× Women Physicians

Not happy with outpatient IM. Need career advice!

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6 years 9 months ago #88419 by vitaminng
Hi Everyone! I'm new to this forum. I found the MomMD website while starting my search on alternative, non-clinical careers for physicians. I would greatly appreciate any advice or words of wisdom!

I recently graduated from IM residency in the summer of 2012. To take a step back, as a medical student, I thought IM would be a great career path-- IM embodied "medicine" to me, and there are so many subspecialties to choose from. I had envisioned myself going into fellowship, but by the end of residency I had training fatigue, didn't love any of the subspecialties enough to stomach fellowship hours, and felt a nagging urge to start making an income so that I could pay off my hefty student debt. Furthermore, I really dislike acuity and inpatient medicine, so by process of elimination, I went down the route of outpatient medicine. In theory, I like outpatient medicine and the idea of being someone's PCP and talking with patients.

So what's the problem?

I'm 6 months into my new job and I wonder if I've made a long series of mistakes going into medicine and I don't know if I can see myself doing this for the rest of my life!

I won't say where I work, but there are a lot of pros to my job: great colleagues, I like most of my patients, great ancillary staff so that I'm able to delegate a lot of work to the MA's or RN's, zero call (our patients get admitted by hospitalists, and we have an answering service to handle phone calls), and hours on "regular" days would be something like 8am-6pm M-F.

What are the things I don't like? Well, the problem is, I don't think my issues are specific to my current job, but apply to virtually any outpatient IM job out there. Specifically, we are only allotted 20 minutes per patient visit (never mind the fact that most patients show up late, the MA's have to process the patient, and chart biopsying and note-writing take at least several minutes); sure, 20 minutes works for your URI or young, healthy patient without any medical problems, but I have tons of 60+ year old patients with many chronic medical conditions. I just find myself being stressed out, rushed, and unhappy trying to fit into this time constraint. I feel like it's not a good way to practice medicine. Additionally, we are required to work 2 evening shifts a month and one weekend morning shift a month. When I have a full day + evening clinic, and everyone shows up-- that is 30+ patients and notes...that makes my head spin! Lastly, I think I'm a pretty tolerant and patient person, but I can't help resenting the fact that half of the patients I see each day are people with URI's who have only had symptoms for 2 days, have not tried OTC meds, and are demanding antibiotics. I do my best to educate patients about antibiotic ineffectiveness for viral illnesses, but secretly when I'm back in my own office I can't help but get exasperated and throw my hands up in the air!

So what would make me happy? At the most basic level, I wish I had more time for patient encounters. Sometimes when I read consultants' notes, they document that they spent 40 or 60 minutes counseling patients, which I would love to have. Even having a 30 minute encounter would seem like a luxury. Also, I wonder if I would be happier not dealing with URI's and UTI's and lower back pain, and other common IM complaints-- yes, they are easy encounters, but they are mind-numbing.

I'm at a crossroads and trying to figure out what to do, so far the options I've thought of are:
1) Stick it out at my current job; I figure at the least I should stay with this job for 1 year. I'm fully aware that there will be growing pains with learning a new system and the learning curve for outpatient medicine is steep after spending 3 years learning mostly inpatient medicine in residency. I even asked around my office to find out when things get better: one guy said 3 years, another said it NEVER gets better and that he always feels tired, rushed, and stressed out (both of these doctors have been practicing 15+ years).
2) Find another outpatient job in IM...maybe concierge medicine?
3) Either subspecialize or go into another field entirely.
4) Find an alternative, nonclinical job.

It really is disappointing to have survived med school and residency, and then come out on the other side not loving what I do. It's also disheartening to feel like I often work long hours and am stressed and tired all the time, and to top it all off am in a lower-compensated field. I graduated AOA and with step scores in the 250's, and now wonder what would have happened if I had tried for one of the more lucrative "lifestyle" specialties; at the time when I went into IM, I thought I was following my gut and my heart, and I didn't listen to all the naysayers who warned me not to go into IM. "I will be different, and I will love IM", I thought. Anyway, I know there isn't a one-size-fits all answer and that there isn't a particular job or specialty that is the holy grail that is guaranteed to give fulfillment, satisfaction, and a good work-life balance. Have other women struggled with dissatisfaction with their careers or chosen specialties, and what did you ultimately do?

Thank you so much in advance for reading and replying-- any responses will be greatly appreciated!

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6 years 9 months ago #88424 by sahmd
It is really a shame that there is so much production pressure in medicine these days. It is in all specialties, not just IM. I am not in IM, so these ideas may not be realistic, but I wonder if it would be possible to see 2 patients an hour instead of 3 and be paid 2/3 as much. And maybe it would be possible to do some of that work on your own time, such as the "chart biopsy" and writing up a note after the visit (obviously you would take notes during the encounter).

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6 years 9 months ago #88425 by vitaminng
Thanks for the reply sahmd. I've pondered that set up as well, but I don't think it's possible where I work. I think you have to see X number of patients per half day and you can either be FT or PT, but I haven't seen a solution like what you're suggesting. It may be worth looking into, but I honestly would feel stigmatized or judged for even asking. I do as much as I can during each patient encounter, but I often do end up charting at the end of the day for an hour or so. And sometimes I have to take work home, which is not ideal. Also, I have friends in peds, who have it much worse, and only have 10 minutes per patient encounter.

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6 years 9 months ago #88426 by FPDOmama
Oh, man...do I feel your pain! I am a newly minted attending as well, almost 5 months into my outpatient primary care gig, and this is a humongous problem. Nothing takes 15 min; most things take more than 20...AND patients hate waiting and don't understand that we have to meet a quota to keep the lights on! The only things that are keeping me sane are the facts that: I do enjoy the interactions and the continuity with (most!) my patients; most of them are (so far) fairly patient about me running behind because they feel like I listen and spend the necessary (but more than scheduled) time with them to address their needs; and mostly, my saving grace is that I am doing it part time. I am only seeing patients 3 days per week...though because of all the documentation and patient time and messages, etc, that come with primary care, most of those days end up being 12-13 hours days (still feels like residency that way!) with nearly always some of the work being done at home after my kids are in bed. However, because I am off every Tuesday and Friday (and weekends, other than light home call), at home with my family, I am able to recharge and remain balanced and less-stressed. I realize that it is isn't financially possible for everyone due to loans, but if you can swing it, cutting down your number of days is (in my opinion) worth the pay cut!

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6 years 9 months ago #88438 by AmmaMD
Ugh. I can totally imagine the frustration of simultaneously being rushed and bored much of the time.

Agree that if you can cut back total hours you may feel better about it - and then you can choose to run behind a bit and chart as you go / spend a little longer without it lengthening the day for you (although it's a longer wait for your patients).

If there's a way to make it work, I think the concierge medicine option could be AWESOME. As an MS3, I worked for a month with someone who had had almost your exact complaints at his big med center practice (which he stuck at for like 10 years), and felt he was just getting angrier and angrier by the year. He finally quit and developed his own low-cost concierge practice - he prefers calling it "subscription" medicine, as he sets his prices very low, and actually a huge chunk of his patients are not wealthy at all, but rather working people whose jobs don't come with benefits, and they have some sort of chronic disease that makes out of pocket insurance on a blue collar income prohibitively expensive. So they pay ~1.5k or 2k a year for his services, and, if they can, a bit of catastrophic coverage on top. From his perspective: he schedules every visit for an hour slot, can always offer same-day appointments, gets to see pretty complex people for long enough to really sort things out right, manages as MUCH as he can from his office for people with no other insurance, and even on the runny-nose visits, he can use most of the time to check in with people about ongoing care and psych and lifestyle issues - ie, he gets to actually help people stop smoking and lose weight in real ways, rather than 30 second lectures. And people are SO GRATEFUL. It's amazing and awesome.

Only problem: he doesn't make nearly as much money.

PM me if you want any more info about him / his practice.

And, good luck - that sounds so hard!!!

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6 years 9 months ago #88442 by CMR

vitaminng wrote: I just find myself being stressed out, rushed, and unhappy trying to fit into this time constraint. I feel like it's not a good way to practice medicine.


That was the main reason I left primary care medicine (pediatrics). Our acute appointments were scheduled every 10 minutes. That's fine for a quick strep throat, but my practice involved a large underserved population, and a quick strep throat visit was the exception. The rule was an asthmatic with an acute flare who hadn't been taking his/her controller meds--didn't even really understand what a controller med was. Trying to treat the acute problem as well as address the chronic nature of asthma in 10 minutes was obviously impossible, especially with all the documentation requirements of an EMR. I kept thinking, there must be a better way!

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