Neuro Inpt and Outpt Practice

[AnonymousD.O.]

So I am a second year student with a strong interest in Neurology. I have a very open mind however about potential specialties, including IM. One thing that I have heard from residents and current docs is that IM is leaning toward either practicing as a Hospitalist or private practice, but the days of having a private practice and taking call are rare today.

I like being in the hospital (I'm a second year still but I can't imagine practicing only outpt) but I like the long term care of pts. I think that is why Neuro is really attractive for me. Do many neurologists practice with their own private practice and also take call at the hospital for stroke etc.? Or is the inpt care reserved for Neurovascular Specialists and Neuro Intensive Care Specialists and the like.

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[OasisMan]

there are many jobs that are outpt + inpt (30/70, 50/50, 70/30, etc)

you can pretty much set up your schedule how you want

 

[Hank Rearden]

Actually, most of the jobs in private practice are polarizing to either all inpatient neurohospitalist positions or all outpatient. It just doesn't make sense to go to the hospital early in the morning and see your few patients that were admitted, then spend the rest of the day in clinic. More and more groups are employing neurohospitalists to make things more efficient.

 

[neurologist]

Actually, most of the jobs in private practice are polarizing to either all inpatient neurohospitalist positions or all outpatient. It just doesn't make sense to go to the hospital early in the morning and see your few patients that were admitted, then spend the rest of the day in clinic. More and more groups are employing neurohospitalists to make things more efficient.

That being said, keep a few things in mind:

#1. Neurohospitalists are "expensive," meaning that they don't generally bring in enough revenue to cover their salaries - they have to be subsidized by other department activities, so mostly only larger, more financially sound hospitals will be using them. Smaller hospitals still rely heavily on the traditional model of a general neurologist covering the inpatient service before and after office hours, plus call at nite and weekends.

#2. An individual neurohospitalist can't be there 24-7. If you're going to have 24-7 neurohospitalist care, you need several of them to cover shifts, weekends, vacations, sick days, etc. Then issue #1 comes into play again. So, if you only have 1 neurohospitalist, that person's downtime has to be covered by a general neuro person.

#2. Because of the cost, a private group-employed neurohospitalist is unlikely to be spending all day in the hospital (unless it is a very busy hospital with a big and very busy neuro inpatient service). They'd be doing something else as well, like outpatient hospital followups, ER consults, EEG reading, outpatient LPs, etc.

So, there are still plenty of opportunities to do both inpatient and outpatient work, although they are less likely to be at big academic medical centers.

 

[AnonymousD.O.]

Actually, most of the jobs in private practice are polarizing to either all inpatient neurohospitalist positions or all outpatient. It just doesn't make sense to go to the hospital early in the morning and see your few patients that were admitted, then spend the rest of the day in clinic. More and more groups are employing neurohospitalists to make things more efficient.

That's what I'm worried about. That's been the number one thing I've heard about Internal medicine. That Hospitals don't want to employ private practice when they can just get a hospitalist. And the IM docs themselves find it too troubling today's Medical atmosphere to do both outpt and inpt. But it seems to me (being an ignorant 2nd year) that because Neuro is a smaller field compared to IM, that you would have a little more say in how you run things. I guess I'm concerned though that without a fellowship in Vascular Care, i would be stuck with doing only out patient care.

 

[AnonymousD.O.]

That being said, keep a few things in mind:

#1. Neurohospitalists are "expensive," meaning that they don't generally bring in enough revenue to cover their salaries - they have to be subsidized by other department activities, so mostly only larger, more financially sound hospitals will be using them. Smaller hospitals still rely heavily on the traditional model of a general neurologist covering the inpatient service before and after office hours, plus call at nite and weekends.

#2. An individual neurohospitalist can't be there 24-7. If you're going to have 24-7 neurohospitalist care, you need several of them to cover shifts, weekends, vacations, sick days, etc. Then issue #1 comes into play again. So, if you only have 1 neurohospitalist, that person's downtime has to be covered by a general neuro person.

#2. Because of the cost, a private group-employed neurohospitalist is unlikely to be spending all day in the hospital (unless it is a very busy hospital with a big and very busy neuro inpatient service). They'd be doing something else as well, like outpatient hospital followups, ER consults, EEG reading, outpatient LPs, etc.

So, there are still plenty of opportunities to do both inpatient and outpatient work, although they are less likely to be at big academic medical centers.

Hmm....that all makes sense. To practice stroke care in the hospital, do you pretty much have to do a vascular fellowship?

 

[Hank Rearden]

No, you don't have to have a vascular fellowship to do stroke care in the hospital. There are too few vascular trained neurologists to care for all of the stroke patients in our country. For this reason there will always be general neuro trained folks doing inpt stroke care. Vascular training certainly gives you a lot more job security if you want to go that route.

 

[typhoonegator]

Yep, there's a dearth of BE/BC vascular neurologists out there unless you're in a major metropolitan area or an academic center. But if you really want to practice vascular, it's only a 1 year fellowship and in addition to job security you'll also have more leadership/directorship opportunities as you work up the ladder.

There are a ton of non-vascular neurologists giving outstanding secondary prophylaxis and acute stroke care across the country. But the formal training really does help you deal with the more atypical cases -- and the longer I practice the more patients seem to fit into that "atypical" range.

And I agree with neurologist that hospitalists are neither an easy financial decision nor are they a complete solution. Sure, if you have resident coverage overnight and two hospitalists covering 7 days a week and holidays, then you're all set, but that's a very small proportion of the country. And good NP/PAs are not that much cheaper and they also need time off. You run into this too much vs. not enough situation: small hospitals don't have enough admitted patients for them to work in-house full time and cover their salary, so they need other things to do. Big hospitals need more than one once you start factoring in weekends and holidays, so people still take overnight and weekend call. I'm not saying there aren't plenty of jobs for them out there, just that from a practice standpoint they aren't a no-brainer. There are plenty of practice models for which a hospitalist still just doesn't make sense on the bottom line, unless the hospital wants to chip in so they can get stroke accreditation or something along those lines. As such, there are still jobs where you can swing by the hospital at 7, start clinic at 9, and maybe see some consults after your 4 o'clock. If you like that variety, then good for you!