Fellowship vs Hospitalist

[DOk1ng]

Hi

I can't make up my mind regarding pursuing fellowship or hospitalist.
When I'm in supspecialty rotations, i miss general inpatient medicine a lot
When I'm in Inpatient medicine rotation, I wish that i were a subspecialist so that i don't have to deal with multitude of problems.
I'm thining about nephro>> endo -- rheum

any one in same boat ? or any recommendations?

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[Becket]

Hi-

If you're thinking of nephro, check out this year's fellowship application thread under the Subspecialty section- kind of depressing stuff with regards to job prospects. I was thinking of applying for nephro a few years ago after starting my hospitalist job- I never went through with it and, seeing the way our renal guys work, I'm grateful every day for my decision.

You said you enjoy inpatient medicine...maybe the better question is whether you also like outpatient medicine, as rheum and endo are almost entirely outpatient-based. If so, these offer good lifestyles and decent income.

 

[obiwan]

you could always do a year or 2 of hospitalist and then go back for fellowship which isn't unheard of

 

[rokshana]

you could always do a year or 2 of hospitalist and then go back for fellowship which isn't unheard of

or do the fellowship and then decide after…if you do the fellowship you can always go back to being a hospitalist (though moonlighting as a hospitalist probably would help to get a feel of what its like and keeping up to date with gen medicine), but if you go straight into hoeing a hospitalist, then change your mind, it can be harder to get into a fellowship (plus by that point you will probably get use to the time off and money that comes with being a hospitalist)!

 

[SmokingMonkey]

One of the hospitalists at my current job did a nephrology fellowship but because of the setup of the local nephrology group is making more money as a hospitalists. So it definitely happens...

 

[mercaptovizadeh]

Hi

I can't make up my mind regarding pursuing fellowship or hospitalist.
When I'm in supspecialty rotations, i miss general inpatient medicine a lot
When I'm in Inpatient medicine rotation, I wish that i were a subspecialist so that i don't have to deal with multitude of problems.
I'm thining about nephro>> endo -- rheum

any one in same boat ? or any recommendations?

I don't think nephro is a good idea. They are worked hard, probably the busiest consult service in most hospitals, the patients are sick as stink, and many (both outpatient and inpatient) are slowly circling the drain. No improvement in compensation from general IM, unless you own your practice or something.

Endo, rheum, and allergy are much more lifestyle friendly and just psychologically lighter, and if you want to do research there are plenty of problems within these fields you could tackle.

 

[obiwan]

or do the fellowship and then decide after…if you do the fellowship you can always go back to being a hospitalist (though moonlighting as a hospitalist probably would help to get a feel of what its like and keeping up to date with gen medicine), but if you go straight into hoeing a hospitalist, then change your mind, it can be harder to get into a fellowship (plus by that point you will probably get use to the time off and money that comes with being a hospitalist)!

the thing is you are leaving a lot of money on the table if you go through with the fellowship route and then become a hospitalist. i know several people who did fellowships particularly in the nephrology area who then opted just to do hospitalist work afterwards and thats a difference of 2-3 years of at least 150,000 of wasted income potential that you don't get back. if you do the hospitalist route first, you definitely can see if it fits your plan and make some money and if hey it doesn't work out, then go back to fellowship. and lets be honest, nephrology fellowships are not that hard to get into these days. they are practically giving them away

 

[DOk1ng]

Hi-

If you're thinking of nephro, check out this year's fellowship application thread under the Subspecialty section- kind of depressing stuff with regards to job prospects. I was thinking of applying for nephro a few years ago after starting my hospitalist job- I never went through with it and, seeing the way our renal guys work, I'm grateful every day for my decision.

You said you enjoy inpatient medicine...maybe the better question is whether you also like outpatient medicine, as rheum and endo are almost entirely outpatient-based. If so, these offer good lifestyles and decent income.

I don't enjoy, infact i hate, outpatient GENERAL medicine because it comes with lots of paperwork which i don't like. also, you are stuck with patient that you don't like and have to see them on a more regular basis than subspecialist would have to see them.
outpatient endo and rheum doesn't seem to be as bad when it comes to paperwork.

 

[DOk1ng]

you could always do a year or 2 of hospitalist and then go back for fellowship which isn't unheard of

Thats what i'm leaning more towards after talking with friends, colleagues, and attendings.

 

[Bostonredsox]

I don't enjoy, infact i hate, outpatient GENERAL medicine because it comes with lots of paperwork which i don't like. also, you are stuck with patient that you don't like and have to see them on a more regular basis than subspecialist would have to see them.
outpatient endo and rheum doesn't seem to be as bad when it comes to paperwork.

My friend if you hate paperwork being a hospitalist is not for you, trust me.

 

[flipmd]

In my experience, there isn't really much in the way of paperwork as a Hospitalist. Dispo issues yes. But that's what (good) social workers and an interdisciplinary team are for.

 

[Bostonredsox]

In my experience, there isn't really much in the way of paperwork as a Hospitalist. Dispo issues yes. But that's what (good) social workers and an interdisciplinary team are for.

You have to sign home health forms. Discharge instruction forms. Discharge orders/med forms. Stretcher forms for transport. Death certificates. CQI forms. Physician callback forms. Face sheets for your daily billing. Outpatient services forms (for infusions, outpt Iv antibiotics, etc). Any script your resident writes for outpatient labs or medical equipment, not meds, you just sign. All admission paperwork filled out by resident must be signed.

Interdisciplinary teams and social worked help solve problems and answer questions on dispo issues, but the paperwork required to enact those things is all hospitalist work.
And the amount goes up significantly if you are at a place where there are no residents to fill them out for you.

At my outpt clinic during residency, you did an EMR note. Nurse sends all scripts via escripts. Only thing you ever filled out was your billing sheet and by fill out I mean check labs you want and circle 99213 or 99214....

I do ten times more paperwork in the hospital then in the clinic. And it's only going to get worse.

 

[JacobSilge]

You have to sign home health forms. Discharge instruction forms. Discharge orders/med forms. Stretcher forms for transport. Death certificates. CQI forms. Physician callback forms. Face sheets for your daily billing. Outpatient services forms (for infusions, outpt Iv antibiotics, etc). Any script your resident writes for outpatient labs or medical equipment, not meds, you just sign. All admission paperwork filled out by resident must be signed.

Interdisciplinary teams and social worked help solve problems and answer questions on dispo issues, but the paperwork required to enact those things is all hospitalist work.
And the amount goes up significantly if you are at a place where there are no residents to fill them out for you.

At my outpt clinic during residency, you did an EMR note. Nurse sends all scripts via escripts. Only thing you ever filled out was your billing sheet and by fill out I mean check labs you want and circle 99213 or 99214....

I do ten times more paperwork in the hospital then in the clinic. And it's only going to get worse.

That must have been a somewhat sheltered outpatient experience. FMLA forms, diabetic testing supplies forms, transportation forms, narcotic agreements (admittedly, you can avoid this if you want when you are an attending), continuing VNA service forms... And don't get me started on prior-auth/peer-to-peer for medications that a patient has been stable on for years!

 

[jdh71]

Did this thread just turn into a who does more paperwork slug fest?!?

Yay!

 

[nephappl]

Let's save this soul.
Please DO NOT do nephrology!!!!
See our forum for all the discussion.

 

[flipmd]

You have to sign home health forms. Discharge instruction forms. Discharge orders/med forms. Stretcher forms for transport. Death certificates. CQI forms. Physician callback forms. Face sheets for your daily billing. Outpatient services forms (for infusions, outpt Iv antibiotics, etc). Any script your resident writes for outpatient labs or medical equipment, not meds, you just sign. All admission paperwork filled out by resident must be signed.

Interdisciplinary teams and social worked help solve problems and answer questions on dispo issues, but the paperwork required to enact those things is all hospitalist work.
And the amount goes up significantly if you are at a place where there are no residents to fill them out for you.

At my outpt clinic during residency, you did an EMR note. Nurse sends all scripts via escripts. Only thing you ever filled out was your billing sheet and by fill out I mean check labs you want and circle 99213 or 99214....

I do ten times more paperwork in the hospital then in the clinic. And it's only going to get worse.

I don't have most of these paperwork in my gig.
Billing - done in EMR
Death cert - yes, but this happens what, 1-2x/week?
Callback forms - I don't have these, just document in EMR that I talked with PCP
Outpatient labs / home health / med equipment / Stretcher forms - DC planner takes care of. If they need my signature, they leave a filled out form in the paper chart

I guess my whole point is I don't want the OP to be misled about the amount of paperwork inpatient. I guess it depends on the gig, but I've moonlighted in 2 hospitals, done locum for another, and am now salaried at my present gig. None of them needed any kind of paperwork except my signature. Exceptions would be for death cert but that takes 5 mins at most. Sometimes I may fill up a disability form if it was an acute disability that was related to the current hospitalization, but then I say "see notes" on most of the blanks and have the financial advocate print that stuff out (that's their advice to me - hasn't been sent back to me ever).

I would put it out there that outpatient has 10x more paperwork BS than inpatient, but YMMV I guess. And I don't have residents most of the time. Sorry but your gig sounds worse and worse everytime. I hope you're raking in $$$!

 

[mrpankration]

I think the amount of paperwork you do as a hospitalist is dependent on your practice environment. Some places have distinctions between admitters and rounders. As an admitter, the amount of paperwork that you have to do is minimal (besides an H & P). I currently work as a nocturnist for Kaiser and the amount of paperwork I do is essentially zero.

 

[Bostonredsox]

I think the amount of paperwork you do as a hospitalist is dependent on your practice environment. Some places have distinctions between admitters and rounders. As an admitter, the amount of paperwork that you have to do is minimal (besides an H & P). I currently work as a nocturnist for Kaiser and the amount of paperwork I do is essentially zero.

Agree, I'm leaning towards mostly nights at my shop and the paperwork is minimal, volumes less then day team

 

[IMICUer]

You have to sign home health forms. Discharge instruction forms. Discharge orders/med forms. Stretcher forms for transport. Death certificates. CQI forms. Physician callback forms. Face sheets for your daily billing. Outpatient services forms (for infusions, outpt Iv antibiotics, etc). Any script your resident writes for outpatient labs or medical equipment, not meds, you just sign. All admission paperwork filled out by resident must be signed.

Interdisciplinary teams and social worked help solve problems and answer questions on dispo issues, but the paperwork required to enact those things is all hospitalist work.
And the amount goes up significantly if you are at a place where there are no residents to fill them out for you.

At my outpt clinic during residency, you did an EMR note. Nurse sends all scripts via escripts. Only thing you ever filled out was your billing sheet and by fill out I mean check labs you want and circle 99213 or 99214....

I do ten times more paperwork in the hospital then in the clinic. And it's only going to get worse.

Agree with above posts, this is unheard of in most gigs I've interviewed for including the one I signed for this coming summer. There are NP's nowadays that basically replace residents in non teaching hospitals to help with almost all of these when they come up. There are also discharge interdisciplinary teams that do most of these things and the paperwork is dramatically reduced because of them (boiling down to maybe just a signature on a prefilled document for the MD blessing). It all depends on where you are.

Also agree with above, if you are not sure, go the hospitalist route for now. Nephrology is too big a commitment unless you are ABSOLUTELY sure it is your one passion.

 

[DOk1ng]

now down to Rheumatology vs hospitalist but leaning more towards Rheum.

 

[rokshana]

now down to Rheumatology vs hospitalist but leaning more towards Rheum.

thats easy…you like outpatient…go Rheum….hate outpatient medicine? go hospitalist...

 

[Bostonredsox]

Rheum is a lot of chronic pain. F that.

 

[Silent Cool]

You have to sign home health forms. Discharge instruction forms. Discharge orders/med forms. Stretcher forms for transport. Death certificates. CQI forms. Physician callback forms. Face sheets for your daily billing. Outpatient services forms (for infusions, outpt Iv antibiotics, etc). Any script your resident writes for outpatient labs or medical equipment, not meds, you just sign. All admission paperwork filled out by resident must be signed.

Interdisciplinary teams and social worked help solve problems and answer questions on dispo issues, but the paperwork required to enact those things is all hospitalist work.
And the amount goes up significantly if you are at a place where there are no residents to fill them out for you.

At my outpt clinic during residency, you did an EMR note. Nurse sends all scripts via escripts. Only thing you ever filled out was your billing sheet and by fill out I mean check labs you want and circle 99213 or 99214....

I do ten times more paperwork in the hospital then in the clinic. And it's only going to get worse.

BR,
Can you expand on what you mean by this? Is this because of the ACA?

 

[Bostonredsox]

BR,
Can you expand on what you mean by this? Is this because of the ACA?

Because of the way medicine is transitioning. More and more stuff has to be documented in our notes. More and more forms for heart failure and mi core measures have to be filled out. I have to literally fill out a form with pre and post hospital o2 requirements, what ACEI/arb and bb the pt is on, the EF, aldactone indication, pre and post weights and fluid status for every heart failure pt I discharge. Forget that I address all of it in my discharge summary. I have to write it all on so e stupid form. There's one for hf, PNA, mi, stroke, etc etc. more and more crap cms wants us to do because they want to find anyway they can to reimburse us less.

 

[anbuitachi]

How often do you guys see someone who completed a cardio/gi fellowship going back to do hospitalist work? Also does it go against general contract to have a clinic outside of hospitalist work? like after working 12 hr shifts, then working in your clinic for ie 6 hrs etc. does that work?

 

[gutonc]

How often do you guys see someone who completed a cardio/gi fellowship going back to do hospitalist work? Also does it go against general contract to have a clinic outside of hospitalist work? like after working 12 hr shifts, then working in your clinic for ie 6 hrs etc. does that work?

Every contract is different but most probably wouldn't limit what you could do outside of your job. But working 18 hours a day for half the month (and 6-8 hours a day the rest of the month) with only 2 weekends off (assuming a 7/7 schedule) sounds like a recipe for putting a bullet in your head.

 

[DOk1ng]

Because of the way medicine is transitioning. More and more stuff has to be documented in our notes. More and more forms for heart failure and mi core measures have to be filled out. I have to literally fill out a form with pre and post hospital o2 requirements, what ACEI/arb and bb the pt is on, the EF, aldactone indication, pre and post weights and fluid status for every heart failure pt I discharge. Forget that I address all of it in my discharge summary. I have to write it all on so e stupid form. There's one for hf, PNA, mi, stroke, etc etc. more and more crap cms wants us to do because they want to find anyway they can to reimburse us less.

I think its more about making sure all the doctors in this country do whats right for the HF, MI, stroke patient. Also, to make sure that we don't write script for something that patient don't need it.
there might be doctors out there who don't follow guidelines or not aware of it. Filling out this forms, makes them do whats right.
also, its hard to track whether patient are getting what they need from d/c summary.
At my hospital, we have electronic discharge order sets that we have to fill out by clicking.

 

[IM2GI]

Every contract is different but most probably wouldn't limit what you could do outside of your job. But working 18 hours a day for half the month (and 6-8 hours a day the rest of the month) with only 2 weekends off (assuming a 7/7 schedule) sounds like a recipe for putting a bullet in your head.

To moonlight a shift every now and then? Sure, especially the young/fresh ones. If you need some extra cash, its much easier to pick up a gen med moonlighting gig. I dont know anyone taking a full time gen med gig after cards/GI though....

For the other question, you would have to read your contract carefully. Some restrict practice outside of your work hours. There is also a reason most gigs are week on/week off. Coming from residency, that sounds amazing, but eventually you are going to want to have a life and family and not be at work every hour of daylight possible.

 

[Otto of the Silver-Hand]

I think its more about making sure all the doctors in this country do whats right for the HF, MI, stroke patient. Also, to make sure that we don't write script for something that patient don't need it.
there might be doctors out there who don't follow guidelines or not aware of it. Filling out this forms, makes them do whats right.
also, its hard to track whether patient are getting what they need from d/c summary.
At my hospital, we have electronic discharge order sets that we have to fill out by clicking.

We're headed towards "Cookbook" medicine ... and we're all going to be hash slingers

 

[LoudBark]

How often do you guys see someone who completed a cardio/gi fellowship going back to do hospitalist work?

Never. Also have never seen Heme / Onc trained doing hospitalist either.

Most common ones seen doing hospitialist after subspecialty training are nephrology, ID, and pulm / CC.
Have seen a rheum do it. Most oth

Let's save this soul.
Please DO NOT do nephrology!!!!
See our forum for all the discussion.

There seem to be a lot of "I want to decide between hospitalist and nephrology" folks out there.

Or the "I am a hospitalist and thinking about doing nephrology because being a hospitalist is a drag" folks too.

 

[Bostonredsox]

i think its about lifestyles more than the medicine you love. the several hospitalists I have worked with who went back to do Endocrine, rheum or ID, they were never cut out to be inpatient slaves to begin with, they just didnt enter fellowship initially for whatever reason and are now getting around to do what they wanted all along. Or they realised how much they hate being an inpatient slave and are leaving for a less stressful worklife in the office. Conversely, those that did one of those three and are now doing mostly hospitalist work have decided they either A, miss being in the hospital, B, dont like working every day and would rather work week on/week off, or most often C, realise they are making less money then had they not done the fellowship and want more cash on a shift model

I hae never met anyone trained in GI, Cards or H/O doing hospitaist work. I know 2 who werehospitalists that went back to do cardio or GI.

Nephro seems to be taking a big hit recently. I know several who are paying the bills doing week on/week off hospialist work, and doing academic or PP nephro on their weeks off.

straight CC work is a hosptialist model most places I have seen, you are just 7/7 in the unit instead of the floor. And I do not know any pulm/cc doing hospitalist work. Why would you? you could do those hospitaist shifts as intensivist shifts and make way more.

 

[DrVanNostran]

I wish becoming a hospitalist wasn't so damn tempting. I keep looking at my students loans and get a headache lol. 3 extra years of fellowship with the interest on top of the student loans seems like a disaster. I keep telling myself that going into fellowship will be worth it both professionally and financially. I hope the latter is true.

 

[inspirationmd]

At one of the Hospitals where I moonlight there are a couple of old school Pulm-CCM and Pulmonary (did it before Pulm/CCM became big but did a lot of Critical Care in his career) docs who are Hospitalists. I talked to the Pulm guy and he said the ICU burns you out and it is for the “youngsters”. They admit pretty straightforward PNA, DKA, Cellulitis, “mild” sepsis at this place and anything that’s more hardcore goes to the big academic center. They pretty much just sit around there and collect a check. I’ve gone on the floors there and relative to what I am used to its not that bad with a nice place for physicians to hang out. I haven’t talked to the Pulm-CCM guy personally yet but the Pulm guy says they are both going to be retiring in the next 1-2 years.

I am aware of Nephrology and ID academic attendings that do Hospitalist moonlighting to supplement incomes. An Endo attending I am aware of used to do disability physical exams every other Saturday to supplement his income. A Gen Med attending is leaving for
Endocrinology fellowship.

I too have never heard of H/O, GI or Cards going back for Hospitalist work. Multiple Hospitalists I am aware of have left for Cards, GI, Pulm-CCM and H/O.

Personally, I think Hospitalist in the traditional 7 on/7 off set up is not sustainable unless you are in the right environment. There has to be a reason it’s largely a pit stop on the way to fellowship for so many. My theory is that it is soul sucking work since you have so many services that can just say “admit to Medicine, we will consult”. Whether they pay you well or not, no 50 year old attending wants to be told by a fresh fellowship trained grad that they have to admit a patient and have hospital administration backing up the specialist. A hospitalist is squeezed by the ED (and EMTALA) and what I call the “right of specialist refusal”.

Intensivist work is better because 1) you get paid way more than as a Hospitalist, 2) patients have a baseline level of acuity (generally) that requires a minimum level of diagnostic chops, and 3) you can refuse to take someone into your unit if they don’t meet criteria so even though its 7 on /7 off at a lot of places you still have some control over your practice. The latter is of course a theory and remains to be seen but it is certainly a big part of why I am gung ho about critical care.