Family medicine MD/DO will be obsolete?

[CordMcNally]

You are one of the great ER docs out there. Not all are of your caliber!

I don’t think that’s true but I think it’s more of physicians clinging to old mantras and ways of practicing medicine.

[K82]

Your doing the procedure in the radiology department is like my doing a bone marrow in my office. My tech knows how I like it, has it set up and it takes me 20-30 mins of being in the room.

Doing that on the floor - to put it mildly, it is like working in a zoo. Nothing is ever there, no nurse to assist, no lidocaine or ativan, not sufficient slides inside tray or appropriate tubes and so on and on. After a few attempts of doing this nonsense routine the doc gives up and sends to IR. After a year or two he gets rusty and does not know how to do it well.

My last LP to inject intrathecal methotrexate was about 6 years ago. That was a near disaster from getting sterile preservative free MTX to the appropriate kit to having a nurse to assist me having the patient in the appropriate position. I have given up after that. I can still do LP and central lines but it is not worth the time or money.

I can see how that would be and I appreciate your point. I assumed that the Hospitalists would have the same support staff on the floor similar to what I have in my dept. I'm sure that's not always the case.

At some of the smaller hospitals we cover where the techs don't do much in the way of procedures it can devolve into a goat rodeo. Those LPs may take me 20 minutes! ( tech: I thought we had 22G spinal needles down here....I go find one...)

[K82]

My hats off to you for coming in but if it’s so emergent the hospitalist should just go ahead and treat (insert comment about messing up the cultures). I know for a fact our IR people won’t come in and I’d never ask them to. If the LP truly needs to be done emergently it’ll get done in the ED. All others (almost all of them) can wait.

You are one of the great ER docs out there. Not all are of your caliber!

[K82]

We are quickly finding that IR does not want to do these low RVU procedures either.

The degree to which things are set up by techs depends on the availability of techs, who right now are almost impossible to hire. If the techs work for the hospital, not the radiology group, then it is not up to the radiologist how things work. Forget about having a nurse in the room. Doing the procedure in Radiology is the same as doing it on the floor, except for those cases that actually require imaging.

These sort of lower skill procedures are ideally suited for physician extenders. Or maybe some primary care docs who worry about becoming obsolete should start offering their services?

My group doesn't get to pick and chose which cases they will or won't do. In private practice you have to take all comers if you're able to do the case, at least that's what our contracts stipulate.

[CordMcNally]

Suspected meningitis, according to the Doc it can't wait. When you're in private practice radiology you just go in and do it to make sure your contract hospitals are happy.

I got called in a few weeks ago at 3 am to do an esophagram for suspected foreign body in a young gal who since 1 pm that afternoon had a sensation of something stuck in her throat after eating. She decided to go the ER around midnight because it was still bugging her. She could still eat and drink fine, no vomiting or salivating, just a sensation. This kind of stuff bugs the heck out of me but what are you gonna do? One of the many annoyances of my work life that I won't miss when I call it quits in a little over a year.

My hats off to you for coming in but if it’s so emergent the hospitalist should just go ahead and treat (insert comment about messing up the cultures). I know for a fact our IR people won’t come in and I’d never ask them to. If the LP truly needs to be done emergently it’ll get done in the ED. All others (almost all of them) can wait.

[K82]

What is the point of doing it on the floor in substandard conditions?

It's totally pointless. Bring them down to someone that does a million of them in controlled conditions and it will frankly go way smoother.

Same thing for biopsies. See gen surg doing like open lymph node biopsies in the groin and etc, it's just laughably bad. You do 1 of those a year, how good can you be, versus IR who does 20 of them a week in a non-invasive manner. As a patient it's pretty clear which one I'd pick.

I totally agree with you regarding bxs that can be done percutaneously vs open. That's a no brainer. With an LP, I think its easier with non obese pts to put them on their side and have them curl up to open the posterior spine and plop the needle in, versus taking them to radiology, generating a higher charge for the pt, exposing them to radiation, have them on their stomach which makes the window smaller for the needle, for the same procedure. I don't know, maybe I'm just getting old and cynical!

[K82]

I'm curious why they're having you drive in for an LP at 3am. LPs have largely moved away from being an emergent procedure.

Suspected meningitis, according to the Doc it can't wait. When you're in private practice radiology you just go in and do it to make sure your contract hospitals are happy.

I got called in a few weeks ago at 3 am to do an esophagram for suspected foreign body in a young gal who since 1 pm that afternoon had a sensation of something stuck in her throat after eating. She decided to go the ER around midnight because it was still bugging her. She could still eat and drink fine, no vomiting or salivating, just a sensation. This kind of stuff bugs the heck out of me but what are you gonna do? One of the many annoyances of my work life that I won't miss when I call it quits in a little over a year.

[afan]

We are quickly finding that IR does not want to do these low RVU procedures either.

The degree to which things are set up by techs depends on the availability of techs, who right now are almost impossible to hire. If the techs work for the hospital, not the radiology group, then it is not up to the radiologist how things work. Forget about having a nurse in the room. Doing the procedure in Radiology is the same as doing it on the floor, except for those cases that actually require imaging.

These sort of lower skill procedures are ideally suited for physician extenders. Or maybe some primary care docs who worry about becoming obsolete should start offering their services?

[Panscan]

Fair point. I was referring to the more routine stuff. Paras, thoras, and LPs. I'm actually amazed how few hospitalists and now fewer and fewer emergency docs actually do these procedures anymore. I definitely haven't seen PAs doing any of those procedures you mention.

What is the point of doing it on the floor in substandard conditions?

It's totally pointless. Bring them down to someone that does a million of them in controlled conditions and it will frankly go way smoother.

Same thing for biopsies. See gen surg doing like open lymph node biopsies in the groin and etc, it's just laughably bad. You do 1 of those a year, how good can you be, versus IR who does 20 of them a week in a non-invasive manner. As a patient it's pretty clear which one I'd pick.

[Panscan]

Why would this be primary care specific? I booked a hand appointment the other day for my daughter. Guess who saw her? Guess who does all the procedures in IR? There are now APC only EDs. This trend (including the online NP school phenomenon you've likely noticed) has nothing to do with primary care and everything to do with economics.

It's beyond me why an insurance company or any other payer would pay the same rate to an APC (with a chart signed later by a doc) as a doc, but until that changes, you're right. Medicare only pays 85% of what it pays a doc if you are only seen by an APC, but I don't think that premium is high enough. When a hospital/clinic etc is paid 50% for an APC visit, there will no longer be the economic incentive to use APCs that exists now. Then they'll only be in places that can't recruit a doc, which is how independent practice is generally sold to state legislatures.

if by all the procedures, you mean the minor procedures that physicians don't want to do.

[Kamban]

It shouldn't take an hour to do an LP. I do one in about 10-15 minutes. I have techs that set everything up for me, but I assume the floor nurses do the same for the hospitalist.

Your doing the procedure in the radiology department is like my doing a bone marrow in my office. My tech knows how I like it, has it set up and it takes me 20-30 mins of being in the room.

Doing that on the floor - to put it mildly, it is like working in a zoo. Nothing is ever there, no nurse to assist, no lidocaine or ativan, not sufficient slides inside tray or appropriate tubes and so on and on. After a few attempts of doing this nonsense routine the doc gives up and sends to IR. After a year or two he gets rusty and does not know how to do it well.

My last LP to inject intrathecal methotrexate was about 6 years ago. That was a near disaster from getting sterile preservative free MTX to the appropriate kit to having a nurse to assist me having the patient in the appropriate position. I have given up after that. I can still do LP and central lines but it is not worth the time or money.

[CordMcNally]

Totally agree. Its so frustrating to have to drive in at 3 am to do an LP because the hospitalist doesn't know how!

I'm curious why they're having you drive in for an LP at 3am. LPs have largely moved away from being an emergent procedure.

[Savedfpdoc]

I do understand the economics of it, but it doesn't lessen the frustration at 3 am.

It shouldn't take an hour to do an LP. I do one in about 10-15 minutes. I have techs that set everything up for me, but I assume the floor nurses do the same for the hospitalist.

As it should be, I know the IR guy walks in when the pt is prepped/draped. Picks up the ultrasound, sticks the needle in the jugular , feeds the wire, puts catheter over wire then walks out. Tech stitches in place and cleans up. Takes him maybe 5min if that.

[K82]

Medicare pays $85 for a LP. Terrible reimbursement for a bedside procedure that will use up 1 hour of time from start to finish, if not more. So why would any hospitalist do it?

I do understand the economics of it, but it doesn't lessen the frustration at 3 am.

It shouldn't take an hour to do an LP. I do one in about 10-15 minutes. I have techs that set everything up for me, but I assume the floor nurses do the same for the hospitalist.

[Kamban]

Totally agree. Its so frustrating to have to drive in at 3 am to do an LP because the hospitalist doesn't know how!

Medicare pays $85 for a LP. Terrible reimbursement for a bedside procedure that will use up 1 hour of time from start to finish, if not more. So why would any hospitalist do it?