Just sharing because I'm amazed at the audacity. Had an 18 yo pt see one of our midlevels for some heat exhaustion last week, no big deal. Then I got a message from the triage nurse asking if I had hand written a work note for this pt. I told them no, the midlevel saw them, note would have come from them. Pt's employer called to verify the note because it was giving the pt off for the rest of the month, and my name was signed on the bottom. That kid's going to learn a very adult lesson today...

I graduated residency and started my first attending job. I felt so excited and really liked the physicians I was going to work with and still do, they’re great. However, I’ve found out that apparently staff have been talking about me behind my back. I feel like it’s a weird environment to gossip in, you would think people would be past this. This “feedback” only comes after I make any request to staff members (like can you make that patient as a no show, minimal things like that). I’m at a loss because I feel like I’m generally a happy person and I do have a passion for medicine. I don’t talk down to anyone and am always open to feedback. I’ve been told I’m doing great clinically. Apparently, the staff has “hazed” some of the other physicians in the past as well.

Anyone deal with this? Have any advice? No one says anything to my face… I hate gossip and really don’t want to be a continued target. I’ve already talked to the manager about this once and was told everything is fine and the staff were just getting used to me.

Edit: Thank you guys! That puts things in perspective. I think it’s getting to me because they’re now starting to tell my manager who told one of my coworkers that I am declining patients/ not meeting productivity even though I am not RVU based yet. Which I have proof in text messages that I have not “declined patients” and why would staff have any input in my productivity numbers? The feedback to me made no sense. I’m just not used to this.

I also found it odd that manager didn’t just tell me instead of using my coworker. -__- it’s so unnecessary. I just want to see patients and leave.

Here’s my candidate:

Home health company called to notify PCP that they would not be able to see the patient today due to having a PCP appointment scheduled at the same time. 

She left my office an hour ago. Getting this vital message to me required the time and effort of four people.

HH nursing or HH PT OT doesn’t work unless there are very specific indications. I know a lot of what a person qualifies for depends on their finances and so I typically recommend speaking with a social worker, but people don’t like this. What do you guys do?

Thought I would ask if anyone else has seen patients taking retatrutide from off the internet who are having biliary colic. I have a 48 yo female whose been on it for six weeks and all of a sudden had textbook biliary colic. Only problem is that the initial ultrasound shows no stone disease, sludge or wall thickening! Wasn’t sure if anyone else has seen this?

Had a patient leave a note at the front desk for me to sign saying I medically clear them for esketamine at a ketamine clinic. Had my MA call them and ask what they wanted for medical clearance? Got a call back with them asking for a peer to peer.

What the heck? Another prescriber is asking for medical clearance for a medication they will be prescribing and they want to do a peer to peer about it?

Has anyone run into this before?

Hello, I am currently an M2, very interested in family medicine. I was wondering if any family med docs would be willing to share how much they spend on insurance, like health, dental, vision, life, and malpractice. I know there are price differences based on whether you are W2 or 1099. If you could also include what state you practice in and whether you have a spouse and/or children, that would also help. The only reason I am asking about this is to get a better idea of how my finances would look in the future. I am completely aware of average salaries for family medicine docs, and it is not something that deters me from the field in the slightest. Thanks in advance!

Regards,

A curious lowly M2

He gave me his card and boasted about movies he's produced... I'm not really sure of the right word, I don't know what producing a movie is. The point is he worked in movies and he was successful.

His website has photos of him with movie stars and he is dressed extremely well. He drives a bright colored very expensive sports car and his cologne is loud and smells fantastic. His shoes are either perpetually new or he gets them cleaned professionally every single time I see him. Why am I seeing him in an FQHC with his medi-cal?? Well, saw. His insurance changed so I'm not seeing him anymore.

Hi all, I just finished residency and I have about 2 months until I start my new job. I was wondering how you all navigated having no income during this time. I am thinking I can ask my job if they'd give me my signing bonus before starting, but I feel weird asking for that. Would anywhere give me locums work for just 1-2 months?

I have been attending for 2 years and I question whether I handle situations correctly. I have been handling some situations slightly differently and I feel like it has really helped prevent burnout and make the job less stressful. Would you please review each of these scenarios and give me your thoughts on how I handled them.

1a. I have had this situation more than once. How do you deal with patient coming in with foot pain on going for a few weeks, foot feels cold, discolored. Symptoms have been stable. You're worried about chronic limb threatening ischemia. You dont have dopplers in clinic and you cant feel pulses in legs. Do you do STAT US arterial lower extremity, start clopidogrel + statin, if significant forPAD send urgent referral vascular?

1b. Patient is a diabetic, comes in with new foot ulcer that is red and painful. Vitals stable. Would you place on Augmentin, get xray and urgent referral to podiatry for management of possible osteomyelitis.

1. Previous PCP started patient on opioids for lumbar stenosis. Has been on regimen for a few years. I continued the opioid. Tried to taper off however patient resistant. A few months later patient brings me Department of Transportation paperwork to fill out. I do not think you should be on opioids and driving DOT vehicles. I refused to fill it out. Patient is unhappy with that. However, in my mind I am not can to sign off on you driving a truck while taking prescription opioids.

2. Obese men that are fatigued. I don't care if you want your testosterone checked. You need to loose weight, that's why you so tired. Should do a sleep study, CPAP will likely help you. Will not start you on testosterone unless you loose weight, if you want testosterone can get it from somewhere else.

3. I have a fair amount of patients with depression and anxiety. It seems like everybody wants a medication-a quick fix. I counsel and offer SSRIs, therapist etc. Meds have helped a few people. However, when I listen to these patients all of them have the same problem. Their life is a mess (dysfunctional marriage/family, no exercise routine, money problems, work stress). I do not often tell these people what I actually think, and I am thinking I should. I often want to say medication can be helpful, but I think your problem is that you need to get life in order. that is on you, and no doctor is going to help you with that.

4. I inherited a lot of patients on opoids, opoid+benzo. Ive been continuing current doses with trying to wean them. I'm doing UDS and pain contracts with these people which prior PCP did not do.

5. Patients often call my office or MyChart message with symptoms. Examples include I am having intense abdominal pain and anything I eat I throw up; my baby looks yellow, stomach feels firm and they are not eating; dark stools and dizziness in elderly patient ect... My schedule is usually full and I have no space to see these patients so I started to tell my nurse to have them go to ER instead of squeezing them in to see me.

6. Patient in clinic asks me "I want to apply for disability" or " I need to get on disability, will you do that for me?". I tell them I do not fill out disability paperwork and refer them to Social Security office.

7.Sometimes I get faxes from what looks like a private insurance company disability evaluation request. It asks me to evaluate how much the patient can lift and what range of motion they have in their body. I always tell them they need to go to occupational medicine for functional capacity evaluation and need specialist to fill out what ever they are claiming disability from.

1. FMLA or short-term disability for an obvious recent acute medical problem (admitted to hospital now discharged and recovering, family member who passed and you are grieving, broke your foot….) Sure no problem will fill it out. However, if it is a specific surgical issue I will tell him the need to surgeon to fill it out because I have no idea how long it will take you to recover.

2. Tachycardic and pleuritic CP. Order d-dimer in clinic. If elevated send to radiology for CTA Chest ( we can get it done same day when ordered by PCP) If BP good and heart looks good start on eliquis and send home with percautions.

3. There is never a reason to order a troponin in outpatient clinic for a patient with chest pain. Just send to ED if your mind is going there.

4. Unless patient has acute illness, just go get your cataract surgery. There's no med i'll tell you to hold

5. stop doing colonoscopies at 75 unless patient had polyps on prior and patient wishes to continue screening as long as they are in generally good health and are aware of risks and benefits.

6. IF you are scheduled for a wellness exam and you bring up any issue, I'm sorry you are atleast getting billed a 99213 +g2211 on top of your preventative visit. I've been consistent with this.

This is probably more a vent than anything, though if you have advice I’ll take it.
I work at an FQHC in the north east but I have so many patients traveling to Miami for BBL, breast aug, liposuction, tummy tucks, etc. that require that I order labs, EKG and “clear” them for surgery. The problem is, sooooo many of them come back literally hacked up with absolutely no recourse from the surgeon. Some are uninsured so when they come back with their entire abdomen dehisced, they’re not willing to pay to go to a wound center and it turns into an absolute nightmare. I feel uncomfortable shouldering any liability for these fly by night “surgeons” who are obviously praying on people with very low health literacy. I usually put in a blurb about how the surgeon ultimately determines the risk to the patient but I see this situation often enough that I’m just at a loss.

Hey everyone, when it comes to adult ADHD, do you guys actually diagnose yourselves, and realistically how long does it take? Was talking to a GP compatriot recently who claimed they do the whole assessment including scales in 20 mins, but I've always avoided doing them myself because I figured a real workup takes too much time. Curious how the rest of you handle this or if I'm missing something.

I work for an employer as an ‘at will’ employee. It would seem that I can be dismissed with or without cause, and without notice. How much notice should I give them as a courtesy when I move on to another job?

eta: i don’t have a contract per se, just a letter outlining salary, duties, the at-will clause, etc.

Drug reps hawking new aldosterone synthesis inhibitor drug Baxfendy. Can’t find much about it yet. AAFP certainly hasn’t said anything that I can find. Read a few promising studies. I imagine coverage with be little to none, insurance wise. Just wondering if anyone has any thoughts or good resources. For now I’ll keep my love affair with Telmisartan going strong.

Has anyone worked locum tenens as a PCP or done it after residency? Did you get positions where no one wanted to work or had toxic environment? Why did you decide to do locums? What were your experiences, and what advice would you give to new graduates?

Do you recommend contacting hospitals directly instead of using locum recruiters to avoid potential pay cuts?

When negotiating locum PCP roles, can we specify preferences such as the number of patients per day, the types of procedures we’re willing to perform, OB vs no OB, and the patient age range we want to see?

What hourly rate would you suggest we ask for in Mid-Atlantic and northeastern area?

Hello All!
Is anyone taking boards later this year ?
Also those who have passed what all resources helped you the most ?

Fellow docs who schedule/bundle wellness visits with followups how are we explaining this to new staff?

My old practice this was automatic and all of the mas were aware. I've had sit-down conversations with the mas to discuss this, however it's consistently missed. Regarding scheduling. I think the main issue seems to be from the schedule itself on epic as there's a separate scheduling visit encounter for wellness visit that triggers the health risk assessment being sent out, etc.

I've always operated with Medicare/ Medicare advantage people being scheduled every 6 months for chronic medical issues unless needinng to be seen sooner or they are completely healthy and only get screenings yearly. The Medicare wellness visit usually falls under a 40-minute visit for one of those follow-ups and then the visit in 6 months is just a 20 minute 6 month follow-up.

We are currently having a lot of access issues along with chart audits showing under billing as providers are doing wellness visits with components of an e&m visit. When looking at scheduling, a lot of people are scheduled for wellness visits, however are being missed on metrics as some providers don't want to trigger an additional copay if they do bill an e&m

Obviously a lot of this is education to the other providers. However, it seems like the explanation for this is too confusing for the provider. My MA typically schedules a 6-mon follow-up and then on the visit complaint shell type plus awv and put it in a 40-minute slot to remind her. This works very well for our team, however, we're having a hard time getting other teams to adopt this.

This would avoid the inevitable phone call of why do I have a copay for a free visit. We already alert patients with flyers about preventative vs eval with pamphlets but I'm trying to attack the other side.

Next year.... Medicare advantage plans not being seen for physicals as well...

Any insight from the masses? Haven't found a good resource to hand to staff for this.

Anybody have advice on a patient, 74 yom, with delayed orgasm, gradually getting worse. Estrogen was high, so put him on anastrozole .5 mg q wk. Now testosterone and estrogen are normal but that does not seem to have helped. He is otherwise healthy, very active, no problems with erections. Other meds include lamotrigine 100 bid for mood, and doxazosin 1 mg qd for bph. No improvement when those were stopped for awhile.

There are lots of treatments and even dedicated clinics for ED and premature orgasm, but I am finding nothing for this. Urologists are generally interested only in surgical diseases. But FP’s know everything, right? We regularly get the stuff specialists have no idea what to do about.

In early 2026, G0136 changed from SDOH to what looks like "diet or exercise" assessment -  “administration of a standardized, evidence-based assessment of physical activity and nutrition, 5–15 minutes, not more often than every six months.” Are you all coding this? Our HRA includes the Physical Activity Vital Sign - if I add a nutrition screener and get to 5 minutes total diet/exercise, could I code G0136? I'm also interested diet OR exercise vs diet AND exercise -- specifically how you address this.

I am feeling like a patient seen for GLP1 could get a G0136 (diet/ex) or brief obesity counseling or G0537 ascvd etc - or a combination. Frustratingly my site doesn't have any standardized phrases, nor any coding assistance to avoid billing too freuqently.

--------------

The tool used must be tested and validated through research. Examples of nutrition assessments include the Mini-EAT tool, Starting the Conversation: Diet tool, and Short Dietary Assessment Instruments. --> what is the most useful & concise?

Examples of physical activity assessments include the Physical Activity Vital Sign tool {EPIC's] , CHAMPS Physical Activity Questionnaire for Older Adults, Rapid Assessment of Physical Activity (RAPA), or Telephone Assessment of Physical Activity (TAPA). The code is payable when either or both assessments are performed.

I am done with residency and will be starting my first attending job soon at a rural critical access hospital. My training has been in an unopposed rural FM program with a busy outpatient clinic, inpatient service (cross coverage with 8-15 admissions per night), open ICU, and emergency department. I've been fortunate to get a lot of hands-on experience with outpatient procedures (joint injections, skin procedures, etc.), ICU care, ventilator management, intubations, central lines, chest tubes, and the usual inpatient/ER management.

The job will be mostly outpatient clinic (4-day work week), with ER and inpatient responsibilities one weeknight each week plus one weekend in every five.

I've already asked to meet with the clinic manager before I start so I can understand how everything works and set expectations early. Some of the things I plan to discuss are:

• What my typical daily schedule and template will look like.
• Inbox management and expectations (results, refill requests, patient messages, etc.).
• How FMLA, disability, and other paperwork are handled.
• Expectations for documentation and turnaround times.
• Whether I can eventually dedicate part of a day to procedures once my patient panel grows.

For those of you practicing in similar rural full-spectrum FM jobs:

• What surprised you the most during your first year?
• How did you learn billing in this kind of environment?
• What do you wish you had discussed before your first day?
• What expectations or boundaries are worth establishing from the beginning?
• How do you keep your inbox and paperwork from becoming overwhelming?
• If you have a dedicated procedure clinic, how did you build it?
• Any advice for balancing clinic, ER, inpatient, and call without burning out?

I'd especially love to hear from physicians practicing in rural critical access hospitals or similar full-spectrum FM positions. Looking back, what advice would you give your new-attending self?

Any family APPs that can give some insights?

I work for a family practice now and I’m struggling with the expectation regarding number of patients/schedule capacity versus managing other tasks, including prescriptions; inbox, note routing, labs etc.. i’m coming up on two years of practice and know that there will always be much more to learn and skillsets to improve on. However, I am feeling so burnt out. The pay is less than make as a home infusion RN. The practice is fairly small but growing rapidly. We have 2 docs and 4 APPs and no additional support such as RNs/LPNs.

If you’re comfortable with saying:
\\-how much are you making
\\-what is your location
\\-how long have you been practicing
\\-how many patients do you see daily
\\-any tips and tricks for a struggling FNP

Thanks so much!

This is part rant, part discussion.

Lately I’ve been getting really burnt out with MyChart messages. I know we all dislike it and there’s plenty of posts about how much it sucks.

I have a good triage system, I’ve told patients that it takes me time to reply on MyChart, or even just having them schedule an office visit.

The problem is, even with ALL of this in place, my inbasket still gets flooded with MyChart messages. Honestly part of me doesn’t like to take days off because of how much crap I come back to in inbasket, which sucks because vacation truly should be a break and time for relaxation.

We have the option now to convert them to E-visits, which I’ve been doing more frequently if I spend more than 5 minutes on something or if a patient asks for a med change that may not require a full office visit, or if they have an additional question after being just seen, or requesting a referral we haven’t discussed before. Many times I do recommend people make office visits, but I’m also booked out for months and while I can sometimes work people in, I can’t do it for everyone. And quite frankly many of them are extra work for me that I normally wouldn’t get reimbursed for.

So I’m curious how often or how many of you have been using this function?

Hi FM docs,

I'm pretty dead set on pursuing family medicine and I'm looking for some advice on what elective rotations might be useful down the road. My current list is derm, PM&R, ID and opthal. I'm trying to decide if nephrology, radiology and/or what other specialty that you think might be useful for my education.

Thank you so much