I earned $4,750 of gross income working at this clinic for 5 days. That’s 30 hours and 55 patients. This article is about my community health center work experience as a primary care doctor.
I say ‘Primary Care’ because as of this writing in 2019, I can’t tell anyone that I’m a Family Medicine doctor, California won’t allow me to do that. The ABMS has trademarked the phrase “Family Medicine Physician,” for which they are being sued.
So, for the time being, I’m a Primary Care doctor. And for the time being, I’m still able to earn good money as a doctor in California despite my 18-page criminal record on the dreaded NPDB.
If you haven’t done so, I would recommend that you obtain a Self-Inquiry to see if any previous employer or potential employer has entered anything negative about you on your professional record.
Guys, the work in this community health center clinic was as easy as refilling a prescription. Primary Care Medicine … I legit forgot how easy it is compared to Urgent Care Medicine.
I really had to earn my money in the Urgent Care. I saw 50 sick-ass patients in 10 hours, not counting all of the cases for which I was curbsided. I was constantly multitasking and doing procedures and babysitting patients on IVs or waiting for studies to be done.
That first couple of days, I only saw 5-7 patients. The clinic ramps their per diems up slowly until you get to know the EHR. I was getting bored, so I asked for a full schedule.
I got that paper check hand delivered to me since my mailing address is out of state. So that was easy money right in my pocket.
I snapped a picture with my bank app and deposited the money. The only money I’ve earned which was this easy was money from my consulting clients.
I will set aside 15% of this money for income taxes. For the last 2 years, I’ve only paid around 12% for both state and federal income taxes – so it should be more than enough.
Primary Care Medicine
In a Primary Care clinic, you’re dealing with 1 patient at a time. They come in and tell you about their chronic issues and you address them one-by-one. Maybe they are there for a physical or well-child check or prenatal care.
The hardest part is sitting there on the computer, figuring out how to enter everything into the EHR.
The patients are incredibly grateful. They are accustomed to having NPs handle their cases. Not that NPs are bad but my patients have expressed how nice it is to see an MD.
I’m very efficient and so I’m fast in clinic. I’m able to address a lot of things in a single visit. With the majority of patients I’m able to discuss diet, exercise, and manage their chronic medications.
This feels really good. It gives me that warm fuzzy false feeling that I’m actually doing a lot of good for my underserved patients.
Picking Up Extra Shifts
My assignment is to work 4 days a week for a total of 30 hours per week at $100/hour in this health center.
I can pick up plenty of extra work. I can see patients later into the day, and I can pick up shifts on other days of the week, except for Sundays.
The upside with picking up more work is that you’re already in this strange new place doing a locum tenens gig. If you’re not doing anything too interesting, you might as well maximize your income.
The downside is that it can wear you out. Depends on you. It makes sense if the work is easy and you can feel good about offering your patients more access.
Negotiating the Income
My clinic manager asked me the other day to pick up a shift on Saturday. I said I wasn’t interested so she offered me a full day’s pay for working only 4 hours. That would have been $200/hour.
She asked me again if I wanted to pick up a Friday and when I kindly declined, again, she offered to pay me extra money.
The point is that you can negotiate a higher pay for any work you do on top of your set schedule. I think it’s worthwhile. Maybe next week I will take advantage of this and write about it.
High Volume Provider
You know, back in the day I would see anyone and everyone. I would have the nurses add as many patients as they wanted to my schedule. I’d stay later. I would take the difficult drug seekers and chest pain patients from other providers.
I always felt like every clinic needed that kind of provider who was willing to do the hard work. And I was fortunate in that I was fast and thorough enough (in my head, at least) to be able to see more patients.
My good friend Tim always said that it doesn’t make sense to force every provider to see the same number of patients. Let those who are fast be fast and let those who are slow be slow – in the end it all balances itself out.
Looking Out For Myself
But I’ve changed my ways.
I learned the important lesson that your employer can throw you under the bus if they need to. And the medical boards will hang you for the things you did wrong.
You don’t get credit for the things you did well; there is no bank account which keeps track of the good and the bad. You don’t build up credits in the world of medicine. When the hammer comes down it’ll ignore all the those days you sacrificed your fucking sanity fo the sake of patients and the clinic.
But you can say no without being harsh; there is a sweet spot. I had 2 very difficult patients added to my schedule yesterday because the other NP’s couldn’t/wouldn’t see them. I happily accepted.
But it came with the caveat that if they’d like to add 2 to my schedule I would need 2 moved off of my schedule. They happily obliged and the medical universe was in harmony again.
l would have never asked for something like this in the past. Maybe I’ve matured or maybe I’m joining the rank of jaded doctors.
Complicated Clinic Cases
In this week of work I saw maybe 60 patients. The majority of which had no health insurance and were considered minorities. And most had several chronic diseases.
The chronic diseases are easy to manage; increase the diabetes medications, add in the insulin, add in another blood pressure medication.
The difficult cases for this week required a lot of legwork. You have think outside of the box in a Community Health Center because you don’t have the resources.
I had a 2 year old with severe, uncontrolled asthma. Impossible to manage at home. lmpossible to get a nebulizer for.
I had 1.5 month old with cough, low-grade fevers, and congestion. Fevers in infants under 2 months of age are tricky.
And a 50-yo dude with gradually worsening right elbow effusion. It’s since turned into a fairly solid mass with enlarged nodes near the right clavicle. The elbow is the size of a knee. I suspect a malignancy.
And finally a diabetic woman with swelling and pain in the left thigh. Probably diabetic myositis. She was crying in pain and it’s been going on for several weeks and getting worse.
Punting or Addressing
What do you do? Do you handle these cases with the care and attention they deserve or do you punt them to the ER?
Do you just keep the patient waiting until you get the next test and control their symptoms in the meantime with medication?
Or do you sit there and get every piece of history you can. Maybe attempt that joint aspiration. Call every place nearby to get that last-minute chest xray on the infant? Attempt a muscle biopsy in clinic or at least find an endocrinologist whom you can get on the phone on a Friday evening?
I look back at my medical career since 2006 and I ask this handsome Dr. Mo if worrying about these patients and sweating over them is worthwhile.
I’m 13 years into my clinic career and I’m torn. I don’t have a good answer and that makes me feel inadequate.
Many Close Calls
I had a guy who didn’t get to the low-income pharmacy in time to pick up his insulin. That pharmacy is now closed until next week. He’ll be without his long-acting insulin for nearly a week.
My initial thought was to send him home with pre-filled syringes of insulin so that we could get him through the rest of the holiday week.
Then I realized that I was about to do what I did a couple of years ago which got me into all of this hot medical board mess that I’m in now. So I quickly passed on that idea and did the safe thing – I punted the patient to nearby Urgent Cares where he’d have to pay out of pocket daily for his insulin shots until the pharmacy opens up again. Bummer.
I had another lady who needed quick blood sugar check because she didn’t have a glucometer. But she’d already been seen that week for a cold and didn’t qualify for another free visit and would have to pay $60 for the visit.
Just do a quick back office glucose check, document it, and send her home? No. Dr. Mo-2.0 can’t get caught up with that mess again. I refused that option and told let the nurses know that she’d need to be checked in before we could check her sugar.
The last case was a new onset diabetic who was my last patient for the day. Glucose of 400 and ketones in the urine and dehydrated. She needed some blood work and some insulin teaching and a 24-hour recheck.
I could have easily done it and seen her back the next morning. She desperately wanted to avoid going to the ER which would have been a 6-hour ordeal in South Central LA.
But I had a QA case at Kaiser for exactly this kind of issue. So no, sorry, she had to go to the ER because I’m not ready to hang for any of my patients anymore.
I’m so tired of having to make these decisions. It’s harder for me to punt these patients instead of just handling it right then and there. But that’s the fucked medical universe in which I find myself.
Maybe I’m wrong. I have no way of having my shit checked. Half of my physicians friends say I did the right thing. The other half say that I should fight for my patients.