Hindsight is 20/10: Parker Edition, Part 3: Outpatient Clinic

This is the third and final installment of my look-back at all the gems people have wisely passed on. Much like a secret handshake, good advice won't necessarily jump out at you; you have to go seek it. My hope is that these posts change at least some of that. :)

Outpatient clinic feels like high school. Finally you're out of the elementary school (Tri's 1-5) and junior high (Tri 6 student clinic) and you have arrived, finally having hit the big time. So, here are some pearls to help you get a passing grade.

* I wish someone had warned me about faculty patients. They're very good people, very nice, very deserving, and appreciative, but for the most part, they are not the picture of compliance. They receive intern chiropractic care as an employment benefit, and it's really hard to value something you don't have to pay out-of-pocket for. Also, you can only get up to 50 TOTAL faculty adjustments (all your faculty members put together). You can't just stop treating them when you hit your 50--that would be patient abandonment, a big no-no--but you can't receive credit for more than 50.
* I wish I had brushed up on my Spanish! Know this: the demographics immediately surrounding the school are roughly 80% Mexican. They are much more natural health-oriented. They are more family-oriented, so they'll bring their spouses and kids in. They tend to have bigger families, so scheduling a family to come in can rack you up a ton of adjustments at once. They're also nice, humble, and respect their doctors. They're hardly non-compliant unless they just don't have the money. Problem is, they often don't know enough English to feel comfortable with you unless you also know some Spanish. Spanish-speaking interns get a TON of walk-ins, because people who need your services will walk in off the street and ask for a Spanish-speaking intern. They get called to the front desk all the time and handed new patients. I could've had so many more patients had I been more confident with Spanish. So start learning and brushing up early!
* I'm glad I was already aware of the fact that people will say things, promise to come in to see you, and then never follow up. People are fickle that way. They will say all kinds of things they never mean. Never get excited when someone says they'll come see you and think it's a done deal. The fat lady hasn't sung yet; a new recruit has to come in, get their exam and x-rays, and attend a health talk before you can even adjust them. And it's only when they actually come in and get the adjustment that seals the deal.
* I am really glad someone told me how to meet the exam requirement. See, I did the math...you need 24 exams. Only New Patient exams (99203), Intern Transfer exams, and SRUs (Special Review and Update, for when an existing patient has a new chief complaint, 99213) count; RRUs (Regular Review & Update - the re-exam for someone who's been under care, to check their progress and update their treatment plan, 99212) do not. (They assume you'll do RRUs on everyone; that's the standard--but don't.) Neither do pediatric or extremity exams. So that certainly whittles things down, no? And be VERY careful when coding; if the patient is an existing patient, not a transfer but still new to your roster, you choose existing patient 99213 when doing their exam - and if they're a transfer, don't code it at all - mark it as an Intern Transfer Exam. You could do everything right, finish on time, get the correct signature, code the diagnosis properly, and even code the level of exam properly, but if it's an existing patient and you coded for a new one, or vice versa, they'll yank your credit...almost with glee. The main thing is, NEVER do an RRU. Seriously. Anytime a patient is up for re-exam, COME UP WITH A NEW COMPLAINT and do an SRU. That way, you'll get credit for the exam. Warning: do NOT try this on staff doctors who are your patients, or any other staff that are enlightened - a lot of staff don't know about this tactic, but some do, and if you're not careful, they'll bust you. Put the feelers out first. Do the math. You're only going to get 10 exams off your new recruits, and you can't technically count on any transfers, although the average is about 2-3. So that leaves you with a shit-ton of exam credits to obtain via other means. Learning about this workaround early on saved me a ton of wasted time for zero credit.
* I'm glad someone told me how adjusting really works, both to satisfy your patient and to keep things cheap for them. You bring your patient back; find everything wrong with them and document it in the "O" section. Then you adjust everything you find, everything you feel like adjusting. When you write your "P" section as to what you actually adjusted, write only the major problems; this way your patient won't get charged for extremities and extra regions and whatnot. This way, they get taken care of without being nickeled and dimed to death.
* I'm glad someone warned me ahead of time to follow up on all those radiology recommendations PRONTO. A rad rec is when the DACBR reading your x-rays says they found signs of osteoporosis and they recommend a follow-up DEXA scan to quantify the bone loss. You have to run this DEXA scan, even though you've never been trained on how to use the machine. If not, I have heard you may not be able to check out. I heard some first-hand stories about interns having to call patients they hadn't seen in months and trying to make sure they come back to the clinic to either have said DEXA scan performed, or sign off on the fact that they opted not to have it done at this time. But either way, it has to be their signature. And get your staff doc to initial it AT THE TIME. This can be bad if said patient's file was closed and care terminated due to the patient moving out of state or something. I don't know how they handle that, but I didn't want to find out. The last thing you want is another tri when you worked your ass off to get through on time. If the patient declines ANYTHING, write it on the green sheet, and have them--and your staff doc--sign it THAT DAY.
* Extra services - win some, lose some. DO the nutritional assessment with the food diary. DO supplements, but SKIP those from Standard Process - they're weak, unsupported by any decent research, and they're expensive for what you get. Go with Metagenics instead. They do proper genuine testing on their products, down to specific lot numbers. Forget the subluxation station; it's eye candy at best. Screw the orthotics. Patients stand on a platform which measures their feet (in need of an adjustment) and makes a mold to that shape. As if it's not bad enough to try and make a 3D mold from a 2D image of a 3D structure. Yeah, because I really want to keep my patients in bad pre-adjustment shape. Foot Levelers orthotics screwed me up more than anything.
* Clinic Camp - you have to go. It's required in order to graduate. Make the best of it. Tune out the bullshit. Some advice: if you have special dietary needs, bring your own snacks! You won't have access to a fridge or microwave, so make sure no cooking is required. You get meals, but sometimes they're not big enough, so you might want to bring some supplemental food anyway. You can choose which tri you want to go: 7, 8, or 9 - so if you're weather-sensitive, plan accordingly. Also: it's important to bring gloves (like sturdy yard-work ones) because the first day is all ropes and you WILL get rope burns if you don't. Also, bring a warm sleeping bag and earplugs. You'll be bunking with a ton of people. Bring sandals for the shower; the floor is not mold-free. And lastly, bring a fold-up lawn chair - one that resembles a hammock or whatever makes you comfy; the 2nd day is ALL sitting and all they have are crappy fold-up chairs. To add insult to injury, you'll be sore from the day before, making it harder, so bring extra padding.
* I'm glad I got a clinic binder before starting. I had everything organized - protocol cheat sheets, halfway filled-out exam forms (so I knew how each ortho test went, etc), and places for my green adjustment confirming slips, my recruit confirming slips, my exam confirming slips, and any of Sharla's printouts.
* Last but not least, I am really glad I saw Sharla OFTEN for a printout of my numbers. People have experienced thinking they were done and closing their files, only to arrive at checkout to see that they were indeed 40 short because they had gotten NC'd on a bunch of adjustments. Or exams or recruits or whatever. Not cool! Sharla actually WANTS you to come to her office...often! She won't chase you down to tell you that, but she does not mind when you come to her. It's what she's there for. Do not get cocky and figure you're home-free until you've checked with her!

I've said it before; it's a jungle out there. This will hopefully help you navigate some of the trees.