What I learned I should have asked/done in my first year of practice

If you are taking on someone else’s practice, you will also be taking on their mistakes and successes. It will take time for their patients to trust you.

Booking in Patients: Unfortunately, b/c the Ontario Government can’t get their heads out of their collective ass, you won’t have the luxury of “ramping up”.  Because the patients are going to be coming in at full speed, you will need to have a plan. I made a few hours every day my “meet and greets” where I would get families to come in to meet me and go through their health history to get me caught up. Priorities were patients with diabetes, using narcotics, with cancer, polypharmacy, etc. My staff helped flag them as they refilled their meds. 2 - 3 hours were for seeing acute patients/patients that were booked in over the past couple of weeks. At least one hour for labs, scripts and reports.

No general assessments for at least 6 months. If a patient is due for their pap, either divert to an NP or have them booked in for just a pap. Lots of your patients think they need a general assessment to see you. Have staff ask if a meet and greet will do what they want. 

Spend time with each patient’s chart updating it to fit the way you want to practice. It will save you lots of time in the future. 

Your access time in the first year is going to suck. Get over it. As long as you are treating your patients well when they come in, they will forgive you. 

Med Refills: They will be on meds that haven’t had the appropriate labs set up in ages. Set up standard labs and protocols for patients who are calling in for scripts and have your staff automatically order what you want (e.g. LFTs for statins, metabolic panel for antipsychotics, TSH for Li and synthroid…). 

Decide what your rules will be for certain drug classes (opioids, benzos, etc.). My rules were considered stringent by my patients in my first year. I was very clear about max amounts of morphine equivalents I was comfortable with (200). Anyone above that had to see the clinic pharmacist for a review and to see if there are changes that can be made, if the level of pain management is appropriate. Use the McMaster Pain Guidelines. Having the objective tool makes it easier to be firm. http://nationalpaincentre.mcmaster.ca/opioid/  I asked pain and bento patients to be in q4months. I wouldn’t renew scripts unless they came in. Drug testing was mandatory. 

Money: Get everything in writing. All the little bits and pieces that you are paying for in your overhead. Do any of your billings go directly to the clinic? Who is in charge of your billing? How often do they go for training? How do they deal with billings that get sent back? How is overhead split? Do you have to pay rent for the FHT staff or just your FHO staff? Who exactly contributes to the pot for your clinic? Is it the same people who are using the clinic? If you are working rurally - dose your ER billing go to the same billers? hospitalist? OB? 

Governance: How are budgeting decisions made? What makes a vote go through (i.e. is it majority or unanimous?) How are disagreements within the group managed? (ask for an example) What committees will you expected to be a part of? How many days vacation do you get? How does your team feel about you going on vacation? Are locums expected or will they cover your patients when you are not around? Does the team have a plan for mat/pat leave? How many hours are you expected to devote to in clinic time? Who manages your staff? How is that person evaluated? What sort of observation/probation does your team use?

What to expect in your first year of practice.

Every borderline personality patient will come out of the woodwork and want to be your patient. The kind things they will say, the flattery, the sob stories, oh, my, god, will they make you think you need to take them on. You do not. If they have a doctor, you are covered, so are they. Ask them to apply again in a few years when you are able to breath air again. 

You will see more cancer than you ever thought possible. The patients you are seeing either haven't seen a doctor in 20 years, or have not been followed as tightly as a new doc will. You will see the lumps and bumps that their previous physician missed, not because they are incompetent but because they are too familiar with their patient. 

The number of labs that you are ordering are going to be tsunamic. (Is that a word? It should be.) You think that you need to know everything about every patient. I sure did. I don't regret it. But it did mean that I needed significant amount of time to review it all, then do the follow up labs, investigate the things that went wrong...

You are going to want as much money as you can get as quickly as you can. I promise, it will come. Take an extra 6 months before expecting to pay down significant portions of your loans. Until then, take your time rostering patients. Taking on too many right away will make things impossibly hard and you don't need that. Taking on too many responsibilities (long term care, oncology, etc.) will put you under water too quickly. Don't do it. 

Keep in touch with friends. Everyone says to do it. No one does. Make actual dates and keep them. Spend time with people who are not your patients, employees, colleagues. Gossip about pop stars and athletes. 

Make dates for massage too. At least monthly. And with a therapist. Even if it's spent just getting to know each other initially, there will be times that you need an impartial person to call you out on your bullshit, remind you to complete your self care, to tell you whether or not this medical culture we call home is reasonable or not. They can help you will your relationships. Just get one. Seriously. 

Book all your vacations and conferences as soon as you can. Plan your whole year, don't let it get to the end of the year and you don't have time to get away. This way you can get locums if you want to cover you, get early bird deals, get the vacation you want. Use your maximum vacation and CME time. Do not use your time off to do paper work. That's not time off.

Book an hour every day that is just for you to book. You can book it in advance, the day of, or not at all and use it for napping. Spend the time the way you want to. You may not know at the beginning how you want to spend that time, but eventually you will.