Home Forums Discussions General Discussion Burned out. Need advice from everyone.

Hi everyone. All my friends.

I think never than ever before I need advice from my most trusted colleagues.

I have always been proud that in my five years of solo practice, we have never sent anyone who wanted an acute appointment to the emergency department. Never. I just can't seem to cross that line.

We see an average of 25 patients a day, and with the work that goes with them after hours along with the paperwork, I and my staff are becoming burned out. The summer is usually easy, but we had one easy week. Winter is upon us.

Does anyone have advice as to how to manage the schedule and still be there for your patients? If you do send patients to the ED due to no more slots, how do you do it? How do you not feel guilty. Currently, every day my staff asks, "We are full, where do we put the patients." Every day I say, "Just book them down." Some times they go to 7:30 pm.

I know the pat answer will be if I am not healthy I can't see the patients at all. But, that won't be of any solace to the parent that calls at 10 am, and we are already booked to 5:30 pm.

There is no easy answer here.
I have been in practice 18 years and this past year struggled with the same issue but in a different mode. The issue came up of having the hospitalists care for my inpatient needs, at first I was extremely resistant since I had dedicated 3 years of residency nearly exclusively geared toward inpatient medicine and felt I wss really good at it. But having a 9 year old and 11 year old at home becoming more involved with activities helped me make my decision as well. But I decided to go strictly outpatient only 8 months ago. I was rather suprised but my charges and income did not fall, in fact improved. I was able to start earlier and work later in the office. And looking back on things I realized that with aging, being 47, I wasn't handling the stress of managing everything as well as I did just 10 years ago.
Bottom line I had to let go of the notion I could manage a practice at the level I was without ramifications--It became all consuming. Do I still feel guilty not being there. Of course and that will never go away, but I have learned to narrow my responsibilities and focus just on what I can do as an outpatient internist, and let others take care of the needs I no longer provide.
I don't know what options are available in Brewer, but if there is any way you can start saying no and setting set hours and cutting off at 5pm so you and your staff can get away from the rat race, I would recommend it. It seems that the work will always be there and one can work oneself into oblivion and one of the hardest things I have learned is to say no.
I hope this doesn't sound condescending or simplistic, but sometimes the written word doesn't come out as intended.
I am rather new to this forum but you already have responded multiple times to my queries and have been quite helpful.
Hang in there. jimmie

jimmie,

Thanks a lot. Great advice. I had to go with hospitalists as well. As was the last hold out. I am glad now since I never have to drive five miles out of my way, search for a parking spot and argue with the staff there.

The only frustrating thing is when I don't agree with their care. I don't mean there are more ways to skin a cat type of care, but sending home a cellulitis too early or choosing the wrong antibiotic. But, that goes with the territory, I suppose. The other hard part is the admission that is unique like admitting an infant with a chronic ear infection for IV antibiotics.

But, it's the outpatient stuff I need advice on. I will gladly trade you my help for yours.

I will come back later with a more well-thought response, but do you think maybe you need a partner?

Bert,

How many staff do you have? We're also a solo general pediatric practice (12 yrs). Right now there's 3.5 staff, no nurses, do billing ourselves. But I think 4 fulltime would be more suitable. We see about 30 patients a day from 8:30 - 5:30. We hardly ever stay later than that, but the doctor is behind on finishing notes (she doesn't take the computer into the exam room, does all notes after the exam) and the billing is about 2 weeks behind. If patients call during business hours we never send them to the ED.

I got a lot of tips from the board to make all this work. I think she was seeing 20 patients before we started using AC. I had to research what steps are really necessary and cut out anything that used to be done before but is not really needed.

I think our doctor is tired but she really loves what she does and is willing to finish her work at home. Her kids are grown up, out of college now so she has more free time.

Serene

Thanks serene,

But, it doesn't sound like she has more free time if she is taking her work home with her. I could never see 35 per day especially without an MA.

I guess you hit the nail on the head. You never send same day calls to the ED. That's what we're struggling with.

Stop taking new patients, drop Mainecare (or whatever your Medicaid there is) and their patients and/or go to cash only. Stop taking low paying insurances (blame the insurance company rather than yourself for having to turn patients away). You would lose a lot of patients but the ones you keep are the ones you would want and need. They want and need you. And, come to Tahoe.

We did stop taking new patients today. The problem is that Mainecare is a double-edged sword. Can't live with them, can't live with them.

Say I have 60% Medicaid and 40% private or self pay, I will seen 25 patients in a day consisting of 15 Medicaid and 10 private. So, you can see where it would be 10 patients a day, which wouldn't pay the bills.

We try to keep our sanity by not overloading the schedule. We don?t accept walk ins, but we try to accommodate as many phone calls as possible. We keep a few slots open for same day appointments, especially on Mondays.

A lot of same day phone calls (internal medicine) are from pts who have been experiencing symptoms for more than a few days and, for whatever reason, they decide to be seen right away.
We screen these phone calls and for the non-urgent ones we give them the choice of being seen in the next day or two, as schedule permits, or go to the nearest ER, urgent care, if pt decides not to wait for the appointment given. I don?t think it is fair for me or patients to short their scheduled visit, or rush a previously scheduled physical to see someone who has had a cold or a GI upset for a week and demands to be seen the same day. We strive to make everyone happy, but can we?.

We have patients that come in right when we are about to close and demand to be seen for their "emergency". Rarely do we see those patients. If it's a true emergency we refer them to the ER.

We offer to schedule them appointments for the following day. If they insist on being seen, we tell them to go to the urgent care or ER. The usual response is "I have to sit and wait for 4 hours at the ER" and then they accept the appointment (must not really be an emergency)

We do our best to accomdate our patients but not to the point where we are having our staff stay late and pay overtime when the reimbursement from medi-caid or their insurance is so low. There are always exceptions but those are rare.

But Bert, of those 15 medicaid you would lose you would quickly make up for with additional private patients who love you because they can see you the same day they call. And your staff and you will live longer.

Bert,
I agree with Leslie on the Medicaid. We stopped taking our medicaid patients about 5 years ago and only take current patients with it. We limit how many new patients a day we take. Currently 2 in the AM and 2 in the PM. and we will limit it even more it necessary or stop taking new patients if it is a really busy time of year. We do physicals at certain times of day and these are generally booked out 6 to 8 weeks since it is routine this leaves us more room for f/up, acute and urgent appts. We do send patients to urgent care from time to time. We have spoiled our patients a lot and they have the mentality that we will get them in any time they call but unfortunately that can't always happen. We have been known to reschedule appts that can wait in order to get in the sick patients that need seen sooner. I would assume if the patients that are wanting the same day are truly that sick and can't wait a day then they probably should be at the ER or Urgent care. Most can wait from my experience.
We are not a solo practice so we have the luxury of having another provider see the patient if necessary. Have you every thought of adding a PA or ARNP to help out? Can start out Part-time and work up to full time until they have a full schedule.
One person cannot do it all. That is how we started over 21 years ago. I think you should review how your schedule is set up and see where you might be able to make some changes.

Best of luck.

Thanks Robynne,

It's ironic because we used to nearly dismiss someone for going to the ED especially during office hours.

We closed to Mainecare five months ago and closed today to private patients. I try to predict the schedule so six months before summer, open, then close at the end.

While it has been advised twice and could be a good idea, I would NEVER, EVER work with another provider again. Just personal reasons.

Bert,
We were in the same boat with the patients going to ER when the office was open. We were known to scold patients for doing it and misusing the ER but unfortunately the times have changed. We do our best to not send patients to ER but we can't see everybody and that is why urgent care and walk-in clinics exist today.

I understand the not wanting to work with another provider but don't forget you would be the boss and set things up the way you want them done. Having a ARNP would allow you to have a life and not burn out and be able to take time off once in awhile and still have someone in the office to see your patients and know income is still coming in when your not there.

There is no perfect solution for you unfortunately you have to give up some where in order to gain back your sanity for you and your office staff. I hope it all works out in the end.

It fascinates me that at the beginning of my practice I was frightened about "making it." Very quickly, it became an issue of controlling the monster.
One option, other than the ER, is to cultivate a relationship with a good local urgent care group who has later hours than you. Our problem was that the acute patient would show up at 3:30, need lab and x-ray that we could not get back for 3 hours, and we just are not set up to deal with that. Maybe we would be willing to be a martyr and have no life, but the rest of the staff wasn't. Absent that, the ER is the only realistic solution.
Closing your practice, even if temporary, does help. My inner rebellious "child of the 60's" does have some issues with selectively closing it to patients with poor coverage, but the older businessman part has learned to slap him down. Still, the kid slips through occasional M'care/caid patients for whom I seem to have something special to offer.
The final fact is, your patients are better off with 85% than 0% of you. 100% is not a realistic possibility, especially as you grow older.

Great ideas. I really don't want to name the insurance, and we see the most of anyone in the state, but it seems like the patients with the lowest reimbursement are the most demanding and need the most paperwork, PAs, etc.

I hope I have not offended anyone.

Bert,
What do you do when you go on vacation? What do your patients do then? Unless you bring in a locum, the patients realize they cannot see you... and they accept it.
I agree with Leslie, stop the Medicaid equivilant, if you want, create a quota (like one a month) and allow for a waiting list for new pts. We have a waiting list we open in January, close in February, to accomodate the slight slowing of the March/ April time frame. We open the waiting list in April, and close it at the end of June, to accomodate the summer months. Of course, IF we see that the schedule has a slot, we go back to that list, and offer that slot.
I have found that most will wait, and appreciate more that they are seeing an MD that has a wonderful reputation, with such a list.
You don't want a patient to treat you like a fast food "drive-thru" you are not a piece of meat the pt can have "done their way." You are the only one that can claim that. Its tough, and pts demands are non stop.

Maybe its time for a little flyer that outlines new policies for the office, outlining the schedule policies you choose, reminding the patient of your committment to their care, and that it can only be done one patient at a time; educating the staff on these rules, and always allowing for a breather for you somewhere so you can get caught up.( and check up on the gang here and bestow some of your much sought after advice).

You want to be able to hear the thank yous that come to you, rather than mumble under your breath that you are still at work when you could be at home, like the rest of the families that come to see you.
It is a right, not a luxury.

I have been in practice over 20 yrs, 10 of that solo. I get around the overbook problem by leaving plenty of open spaces in the schedule for same day appts. In the winter, we increase the number of spaces we leave open for same day scheduling. Most of the 3-6mos regulars book their appts ahead so the staff can achieve this. I have never taken Medicaid, so I cannot speak on that.
I do utilize the ER if I think that the pt will need stat labs/xrays/IV fluids. Plus, my area is saturated with UrgentCares so people are not forced to the ER after hours.

Bert,

We all have to deal with burnout at some point in our careers--I have faced it a couple of times.

I'm glad you can recognize the problem--that's half the battle. You've taken the most important step--not taking new patients. Like you, I feel an obligation to care for my patients. If I don't limit the numbers it quickly becomes a monster. I've been doing family practice for almost 30yrs either in a small group of three docs or solo--the last 10.

Besides limiting your number of patients, here's a couple of other suggestions: get to bed at a reasonable hour (sleep deprivation will create burnout in a hurry), get some exercise on a regular basis, de-caffeinate, be sure you're eating well, get a checkup if you're overdue, take some time off (vacation, etc), look at your total workload (not just seeing patients) and see if there's some non-essentials you can cut back to have more time to relax and recharge.

A few years ago I got really burned and had to really cut back. I took two afternoons a week and went up to St. Josephs's Abby and "stared at the wall" for a couple of hours. It took about 2 months to get back on track. Thank God I had a couple of partners who were willing to pick up the slack for me for a little while.

Don't sweat it if you have to lay low on ACUB for a while. There are 5000+ old posts of yours we can enjoy re-reading! :-)

One addition to make.... some years ago I had a medical issue that took me out of my solo office suddenly and for a couple of months. I came back, and found that nothing significant had changed, I wasn't deserted by my patients, and not bankrupt. Since then, I have not been nearly so concerned about being indispensable or totally available.

We have very similar practices. I take about the same ratio as you with medicaid and private. I have no problem with telling them to go to the ER after 2-3 PM. We will triage the problem because many of the "acute" problems are actually not that acute and can wait a day or two.

I have a NP and she is essential. Without her, I would probably burn out, and also would not be able to run 2 offices.

You need to take a break periodically. I head out from Chicago to Michigan about every other weekend in the the summer.

My after hours pages come to my cell phone. By agreement, I take 3 or 4 weeks of telephone but we trade up any time either of us is feeling tired of it. I can handle the phone easier than my NP.

I can have the hospital cover me any time I want, but I still take my own hospital. I have considered dropping it thought.

Next week I will be heading to Reno, you should too! It will make your mind more relaxed. You don't have to talk about AC if you do not want to.

Seriously no pressure, but the patients will do fine if you don't see them all the same day. Yes, you may disagree with the ER, so what! I explain to the patients all the time why their child did NOT have an ear infection I am seeing 3 days later. Not only an easy visit, but encourages them to stay out of the ER. There is enough business for everyone and you can't cover it all. Just set cut off times.

Oh Bert. You're right. Take care of yourself and your staff. You're killing yourselves and becoming bitter because of it. That doesn't help you or your patients.

I get a lot PCPs who call me and want to get a patient in the same day. I can do it sometimes and other times I can't but get them in the next office day. Why not triage a little better and tell the mom that you can get them in the next day if it's not super emergent (most are not or they really do need to go to the E.R.)

You're just going to have to set limits. Is it easy? No. We're self-sacrificing individuals. But your patients waiting an extra day will almost never harm them. Get them an appt in a day or two and tell them that if the patient gets worse, they are just going to have to go the E.R. unfortunately. There are so many hours in the day.

Thanks Travis. Thanks everyone.

Great advice, Wendell. Just where I was headed.

Another great post by John Howland. Thanks everyone. They have all been helpful. I hope I don't miss anyone.

Please come to Tahoe. You can sit on my porch with me and Martin . I'll even stock some Heineken for you.

In NYC we only get $30 or $35 for a medicaid patient regardless of the lenght or complexity of the visit. We never had many because I made Alice stop taking them. But if Mainecare compensates like they do here, thats $400/day in Medicare payments for 15 patients. If you can replace them with 5-7 commerical patients, it will lower your workload.

Bert,
You have to make rules and stick with them. You need time off and you have to control your work day the way you like it. Exercise is also good to deal with stress and burnout.
I have been in solo practice last four years, with group and one partner before which didn't work to well. I am open 4 days a week, no weekends or evenings. Schedule is usually about 25 with few open spots for emergencies. I use hospitalist and I do send my patients to ER if I have to, without office visit. I am not always very happy about hospitalist or ER work but I am not able to work 24/7 7 days a week. I don't accept any HMO plans. Even with this set up by the time I am done with my week I have enough work.
Bert, you have to slow down.

Lots of good advice above. I would add "Learn how to say NO".

Look at what is in your day that is non-income generating (Prior authorization forms, School forms, VA forms, Prescription refills (we now threaten to charge $25 per batch, we seldom actually charge patients, but since they were warned they try to get their needed refills at appointments). Try to reduce time that is uncompensated or under compensated. It's not that one is greedy and wants more $$$, we just want to get home to our families at a reasonable hour. By all means, shut off new patients for a while.

Good example, I had a potential new patient want to come in and "interview me" to see if would be an appropriate physician for him. I said... "No." That one word got me home 20 minutes earlier.

Yeah no vacation in over 7 1/2 years except for the one ACUC. Carry pager 24/7.

We also use a group that provides after hour telephone triage and backup. They can arrange for reasonable prescriptions... antibiotics for a clear UTI in a young woman for example.. or refer to the ER if it really sounds urgent. We even made them a user on AC so they can access charts via LogMeIn if they really need. That change in our practice plus hospitalists took care of nights and weekends. I am now 66 years old with no plans to quit. Any guess if I would still be doing this if I were still carrying a beeper? Yeah, no one else does it quite like I would, but my patients are still better off with most of me than with none of me, which was becoming the only option.

How can I use that group?

Google "Physician Triage Services". The one I use is operated by an MD friend out of Seattle, and as such has some greater leeway in prescribing, etc., plus I have known him for a long time and trust him totally. We previously used a nurse triage service that was quite good, but he is better. But google shows a lot of action and someone may be closer to you. We turn the phones over at 5:00 and weekends, and the patient gets a message that they can either leave a message for the next day or call an 800 number to discuss with a physician. There is a charge to the patient for that (Visa), sometimes waived. I'll PM you his e-mail address, and feel free to contact him. It is not a secret, just don't want to look like I'm advertising for him on this board.

Thanks David.

A simple set of questions to Bert. What takes up most of your work time? Also, what do you MOST dislike doing?

We don't say no. We say this takes up time that the doctor could be treating a sick person. So you will have to pay $40 or your copay, whichever is Higher, and she will grant you a 15 minute interview. Some actually do it.

You have got to get a break. Staff goes home on the weekends and hopefully puts the office behind them, you NEVER do.

I'm sure there is another doc who may cover for you, possibly in exchange for covering for them. Get some time, get a break, breathe.

What would you say if a parent came to you with a similar schedule?

@mkweiss

I hate seeing patients past 6 pm who then need to be researched or need a letter of medical necessity.

@Those who don't interview prospective patients.

In a town where private pediatric patients are treasured, 99% of those who wish to interview you or do a prenate have private insurance.

@Wendell

Completely correct.

I spent some time last night musing about the 25 years of the "old days" when I was taking my own call, taking care of inpatients on the floor and in ICU, having no life, and generally starting to feel I had made a terrible mistake in my choice of career. I can only reiterate that using an after hours service and letting the hospitalists run the hospital saved me. It was an adjustment.... sometimes I wonder if I am still a "real" doctor... but now I devote my energies to being the best outpatient physician I can be. I'm not tired, I have the energy to research questionable issues, I have the interest to listen to my patients and their problems, and I am pretty much over the need to feel that I can handle every possible aspect of care for everyone. I really like coming in to work, and I feel I do an honorable job better than I did before.

David,

I am pretty close behind you. The best thing I ever did was give up the hospital, although I really do miss it. I miss being the boss and I miss having the continuity of care. But being home by 6, rare after hours calls and free weekends has made medicine tolerable for me. I had to chuckle about your not feeling like a real doctor. My staff and I are constantly laughing about those days "when we were a real doctor's office", did a lot of ditzle surgery, did endoscopies, drew labs, knew the latest ACL protocols and got out of the office around 8 pm.
But, like you, I am working hard at being the best outpatient physician I can be and my patients do notice the difference. It took me a while to realize and longer to get over the fact that things will go along just find when I am out of the office. I have my patients and my staff pretty well-trained. My ego took a little longer to convince.