For The Rare Few Who Want to Remain Unspecialized are You Planing to Do Outpatient or Inpatient

[Shambere]

So there is a share of IM residents who will not go into a fellowship, that is what happens every year. Some people want to do IM as a career, some dont want to move far away for a fellowship, other prefer start collecting attending salary sooner, a few dont have the stats to go into a fellowship, others really likes the model of IM practice over specialized consulting and clinic.

Do you want to get a job as a hospitalist doing solely inpatient work, are you planing to do solely outpatient clinic seeing patients in clinic 9 to 5 or are you anticipating to practice in a classical setting with 2 days clinic, plus hospital work.

It would be interesting to read your plans.

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[IMreshopeful]

Rare? A large portion of my residency alma mater (at least 1/3) becomes hospitalists every year.

 

[Shambere]

Rare? A large portion of my residency alma mater (at least 1/3) becomes hospitalists every year.

I was being tongue-in-cheek
Let me correct and say "minority".
But rare does sound more appealing. I associate rarity with value.

 

[VA Hopeful Dr]

Rare? A large portion of my residency alma mater (at least 1/3) becomes hospitalists every year.

18% of internal medicine residents don't go on to fellowships per ACP in 2017.

15% go on to become hospitalists. So 3% of graduating residents go into outpatient general IM.

That seems about right.

 

[sunshinefl]

18% of internal medicine residents don't go on to fellowships per ACP in 2017.

15% go on to become hospitalists. So 3% of graduating residents go into outpatient general IM.

That seems about right.

WOW. I’m actually shocked it’s so low.

 

[VA Hopeful Dr]

WOW. I’m actually shocked it’s so low.

I'm not. In my wife's class of 12, one went outpatient

 

[IMreshopeful]

18% of internal medicine residents don't go on to fellowships per ACP in 2017.

15% go on to become hospitalists. So 3% of graduating residents go into outpatient general IM.

That seems about right.

Sure. Outpatient rate definitely. But hospitalist becoming more and more popular

 

[Raryn]

18% of internal medicine residents don't go on to fellowships per ACP in 2017.

15% go on to become hospitalists. So 3% of graduating residents go into outpatient general IM.

That seems about right.

No way are those numbers accurate. It's at most 60/40 for IM docs doing fellowship/practicing IM. I think you're confusing it with 18% of people starting IM residency want to do exclusively general IM, but as time goes on the # goes up (people decide they don't want to do or can't match in fellowships), with the # at graduation being about 40% of people doing primary care or hospital medicine.

Proof:

In 2015-2016, there were a total of 7761 PGY3s in IM. The following year (2016-2017), there were a total of 5044 first year fellows in ABIM accredited fellowships. That includes fellows in cardiology subspecialties (electrophysiology, heart failure, interventional cardiology), sleep medicine, hepatology, and anyone else who may have done a second accredited fellowship. If we remove at least the cardiology super fellows and the hepatology fellows (who must have done prior GI training to be in an accredited program), we're down to 4465 first year fellows. Some proportion of the geriatrics, hospice/palliative care, and sleep medicine fellows did not do internal medicine (but are coming from a different base specialty such as FM). Allergy isn't ABIM accredited so we could add them, but that's at most 140 people, of which some did peds as their base specialty.

Even if we ignore the non-IM people doing IM fellowships AND ignore the ability for people to do two base fellowships (which isn't THAT common but does exist) while counting 100% of Allergy fellows as IM trained, the highest the real proportion of IM docs going into fellowship would be ~59%. I suppose you could also add unofficial "fellowships" like "vascular medicine", "obesity medicine", "advanced hypertension", QI fellowships, "hospitalist fellowships", unaccredited hepatology fellowships, and such, but I'd be amazed if they added up to more than 1-2% of extra folks.

 

[VA Hopeful Dr]

No way are those numbers accurate. It's at most 60/40 for IM docs doing fellowship/practicing IM. I think you're confusing it with 18% of people starting IM residency want to do exclusively general IM, but as time goes on the # goes up (people decide they don't want to do or can't match in fellowships), with the # at graduation being about 40% of people doing primary care or hospital medicine.

Proof:

In 2015-2016, there were a total of 7761 PGY3s in IM. The following year (2016-2017), there were a total of 5044 first year fellows in ABIM accredited fellowships. That includes fellows in cardiology subspecialties (electrophysiology, heart failure, interventional cardiology), sleep medicine, hepatology, and anyone else who may have done a second accredited fellowship. If we remove at least the cardiology super fellows and the hepatology fellows (who must have done prior GI training to be in an accredited program), we're down to 4465 first year fellows. Some proportion of the geriatrics, hospice/palliative care, and sleep medicine fellows did not do internal medicine (but are coming from a different base specialty such as FM). Allergy isn't ABIM accredited so we could add them, but that's at most 140 people, of which some did peds as their base specialty.

Even if we ignore the non-IM people doing IM fellowships AND ignore the ability for people to do two base fellowships (which isn't THAT common but does exist) while counting 100% of Allergy fellows as IM trained, the highest the real proportion of IM docs going into fellowship would be ~59%. I suppose you could also add unofficial "fellowships" like "vascular medicine", "obesity medicine", "advanced hypertension", QI fellowships, "hospitalist fellowships", unaccredited hepatology fellowships, and such, but I'd be amazed if they added up to more than 1-2% of extra folks.

ACP pleased with continued increase in internal medicine residency positions in 2017 | ACP Newsroom | ACP

only about 18 percent of internal medicine residents eventually choose to specialize in general internal medicine, while 15 percent choose to become hospitalists.

Now its possible when they say specialize in general internal medicine, that's just counting outpatient PCP types but that's not how I read it.

 

[Raryn]

ACP pleased with continued increase in internal medicine residency positions in 2017 | ACP Newsroom | ACP



Now its possible when they say specialize in general internal medicine, that's just counting outpatient PCP types but that's not how I read it.

They mean "general internal medicine" as PCPs and the traditional types (who do both in- and outpatient). Hospitalists are on top of that.

I still would say they're undercounting somehow, but I'd need to know which data source they used. (I believe the ABIM data does lump in the combined programs like med/peds and such in their numbers, so if you take them out of the denominator it's possible the # of people doing fellowship rises to the mid 60s. But no higher)

There are physically not enough fellowships for >80% of internists to do one.

 

[VA Hopeful Dr]

They mean "general internal medicine" as PCPs and the traditional types (who do both in- and outpatient). Hospitalists are on top of that.

I still would say they're undercounting somehow, but I'd need to know which data source they used. (I believe the ABIM data does lump in the combined programs like med/peds and such in their numbers, so if you take them out of the denominator it's possible the # of people doing fellowship rises to the mid 60s. But no higher)

There are physically not enough fellowships for >80% of internists to do one.

Also I guess have to take into account academics, people who go into non-practicing jobs, stuff like that. 4th year chiefs would screw up the numbers to, and to my understanding those are increasing in popularity for some stupid reason.

 

[IMreshopeful]

ACP pleased with continued increase in internal medicine residency positions in 2017 | ACP Newsroom | ACP



Now its possible when they say specialize in general internal medicine, that's just counting outpatient PCP types but that's not how I read it.

GIM = outpatient or outpatient/inpatient hybrid traditional - the latter is a dying breed outside of academics
Hospitalist is likely separate from either

Now, most traditional IM academic residencies (meaning at least mid tier academic and not a primary care track or research pathway) usually the majority of residents do go into fellowship. Proportion probably is much higher for the top tier residencies like Hopkins or BWH/MGH - but those are a very select few. I would say most community/low tier places send the bulk of their grads into primary care or hospitalist groups. Probably large reason for that is that most IM fellowships outside of ID, nephro, endocrine are pretty competitive (cards, GI, pulm/CC, rheum, heme/onc, etc) and thus usually those program residents can’t really compete for those fellowships. I don’t have data to back this up but it seems likely.

Also being a hospitalist is becoming a more and more desirable career path for many... work half the year, good pay, no filling out endless PCP forms for mobility, nursing care, prior auths, no dealing with vague joint complaints in the outpatient office, etc. I personally don’t enjoy it (feel like its almost like being a highly paid resident) but it appeals to a LOT of folks... so I think that the proportion of folks doing this over subspecialty - especially if subspecialties are equivalent in pay or even less (nephro, ID, endo) will increase.

 

[jdh71]

Out patient IM is RARE. They are like snow leopards. It's amazing their base pay isn't more.

But right now if you are a board certified (or eligible) internist with a pulse and less than three DUIs you can find a job ANYWHERE.

 

[VA Hopeful Dr]

Out patient IM is RARE. They are like snow leopards. It's amazing their base pay isn't more.

But right now if you are a board certified (or eligible) internist with a pulse and less than three DUIs you can find a job ANYWHERE.

In the last 3 cities I've worked, the FM:IM ratio for outpatient is like 20:1

 

[NewYorkDoctors]

Outpatient GIM is an okay gig if you are not a salaried RVU indentured servant . If you are private and have a good patient base you can definitely make more than an academic based subspecialist.

 

[W19]

Inpatient IM (aka hospitalist) for me... I would prefer a gig where I can work 4 days and 3 days off in a week instead of the 7 on/off. Not sure if that will be difficult to find...

 

[VA Hopeful Dr]

Inpatient IM (aka hospitalist) for me... I would prefer a gig where I can work 4 days and 3 days off in a week instead of the 7 on/off. Not sure if that will difficult to find...

If that's what you want, outpatient is the way to go. That schedule is very common in outpatient.

 

[jacksparrow82]

Inpatient IM (aka hospitalist) for me... I would prefer a gig where I can work 4 days and 3 days off in a week instead of the 7 on/off. Not sure if that will difficult to find...

You can definitely find this in the hospitalist world, but it won't be set in stone like that each week. Even the big national companies like Team Health offer a continuity of care model where they take the average length of stay for a hospital, add a day and that's your typical length of days on. You won't always have the exact same number of days off after each block though because that's just the way scheduling works. It might be 4 on, 3 off one week, but the next it might be 4 on, 2 off or 4 on, 5 off. Depends on a lot of factors with other's time off. Sometimes they might ask you to work 5 days in a row as well. Schedules in the hospitalist world are fluid unless you're in a 7on/7off situation.

 

[W19]

If that's what you want, outpatient is the way to go. That schedule is very common in outpatient.

I haven't done outpatient yet since I am only 2 months into residency, but if it is something I like, and I can earn 275k doing it without killing myself, I will be open to that.

 

[W19]

You can definitely find this in the hospitalist world, but it won't be set in stone like that each week. Even the big national companies like Team Health offer a continuity of care model where they take the average length of stay for a hospital, add a day and that's your typical length of days on. You won't always have the exact same number of days off after each block though because that's just the way scheduling works. It might be 4 on, 3 off one week, but the next it might be 4 on, 2 off or 4 on, 5 off. Depends on a lot of factors with other's time off. Sometimes they might ask you to work 5 days in a row as well. Schedules in the hospitalist world are fluid unless you're in a 7on/7off situation.

I will open to a schedule like that as long as it's not the typical 7 days on/off

 

[VA Hopeful Dr]

I haven't done outpatient yet since I am only 2 months into residency, but if it is something I like, and I can earn 275k doing it without killing myself, I will be open to that.

At my group if you are willing to see 25 patients per day, 4 days/week, 46 weeks a year and bill appropriately you'd hit that mark.

 

[IMreshopeful]

At my group if you are willing to see 25 patients per day, 4 days/week, 46 weeks a year and bill appropriately you'd hit that mark.

Suspect you’re not on the east or west coast - salaries + RVU don’t get near that in most large cities. Maybe an hour outside most

 

[ReviewOfSystems]

Inpatient IM (aka hospitalist) for me... I would prefer a gig where I can work 4 days and 3 days off in a week instead of the 7 on/off. Not sure if that will difficult to find...

OR you just have to find a facility/facilities that does PRN and do that alone instead of being an employee. There are pros/cons to this as well...for example, no guarantee that you will get 4 on 3 off every week but you have better control over your schedule.

 

[VA Hopeful Dr]

Suspect you’re not on the east or west coast - salaries + RVU don’t get near that in most large cities. Maybe an hour outside most

East coast, productivity based.

My 3 days/week IM wife is on track to make 160-180k for the year

 

[DoubleBogey]

Outpatient IM doc who graduated residency last year - I guess I’m a snow leopard. My base with bonus (new practice and getting about 1000 new pts/year) is 240k for 4.5 days/wk, add in clinic moonlighting (2 Saturday a month) and that goes to 280k, add in hospital rounding intermittently and I’m at 310-330k (depending on how much I round in the AM).

I have a wife and kids, built a new house, got a late start to medicine, and I like general medicine, so I didn’t want to specialize. Tons and tons of jobs out there, sure I have to work harder to make > 300k compared to my GI and cards, but I’m ok with that. Do what you enjoy and then it’s not work

 

[il pani]

Outpatient IM doc who graduated residency last year - I guess I’m a snow leopard. My base with bonus (new practice and getting about 1000 new pts/year) is 240k for 4.5 days/wk, add in clinic moonlighting (2 Saturday a month) and that goes to 280k, add in hospital rounding intermittently and I’m at 310-330k (depending on how much I round in the AM).

I have a wife and kids, built a new house, got a late start to medicine, and I like general medicine, so I didn’t want to specialize. Tons and tons of jobs out there, sure I have to work harder to make > 300k compared to my GI and cards, but I’m ok with that. Do what you enjoy and then it’s not work

This sounds like a great deal! Thanks for sharing. Would you mind sharing in which city or state you are working in? My thought is that these numbers may vary significantly depending on where you are working. Thanks!

 

[DrMetal]

anybody here work in the Socal market, particularly riverside county?

 

[wjs010]

If hospitalist base pay gets to 300, with extra 30-40 k with relative ease, I will be throwing in the towel after 3 years and getting out into the real world. But unfortunately All I see is like $220 k.


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[Raryn]

If hospitalist base pay gets to 300, with extra 30-40 k with relative ease, I will be throwing in the towel after 3 years and getting out into the real world. But unfortunately All I see is like $220 k.

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Go to Wyoming and you'll beat that 340k easily.

 

[DoubleBogey]

If hospitalist base pay gets to 300, with extra 30-40 k with relative ease, I will be throwing in the towel after 3 years and getting out into the real world. But unfortunately All I see is like $220 k.


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Most Hospitalist stuff I see on east coast (1hr drive from major city) is around 280k. I thought I saw an Alaska/or other very isolated area paying 500k/year. I would be wary of very rural high paying jobs as you probably have very minimal support and are being put in to situations that stretch the scope of your license.

 

[gutonc]

Most Hospitalist stuff I see on east coast (1hr drive from major city) is around 280k. I thought I saw an Alaska/or other very isolated area paying 500k/year. I would be wary of very rural high paying jobs as you probably have very minimal support and are being put in to situations that stretch the scope of your license.

Were you a nurse in a previous life? That sounds like nurse talk.

The scope of a physician's license is unlimited within all fields of medicine. That's why we don't have FM licenses, and Peds licenses and Plastic Surgery licenses and Radiation Oncology licenses.

Now...credentials, privileges and, most critically, training, are a different story altogether.

 

[CDI]

If hospitalist base pay gets to 300, with extra 30-40 k with relative ease, I will be throwing in the towel after 3 years and getting out into the real world. But unfortunately All I see is like $220 k.


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It’s possible. Base + PTO payout (schedule shifts around your vacation if on a 7 on/7 off) + paid federal holidays + 2 shifts extra/month = ~$330k

 

[DoubleBogey]

Were you a nurse in a previous life? That sounds like nurse talk.

The scope of a physician's license is unlimited within all fields of medicine. That's why we don't have FM licenses, and Peds licenses and Plastic Surgery licenses and Radiation Oncology licenses.

Now...credentials, privileges and, most critically, training, are a different story altogether.

Should I be starting chemo, placing centrals on peds or initiating HD- nope licensing vs credentials vs privileges...semantics IMO, but hey, in a rural setting no malpractice lawyer cares to split these hairs when an adverse outcome occurs.

 

[clausewitz2]

Should I be starting chemo, placing centrals on peds or initiating HD- nope licensing vs credentials vs privileges...semantics IMO, but hey, in a rural setting no malpractice lawyer cares to split these hairs when an adverse outcome occurs.

The hair-splitting would be between whether it was a criminal or civil matter. While malpractice suits are bad, they beat the hell out of jail time.

 

[Lawpy]

Out patient IM is RARE. They are like snow leopards. It's amazing their base pay isn't more.

But right now if you are a board certified (or eligible) internist with a pulse and less than three DUIs you can find a job ANYWHERE.

In the last 3 cities I've worked, the FM:IM ratio for outpatient is like 20:1

wait would like some clarification.

what's the difference between outpatient IM and FM? is it mainly just the patient base (i.e. outpatient IM focuses only on adult medicine but FM can focus on adult medicine with peds, OB/GYN etc.)? or are there additional differences?

 

[Raryn]

wait would like some clarification.

what's the difference between outpatient IM and FM? is it mainly just the patient base (i.e. outpatient IM focuses only on adult medicine but FM can focus on adult medicine with peds, OB/GYN etc.)? or are there additional differences?

Officially, that's the main difference. IM sees adult only, FM sees adult+peds+ possibly Ob (while all are trained in it, many do not do it). Training-wise, most FM programs also have more exposure to outpatient procedures - skin biopsies, knee injections, etc. Even stuff like irrigating out cerumen. I did a few of each as a resident but my colleagues in FM did a lot more than I did and did other things I've never done (take care of an ingrown toenail for example). They also do a LOT more clinic over their 3 years than we did, but that may be a program-specific thing.

In addition, there's traditionally more of a focus in IM training to take care of more "complex" problems. But I don't think that bears out in real life.

 

[jdh71]

wait would like some clarification.

what's the difference between outpatient IM and FM? is it mainly just the patient base (i.e. outpatient IM focuses only on adult medicine but FM can focus on adult medicine with peds, OB/GYN etc.)? or are there additional differences?

Well. I want to be careful how I say this because there is a lot of overlap and I don't want it to sound like I'm saying FM sucks but generally those older and chronically sick with multiple multiple things wrong with them especially if those things are all complicating each other at the same time then person who spent their three years focusing ONLY on that type of of patient is better for the patient. Therefore: the internist.

If you've got stable chronic illnesses either/or but when they all start running into each other . . .

 

[jdh71]

Officially, that's the main difference. IM sees adult only, FM sees adult+peds+ possibly Ob (while all are trained in it, many do not do it). Training-wise, most FM programs also have more exposure to outpatient procedures - skin biopsies, knee injections, etc. Even stuff like irrigating out cerumen. I did a few of each as a resident but my colleagues in FM did a lot more than I did and did other things I've never done (take care of an ingrown toenail for example). They also do a LOT more clinic over their 3 years than we did, but that may be a program-specific thing.

In addition, there's traditionally more of a focus in IM training to take care of more "complex" problems. But I don't think that bears out in real life.

In my clinical practice I think it does bear out in real life with regards to complex problems especially as they increase in number.

It's a reflexes thing more than FM is no good.

I might be getting ready to get flamed tho. I hope it's clear I'm not crapping on FM.

 

[VA Hopeful Dr]

In my clinical practice I think it does bear out in real life with regards to complex problems especially as they increase in number.

It's a reflexes thing more than IM is no good.

I might be getting ready to get flamed tho. I hope it clear I'm not crapping on FM.

Honestly, I've found that there is lots of variation in FM (probably is in IM as well, I just have less experience there). A good FP is likely indistinguishable from IM in the outpatient world. Problem is, the good FP and the bad FP look the same to almost everyone.

 

[VA Hopeful Dr]

Officially, that's the main difference. IM sees adult only, FM sees adult+peds+ possibly Ob (while all are trained in it, many do not do it). Training-wise, most FM programs also have more exposure to outpatient procedures - skin biopsies, knee injections, etc. Even stuff like irrigating out cerumen. I did a few of each as a resident but my colleagues in FM did a lot more than I did and did other things I've never done (take care of an ingrown toenail for example). They also do a LOT more clinic over their 3 years than we did, but that may be a program-specific thing.

In addition, there's traditionally more of a focus in IM training to take care of more "complex" problems. But I don't think that bears out in real life.

Yep. The main differences are "in theory".

For example, in theory I can delivery babies and do endometrial biopsies. In practice, not so much (although I do get some acute care of pregnant patients which most FPs are more comfortable with than IM, but its not even an every week thing).

Conversely, if what I saw of my wife's board review material 4 years ago is accurate she's capable "in theory" of starting chemo on cancer patients or biologics in rheum patients. In practice, not so much (though she minds starting things like methotrexate less than I do).

As for procedures, most outpatient stuff can be easily learned from a good procedure book or workshop.

 

[Planes2Doc]

Inpatient. No outpatient. Ever. If I had to do clinic, I would hit myself over the head with an iron skillet. I would then go to my nearest emergency department for treatment.

 

[CatFactorial]

Inpatient. No outpatient. Ever. If I had to do clinic, I would hit myself over the head with an iron skillet. I would then go to my nearest emergency department for treatment.

In a hypothetical sense, people like you are bankrupting the American healthcare system.

 

[Raryn]

In a hypothetical sense, people like you are bankrupting the American healthcare system.

How does the existence of hospitalists, in any sense, cause bankruptcy of the system?

 

[DoubleBogey]

How does the existence of hospitalists, in any sense, cause bankruptcy of the system?

I presume his statement is based on the overuse of the ED instead of using your primary care doc - not necessarily a dig at hospitalist IMO

 

[Raryn]

I presume his statement is based on the overuse of the ED instead of using your primary care doc - not necessarily a dig at hospitalist IMO

Trauma is probably appropriate use of the ED. YMMV.

 

[CatFactorial]

How does the existence of hospitalists, in any sense, cause bankruptcy of the system?

I’d rather my tax dollars pay for skillet injury treatment in the clinic instead of the ed.

And/or an attempt at humor.

 

[W19]

East coast, productivity based.

My 3 days/week IM wife is on track to make 160-180k for the year

This is the best job in the world for docs with no student loan...

 

[VA Hopeful Dr]

This is the best job in the world for docs with no student loan...

She still has loans as do I.

If you're that worried about it, 1 weekend/month of UC will cover loan payments.

 

[InvestingDoc]

TO answer OP question, I did not specialize and I did inpatient and transitioned into outpatient. I opened my own clinic and wonder why I didn't do this earlier.

 

[PlutoBoy]

Outpatient is the way to go. This is true for any specialty, not only general IM. The more removed you are from the hospital the better.