Home Forums Discussions General Discussion Three subjects to stop my burnout

To everyone:

The amount of help for me and suggestions was overwhelming. This board truly is a family to me, even if I can be quite the [censored]....at times. I apologize.

I have three major issues I would like feedback on, and I didn't want to have three different threads.

1. I have thought of hiring a NP/PA for Wednesdays only with Well child care obviously not on those days. I would, of course, still see them. The mid-level would see only acutes that day. Given I see 25 (18 minus the wcc that would be slotted elsewhere, would her/he (hereinout called her) bring in enough revenue to make it doable? It would allow me to take two vacations per year and maybe allow some paper-free nights.

2. As I make my new schedule,I am thinking that any calls after 2:30 pm get seen if there are slots. If not, we would offer slots the next day if they could wait (anything can for the most part), but if not they can go to the ED. I have NEVER done this, and find it bad medicine.

3. I have dismissed patients for acts such as being rude to my patients or a one-time egregious event. But, there was a person on here who stated he didn't put up with problem patients, because they were simply a pain all the time and made everyone miserable. What is the general concensus on patients who are always hard on us and we dread getting phone calls from them. They call at 9 am and we tell them we will get back to them about the Zantac, and they call three more times. Or my favorite, I set up an MRI for the following day, but the mother stayed outside the ED until she got the MRI that night, which, of course, was negative.

1. I think it would be tough to find a PA/NP for a single day and make it doable economically. I know very few pediatric offices with part time NP/PAs. Hell, in our are 2 PAs cover 8 orthopedic surgeons.

I promise you this Bert. You can still take 2 vacations per year. You send a letter to your patients or simply put a posting on your wall that you will be out these dates. You close the doors and you open them when your back. You tell patients that any emergencies can be seen in the E.R., urgencies in an urgent care clinic, or they may try to get in with another local doc if non-emergent. Patients HAVE to realize that you can't be there 24/7/365 without getting burned out. Just take the damn vacations or you're going to die an old and bitter man.

2. It is not bad medicine to tell a non-emergent patient you can see them the next day. It's bad PARENTING when the crazy [censored] momma thinks they have to be seen today and takes them to the E.R. Telling a truly emergent patient (asthma exacerbation, trauma/fracture, etc) to go to the E.R. is GOOD medicine. I say any calls after 12:00pm go to the next day. If a parent doesn't realize their kid is sick until 2:30pm, then it can wait. Quit torturing yourself about this one. I promise you I'm right on this. You're being to sacrificial.

3. That MRI patient is fired from my care. This person has no clue what pre-certifying an MRI entails, the time it takes, and the fact that waiting one day would not make a bit of difference. Apparently they don't trust your judgement and should seek care elsewhere. Time to start being a bit of an [censored] Bert. Parents/patients who call numerous times in a short time are sternly warned by my office that we will take care of it and if they call again, risk having to see another doctor. We tell them we have 3,000 patients in ours system and we take care of each the same. Abusing the office staff because they are readily available and "nice" is not accepted.

These people are not only using and abusing you, they are torturing your staff. Quit letting that happen. It's your responsibility to take care of your employees.

As always, I am pleased to jump in with an opinion.

1) We have two full time PA's for two MD's. They more than carry their own weight financially. This seems to be the experience nationwide. I would think in Peds they might be even more useful with well kid checks and minor acute problems. In our practice, the PA's have developed their own patient following, and they see most of our walk-ins and occupational exams. Different practice profile for Peds vs. IM, but still a plus.

2) Having a PA may help loosen this up a bit, but lab/x-ray is always going to be the hangup. We can get a plain film and CBC result back within half an hour, but there is always going to have to be a cutoff time. Make yours realistic so that you can plan to get out the door on time almost without exception (else why have gone electronic in the first place?)

3) I am almost certainly "that person" you refer to above. There are degrees of annoyance which start to get in the way of my providing care. Some patients are just plain oligophrenic, and we put up with a lot from them, considering them a challenge. But then there is the lawyer whom we sent to collections for a $300 bill, wants three prescription extentions for his thyroid because he is "too busy" to get a TSH, and is demanding things be done to his schedule. I am sufficiently annoyed that if his behavior does not change after a chat, he will be asked to go elsewhere. In short, there are people who are dumb but trying their best, and people who are rude, entitled and just plain willfully bad. I have an obligation to the former, but not the latter IMHO.

Why would you still see them if the NP has done that, it would be OK initially so you are comfortable with their level of care, but afterword, just review the chart.

I somewhat agree with Travis, can you find someone that part time. Another issue is are you going to have them to WCC or sick visits. They are often more appropriate for WCC since sick can run the gamut. That depends on the midlevel. As to money... See what medicaid pays. Often private only pays half but if you sign off on the notes they can be billed under you. Typically a midlevel will work at about 1/2 to 2/3 your efficiency. My NP is scheduled 3 patient an hour.


That would be fine, some of it depends on the schedule. Maybe you walk in 1 patient an hour. It is NOT bad medicine not to see a NON urgent patient the same day. It is bad care for the parent to wait until 1430 for a problem that has been going on for days. There is a legitimate reason for ER's but they can be abused.
ONe of the differences in Peds is that many of out PARENTS are very immature themselves. Many do not understand that their behavior is rude. This is multiplied in medicaid patients because they often do not have education or are from disadvantaged situations. Some of our parents are just pushy. We tend to try to ignore them unless they are just unreasonable. At that time we tell them to find another provider. Where the line of "unreasonable-ness" is has to be determined on an individual basis. ONE thing though is that parents ALWAYS act better with us than with our staff. We do need to both take that into account and treat accordingly.

I think finding a PA/NP for one day a week would be difficult. How could you truly access whether they really "fit" into your practice only working one day a week.

Obviously I am pro PA. I think hiring a PA/NP would help your practice. You could "squeeze in" those sick visits easier, take some time off and enjoy a vacation now and then.

Have you ever hired a PA or NP?

>3. I have dismissed patients for acts such as being rude to my patients or a one-time egregious event.

Good advice by Wendell. I think the three strikes you are out rule is a good one. We keep track of bad behavior and after the 3rd time they get a discharge letter. Their behavior has to be really bad. We realize that many times when patients are sick they are in a bad mood and we put up with a LOT. If you dont standup to your ugly patients, your staff will eventually leave you. Sometimes we don't send out a discharge letter but just be a little bit passive aggressive and the patient leaves on their own. The patient is happy thinking "I've shown you!" and we are happy as we didn't have to send out a confrontational letter.

Most of our burn out in solo practice doesn't come from our patients or medicine but the business of it. I would suggest you read Michael Gerber's E-Myth Physician and reset your business plan first becuase if you don't set up your practice to get what you want out of it nothing will change. He writes "Most Doctors who own their parcitce don't own a true business but a job... doing it, doing it, doing it ... hoping like hell to get some time off, but never figuring out how to get their practice to run without them. That's where E-Myth comes in." He also states some where the better you are at medicine the worse you are at business which is probably your problem. I have been trying to make change according to his book but have been slow to do so but the changes have paid dividens. He also talks about how to deal with hiring physician and PA's and NP's and the prep stuff that goes with it. If nothing else it will give you hope and a plan and then you can move forward. It is about 100 pages of easy and sometimes funny reading but you'll read about yourself and what burns out most other sole practioner.

Sounds like a great book. I will have to get it.

Thanks everyone.

@Wendell, I didn't word that very well. What I meant on the wcc was if they weren't scheduled that day, I would have to see them somewhere so it wouldn't be lost revenue. I have always struggled with acutes vs well child with mid levels. On one hand, the wcc tend to not be sick, but on the other hand, patients like to have their own doctor see them on the 2, 4, 6, 9, 12 month visits, etc.

@Marty, the logistics of the practice would not make for two providers at the same time. I do think working one day a week would work. Whether or not a mid level would do that, I don't know. I don't expect a mid level who wants full time to work eight hours. But, we have NPs here that work in the ED, NICU and other places part time.

Bert,
I found it took some adjusting to effectively incorporate a PA into my practice. Control issues on my part were the big problem, not patient acceptance. But, it really helped us out, and makes the work day much more controlled and pleasant. Maybe you should consider a PA full time?

How does one afford one?

This was a good thread for me to review for myself. On the question of firing a patient, I realized we don't have a hard or fast set of rules, a lot of what we do depends on my mood at the moment, combined with the rest of the circumstances. Recently a patient pissed me off and I told him we could only continue if he apologized to my staff on his way out, he refused and we parted ways. But in 48 hours he called to apologize to everyone and I worked him into the schedule and we seem to have made some progress.

I think I may be overly accommodating but when we stick it out, there is often an underlying reason for peoples behavior which occasionally is pertinent to their care.

And some are just a........les.

Bert,
If you have the room for a PA to see patients simultaneously with you, you will surely find him/her to be more than self supporting. I'll bet Marty can supply some sources for financial analysis.

Bert,

I know a lot of PA's who work part-time and have more than one job. I guess what I was trying to say is it would be hard to evaluate how they well they are doing if they only come in one day a week.

Our patients are mostly comfortable seeing either myself or the MD. If they have a preference, we try to accomodate that. I do have my "own" patients who just want to see me. Obviously the doctor and I have a good working relationship and I consult him as needed. Having PA's does free up the doctor to take more time with our complicated patients. PA's are dependent practitioners working under the physician (as opposed to NP, who are independent practitioners).

If you hired a PA, you'd have to decide whether to hire them as a part-time employee or 1099 them. Would you cover their malpractice, workers comp etc?

May I suggest you contact the AAPA (American Academy of Physician Assistants) for more information. Here's a link for information for potential employers of PA's.

http://www.aapa.org/your_pa_practice/for_employees.aspx



Here's a great link with info if you are considering hiring a PA

http://www.aapa.org/uploadedFiles/content/Common/Files/PI_HiringPA_v5%20-%20052711%20UPDATED.pdf

Thanks. Very helpful. I wish I had three rooms.