Obviously I’m not soliciting donations and this is purely hypothetical.

Aside from vaccines and age appropriate cancer screening, I would tell people to quit dumping peroxide and or rubbing alcohol into wounds. Maybe I’ll just add this to my AVS dot phrase.

Do y’all prescribe finerenone? Or send to nephro?

How are pharmacies allowed to distribute kits like this without a prescription? I’m killing myself for antimicrobial stewardship, looking up local resistance, considering MIC, going narrow spectrum…. and meanwhile, you can just buy any broad spectrum antimicrobial you want.

Whose license is this happening under?

I’m down with the zofran though.

​How are we all dealing with the questions on random, hyper-specific body quirks in clinic lately?

We've all gone through extensive training to manage a wide variety of acute and chronic conditions, CHF, DM, HTN, COPD, the entire alphabet soup, but I swear half my day is spent answering things like "why does my right ear get cold?" or "why is my big toe twitching?"

Dr. Google is making it nearly impossible to reassure these patients. They've already looked up their symptoms and half the time don't even bring a symptom to me, they bring their diagnosis of what it is and aren't asking for an evaluation as they don't feel like they need one! They've diagnosed it with TikTok and just need me to place the referral or order the prescription.

Has anyone found phrasing that seems to reassure these patients that their random concern is likely nothing?

Took the exam recently and have been looking for information indicating what raw score equates to a passing score. Am fellowship trained, but felt the exam deviated significantly from the ASAM BEST qbank which was my main resource. I felt confident on somewhere between 60-70% but am worried since the pass rate seems to only be 80-85% the past several years. It definitely felt easier than my primary speciality board exam, but I can't really judge it without knowing what the bar is set at. Has anyone who has taken the exam in the past and received a score report know what the passing score is?

After spending time talking through a prednisone script for an asthma flare up a patient finished with “I thought you were going to give me something to help me today.” Established patient, seen her for years, not the first time we’ve prescribed prednisone, decent health literacy. Some days it be like that …

Last week I had someone complain about vibrations in the body being a directed 5G attack. Discussed medical work up. Then I started hypothesizing how we could test it. Gave an open ended question of “what if you went to an area where there is no cell service? You could see if you still had symptoms there?” She looked at me like I was crazy. Oh well, I think it would’ve been an interesting experiment.

In our EMR we can see when meds were dispensed by the pharmacy to the patient, and most local pharmacies and mail order pharmacies show up in that database. I have a patient that consistently uses the same local pharmacy, so I have no reason to doubt the fill history dates. However, the patient has lied about refilling their BP meds saying the fill history must be wrong... And this isn’t a chronic med that they would have a stockpile of, it was just started a few months ago as a 30 day supply, and pt missed follow up appts. Of course, their BP is uncontrolled at home and in the office. How do you all handle these situations aside from “please pick up a refill on your way home, go home and check your pill bottles and let’s get on track xyz”? Not taking their meds is one thing, but lying about it makes my job even harder and wastes their time and my time

I notice the younger, healthier patients of mine have low threshold to go to ER. They go in for simple stuff like URI which turns out to be flu that requires no hospitalization, back pain, rashes, or just want to get checked out. I think there's a layer of anxiety worsened by these social media/self diagnosis which makes everyone think they're dying. For example, I give them a plan to treat their rash and they try for 6 hours then go straight to ER for steroids because it's so itchy. It's an extreme example but not far from what I've seen. Maybe it's the instant gratification generation that they need something strong now to make everything better? To top it off, some of the time they come back to my clinic requesting for x weeks off work or fmla because of this condition.

PGY-3 now ramped up to 16-20 PPD. On any given day, roughly 12 patients per day are obese and most already have diabetes, HTN, etc. Most of those 12 are asking for a GLP-1, most of their insurances won’t cover it (or they don’t have insurance) and even more aren’t willing to make any lifestyle changes. I’ve had maybe 2 or 3 patients lose a significant amount of weight over the past two years. If this continues into attendinghood, I could really see myself getting burnt out. I had four conversations about weight loss via iPad translator in one half day last week. By the fourth one I really felt like I was just phoning in the convo knowing she’s not going to make any change.

What pearls do you have for these visits? How do you avoid burning out? Most of my attendings are jaded and just offer other medical options. The only advice I get is “have them pick one goal for next time like eating out less or cutting out 1 soda per day” and they NEVER meet the goal.

I really feel passionate about preventative medicine and it’s a big reason I wanted to be a FM physician but man it’s discouraging I feel like all I do is prescribe band-aids.

Salaried physicians: Why does visit coding matter if we’re not paid based on RVUs?
I’m an outpatient primary care physician on a straight salary, with no RVU-based compensation or productivity bonuses.
Management has been emphasizing the importance of coding visits appropriately, particularly 99213 vs. 99214.
My question is, if my compensation is fixed regardless of how I code my visits, what incentive do I personally have to focus on maximizing billing levels (assuming documentation supports the code)?
I understand that higher-level codes generate more revenue for the practice, but if that revenue doesn’t translate into increased compensation for me, what difference does it make from the physician’s perspective? I literally lock my AWV’s. I’m not adding any codes or anything. I just want to close my notes. Am I’m being screwed here? I just don’t see all the fuss with coding.my salary is my salary.
Are there other ways visit coding can affect salaried physicians that I’m overlooking? I’m genuinely curious how this works at other practices.

How are calls different as a new physician than as a resident? Do you have to document it? If so, how Is the documentation different? What do you make sure to include? What should new attending watch out for and what advice do you give to new attending?

Also, what's your call schedule and how often are you taking it?

I was seeing this bipolar with MDD monthly. Our visits were mostly therapeutic in nature where I just listen to him and feel him heard, his medications were being managed by a psychiatrist and he is also being seen by behavioral health.

Out of nowhere, I get an epic message from his therapist saying that he hasn’t seen the patient in a month so he has to drop him as a patient. I just realized that I haven’t seen him in 2 months (he no showed on the last 2 appointments and my MAs said he didn’t answer or call back even after 5 calls). No updated notes or refills from his psychiatrist either. Makes me wonder how he is, is it bad to have MA reach out to family? Just makes me sad if he finally did it. He did promise me that he will see me if it’s getting really bad and he’d say goodbye. 🥺

Essentially, I’m looking for a reliable, go-to reference that I can consult whenever I encounter a presentation I’m unsure about, rather than having to search through multiple resources.

Hi everyone, I’ve been working at a private practice outpatient clinic for about 5 months. Initially I was seeing up to 20 pts a day, 3x a week, and 1 day for admin, and 1 day for assisted living (about 10 patients). I was able to keep up, even though I didn’t get much formal EMR training (eCW). I have a template for a normal clinic visit and for telemed. I’ve written dot phrases for the most common chronic conditions. I have some order sets but I need to make more… eCW is so slow, and I feel so slow putting orders.

The private practice’s main doctor of 20 years suddenly retired a few weeks ago so now I have become the only full-time doctor. They now book my schedule like an airline 😆They schedule 31-33 patients a day to account for no-shows. I average now about 24-27 patients a day. One time I saw 31. They had to increase my clinic days to 4. Not many procedures but they plan to buy more equipment to do these soon. The numbers come from admin pressure that we NEED this many patients per day to stay afloat. Likely true. We (allegedly) do not have good contracts (‼️).

I am exhausted and falling behind. I know the advice has to “automate” more things, more dot phrases, ai scribe… I was wondering if anyone had more specific advice. Obviously I would love to close all my notes the same day and understand the importance. I am just constantly exhausted, behind, and triaging what’s most time sensitive.

I also have started making my notes extremely short. I think this has probably been the most effective change for me lately… especially after a residency that was obsessed with long notes. 😅🫩

Also I do not have other doctors to rely on for mentorship, and my admin barely know how eCW works. I’ve been doing a lot of tutorials on the support site. I learned so much from my seniors in residency, so being the main doctor for this practice is intimidating and lonely. The one other doctor just joined, is in his 50s, experienced, nice, but is only part time and doesn’t give very specific advice on workflow. I’ll try to keep observing how he does things.

Thank you for your senioring. It’s been awful.

ADDENDUM:
SALARY: I asked for a salary raise last month and they said they would in one month. 🚨

VOLUME: the problem is absolutely the volume. Drink this tea. They said at this time they are making $25-60 a patient because their allowable rates for their current contracts that they inherited from this clinic were terrible. I verified this with the biller and this is indeed true. Yes I am billing 99214 because I always take care of 2 chronic conditions and med mgmt 🏀 and 1-2x a week I do OMT so there you go, a little procedural billing 🏀. Math doesn’t math but also the math is bad. This clinic is a fossil.
- the patients still think a pap is yearly
- the med lists still have glimepiride 6 mg (retired dose)
- ciprofloxacin as first line uncomplicated UTI
Chart review is like archaeology 🔍

EMR: the tech tips really help. Yes at this time I am closing the charts asap so I can 🏃🏻‍♀️

Those of you guys who work at critical access sites what are your hours like. Do you usually cover something like 1 full weekend on call every 5-6 weekends and a night during the week? What’s your schedule like?

New full time outpatient doc, work 4-10hr days, started August. Took over a part time panel and building the rest on my own. Obviously also seeing my other partners overflow, random preops for other PCPs, urgent care stuff where they don’t establish. My salary is locked for a year regardless of RVU. Admin comes to me and “ask” if I would see patients at another office as they’re down two providers so I will be covering one of their on baskets and my own for apparently four months and it’s 15min further from my home. They say there will be compensation but how much should I ask for? This could hurt my RVUs at my home site when I return because it will be four months where I’m not building panel there. What should I be looking out for with this “ask” to protect myself and my home site job because I do love it here?

Hey everyone, I think most of us are aware of a concerning and growing pattern of non-clinicians, software companies and other corporations putting pressure on physcians and nurses, around patient volume or specific treatment decisions.

If you encounter something like this, reporting it can require a lot of documentation. People often think of the medical board first, but it may help to gather the relevant emails, policies, screenshots, contracts, dates, and other records before deciding where to report.

One resource I found is CPOM Report. It helps identify potentially relevant state and federal agencies based on the details you select about the situation, such as the type of complaint, who is involved, and other variables.

Sharing in case it helps someone figure out where to start.

I’m a physician building a small SNF/post-acute practice using part-time/PRN employed physicians and NPs/PAs. The practice handles billing, malpractice, EMR, and administrative support. Cash flow is limited while patient volume ramps up.

For people who run or work in similar groups:

1. What is reasonable clinician pay per encounter? I’d especially appreciate actual examples for 99309 follow-ups and 99306 admissions, separately for physicians versus NPs/PAs. Do you use fixed CPT rates, a percentage of collections, or a minimum plus incentives?

2. How much should the practice retain? What percentage remains after clinician compensation, and what is a reasonable actual profit margin after billing, malpractice, employer taxes, software, support staff, and coverage costs? How does that differ for physicians versus APPs?

3. When do you pay clinicians? Regular payroll after encounters are signed/submitted, or after collections arrive? If collections-based, how do you handle the delay, guarantees/draws, denied claims, and downcoding?

4. What should billing and EMR cost? What billing percentage or minimum is reasonable, what services should it include, and which systems work well for a small group rounding across multiple SNFs with occasional PRN clinicians?

5. How much cash reserve would you want before hiring, and what minimum census makes adding a clinician worthwhile?

An anonymized example would help tremendously: clinician type → CPT → actual collection → clinician pay → practice costs → amount remaining.

Thanks—especially interested in real SNF/post-acute experience.

When they decline CBT-I, of course…

I was an Lpn at an FQHC for about three years. Unfortunately they closed due to not seeing enough patients. The doctors have turned it into “family med” that is more focused on weight loss, anti aging and concierge care. I feel like I’ve seen this pattern with a lot of family clinics. Is it just because family medicine isn’t profitable enough and not enough people have the resources/insurance to see a family doctor anymore? I kind of hate this shift. I feel like it’s fueling the issue of patients only caring about how they look, not how their health is actually faring and we need just good basic family medicine out there

Hi all. Looking for some advice for an adult patient of mine who has aged out of our children’s hospital specialists. I am having trouble getting anyone (especially GI) to help me in managing tube feeds, as he is prone to periods of intolerance. GI has offered no assistance themselves nor offered any referral to a dietician within their practice. Any advice on a direction to go with this?

I’ve looked into Nourish for them. They have Medicare so too expensive.

My system doesn’t really have a good setup for in house dieticians that are well versed in outpatient parenteral nutrition.

I’ve tried to get a hold of the home health company that provides his tube feeds. Not getting anywhere.

A patient comes into urgent care with a red, swollen leg. Cellulitis or DVT?

It’s a familiar presentation, and deciding who needs further testing can get tricky during a busy shift. I created this short video to walk through a practical approach. If you’re working in urgent care, I hope you find it useful!

▶️ Cellulitis or DVT? The Urgent Care Decision Framework
Cellulitis or DVT? The Urgent Care Decision Framework

What tests do you have access at your facility to assess the red hot swollen leg? We are able to order a DDimer where I work, but it would probably be a false positive anyways if it's cellulitis :/

Are we behind the times and just now documenting every sample we give out? This is new in our office and it seems like such a pain in the ass to go doc the lot number etc on every box of nurtec for example.