× Women Physicians

Not happy with outpatient IM. Need career advice!

6 years 9 months ago #88496 by displaced
Hello! You're not alone! Check out "A Survey of America's Physicians..." by Physicians Foundation. About 60% of physicians surveyed would not recommend medicine as a career, and more than 1/3 of us would not become physicians if we had to do it all over again. That's significant and incredible!
I am currently working in a clinic with time slots and am STRESSED and have more bad days than good. And a just heard a colleague crying the other day because she was having a crappy day and they were just stacking patients up and up on her. I have also worked part-time at an urgent care center. This was low stress in that it didn't matter how long you took with patients because it was not appointment based. I also worked as a teacher. That job was stressful because of the long hours (FT+), and environment. I would probably have done best with the part time urgent care but the commute was a pain so I changed. Now I wish I had asked to work less days.
My advice is try to work part-time. This will lower your hours, stress, and work load significantly. After residency we feel that working 50-60 hours per week will probably not be a big deal (and I guess relatively that's true-ish). But it still sucks, especially after spending all that time just to get where you are.
I think doing a fellowship at this point, unless you have a burning desire, will just mean 70 hour weeks for the next three years, and then you'll be in the same position, except 30 min slots for sick patients.
I can't speak about concierge medicine, except you'll basically own your own business, which may be good or bad.
If you decide to go non-clinical, try to work out a day a week of still seeing patients to keep your foot in the door, because it can be hard to return if you're away from patients too long.
If you don't hate the hospital, consider a hospitalist position, where you can squeeze in shift work probably easier than a clinic position (for instance, working a few 24 hour shifts per month and that's it!). Even some ERs hire docs that are not ER trained to fill shifts.
Unfortunately, the biggest obstacle for a lot of us is our huge student loan payments. But there are new payment programs where you pay a maximum percent of your salary, and if it's not repaid in 30 years the rest is forgiven, so you can still survive on whatever salary you have.
I wish you the best of luck! I think if you find a career non-clinical that you enjoy you can make it work, but getting back into clinical medicine afterwards can be hard. Even then, clinics that serve inner-city are usually hiring anybody.

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6 years 9 months ago #88548 by vitaminng
Thanks for the responses everyone! Quite honestly, hearing your words of empathy and knowing that I’m not alone in my frustrations helped me feel better.

A really common recommendation from people seems to be “cut down on hours.” Unfortunately, I can’t afford to do that due to my high student debt burden. But maybe in a couple of years (particularly if I’m able to make partner), I can leverage less work hours.

With respect to concierge medicine, I’ve tried looking up different practices online, and from what I can tell, most people have existing private practices that they then convert into concierge practices by sending their patients notices and letting them know that they will only be able to continue seeing patients who are willing to pay an annual fee. I would literally need to start from scratch and build a solo concierge practice or be lucky enough to stumble into a private group practice that already has that model set up or would be willing to convert to a concierge practice as a group. But @AmmaMD, your friend’s practice sounds like a very rewarding experience!

As far as time slots and coding—I am not able to schedule complicated patients for 2 time slots. Everyone gets 20 minutes. I do believe the “same day” and “walk-in” appointments are in strategically designated spots to break up the day, but I honestly did not look at the distribution in my schedule that carefully. For my most complicated patients, I code a level 4; someone told me that a level 5 would essentially be an inpatient-level encounter. However, I am a salaried employee—I get a base salary with bonuses based on whether certain clinical metrics are achieved (a hypothetical example would be X dollars if >95% of my diabetics achieve a hgba1c <8%).

I re-read my original post, and realize I must have been extremely cranky when I wrote it! I am not so gloomy and pessimistic anymore. While, I don’t honestly love my job, I am back to liking it. I am committed to staying with this job for at least a year, and hopefully three years (which is when we’re up for consideration for partnership). I am now focused on finding ways I can be more efficient—like @Twinks and @English recommended, I am trying to make my note templates as complete and pre-populated as possible, so there’s less de novo typing I have to do. I am also trying to make more smart text scripts for common situations (i.e. so with a few keystrokes, I can generate a blurb to let a patient know all their labs are normal or that they have a new diagnosis of prediabetes, etc). My next project is to create preference lists for my common order sets, so I don’t have to keep typing in individual order names. Unfortunately, the primary care departments do not use a dictation system. Lastly, I am going to FYI the scheduler that I am actively trying to give up my night clinics—I know of other physicians who are trying to pick up more shifts for various reasons (i.e. paying for a wedding). To be truthful, I actually don’t mind Saturday morning clinics, because if I didn’t get up to work I’d probably be sleeping in and I wouldn't otherwise be productive. The last thing I'm doing to try to make my work day shorter is to work through lunch so that I can at least be caught up with my morning notes and make a dent in my inbox-- this last change does make me a little sad, as I had originally vowed to myself that I would always take a lunch break to slow down, breathe, and spend some time outside to enjoy the perfect SoCal weather to preserve my sanity. But now I realize that getting out of the clinic before 6pm is much better for my mental health. With respect to using consultants—sometimes I worry that the consultants will think that a) I am sending too many referrals or b) they are inappropriate referrals or c) that I am expected to do more of a work-up prior to referring patients. Where I work, the consultants are also salaried, so they have no incentive to amp up the volume of patients they see and you can tell that sometimes they are not so happy about getting new referrals. Also, while I am still an associate and being considered for partnership, I get evaluated by various subspecialty departments—so it really does make you more mindful about whether a patient should be referred or not! Also, @English—I am starting to use the tactic you talked about…if a patient is really giving me push back about wanting antibiotics, I will do my little educational spiel, then tell the patient I will order the antibiotic and the patient has the option of picking it up if their symptoms do not improve in several days. I haven't had a chance to check back with a patient to see what they end up doing, but I have a sneaking suspicion most of the patients run to the pharmacy immediately after the encounter to take it the same day!

@Displaced: For now I am committed with staying at my job and trying to optimize my practice efficiency, but I will for sure have the option of going into non-clinical work in the back of my mind and keep my eyes peeled for job listings and opportunities. But I think your advice about maintaining one clinical day a week is sound, since I have also heard that getting back into clinical work after a long absence is tricky.

Anyway, I just want to sincerely thank everyone for their great advice and for commiserating with me! Honestly, just knowing that there are other people out there who feel the way I do and who are also trying to survive as well, has helped me feel not so alone and less upset about my situation. This seems like a really great community of women, and reading everyone’s supportive words here (as well as on other threads about unrelated topics) has helped me a lot.

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6 years 9 months ago #88643 by raml18
Hi! I'm also new to this forum and actually found it because I was looking for some answers since I am in the same exact situation as you are. I also graduated in summer 2012 and went into outpt IM and I'm dealing with almost the same issues as you are. Lately I've been thinking maybe private practice is the way to go but I'm not even sure. I am looking at several options but I don't want to rush again into a decisions and end up with something I won't like again. I write just because I wanted to tell you, you are not alone and we will figure something out that will fulfill our professional and personal life even if is not practicing, might even be educating. I'll write back soon, hang in there...

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6 years 9 months ago #88647 by Twinks
I'm jealous vitaming! My a1cs have to be less than 7% and their LDLs under 100! Bah!

The years are short but the days are long.

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6 years 6 months ago #89691 by Jes
This is very interesting as I am having the OPPOSITE problem! I am about to finish IM and go into heme/onc and unsure if I have the endurance for another three years. I posted about it "Thinking I made a mistake". Would be interesting to hear what you thought of that, it is just eating at me right now and going day to day feeling like I have "big brother" (residency and soon fellowship program) over my shoulder is just getting old.

I hope it was a wise choice, it felt so right before and now with it looming, I just don't know...

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