 

you should be doing 1/2 that in the first few months then slowly build to 20 by end of year 1 or 2

 

seeing this many patients as a new grad is just to much - you need to go slowly, learn, read, ask questions........ or you WILL miss things

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My thoughts exactly. That's 5/ hr, and no way is everyone getting your complete attention. Worse than that is you will shortchange your learning...it's unreasonable for your SP to expect you to keep pace with him as a new grad. In fact, it's unsafe and unwise too.

After many years I can see 5/hr at a pretty good clip if I don't have to write ridiculous notes. Throw a procedure or two in there--no dice. Of course I actually enjoy talking to my patients :)

 

WHHHOOOOOAAAA

 

slow down

20 patients a day is what an established season's PA see's in FP

 

you should be doing 1/2 that in the first few months then slowly build to 20 by end of year 1 or 2

 

seeing this many patients as a new grad is just to much - you need to go slowly, learn, read, ask questions........ or you WILL miss things

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As a student in FM I was regularly seeing 3 per hour and certainly didn't feel rushed and felt I was being thorough. I think 4 an hour is reasonable right now for the patient population I am dealing with. I'll speak to my SP about this again. I appreciate your concern, guys :)

 

overconfidence is dangerous to both you and your patients.

you have had numerous very experienced PA's saying 4 and inhour is too much

 

careful

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Indeed, I don't think I am overconfident. I have discussed this with my SP (who I worked with as a student for 4 months) and with several of my other former preceptors and professors and they all think this is appropriate. What am I missing here?

 

Perhaps we are talking about different patient populations and types of family practices. I have heard that FM in the USA is considered different from in Canada but I am not certain as to how.

 

 

 

I expressed to my SP that sometimes a patient comes in with a complaint and I am concerned of not doing a thorough job and he told me that is why we see them multiple times. Most of the patients I am seeing come in every week and the ones I see that don't are usually young healthy people coming-in for a periodic health exam.

 

Also, my SP is reviewing every patient with me before they leave so I am not letting any patients go without him coming in the room and hearing about them and seeing them.

 

He said he wants to train me the way he was trained in residency so that in a few years I can function with autonomy.

 

overconfidence is dangerous to both you and your patients.

you have had numerous very experienced PA's saying 4 and inhour is too much

 

careful

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Indeed, I don't think I am overconfident. I have discussed this with my SP (who I worked with as a student for 4 months) and with several of my other former preceptors and professors and they all think this is appropriate. What am I missing here?

 

Perhaps we are talking about different patient populations and types of family practices. I have heard that FM in the USA is considered different from in Canada but I am not certain as to how.

 

 

 

I expressed to my SP that sometimes a patient comes in with a complaint and I am concerned of not doing a thorough job and he told me that is why we see them multiple times. Most of the patients I am seeing come in every week and the ones I see that don't are usually young healthy people coming-in for a periodic health exam.

 

Also, my SP is reviewing every patient with me before they leave so I am not letting any patients go without him coming in the room and hearing about them and seeing them.

 

He said he wants to train me the way he was trained in residency so that in a few years I can function with autonomy.

 

I am Not trying to bash you so please take this as constructive (Along with my colleaues primadonna and ventana, I am sure) but in MY family practice and the ones I went through during Clinicals in PA school, my TYPICAL routine followups have 1 or 2 chief complaints and at least 2-3 comorbidities. In order to PROPERLY assess those chief problems AND the comorbidities and do a pertinent medical exam to cover said problems I would at least take 10-15 minutes and then chart which takes another 10-15 minutes (often I make small notes and then go back and finish it after hours) on my current EHR. so in actuality it takes at minimum 20 minutes and realistically 30 minutes to complete a ROUTINE FOLLOWUP visit in my practice. Again perhaps you have low complexity patients and perhaps in Canada, you aren't bound by the requirements of a SOAP note that we have in the US for billing, and CYA purposes and that can be where you guys make up the time I dunno... but for me to be able to see 5 pts/hr the soap will look like this:

 

S: HTN: Denies all, no other c/o.

O: Unremarkable.

A: HTN: well controlled

P: Cont. current regimen.

RTC 3 mos.

 

 

Then I would get fired....:;;D:

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You bet it makes a difference! Half the crap I chart is CYA and the other half is to justify payment.

If your pts truly come in every week or two, you probably CAN address one simple issue per visit.

This is almost never the case in my experience. At least half of my recent pts over 30 are obese, smokers, drink too much, possibly does other drugs, uneducated and unemployed, has unhealthy relationships, hypertensive, pre-diabetic, hyperlipidemic and depressed. And those are the easy ones.

Add 30 yr and poly pharmacy and you have a combo we call Southern Medicine 101 ;)

 

I do appreciate the advice guys. I will mention why you all have to say to my SP and see what he says. Charting I am soon while I see the patient. It is true that we don't have a lot of the medical-legal concerns that are in the USA from hat I understand. Maybe that does make a difference.
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Yah, if I see a pt like you describe I will often spend 30-60 minutes with him but I only see about once of those a month. Rare in this practice.

 

At least half of my recent pts over 30 are obese, smokers, drink too much, possibly does other drugs, uneducated and unemployed, has unhealthy relationships, hypertensive, pre-diabetic, hyperlipidemic and depressed. And those are the easy ones.

Add 30 yr and poly pharmacy and you have a combo we call Southern Medicine 101 ;)

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You bet it makes a difference! Half the crap I chart is CYA and the other half is to justify payment.

If your pts truly come in every week or two, you probably CAN address one simple issue per visit.

This is almost never the case in my experience. At least half of my recent pts over 30 are obese, smokers, drink too much, possibly does other drugs, uneducated and unemployed, has unhealthy relationships, hypertensive, pre-diabetic, hyperlipidemic and depressed. And those are the easy ones.

Add 30 yr and poly pharmacy and you have a combo we call Southern Medicine 101 ;)

 

Lol I suppose "Southern Medicine" is a lot like my "Oakland Medicine"

 

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Likely :)

I swear I never saw sick people in my cozy corner of Oregon...well, very few of them at least.

Doesn't help that I work in the heart of tobacco country!

(when I am at work...most of my time now is spent sitting in class and missing work. I did pick up a Saturday clinic job in Amish country/NW PA...generally healthier overall and lovely people but they smoke and drink too and don't immunize....)

Back on track though. Carry on, OP ;)

 

Lol I suppose "Southern Medicine" is a lot like my "Oakland Medicine"

 

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People come in that regularly? Does Canadian single-payer cover that?

 

The way I anticipate I'll have to do Family Medicine down here (I'm a recent grad looking for a job, so basing this on my rotations, which includes a potential job site), is address the DM, HTN, hyperlipidemia, obesity, smoking, WHILE ALSO trying to address the cc, which is usually a back strain or something musculoskeletal. The reason I can't focus on their chief complaint is because they haven't been in in over six months (maybe a year?), their sugar is totally out of wack, and their BP is 160/90. Also, they may or may not be taking their meds. And if they are taking it, maybe they are taking it wrong, not keeping track of their sugar etc. So all that has to be explained again. And they haven't had any preventive medicine in a long time. They are overdue on a pap, mammogram, colonoscopy etc. There's no way I could have them come back for any of this education or tinkering with meds, or scheduling, because they won't. Not only that, they only care about their back pain in that moment, and they are really hoping to walk away with a scrip for the pain. Returning again (and every week, wow!) is a bit of a hardship; they usually have co-pays, lost work etc.

This describes maybe 1/2 to 2/3 of the patients I saw at my potential future employer. And we are scheduled every 15 minutes, which the fairly newly minted doc & my potential future SP struggles to accomplish this (fortunately, many people don't show up, so his packed schedule is a bit more manageable). But there is NO way I'll see that many patients or even near it. In fact, I'll probably work with him more like I did in my rotations at least initially. And the EHR is a total nightmare--not intuitive at all...my potential future SP spends 2 hours after his 9 hours in clinic charting.

 

Canadian medicine sounds like a dream. Maybe I need to relocate!!

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People come in that regularly? Does Canadian single-payer cover that?

 

The way I anticipate I'll have to do Family Medicine down here (I'm a recent grad looking for a job, so basing this on my rotations, which includes a potential job site), is address the DM, HTN, hyperlipidemia, obesity, smoking, WHILE ALSO trying to address the cc, which is usually a back strain or something musculoskeletal. The reason I can't focus on their chief complaint is because they haven't been in in over six months (maybe a year?), their sugar is totally out of wack, and their BP is 160/90. Also, they may or may not be taking their meds. And if they are taking it, maybe they are taking it wrong, not keeping track of their sugar etc. So all that has to be explained again. And they haven't had any preventive medicine in a long time. They are overdue on a pap, mammogram, colonoscopy etc. There's no way I could have them come back for any of this education or tinkering with meds, or scheduling, because they won't. Not only that, they only care about their back pain in that moment, and they are really hoping to walk away with a scrip for the pain. Returning again (and every week, wow!) is a bit of a hardship; they usually have co-pays, lost work etc.

This describes maybe 1/2 to 2/3 of the patients I saw at my potential future employer. And we are scheduled every 15 minutes, which the fairly newly minted doc & my potential future SP struggles to accomplish this (fortunately, many people don't show up, so his packed schedule is a bit more manageable). But there is NO way I'll see that many patients or even near it. In fact, I'll probably work with him more like I did in my rotations at least initially. And the EHR is a total nightmare--not intuitive at all...my potential future SP spends 2 hours after his 9 hours in clinic charting.

 

Canadian medicine sounds like a dream. Maybe I need to relocate!!

 

I spend a minimum of 2 hours q day to chart. Last week I got so behind I knocked out 24 (!) Charts Sunday afternoon till midnight. Afterwards I was babbling about tachyphylaxis, integrase inhibitors and high genetic barriers until I crashed out on the bed in my street clothes and with no objection from wifey cuz she felt so bad for me....:o

 

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I spend a minimum of 2 hours q day to chart. Last week I got so behind I knocked out 24 (!) Charts Sunday afternoon till midnight. Afterwards I was babbling about tachyphylaxis, integrase inhibitors and high genetic barriers until I crashed out on the bed in my street clothes and with no objection from wifey cuz she felt so bad for me....:o

 

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You're scaring me, Joelseff. Is this what I have to look forward to?

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You're scaring me, Joelseff. Is this what I have to look forward to?

 

I used to think my days were atypical until I started comparing notes (and gripes) with PA and MD/DO colleagues and this seems to be "normal." You have to figure for a GOOD SOLID 99214 you need 4+ HPI/ROS/PFSH, 5-7 system exam, at least 3 DX with moderate complexity and 25 minutes minimum of time with the patient. For a 99213 you need 1-3HPI/ROS/PFSH, 2-4 system exam, up to 2 Low complexity DX, and 15 minute visits. My patient population consists of minorities in inner city Oakland with T2DM, HTN, Hyperlipidemia as a MINIMUM and then tack on HIV, HCV, Cirrhosis, CKD, Polyneuropathy, OA, etc. etc... you kinda get the picture I hope. This is typically what I go through everyday so I get several 99214s and a few 99213s-which I count as blessings even though the reimbursement is not as much, but at least i know I can knock out the Chart note in less than 10 minutes or so. Having said all that....I still L O V E my job!!!!:love:

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Congratulations on the position! How have the patients reacted to being seen by you? Have you worked out a brief "what a PA is" blurb for them yet? There is always talk on here of patients in the US not knowing anything about PAs, and it seems like that would be even more of a challenge in Canada.

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