Neurohospitalist: 7on/7off versus traditional schedule

[Hockeyfan23]

Hey all

Current PGY-3 here starting to look at jobs following graduation. I find most positions are the classic 7on/7off rotation, although some are traditional (M-F coverage with occasional weekend coverage). What are some of the pros and cons to each? For those doing the 7on/7off schedule, what do you do on the weeks off? I recently spoke to a neurohospitalist with that schedule and he said initially it was nice having a whole week off, but after a while he became bored and started picking up extra Locums shifts to pass the time. Any advice would be much appreciated!

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[Telamir]

I work neurohospitalist 7 on 7 off.

Pros: Work half the year. Can do locums for more money if you want. Week off at a time is nice.
Con: You can get a little bored, I guess.

I think it's better for burnout, honestly. I don't think I could do typical hospital bull**** 5 days a week, I'd go insane. Hospital work is exhausting, and typically the M-F gigs will say 8-5, but really it's 8-5 IF you're done at 5. I don't know...I wouldn't have it any other way to be honest.

 

[Alkain]

I work neurohospitalist 7 on 7 off.

Pros: Work half the year. Can do locums for more money if you want. Week off at a time is nice.
Con: You can get a little bored, I guess.

I think it's better for burnout, honestly. I don't think I could do typical hospital bull**** 5 days a week, I'd go insane. Hospital work is exhausting, and typically the M-F gigs will say 8-5, but really it's 8-5 IF you're done at 5. I don't know...I wouldn't have it any other way to be honest.

What kind of hours are a typical on week?

 

[Telamir]

7a-7p for 1 week
1 week off
7p-7a 1 week (part in house, part home)
1 week off

Rinse and repeat.

 

[neophyte2008]

Hey , i’m also looking into this as an option. Can you tell me more about your work including typical number of consults, admitting Vs consult, salary.

 

[Telamir]

Hey , i’m also looking into this as an option. Can you tell me more about your work including typical number of consults, admitting Vs consult, salary.

These are all very highly variable depending on location, really so I don't know how to answer. There are a few people here who do mostly inpatient though. Typical number of consults for me varies, my census is usually ~16-20. It's variable with stroke alerts, of which at least 50-60% are complete B.S. I am a consult on service, wouldn't have it any other way, personally. I'm salaried, not on production which is fine by me since the way my schedule is set up I make more money this way. Salary is also fine, more than 300, less than 400.

 

[Telamir]

1) Quite different. I have strokes to deal with an "urgent" E.D. consults (seizures and what-have you) so I have to stay there from 7-7. An IM hospitalist if he's not admitting that day and finishes his work early can usually go home and sign out a few patients to a colleague. Is neurology a dumping ground? Yes. Anything and everything can be "neurological". You see it often with stroke or "seizure like events", in which you're stuck trying to prove a negative which is always tricky. That being said, I'm a consult only service so I can at least sign off.

2) Less typical unless you go to a big center where there's a big program. We're just not as common, and it's rare to have a big concentration of neurologists outside of big cities/programs.

3) Not very. I haven't started doing it yet, but I plan to.

4) Neurology has certain market pressures behind it driving up salaries. Namely, there aren't very many of us. In my experience, 250-300 is typical for private practice outpatient, and depending on subspecialty/procedures can be higher. Obviously, in major metropolitan areas this is lower. Inpatient again depends but you can see jobs in the 300's for sure.

 

[deathmerchant]

Thanks for this. Couple of questions:
1) How is your day to day compared to a IM hospitalist? I hear IM hospitalist complaining about being the "dumping ground" and dealing with social workers etc. all the time. Is it similar as a Neurohospitalist?
2) Are there nocturnist positions as Neurohospitalists similar to IM?
3) How hard is it to pick up locum work in your week off?
4) Is ~300 the typical neurohospitalist salaries? I was under the impression that it'd be similar to IM hospitalist who usually make 240-250k.

Thank you

I have a slightly different experience, but I am also in a small hospital in a small town

1) I don’t go for acute strokes or other issues, the ER and IM manage them on site. They just call me and I give advice over phone. If I’m in-house, I’ll go and take a look. My hospital does not have intervention, so any possible large vessel occlusion we transfer from ER. We have like 2-4 code strokes a day. I see about 5-10 patients a day and leave once done. Spend about 2-4h/ day on hospital.

2) yes there are nocturnist positions, but like mentioned above not that common.

3) there are many opportunities for locums

4) 250-350 is the average hospitalist gig depending mostly on location.

 

[ThreatLevel_12:00AM]

I have a slightly different experience, but I am also in a small hospital in a small town

1) I don’t go for acute strokes or other issues, the ER and IM manage them on site. They just call me and I give advice over phone. If I’m in-house, I’ll go and take a look. My hospital does not have intervention, so any possible large vessel occlusion we transfer from ER. We have like 2-4 code strokes a day. I see about 5-10 patients a day and leave once done. Spend about 2-4h/ day on hospital.

2) yes there are nocturnist positions, but like mentioned above not that common.

3) there are many opportunities for locums

4) 250-350 is the average hospitalist gig depending mostly on location.

How small of a town? For example, I have read on the SDN forum before that ENT's need a catchment area of around 30k-40k in order to sustain a practice. What would a similar number be for neuro?

 

[neophyte2008]

Thank you both for your inputs. Death merchant your gig seems awesome.

 

[Telamir]

I'm in a "small city" of ~500k people, with a catchment area that is enormous with small podunk hospitals everywhere. It gets VERY rural VERY fast outside of where I am.

 

[ThreatLevel_12:00AM]

I'm in a "small city" of ~500k people, with a catchment area that is enormous with small podunk hospitals everywhere. It gets VERY rural VERY fast outside of where I am.

Thanks for your input. It's always interesting to hear what small is to other people - I personally have never lived in a city >250k. When I moved to the town I went to college in (75k) I thought I was in the big city!

 

[Alkain]

Thanks for your input. It's always interesting to hear what small is to other people - I personally have never lived in a city >250k. When I moved to the town I went to college in (75k) I thought I was in the big city!

My hometown is 70k, we have exactly 3 neurologists one of whom does strictly outpatient the other two employed by the hospital.

 

[Postictal Raiden]

My hometown is 70k, we have exactly 3 neurologists one of whom does strictly outpatient the other two employed by the hospital.

The neurologist per capital in your town is similar to what it is for the country as a whole 1:22k

 

[neurochica]

There is an employed academic nocturnal neurohospitalist position at the medical college of Wisconsin that can be have for $350k. 11pm-11am I believe. Don’t know if you have to do noon rounds. 7/7.

 

[deathmerchant]

How small of a town? For example, I have read on the SDN forum before that ENT's need a catchment area of around 30k-40k in order to sustain a practice. What would a similar number be for neuro?

My town is 40-50k, the metro area is >100k and catchment around 250k. It is an hour away from 3 major metros in each direction. There are 2 hospitals in the town and 5 neurologists. There are other hospitals and neurologists in the metro area but most of them just do outpatient. Inpatient is teleneuro in most other hospitals.

I am not sure of the numbers, but if I had to guess, something between 10k-20k per neurologist might be ideal for patients and doctors.

 

[ThreatLevel_12:00AM]

My town is 40-50k, the metro area is >100k and catchment around 250k. It is an hour away from 3 major metros in each direction. There are 2 hospitals in the town and 5 neurologists. There are other hospitals and neurologists in the metro area but most of them just do outpatient. Inpatient is teleneuro in most other hospitals.

I am not sure of the numbers, but if I had to guess, something between 10k-20k per neurologist might be ideal for patients and doctors.

Thank you! I haven't chosen a specialty yet but it is difficult to find out what options are out there in medical school, my only exposure thus far has been inpatient neuro at an academic hospital. I want to eventually settle down somewhere more rural, so it is nice to hear that neurology allows for that somewhat.

 

[cerebral edema]

1) Quite different. I have strokes to deal with an "urgent" E.D. consults (seizures and what-have you) so I have to stay there from 7-7. An IM hospitalist if he's not admitting that day and finishes his work early can usually go home and sign out a few patients to a colleague. Is neurology a dumping ground? Yes. Anything and everything can be "neurological". You see it often with stroke or "seizure like events", in which you're stuck trying to prove a negative which is always tricky. That being said, I'm a consult only service so I can at least sign off.

This sounds pretty terrible and will likely get worse as the tPA guidelines change from pure time to tissue (perfusion). The amount of “potential” tPA candidates will swell exponentially and consequently, the amount of calls to you. I think stroke will change to being led by the ED with guidance from tele-neurology and a lot of centers have already made this transition. Otherwise burnout will be untenable.

 

[Telamir]

Oh you have no idea. With the DAWN trial it has risen exponentially. I've already got people asking me about the 9 hour window. To be honest the worst part of it is that specificity for stroke alert calls is garbage. I had a day where 5 were called back to back and they consisted of: 1) bells palsy with hypoglycemia but the sugar went up and his face was still droopy, 2) ocular migraine, 3) conversion disorder, 4) heart attack (dizzy and nauseous but was sweating a ton and grabbing his chest), and 5) AMS due to edible THC overdose.

No one wants to have a miss and so they call for ANYTHING. Most I've had was 8 stroke alerts in a 12 hour shift not counting my census otherwise. I'd say that is the worst part of inpatient neuro. You combine that with a couple of insecure consultants and you'll have nonspecific nonsults raining all day long. Not that it's any better outpatient from what I hear haha.

 

[cerebral edema]

Oh you have no idea. With the DAWN trial it has risen exponentially. I've already got people asking me about the 9 hour window. To be honest the worst part of it is that specificity for stroke alert calls is garbage. I had a day where 5 were called back to back and they consisted of: 1) bells palsy with hypoglycemia but the sugar went up and his face was still droopy, 2) ocular migraine, 3) conversion disorder, 4) heart attack (dizzy and nauseous but was sweating a ton and grabbing his chest), and 5) AMS due to edible THC overdose.

No one wants to have a miss and so they call for ANYTHING. Most I've had was 8 stroke alerts in a 12 hour shift not counting my census otherwise. I'd say that is the worst part of inpatient neuro. You combine that with a couple of insecure consultants and you'll have nonspecific nonsults raining all day long. Not that it's any better outpatient from what I hear haha.

I hear you. I worked in an extremely busy inpatient practice before and physically deteriorated from burnout. Intervention was offered and so we stratified every single stroke alert in person. Now I hear rumblings of a 24 hr window with perfusion. It’s going to get very bad for someone with your practice parameters.

 

[deathmerchant]

Oh you have no idea. With the DAWN trial it has risen exponentially. I've already got people asking me about the 9 hour window. To be honest the worst part of it is that specificity for stroke alert calls is garbage. I had a day where 5 were called back to back and they consisted of: 1) bells palsy with hypoglycemia but the sugar went up and his face was still droopy, 2) ocular migraine, 3) conversion disorder, 4) heart attack (dizzy and nauseous but was sweating a ton and grabbing his chest), and 5) AMS due to edible THC overdose.

No one wants to have a miss and so they call for ANYTHING. Most I've had was 8 stroke alerts in a 12 hour shift not counting my census otherwise. I'd say that is the worst part of inpatient neuro. You combine that with a couple of insecure consultants and you'll have nonspecific nonsults raining all day long. Not that it's any better outpatient from what I hear haha.

I know things are different at your place. But one of the things I've educated the ER attendings about is the recent studies and some expert recommendations on not using tpa for low NIH scores. So if someone has an NIH of less than 3 and they don't have severe aphasia or vision loss or may be severe leg weakness, Medical therapy is as good. So I ask them what is NIHSS? And then many strokes and stroke mimics don't qualify for tpa. I don't know if you still have to go in if its not tpa, but might save some time and stress.

Effect of Alteplase vs Aspirin on Functional Outcome for Patients With Acute Ischemic Stroke and Minor Nondisabling Neurologic Deficits: The PRISMS Randomized Clinical Trial - PubMed

ClinicalTrials.gov Identifier: NCT02072226.

www.ncbi.nlm.nih.gov

 

[Postictal Raiden]

I know things are different at your place. But one of the things I've educated the ER attendings about is the recent studies and some expert recommendations on not using tpa for low NIH scores. So if someone has an NIH of less than 3 and they don't have severe aphasia or vision loss or may be severe leg weakness, Medical therapy is as good. So I ask them what is NIHSS? And then many strokes and stroke mimics don't qualify for tpa. I don't know if you still have to go in if its not tpa, but might save some time and stress.

Effect of Alteplase vs Aspirin on Functional Outcome for Patients With Acute Ischemic Stroke and Minor Nondisabling Neurologic Deficits: The PRISMS Randomized Clinical Trial - PubMed

ClinicalTrials.gov Identifier: NCT02072226.

www.ncbi.nlm.nih.gov

You can have a very debilitating deficit and still have a low NIHSS. For example, the one could have a wrist drop or paresis of the hand and still have an NIHSS of zero.

I’m still a lowly resident but the idea of withholding tPA based off an ED evaluation and NIHSS would cause me to lose more sleep than having to drive to the ED at 2am.

 

[deathmerchant]

You can have a very debilitating deficit and still have a low NIHSS. For example, the one could have a wrist drop or paresis of the hand and still have an NIHSS of zero.

I’m still a lowly resident but the idea of withholding tPA based off an ED evaluation and NIHSS would cause me to lose more sleep than having to drive to the ED at 2am.

I agree, but if there isn't a thrombus that is amenable to therapy, evidence that tpa improves outcomes(for low NIH) is not there. Like in the study above, minor arm/face/leg weakness or numbness or other minor deficits improve pretty fast on their own and may be with best medical therapy alone, without tpa. Some experts are even recommending a non debilitating NIHSS of 6 for not doing tpa.

Also as in the study above, there is 1-5% risk of significant bleed and higher risk of non significant intracranial and other bleeds with tpa.

I also agree that ED assessment is not as good as a neurologist's but I think most ED docs are smart but want to wash their hands off making a decision and doing a good exam, but if pushed few times, they do a good job. Im sure there are sub par ED docs, but in my hospital they have been pretty decent tbh. I think i have had the most issues with Functional stroke patients more than anything.

If you can personally go and evaluate every Code S at 2 am for rest of your life, then good for you. I couldn't do it.

 

[Hank Rearden]

No offense to anyone on here, but you should already be offering thrombectomy to patients with LVO up to 24hrs if they meet perfusion criteria, these are not rumblings. I'm not a rep for the company, but the RAPID software helps a great deal to triage these patients and make things less cumbersome. Works best to get CT/CTP/CTA on all stroke codes up front, but you can also use some ED algorithm to determine who might have LVO and need CTP/CTA.

 

[Hockeyfan23]

At our institution we do have rapid. Usually we go by NIH. NIH<6 just gets a CT, but sometimes I get a CTA if I’m concerned (ie: if cortical signs are present). NIH>6 gets a CT/CTA if under 6 hours From LKW. 6-24 hours gets CT/CTA/CTP w/ rapid. Now back o the original post...any more thoughts? Haha

 

[deathmerchant]

At our institution we do have rapid. Usually we go by NIH. NIH<6 just gets a CT, but sometimes I get a CTA if I’m concerned (ie: if cortical signs are present). NIH>6 gets a CT/CTA if under 6 hours From LKW. 6-24 hours gets CT/CTA/CTP w/ rapid. Now back o the original post...any more thoughts? Haha

That’s a pretty good strategy! I try to do the same. SometImes ASPECT score is also helpful when not getting CTP/Rapid.

Another issue is getting CTA/CTP then shipping the patient; the receiving hospitals then repeat CTA/CTP- that’s a lot of contrast! I’m trying to figure out a way to decrease that.

 

[cerebral edema]

No offense to anyone on here, but you should already be offering thrombectomy to patients with LVO up to 24hrs if they meet perfusion criteria, these are not rumblings. I'm not a rep for the company, but the RAPID software helps a great deal to triage these patients and make things less cumbersome. Works best to get CT/CTP/CTA on all stroke codes up front, but you can also use some ED algorithm to determine who might have LVO and need CTP/CTA.

The point is that some institutions want the neurologist to see and lay hands on every IV tPA candidate. I know because I worked at one. Once the tPA guidelines change from 4.5 hours to a “tissue time,” then the volume of potential candidates will increase substantially. It’s not sustainable long term. This has nothing to do with the utility of perfusion which has its role in LVO. The natural evolution will involve the ED running the stroke code with guidance from teleneurology who can review the perfusion images and make the decision remotely. Are you a neuro-hospitalist?