On a good day, she saw 30 patients. On a bad day, almost 40. She charted at home at night and worked some evenings and one Saturday a month. A light day of 20 patients was the stressful one, because a string of light days put her quarterly quota at risk.
In Episode 116 of the HRT University Podcast, Nico Misleh, MSN, FNP-C, argues that burnout in a high-volume clinic is usually a model problem. He is talking to NPs, PAs and MDs alike. The physician he shadowed in NP school was a good doctor. Her job left no room for the work she trained to do.
What is healthcare burnout?
The American Medical Association describes physician burnout as a long-term stress reaction. It can include emotional exhaustion and depersonalization, meaning a loss of empathy for patients or negative attitudes toward them. In the AMA’s national survey series, 45.2% of physicians reported at least one symptom of burnout in 2023, down from 62.8% in 2021. The Agency for Healthcare Research and Quality lists short visits, complicated patients, lack of control and electronic health record stress among its drivers. The U.S. Surgeon General’s advisory on health worker burnout places the main causes in workplace systems rather than in individual workers.
This episode adds the view from inside one clinic. It shows what a production quota did to one physician’s day, and what changed in a practice built on time.
What does the 30-patient day look like?
Nico calls the physician Sarah, which is not her real name. She was in her early 40s, about ten years into practice, still carrying most of her medical school loans, and paid on a production quota. The more patients she saw, the more she earned. She saw 30 patients on a good day and almost 40 on a bad one, in 10- or 15-minute slots back to back.
The pace followed her home. She charted at night and on weekends. The patients she remembered were the ones she felt she had failed, because there had been no time to do what they needed. Standing in her clinic, Nico remembers thinking that this could not be what the next 30 years looked like.
Why do two providers with the same patients get different results?
During the same rotation, Nico split his hours with a second physician, whom he calls Derek. Derek owned a cash-based practice. His patients had the same complaints, the same symptoms and the same demographics as Sarah’s, and they were getting better results.
Nico is clear that Sarah was a good doctor. The difference he saw was time. Derek had 20 or 30 minutes for a follow-up visit. Sarah had maybe ten.
One visit made the gap concrete. A woman in her 40s had taken levothyroxine for about five years and still had hypothyroid symptoms. She asked Sarah about desiccated thyroid extract. Sarah told her that T4 monotherapy was the standard, that her TSH was in range, and that there was nothing more to do. After the visit, Nico asked Sarah why she did not prescribe it. She said it was a good question and that she had never had the time to look into it. Her patients’ insurance usually did not cover it. Nico remembers it as the moment he saw what the model had done to her curiosity.
Why is the volume model the default?
Nico’s argument is that the insurance-based, high-throughput model became the default because it is the only model most providers were ever shown. Schools train for it, first jobs run on it, and mentors model it.
When burnout shows up, the advice is better time management, earlier mornings, firmer boundaries or a scribe. In Nico’s view, no number of scribes or productivity tools fixes the structure underneath. He also says that some providers do well at that pace. If the model works for you, the episode is not asking you to change it.
The cost he cares about most is curiosity. When the market does not pay a provider to know more, there is little reason to spend an evening with a physiology textbook. The provider who chose medicine to understand the body slowly stops learning.
Do you have to quit your job to leave the volume model?
Nico’s answer is direct: “Nobody, including myself, is asking you to quit your job.” Almost every provider he knows who made the shift kept a day job and built a practice on evenings and weekends. They started at 10 patients a week, then 20, then 50, until the day job became the side work and then ended.
The reason to start thinking about it now is that the alternative gets harder to build every year you wait. Nico describes the golden handcuffs as getting heavier with time.
What does a private-pay practice change?
A private-pay model runs on fewer patients and longer visits, so each visit is worth more and patients stay longer. It also brings back the clinical complexity that keeps a provider learning, including hormone replacement therapy for men and women done well.
Patients notice the difference. “There’s a version of your practice where your patients drive literally hours to see you,” Nico says. His patients have come from Cleveland, Lexington and Paducah, about five hours from Cincinnati. His practice added Kentucky licenses because so many patients cross the river. The providers he sees succeed with this model go into it as clinicians first, and the business follows the quality of the care.
Listen to Episode 116
Hear the full conversation in Episode 116 of the HRT University Podcast on Spotify, Apple Podcasts and YouTube. For the practical steps, Episode 113 covers how to start a medical practice as an NP, PA or MD. Episode 98 covers how to build a cash-pay HRT clinic. Episode 115 covers why principles beat protocols in clinical reasoning.
Frequently asked questions
What is healthcare burnout?
The AMA describes physician burnout as a long-term stress reaction that can include emotional exhaustion and a loss of empathy for patients. In the AMA’s survey series, 45.2% of physicians reported at least one symptom in 2023.
What causes burnout in a high-volume clinic?
AHRQ lists short visits, complicated patients, lack of control and electronic health record stress. In Episode 116, Nico adds production quotas, charting at home and the loss of time to think about a case.
Is burnout a personal failing or a model problem?
Nico argues it is usually a model problem. The physician he shadowed was a skilled and caring doctor. The structure of her job left no time for the care she wanted to give.
Do scribes fix burnout?
In Nico’s view, scribes and productivity tools ease some of the workload and leave the structure underneath unchanged.
Can a nurse practitioner start a private practice without quitting?
Yes. Most providers Nico knows who made the shift kept a day job and built a practice on evenings and weekends until it could support them.
How long are visits in a cash-based practice?
In the cash-based practice Nico trained in, follow-up visits ran 20 to 30 minutes. In the volume clinic, the physician had about ten.
Build the clinical depth a private-pay practice runs on
A private-pay practice works when the care is worth the drive. The HRT University Master Course teaches the physiology-first hormone therapy those practices run on. It covers six clinical modules and 30 CE hours, 12 of them in pharmacology. Explore the Master Course.
References
- American Medical Association. What is physician burnout? https://www.ama-assn.org/practice-management/physician-health/what-physician-burnout
- American Medical Association. National physician burnout survey. https://www.ama-assn.org/practice-management/physician-health/national-physician-burnout-survey
- Agency for Healthcare Research and Quality. Physician burnout. https://www.ahrq.gov/prevention/clinician/ahrq-works/burnout/index.html
- U.S. Department of Health and Human Services. Health worker burnout: Surgeon General’s advisory. https://www.hhs.gov/surgeongeneral/reports-and-publications/health-worker-burnout/index.html
