The "P" is for Purgatory (or Plan of attack)

Now that you know what you're up against and what to expect, it's time to plan a strategy for getting through it. At over 9,000 bucks for the privilege of working for free for 4 months, and so many requirements to meet, you've got to be proactive if you plan to finish on schedule. Here are some gems that were handed down to me. Some of them are rule-benders (if not outright breakers), but they're "the way it's done" in order to get out on time. Because I'm selective about who I tell about this blog, I'm OK sharing this stuff here, but don't go blabbing it to just anyone, because it will inevitably get around to the Unfriendlies In High Places, who will predictably close any loopholes and insert new obstacles just for good measure.

First things first. Day 1 of Tri 1, they spring the 10-Recruit requirement on you and advise you to start getting them in right away. Right? Well, yes and no. Recruiting patients to outpatient clinic before you're actually an outpatient intern is a double-edged sword. You should do so because the profs are right: you can start getting patients in early. Not to mention that it's easier (they forget to tell you this part), because if I understood right, all the new patient has to do is show up for an exam and poof! They're a recruit. Once you're in outpatient clinic and you're recruiting them as your own patient at that time, getting the recruit credit isn't quite as easy. There's more to it, more steps to go through. However, be very, very careful who you refer your prospective patients to. Ideally, seek out an upper tri (the best way is through clubs that meet over lunch--that way you know you share some common interests) and form an alliance with them. When your prospective patient wants to come in, have him/her call you first and (ideally) set up the appointment through you. Act as sort of a liason. That way, there's no question in the upper tri intern's mind about the source of the patient. Most importantly, make damn sure your name and ID number appear all over the patient's intake paperwork (supply them with this and instruct them to specify that it was you who referred them). I never recruited patients in this way but I know some who did. Some got burned, but it was usually a lack of instruction given to the new patient, and a lack of following up on (and tracking) the status of the credit to make sure it goes in your name. I know others who did get almost all of their recruits in even before starting in outpatient clinic and they did quite well. It was nice to have that (often big) stress behind them.

So yes, we have to recruit patients. They're not kidding. People have indeed been held back from graduating simply because they didn't meet the minimum number of recruits. People who struggled through clinic saw that I was getting through OK (even though I did not broadcast this) and asked me how I did it. Patient recruits come from anywhere, as long as it's from the heart. Yeah, it sounds cheesy, but you have to operate from the right headspace in order for this to work. You can't act from a state of desperation, because patients are not stupid--they'll pick up on it in a heartbeat. So what to do? Be confident without being cocky, and step just a bit outside of your comfort zone. The most successful interns I saw pulled in fellow church members or fellow gym/healthclub members. One was a teacher at a massage therapy school and had a captive audience of 20-30 people over the course of 4-6 months with whom to build trusting relationships with, and a lot of them came to see her and/or referred massage clients to her. I was a massage therapist myself, with my own low-volume private practice. People were already criss-crossing north Dallas suburbia to see me, whether from home or from work, so it wasn't a big deal for most of them to drive out of their way to the clinic.

Parker also has a booth at the Texas State Fair. One word of advice: go. Sell the vouchers. Talk up chiropractic. However, make sure the other party is actually interested; I watched some of my (unfortunately) soon-to-be colleagues get obnoxious about it and start practically accosting anything with a pulse. Don't listen to those who say you won't get anyone at the State Fair. You have to operate from the heart and from a place of confidence, because if you are truly ashamed to be there or you think you're wasting your time, then you probably are. You won't get anyone that way. Be real, talk in plain terms to anyone interested, and see if they'd like to sign up. If you handle people nice and easy without putting on the pressure to "sign up today! But wait! There's more!..." then people will feel comfortable with you and if they were ever thinking about becoming a patient, you might just clinch the deal because you now own the most important part of their decision: trust. Another word of advice if you do the State Fair: dress nice (no polos) and when you sell a voucher, try to schedule them right there. (Yep, that means plan ahead and bring your available appointment times with you, written down. Cross them off when a patient schedules for that time so you don't double-book yourself.)

Most of my recruits were people I already knew. You can definitely go this route. If you have friends in the area, or family with a different last name, you can pull this off well. I brought in 3 friends and 4 massage clients. The hiccup was, the school suddenly enacted a rule (shocking) that patients had to attend the health talk after they'd had their exam, so that meant they could no longer attend the health class first and buy the voucher to use themselves. This means they'd have to pay full price ($100 plus) just to jump through all the hoops that finally got you recruit credit. How to circumvent: Line up a bunch of people interested in buying vouchers to be available to do so about 2 weekends from now. Go to the tally office and get the blue voucher kit request form. Fill it out (put your phone number as the contact and make up a location and health talk subject), make sure to check the box that you're doing a health talk ONLY, and NOT a screening (which requires a staff doc). Turn it in. Check back on the availability of the kit a couple days beforehand, because they won't hunt you down to tell you it's ready. Now you have the voucher kit for the weekend--make the rounds among your friends, sell the vouchers (following the instructions in the kit), and schedule the first appointments right then (take your calendar with you). Return the voucher kit on Monday. Not only did they get the voucher for the discounted package, but they also filled out the 1-page health survey that serves as their evidence that they attended a health talk. Now you don't have to rope them into attending one at the school.

Speaking of, let's talk about that little health talk/class every new patient has to sit through. The school claims it's a CCE requirement (nice cover, great excuse, and you'll hear this one a lot), but I don't buy it. Regardless, it's required in order for you to receive recruit credit (I'm not sure if this is the case if you're Tri 1-6, but I know it is if you're an outpatient intern). Some interns had some trouble getting their patients to attend one. (They only have to come to one, and they can choose among various times - usually 8.30a, 2.30p, and 7p.) Patients didn't mind showing up for their adjustment (a plus), but some had no interest in the care class. How to circumvent: the intern who told me about this said that she would schedule their appointment to begin at 3p, but tell them that it was at 2.30p - once they showed up, the clinic was not open, but they would already be there...just in time for the health care class to start. Then the appointment would take place right after that. Problem solved.

Speaking of non-compliant patients...let's talk about reeling them in and keeping them on track. First, take (gentle but assertive) command from the very start. Patients are looking to you for your lead and direction, so deliver the goods. Take the reigns when scheduling that first appointment. Avoid open-ended questions like "when would you like to come in?" Instead, ask if there are any particular days of the week that are good or bad. If you get the gist that they can only do a certain time of day or a certain day of the week, work with that. Offer them specific appointment times.

The next opportunity to set the tone comes from the Report of Findings. Keep it short, real, common-sense, and down-to-earth. Make it about them. Address their questions and concerns. Explain what's wrong with them and tie it in to the symptoms they've mentioned. Without fear-mongering, tell them what's likely to happen down the road if they don't get this treated. Patients are visual people, so conjure up some imagery--again, I stress: keep it real, keep it honest. Here's your chance, don't screw it up. Once they realize what their situation is, impress upon them that you've seen (or heard) of this before, and it has responded well to chiro care (if it has). Explain that at first, you'll need to see them more frequently to get ahead of their condition so you're not going so long in between visits that you're starting from Square One each time, so that would typically require "x" number of visits per week for "y" weeks, to start off. Emphasize that as they get better, the frequency will drop off until eventually they're just mainenance (here's a good time for a dental checkup analogy). Once you've indicated the treatment frequency, they know the score. They get the big picture.

Then, you reinforce compliance with each visit. If they're even 3 minutes late, call them. If they no-show, remind them of your personal cancellation policy, explaining that it's only fair to the other patients who may have wanted that spot but got turned away because it was already reserved for the person who ended up not showing up. Each time you treat them, schedule the next appointment before leaving. Most of the interns I saw struggling through clinic had a tough time taking control of the scheduling and they let the patients schedule themselves. That's like letting the inmates run the asylum. When setting that next appointment, have several specific time slots in mind, and have them choose. Even if your day is wide open, don't let on as much.

Finally, if a patient starts to become unreliable, schedule them either at the end of the morning or the end of the day. This way, if they're scheduled at noon and they don't show, you get to take a long lunch. If they no-show for their evening appointment, you get to go home early instead of having to wait around for a patient after them. If a patient becomes a chronic no-show, do your part by attempting to call them and note your attempts in their file. Finally inform them that since their file has been inactive for "x" number of weeks/months, you'll need to close their file, but let them know they can start care under another intern at a later date anytime they'd like. And then let them go. Walk away from them, especially emotionally. Don't take it hard; it's probably not you.

Another piece of advice given to me was, recruit in waves. Get a couple of patients in. Get them examined and start them on a treatment plan. Then, as they get re-evaluated and their frequency starts tapering off as they improve, bring in a couple more people and examine them and get them started on treatment. This keeps you steady, so that you're not too overwhelmed with a ton of patients from the get go, nor are you freaking out later like some other interns I talked to because all their patients evaporated at about the same time, leaving them with a lot more adjustments to get and no one else to readily recruit.

Let's talk re-evals. This is probably the iffiest part of the post, but it was one of the most valuable insights someone gave me. Every time a patient is due for a re-eval, do an SRU. Protocol assumes you'll do an RRU--how nice of them--they effectively soak up a large chunk of your time for something you don't get exam credit for, and they do make a little money off the patient to boot. Wow, you'd think they did that on purpose. Oh wait... Meanwhile, you've got 24 required exam credits to get, so what's an intern to do? Here's the deal: when you re-eval your patient, make sure they have a different chief complaint. You need not change the underlying diagnosis; their condition is still the same. But if the main area of complaint is different, then you can do an SRU, which counts as exam credit. Make sure to code for 99213. You might get told to code 99212; do NOT do this, you will NOT get exam credit for this code. Also understand the dirty secret about extremities: extremity exams are also not credit-worthy, and neither are extremity adjustments (although they do charge the patient for these too...and as far as your credits are concerned, they are worth absolutely nothing to you). Warning about SRUs: don't attempt them on patients who are faculty staff doctors. They know what you're trying to do and will bust you. Also, do NOT do this with Medicare patients. Their chief complaint can't change or you'll be losing credit for a whole whack of their adjustments somewhere down the line.

Yeah, while we're on the subject of coding, do your patient a favor and fix pretty much everything you find wrong with them, but when it comes to the fee sheet, mark the 98940 if they're private pay. I fail to see the point in charging people more just because you adjusted more areas. To me, that feels like nickel-and-diming, and your patients will see it that way, too. Everybody does it this way. Now again, faculty don't pay for their care, so go ahead and mark 98941. In fact, it's probably best to do this, because statistically, you should have a certain percentage/ratio of 98941's, but I don't know any specifics on that.

On the subject of Medicare patients, be very, very careful in how you code. Do NOT rely on your staff doctor, no matter how competent they are or how much experience they have in the field doing Medicare, or anything else. The school has a printout of the guidelines for coding, and they're at least clearer than mud (which is more than I can say for most of the school's other policies). Know these guidelines inside and out, because a Medicare adjustment is NC (No Credit) until proven otherwise. Make damn sure your Medicare patient has a spinal chief complaint--no extremities allowed for a CC--and make sure your exam and DX codes are all spine-related. Medicare will not cover extremities, so you'll get NC'd (I know a student who got 40 adjustments thrown out for this and had to spend an extra 1-2 trimesters making them up). Make sure there are 4 legitimate DX codes in the blanks, too. You'll need them because technically, your staff doc is supposed to do the first adjustment for their first 2 codes, and then you do the rest, pertaining to codes 3 and 4.

A note to all of you coming of age right behind us: try to take as many x-rays as you can in student clinic, because those patients don't pay for x-rays, so it's a lot easier to talk them into getting films when they don't have to pay for them. Try to take full spine as much as you can. You have 15 interpretive reports to write, and each series is a separate report, so you can get 3 report credits on a single person's full spine. You could do 5 of those and technically be done with those before you even enter outpatient.

Let's talk lab work and radiology recommendations. There's only one caution I can think of here, and that is that several interns that graduated before us were held up from graduation due to the fact that they hadn't properly addressed any existing lab or rad recommended follow-ups (or they had, but hadn't documented as much). These recommendations are flagged in the reports you get back about a week after the x-ray or blood draw. These interns had to have the patient come back and sign the report indicating that they knew about the recommendation and whether they elected to or not to follow up on the flag. Yes, the patient apparently had to physically come back to the clinic to sign. Don't get caught in this situation; it can delay your checkout!

That's all I can think of for now. Our Thanksgiving trip will come too early as it is :)

Be careful, my pretties--it's a jungle out there.