Aug 19, 2015
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Hi all,
Needed some expert hospitalist advise also for a recent IM grad.
I got an offer for a 200 bed hospital. Its 7on/7off. Its 10 hours each working week. Good benefits. Good relo. Good cme. Good vacation. bingo.

So here are 2 of my concerns.
1 - I asked them for procedures and they said "if i don't want to, i don't have to….but I can always call the head hospitalist from home or ED for those". all verbal. Contract says 'deliver all hospitalists services without restriction'. Should I ask they include in the contract to exempt me from procedures?

2- On every alternate working week, i'm to be 'on call' overnight. There is no physician during nights - only a NP. Ive been stressed that the NP almost never calls… like x1 in 5-6 months. Its essentially to have 'an tending on record'.
If i insist on being called and have pts presented so I know what I'm responsible for....then I'm working 24hrs.
But if I don't, then I have no clue how/what the NP did for management acutely and i may not necessarily agree w them (given their limited training)……...Should I be concerned about liability here?

What do you all think? would you take this otherwise perfect sounding job.
 
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OP
D
Aug 19, 2015
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Attending Physician
my hospital where i trained, the PA's (not NPs) were like residents and presented pts to attendings who still saw the pt right away before cosigning their note.
 

VA Hopeful Dr

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I'm not a hospitalist, but I can offer some general advice based on what you're written.

First and most important, if its not in writing then it doesn't count. Verbal promises count for absolutely nothing, especially where hospitals are concerned.

Second, if you are the physician of record for a midlevel, their screw ups fall on you. Period. Me personally, I refuse to supervise midlevels if they are not physically located at the same place I am at the same time.

If your only options for procedures you aren't willing to do are calling the ED or the head hospitalist, I think you're asking for trouble. Both of those people will quickly get angry at you for calling them. Its one thing to have a pulm/CC person to call for intubations/chest tubes/whatever. Its another thing entirely to either interrupt the ED or to call in a different hospitalist who has their own patients to see.
 

pulmoblast

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Oct 17, 2014
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Agree with above.
1.Here it sounds like you will be doing all procedures
2. You are on call every other night. You will be responsible for mid level screw ups if you are the attending on record

I wouldn't recommend signing this contract. Keep looking ...
 

chessknt87

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Oct 10, 2007
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I agree with the above. The overnight midlevel improves your quality of life but is really a cost-saving maneuver by the hospital that also shifts responsibility on to you. Unless you are getting a fat salary that reflects this cost saving and don't mind multiple phone calls overnight your covering week (ie force the midlevel to phone staff with you until you can learn he/she can be trusted) then you should pass for a program that has nocturnists or where you share a nocturnist responsibility pool.

And calling for procedures will be a disaster if you ever had to experience that in residency. People are busy and being derailed to do your procedures is going to poison your relationship with them and possibly set you up for long delays as well.
 

Raryn

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With regards to calling for procedures, everything except a central line or a tube can wait. There's no such thing as an emergent (as opposed to urgent) LP, thora, or para... just put the patient on antibiotics and wait for IR to come in in the morning. Art lines are by and large optional, though the ICU nurses may harass you about them.

Emergency intubations, you can probably bank on on the ED coming up. It's a rare and serious enough issue that I doubt they'll give you much pushback.

Lines will be your only real issue. Are you uncomfortable with them or just don't want to do them in general?
 

DoctwoB

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With regards to calling for procedures, everything except a central line or a tube can wait. There's no such thing as an emergent (as opposed to urgent) LP, thora, or para... just put the patient on antibiotics and wait for IR to come in in the morning. Art lines are by and large optional, though the ICU nurses may harass you about them.
I disagree with the above. Getting an LP 12 hours after starting antibiotics for possible meningitis will reduce your diagnostic yield and is bad patient care. Likewise getting a thoracentesis done in a timely fashion could prevent an intubation or ICU admission. I agree that arterial lines often can be done without, but only if you can get accurate non-invasive BPs, which is often a problem in very edematous patients.

In general, you should want to be proficient in as many things as you possibly can, as you never know what situation will arise.
 

IMreshopeful

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Open ICU systems in general just seem like a terrible idea to me
 

Raryn

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I disagree with the above. Getting an LP 12 hours after starting antibiotics for possible meningitis will reduce your diagnostic yield and is bad patient care. Likewise getting a thoracentesis done in a timely fashion could prevent an intubation or ICU admission. I agree that arterial lines often can be done without, but only if you can get accurate non-invasive BPs, which is often a problem in very edematous patients.

In general, you should want to be proficient in as many things as you possibly can, as you never know what situation will arise.
I could be wrong, but if I remember the last time I looked at the data regarding delaying LPs.... while the gram stain/culture are affected by early abx, the chemistries and cell counts will stay positive for days. And LPs are hard enough in most of our obese patients without fluoro that I've started plenty of patients on abx waiting for IR after an unsuccessful attempt. That and I'd say that a thora saving someone from intubation is a rare circumstance... Most thoras I've (seen) done are diagnostic, or therapeutic just for sx management. If the patient is so unstable that they can't not intubated even on NIPPV and you're trying to do a thora to save them the tube... they'd probably be better off tubed. Regardless, in those circumstances they are probably going to the ICU. If they're just a little short of breath but otherwise doing OK, they can wait for the morning.

I'm in a procedure heavy residency and all of my classmates graduate proficient at lines, thoras, LPs, paras, art lines... and most graduate comfortable with intubations (which are technically "optional" at our program but most of us do a bunch of them anyway). That said, I've talked with a bunch of recent grads who've started working as hospitalists in a variety of environments... and exactly one of them does any procedures at all. It just doesn't pay, and the liability isn't worth it much of the time. I think that's pretty sad, but I understand the reasoning. If the OP is in a smaller hospital where they're still doing procedures, it is still likely only when push comes to shove. Even hospitals without IR have general surgeons around who are usually happy to help.
 

jdh71

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I disagree with the above. Getting an LP 12 hours after starting antibiotics for possible meningitis will reduce your diagnostic yield and is bad patient care. Likewise getting a thoracentesis done in a timely fashion could prevent an intubation or ICU admission. I agree that arterial lines often can be done without, but only if you can get accurate non-invasive BPs, which is often a problem in very edematous patients.

In general, you should want to be proficient in as many things as you possibly can, as you never know what situation will arise.
Cell counts in the LP remain elevated for days. Completely unnecessary procedure.

There isn't a single case of pleural effusion that requires an intubation or ICU admit in and of itself outside of other clinical context of the patent needing the ICU or intubation regardless.
 
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pulmoblast

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The overall trend is for hospitalists not doing any procedures at all. IR can do all these procedures and bill higher. You can see more patients in that time and bill higher. Hospital overall earns more money this way and everybody is happy (except maybe you). Additionally, if you have a complication (and you most likely will at some point), it will be hard to defend especially if there is someone available who is more proficient, skilled and has fluro. Bottomline, if a place is asking you to do procedures, you will generate less RVUs and take on more liability than your peers. So do it only if that's what keeps you afloat as a real doctor. It's a sad state of affairs, but it is what it is. Internal medicine ain't what it used to be. Market forces have made it a like an eternal glorified residency.
 
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That night coverage thing is a bit worrisome to say the least. You are the attending on record while the NP makes management decisions? Sounds exactly like what chesskknt87 said above. It is a cost saving measure.
 

DoctwoB

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Cell counts in the LP remain elevated for days. Completely unnecessary procedure.

There isn't a single case of pleural effusion that requires an intubation or ICU admit in and of itself outside of other clinical context of the patent needing the ICU or intubation regardless.
Cell counts will be elevated, but maybe, just maybe, it can be nice to have culture data and antibiotic susceptibilities? Likewise, cell counts can be elevated from other inflammatory etiologies. Positive culture, not so much.

As to the second, I'm going to have to disagree. Rotating through thoracic I saw many patients with malignant effusions that were pretty rapidly heading towards conditions and/or intubation with increasing O2 requirements, wob, etc. that was avoided with a prompt bedside thoracentesis. Sure it wasn't truly emergent, but a few hours could make a significant difference. Many of these were patients with terminal disease more focused on palliation, so avoiding escalation of care and intubation until we could get a pleurx into them was a big deal to them and their families.
 

jdh71

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Cell counts will be elevated, but maybe, just maybe, it can be nice to have culture data and antibiotic susceptibilities? Likewise, cell counts can be elevated from other inflammatory etiologies. Positive culture, not so much.

As to the second, I'm going to have to disagree. Rotating through thoracic I saw many patients with malignant effusions that were pretty rapidly heading towards conditions and/or intubation with increasing O2 requirements, wob, etc. that was avoided with a prompt bedside thoracentesis. Sure it wasn't truly emergent, but a few hours could make a significant difference. Many of these were patients with terminal disease more focused on palliation, so avoiding escalation of care and intubation until we could get a pleurx into them was a big deal to them and their families.
Again. You're treating with abx regardless. It's always "nice" but never necessary.

Your that's egress examples consisted of dying gomers with cancer. People that were already compromised. Go back and read my point about thoras. Decrepit gomers are going to the unit regardless. Maybe even get intubated. It's what they do.