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  • q-school
    replied









     
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    As an older (54 YO) doc in private practice group that has to this point spent/borrowed $1.1mil on EMR, I don’t think that that anyone would argue against the increased convenience of extracting information from electronic medical records. The primary issue in our case is the inefficiency of Data Input. Older doc’s often never took typing in the past and Dragon Speak still is somewhat clunky. EMR has actually decreased the number of patients our physicians are able to see each clinic, cutting into revenues, and adding significantly to our expenses. It is a simple math problem from a financial standpoint.

    Working harder and making less is the stark reality that many physicians are facing, both young and old, and some, both young and old, will bow out, as this forum attests.

    As an aside, IMO, the government missed an incredible opportunity to increase efficiency and cut cost in healthcare when they failed to mandate that these systems be able to communicate with each other from the very beginning. Much of the data would have needed to be entered only once, especially from the patient’s perspective. Asking an 82 year old with mild dementia to list all of their medications every time she sees a new doc is utterly ridiculous.

     
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    Interesting perspective, thanks for sharing.

    I’m not trying to sound like the young whippersnapper criticizing my older peers, if for no other reason I’m not actually that young anymore, but it’s been a source of some mystery to me why these docs didn’t invest some time in learning to type. Here comes the EMR, it’s sure as ************************ not going away, and you kind of have to learn to live with it. Typing is hardly some kind of arcane skill. Most people can type far faster than they can write legibly.

    Good EMRs like EPIC definitely increase my efficiency and throughput. I started my last job on paper charts and it sucked, constantly hunting for the chart, trying to make sure your medico-legal MDM was legible etc. Occasionally on really complex or risky cases I would just print out a sheet of typerwritten MDM to stamp and stick in the chart. I mean if you’re on T-sheets maybe you can go faster but those are notorious for hanging you out to dry medicolegally.
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    I assure you that I knew my patients' medication lists 1000x better when I had to handwrite every single blessed medication down than when I click okay.

    I knew their history better as well.   it sucked but there were some benefits.

    ymmv.

    the notes are terrible now.

    so much extra bull crap.  they may be legible, but the content in my experience is way worse.

    again, ymmv

     

    Leave a comment:


  • MPMD
    replied







    Fair, enough… Although I get you are not likely to follow the advice,  I write it for others that may.  No, just means start again one level higher.  Who is above your director?
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    i always love your comments.

    however, I hate when people work around me and go one level up.  is that really how decisions are made in your world?  instead of working with the person above you, just undermine them and keep going up?  if there is any kind of reasonable admin structure, the one level up would likely just refer the person back to the original decision maker.  generally if I say no, there are a bunch of good reasons.  trying to ‘get your way’ just engenders everyone else to try and get their way and keep asking up the chain.

     
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    Yeah.... Do not go over your boss's head unless you are ready to be fired over the issue. I literally cannot imagine a situation where I would ever go over my chair's head.

    Leave a comment:


  • MPMD
    replied






     
    Click to expand…


    As an older (54 YO) doc in private practice group that has to this point spent/borrowed $1.1mil on EMR, I don’t think that that anyone would argue against the increased convenience of extracting information from electronic medical records. The primary issue in our case is the inefficiency of Data Input. Older doc’s often never took typing in the past and Dragon Speak still is somewhat clunky. EMR has actually decreased the number of patients our physicians are able to see each clinic, cutting into revenues, and adding significantly to our expenses. It is a simple math problem from a financial standpoint.

    Working harder and making less is the stark reality that many physicians are facing, both young and old, and some, both young and old, will bow out, as this forum attests.

    As an aside, IMO, the government missed an incredible opportunity to increase efficiency and cut cost in healthcare when they failed to mandate that these systems be able to communicate with each other from the very beginning. Much of the data would have needed to be entered only once, especially from the patient’s perspective. Asking an 82 year old with mild dementia to list all of their medications every time she sees a new doc is utterly ridiculous.

     
    Click to expand...


    Interesting perspective, thanks for sharing.

    I'm not trying to sound like the young whippersnapper criticizing my older peers, if for no other reason I'm not actually that young anymore, but it's been a source of some mystery to me why these docs didn't invest some time in learning to type. Here comes the EMR, it's sure as ************************ not going away, and you kind of have to learn to live with it. Typing is hardly some kind of arcane skill. Most people can type far faster than they can write legibly.

    Good EMRs like EPIC definitely increase my efficiency and throughput. I started my last job on paper charts and it sucked, constantly hunting for the chart, trying to make sure your medico-legal MDM was legible etc. Occasionally on really complex or risky cases I would just print out a sheet of typerwritten MDM to stamp and stick in the chart. I mean if you're on T-sheets maybe you can go faster but those are notorious for hanging you out to dry medicolegally.

    Leave a comment:


  • Dr. Mom
    replied







    Fair, enough… Although I get you are not likely to follow the advice,  I write it for others that may.  No, just means start again one level higher.  Who is above your director?
    Click to expand…


    i always love your comments.

    however, I hate when people work around me and go one level up.  is that really how decisions are made in your world?  instead of working with the person above you, just undermine them and keep going up?  if there is any kind of reasonable admin structure, the one level up would likely just refer the person back to the original decision maker.  generally if I say no, there are a bunch of good reasons.  trying to ‘get your way’ just engenders everyone else to try and get their way and keep asking up the chain.

     
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    If the chain is broken, then it needs to be fixed.  It doesn't get fixed if everyone acquiesces.  But, I am realistic and kind in my approach. I know when to stop. I have absolutely walked away from positions that were soul-sucking.  I am INSJ not INTJ.  So making life decisions rationally on math is not my forte.  Nor is keeping quiet.  I push/challenge Lithium with my comments because, for whatever reason, his posts have touched me.  I worry about him and hope for so much more for him.

    Leave a comment:


  • q-school
    replied




    Fair, enough… Although I get you are not likely to follow the advice,  I write it for others that may.  No, just means start again one level higher.  Who is above your director?
    Click to expand...


    i always love your comments.

    however, I hate when people work around me and go one level up.  is that really how decisions are made in your world?  instead of working with the person above you, just undermine them and keep going up?  if there is any kind of reasonable admin structure, the one level up would likely just refer the person back to the original decision maker.  generally if I say no, there are a bunch of good reasons.  trying to 'get your way' just engenders everyone else to try and get their way and keep asking up the chain.

     

    Leave a comment:


  • VagabondMD
    replied




    Lithium,

    I don’t really buy the “let go and do anything” idea of self growth. Most of the time when I’ve done that it was self indulgent in retrospect as it was not reasoned/measured risk taking.

    What I’ve found helped me to grow was to do things that were incrementally difficult. There is a probably a reason you haven’t gone to the admin with a 0.8 ultimatum because your bargaining position may not be great.

    Perhaps in a lot of cases 2X 0.4 is better than 0.8. More of a logistical hassle but better negotiating position and superior in terms of diversity of income and more diversified in terms of organisational risk.

    I’ve found hospitals wax and wane. Admins come and go. Corporate collective memory is low. My strategy is if I find them hard to work with I reduce my involvement gradually until it is 1 day a week. Even if the admin is terrible, I find 1 day a week tolerable. And you know what, if they know you can leave, they do seem to be more accomodating. I find whittling down, I cut out the parts of the job I enjoy least and I find myself less exposed to crazy admins and feeling too stressed.

    I think there will be a part of you that tells you what is sensible and where you can push yourself and perhaps it is good to listen to that. Incremental pushing yourself is healthy I think. But not anything radical that freaks you out.

    Staying at a place that isn’t rewarding for golden handshake is tough. I tend to think life is too short for that, but the weigh up is individual and depends on your situation. Personally, I like to try something different every 4 years or so and might try a new location or institution a day a week to just keep from getting stagnant. Things maybe better elsewhere.

    I was most unhappy when I was at one group and I didn’t get along with the CEO. I moved at a difficult time when our first child had just been born. I found my income went up 80% after the move. The best part was just leaving a place I really had stoped enjoying working at and a CEO who I really didn’t like. After 3 years the new place started going downhill, so I cut it by 50% and took another appointment the other 50%.

    With organisations, I find if they need you at a particular time, they will cut you a sweet deal and when they no longer need you, well they will give you a less attractive deal. And sometimes they can be downright nasty. I find it better to move to where I’m more needed or treated better. I don’t mind moving every 4 years or so if the new place has a better deal. I try not to burn bridges and I try not to leave them in the lurch. But I avoid being in a bad negotiating position.

    I would try to find an option B, for 0.4 that should be at least equivalent to current. Then negotiate with current for 0.4 or 0.6. If there is no option B, that is a problem and they have you by the negotiating balls. It is possibly something you can modify over time though. Have you thought about doing private practice for 2 days a week ?

    That being said, some people are happy at one organisation or 2 for their whole careers and they get through the tough times somehow and find a nice cosy niche. That was never me though.

    Good luck with it all.
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    Really great advice, but also somewhat challenging for an individual to do, especially if he/she is feeling burned out or unappreciated. It’s hard to have the confidence to make bold moves when you do not feel good about your professional self.

    Agree with @startrekdoc that a career coach might be useful to navigate through your current situation.

    Leave a comment:


  • Dont_know_mind
    replied
    Lithium,

    I don't really buy the "let go and do anything" idea of self growth. Most of the time when I've done that it was self indulgent in retrospect as it was not reasoned/measured risk taking.

    What I've found helped me to grow was to do things that were incrementally difficult. There is a probably a reason you haven't gone to the admin with a 0.8 ultimatum because your bargaining position may not be great.

    Perhaps in a lot of cases 2X 0.4 is better than 0.8. More of a logistical hassle but better negotiating position and superior in terms of diversity of income and more diversified in terms of organisational risk.

    I've found hospitals wax and wane. Admins come and go. Corporate collective memory is low. My strategy is if I find them hard to work with I reduce my involvement gradually until it is 1 day a week. Even if the admin is terrible, I find 1 day a week tolerable. And you know what, if they know you can leave, they do seem to be more accomodating. I find whittling down, I cut out the parts of the job I enjoy least and I find myself less exposed to crazy admins and feeling too stressed.

    I think there will be a part of you that tells you what is sensible and where you can push yourself and perhaps it is good to listen to that. Incremental pushing yourself is healthy I think. But not anything radical that freaks you out.

    Staying at a place that isn't rewarding for golden handshake is tough. I tend to think life is too short for that, but the weigh up is individual and depends on your situation. Personally, I like to try something different every 4 years or so and might try a new location or institution a day a week to just keep from getting stagnant. Things maybe better elsewhere.

    I was most unhappy when I was at one group and I didn't get along with the CEO. I moved at a difficult time when our first child had just been born. I found my income went up 80% after the move. The best part was just leaving a place I really had stoped enjoying working at and a CEO who I really didn't like. After 3 years the new place started going downhill, so I cut it by 50% and took another appointment the other 50%.

    With organisations, I find if they need you at a particular time, they will cut you a sweet deal and when they no longer need you, well they will give you a less attractive deal. And sometimes they can be downright nasty. I find it better to move to where I'm more needed or treated better. I don't mind moving every 4 years or so if the new place has a better deal. I try not to burn bridges and I try not to leave them in the lurch. But I avoid being in a bad negotiating position.

    I would try to find an option B, for 0.4 that should be at least equivalent to current. Then negotiate with current for 0.4 or 0.6. If there is no option B, that is a problem and they have you by the negotiating balls. It is possibly something you can modify over time though. Have you thought about doing private practice for 2 days a week ?

    That being said, some people are happy at one organisation or 2 for their whole careers and they get through the tough times somehow and find a nice cosy niche. That was never me though.

    Good luck with it all.

    Leave a comment:


  • StarTrekDoc
    replied
    @Lithium - Please consider getting a career coach.  A few in here have and it helps getting someone with several career experiences and situations to guide you through yours.   Vesting is nice is a nice golden handcuff perk, but so is sanity and a good work/life balance.

    Administrators do their job and not absolutely not your friend; but remember, a turnover of any physician is costly.  Ramp up costs are tremendous and they were lucky to have you at 1.2 FTE -- that was totally eating their cake.  Now it's harder with the part time request, but the alternative is losing you completely and if it's even a decently hard/or bad time to recruit position, there's wiggle room -- they'll never show it either.

    But to the point again, consider a career coach to help you through this journey.  I probably would have gotten to my current path 2 years earlier with one.

    Leave a comment:


  • wideopenspaces
    replied




    The older I get and the better I am at my work; the more mature I am and the longer my relationships with my patients; the less I want to FIRE and get out of dodge. That was my dream when I was 29 and childless. 15 years later the awareness of the incredible privilege it is to care for patients and to have the relationships with human beings that I have grows every day. I do not want to work full time forever but I would have a hard time walking away from my job tomorrow, even though I could (financially). I’m ready to knock it down a little or buy more PTO, but not sure how or when that will happen.

    I want to tell a story about the kind of thing that happens in my work that makes it worth doing, even though there is so much else I like to do and would love to do. Someday I’ll tell the story. And I will walk away from full time work someday, between 45 and 50 years old, despite stories like that.
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    I don't know the specific story you want to tell, of course, but I feel the same way about my work. It's an absolute privilege and honor to do what I do, to know what I know about people and to share in the lives of those that trust me with their care. I nearly always leave my office grateful for the interactions and opportunities I've had during my work day. I feel pretty loyal to my patients, so I can see why some would have a hard time walking away from people they've known for decades.

    Leave a comment:


  • Re3iRtH
    replied







    Ah, the famous “Why do some people..” people question.  My kids used to always ask me these when they were growing up.  IDK why the guy you know keeps working.  I will trust your answer that it is not about money.  I would turn the question to you, Lithium, like I used to with my kids.  Why do you keep working at a job you have stated in past threads that you do not enjoy?  Make a change.  Consider part-time sooner than later.  We have only ever worked part-time and are in no hurry to change.  Look to the examples of WCI, POF, Hatton, and Vagabond’s journeys to part-time medicine.  I have more trouble understanding when people push to work at a job they hate to reach a nebulous number before they change.  I do think generational issues play a role.
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    Valid points.  I asked my director if I could go part-time and he said no.  I asked if I could structure my full-time work in a way that would provide more variety and possibly less stress, and that wasn’t accommodated either.  So I have the option of leaving and forfeiting substantial unvested benefits in favor of something I might like better, or sticking it out in order to accelerate financial independence.  I’ve crunched the numbers every possible way to try to find a mathematical justification to leave, since it’s easier to make decisions that way than try to decide between options with different uncertain trade offs.  When the list of pros compared to the list of cons is pretty similar on both ends, it seems more rational to stay and more emotional and impulsive to leave the status quo.

    I don’t want to sound like a help-rejecting complainer.  I know life is about making tough decisions, and I’m at a point where more info/advice isn’t likely to help.  Comes down to being ready to make a leap of faith.
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    Sometimes, the decisions shouldn't be financial/mathematical. You may look back on this one day. Did you go and try all the things you wanted to try? See all the things you wanted to see? Taken a risk or a leap of faith that made you grow as a person or changed your entire perspective? By definition, the answer very often has to be "no" if you stop working full time when you are old.

    Consider doing a "fear setting" exercise. https://www.youtube.com/watch?v=5J6jAC6XxAI

    Everyone should probably do something like the above every few years, just IMO.

    Leave a comment:


  • FIREshrink
    replied
    The older I get and the better I am at my work; the more mature I am and the longer my relationships with my patients; the less I want to FIRE and get out of dodge. That was my dream when I was 29 and childless. 15 years later the awareness of the incredible privilege it is to care for patients and to have the relationships with human beings that I have grows every day. I do not want to work full time forever but I would have a hard time walking away from my job tomorrow, even though I could (financially). I’m ready to knock it down a little or buy more PTO, but not sure how or when that will happen.

    I want to tell a story about the kind of thing that happens in my work that makes it worth doing, even though there is so much else I like to do and would love to do. Someday I’ll tell the story. And I will walk away from full time work someday, between 45 and 50 years old, despite stories like that. But while I don’t live and breathe medicine like an earlier generation of docs did, it is definitely more than a job and for those who get to that point there is something wrong with your employer, or there is something wrong with you.

    Retention is a major, major consideration in our group (multi-specialty, about 500 providers) and letting a good person go rather than knocking down to 0.8 or 0.6 - well, it would never happen. Of course, there are some providers we won’t be flexible with, and that’s frankly because they have personality deficits that make them less desireable to keep around. Our group values good eggs. And there are a few providers we can’t be flexible with - ie, the only orthopedist in town. But in general, if we can do something reasonable to keep someone, we will.

    Leave a comment:


  • Antares
    replied







    He is 83 and was a doctor who became a lawyer in his late forties.
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    Did he enjoy practicing law (and/or enjoy it more than medicine)? What branch/specialty of law did he practice? Did he work in Big Law, go solo, or other?

    I sometimes think that I might want to start an encore career in law, but most lawyers seem to hate the law. Also, I suspect job opportunities would be limited for an old law school graduate.
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    Yes, he liked practicing law quite a bit. He also loved the practice of clinical medicine - he was a pulmonologist - but started to get burned out by the administrative issues and other downers of medicine. He became interestedly in the legal aspects of death and dying, and was (is!) very strident on issues of patient rights and self-determination. He ended up in his own practice, and when my mother went to law school a few years later (at 48)  they formed a firm and practiced together. He did some plaintiff’s medical malpractice, some work relating to nursing home issues, and quite a bit of elder law in which his medical knowledge was advantageous. He liked the mental challenge, but I think just as much he enjoyed a new professional gig after many years of practicing medicine.

    As far as many lawyers hating law, maybe it’s different when you choose it later in life because you want to do it. Many people go to law school because they are good at school and couldn’t figure out something else to do. I also have a number of friends who like law because they enjoy the chess match against the opposition. Law generally speaking is a better outlet for competitive urges than medicine is.

    Leave a comment:


  • G
    replied





    He is 83 and was a doctor who became a lawyer in his late forties. 
    Click to expand…


    Did he enjoy practicing law (and/or enjoy it more than medicine)? What branch/specialty of law did he practice? Did he work in Big Law, go solo, or other?

    I sometimes think that I might want to start an encore career in law, but most lawyers seem to hate the law. Also, I suspect job opportunities would be limited for an old law school graduate.
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    I've also thought about getting a law degree, mostly to give me the tools to speak Legislation and to get the connections of Big Politics.  But shortly--just like my thought of drinking less espresso--the idea passes!

    I have a friend who got a JD and then an MD.  He hated law, but loves medicine.  Every time I see him I try to talk him into getting involved in policy and he just chuckles and shakes his head....

    In my shop, the old-timers tend to show up at grand rounds (and parties) more so than the lounge.  I think this is really cool.  I like hearing their stories--crazy cases like weird TB or abdominal pregnancies.

    I believe the med staff by-laws grant honorary staff privileges, that is how their badges still work.

    Leave a comment:


  • startupdoc
    replied
    Hearing all these stories of retired physicians staying in the docs lounge...how do they even get in? Soon as docs are retired around here, their badges are inactivated.....

    I think physicians have a very difficult time retiring for many reasons. A major one is the fact that a large percentage of physicians have not cultivated interests, hobbies, or relationships outside of medicine. The prerequisites, training, and finally the occupation itself lends people having to invest the vast majority of their time to the profession. No wonder doctors don't enjoy their retirement. They have not built the social structure necessary to enjoy a fulfillment retirement.

    Leave a comment:


  • VagabondMD
    replied




    I’ve always been partly amused/partly saddened by the retired surgeons who still frequent the surgeons’ lounge to read the paper or eat lunch, or seemingly just hang out. My last day of work will be the last day in the hospital, except as a patient.

    I remember in some dumb humanities class I had to take in medical school how the instructor was almost appalled when we were taking about the “calling of being a physician,” and she asked me what I thought. I told her that being a physician was what I was doing with my life but not who I was as a person.

    My current plan is to work another 15-20 years (I am 39 now and 3.5 years out of fellowship). At that time my youngest child will be 21 to 26 and my kids should be launched by then, hopefully with at least undergrad completely paid for. If I want extra money for something it should be pretty easy to obtain locums work somewhere, but I imagine I would be pretty picky about the options.

    I remember in residency seeing an old general surgeon. His kids were vascular and general surgeons who did approaches for one of our spine surgeon’s ALIFs. They’d let their dad come in and close, and I had to stand there and watch him put vicryl through the skin on his subcutaneous layer over and over because he couldn’t see. Not for me, thanks.
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    We have a retired OB/GYN who gave up his practice at least a dozen years ago and now is in his 70’s. He is an unlikeabke fellow who spends more time in the doctors lounge than anyone, ranting and raving about politics and health care and whatever the topic of the day.

    I remember talking to a plastic surgeon colleague who was initially quite pleased that the OB/GYN was retiring, so that now he could eat a peaceful lunch without listening to the diatribe du jour. Little did any of us know that the retirement meant that he would become a fixture, on his soapbox, in our lounge, Both sad and comical.

    Leave a comment:

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