Hospitalist and Primary Care

[MNCASC]

Do some IM specialists do both hospital medicine and primary care (ie wards one week then clinic the other week)? Or do you have to pick one or the other?

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[IMGASMD]

It’s call traditional practice. You see your own patients in hospital.

Wow, has it changed that much last 10 years? No one rounds on their own patients anymore?

 

[InternistDO]

Do some IM specialists do both hospital medicine and primary care (ie wards one week then clinic the other week)? Or do you have to pick one or the other?

I talked to some residents who got job offers doing 50/50--2 weeks of clinic, one week of hospitalist service, one week off, or some variation on that.

I rotated with an attending who did full blown traditional practice--rounding in the morning, clinic during the day, then returning to the hospital to admit anyone from the ED. The schedule seemed miserable but maybe there are better ways of doing it.

 

[the argus]

It’s call traditional practice. You see your own patients in hospital.

Wow, has it changed that much last 10 years? No one rounds on their own patients anymore?

Some people still do it but it's definitely a dying model. And for good reason, it's a terrible model for modern medicine.

I saw this first hand in multiple community hospitals during medical school and residency, and without exception patients covered by the community PCPs got lower quality and more inefficient care. Which makes sense because it's hard to actively manage a hospitalized person throughout the day when you're also working full-time as an outpatient PCP.

 

[IMGASMD]

Some people still do it but it's definitely a dying model. And for good reason, it's a terrible model for modern medicine.

I saw this first hand in multiple community hospitals during medical school and residency, and without exception patients covered by the community PCPs got lower quality and more inefficient care. Which makes sense because it's hard to actively manage a hospitalized person throughout the day when you're also working full-time as an outpatient PCP.

I’ve always hated hand offs. Something I deem inconsequential, may actually impact patients care eventually. And if the patient is there for more than a week, so multiple teams had worked on patient. On top of that, if any consults are called, medications adjusted, critical test results haven’t come back, without properly conveyed to the PCP.

All these can happen and I am sure has happened. We put improper responsibilities on the patients in the name of efficiency and cost saving.

I digress.

 

[MNCASC]

What about critical care? Or cardiology? Do they do one week on, one week off. I've heard some other specialties are starting to.

 

[cbrons]

Hybrid models where you do clinic for several weeks then act as the hospitalist for a week are becoming somewhat more common in rural areas as a replacement to the traditional model. That’s the one we want to setup where I’m at once we get at least 2 more internists and some of the older traditional-model practicing doctors retire. This model often also uses mid-level providers in the hospital who round with the physician everyday and do the notes and orders. It’s nice because then the physician is focused completely on medical decision-making and patient conferencing/interaction as opposed to clicking and documenting.

 

[tantacles]

Do some IM specialists do both hospital medicine and primary care (ie wards one week then clinic the other week)? Or do you have to pick one or the other?

I've seen a couple models of this.

1. One of my colleagues from medical school does primary care most weeks and has 6-8 weeks of hospitalist service per year. I think she'd rather split it a bit more evenly as she loves acute care and is an absolute genius, and the social aspect of primary care along with a heavy documentation burden at her practice burns her out.

2. A colleague at my hospital admits all of this own patients from his primary care clinic and manages them independently. Unfortunately, with covid, this has not panned out of late, and he is now asking the hospitalists to take over all of his covid patients. Happy to bill to provide oxygen and dexamethasone! No big deal!

3. An attending at my residency hospital would have the senior resident team (it's complicated where I did residency) admit her patients and they would cover in-house issues and staff with her over the phone. She was frequently seen rounding in the evenings after she completed her clinic days.

4. My program director at my tertiary care center occasionally did staffing in the residency primary care clinic, though his primary job was as a hospitalist. Great to work with, and this arrangement allowed him to keep his feet in both pools without being overwhelmed.

5. One primary care physician at my residency hospital would routinely consult on all of his patients in the hospital. He would then run around like a chicken with his head cut off trying to figure out which resident was covering his patients since he needed them to place a consult order in order to bill. His primary care notes were not visible in our EMR, which was a blast. Clock the sarcasm there.

Many ways of doing both exist. I think the first method is probably most effective. I don't enjoy primary care, but if I did, I think I would not appreciate a model where I admit my own patients. Getting up at 5 am to round in the hospital and then having a full day of patients sounds miserable to me.

 

[aafisahar]

What about critical care? Or cardiology? Do they do one week on, one week off. I've heard some other specialties are starting to.

For cards, our attendings do clinic, procedures (TEE, cardioversions, cath, echos) and consults or ccu at the same time. Being on consults or ccu doesn't engender protected time unless the attending carves it out themselves (a few will cancel clinic for the week).

 

[greatnt249]

What about critical care? Or cardiology? Do they do one week on, one week off. I've heard some other specialties are starting to.

Cardiology here. Our system is set up where there are two inpatient cardiology teams, each with their own attending/fellow/residents. Attendings are on service for 7 days at a time and then rotate off. When I'm not on service (probably averages once a month, maybe a little less), I do outpatient clinic and/or echo reading. At the end of inpatient service, we get a "recovery day," but no straight week of being "off."

 

[BaselAz88]

I talked to some residents who got job offers doing 50/50--2 weeks of clinic, one week of hospitalist service, one week off, or some variation on that.

I rotated with an attending who did full blown traditional practice--rounding in the morning, clinic during the day, then returning to the hospital to admit anyone from the ED. The schedule seemed miserable but maybe there are better ways of doing it.

Do you know roughly what is the pay like ?

 

[Chemist0157]

Nephrology typically does consults only unless it is an academic center, but my practice is unusual in that we have a primary service that is ESRD, transplant, and any patient we wanted to admit from clinic. I spend about 10 weeks in the hospital annually, and half of that is the primary service.

With the rise of hospital medicine, docs seeing their own patients in the hospital has gone away. The logistics are a challenge. Family medicine seems to be a little better at doing it, but I also have to say where I work and have trained, there has been an FM residency.

 

[InternistDO]

Do you know roughly what is the pay like ?

I don't know what that traditional attending made, I do know he grumbled about it all the time though.

Primary care and hospitalist pay the same in my current system (and you could easily find a way to do hybrid), I think something like $230 starting salary plus a signing bonus. My understanding is the established attendings make substantially more in primary care. This is in a giant coastal city dealing with an underserved population though.

 

[tylerb1800]

Traditional model may be dying but it is sustainable if you have the right setup. Your consultants in the hospital have to be decent as well. You need to have an office either at or close to the hospital. Driving back and forth can eat up time before and after clinic if you are driving across town to see patients in the hospital. My group has 19 or 20 physicians who still see their patients in the hospital.

Agree with u/EmergDO on starting salary. You will make more than the base easily doing traditional based on the number that you see. I typically see 18 to 19 clinic patients per day 4.5 days/week and 0 to 3 inpatients.

 

[wamcp]

Traditional model may be dying but it is sustainable if you have the right setup. Your consultants in the hospital have to be decent as well. You need to have an office either at or close to the hospital. Driving back and forth can eat up time before and after clinic if you are driving across town to see patients in the hospital. My group has 19 or 20 physicians who still see their patients in the hospital.

Agree with u/EmergDO on starting salary. You will make more than the base easily doing traditional based on the number that you see. I typically see 18 to 19 clinic patients per day 4.5 days/week and 0 to 3 inpatients.

What’s your take home income, before tax, with that kind of volume?

 

[tylerb1800]

Still on my initial contract right now. Have been working less than 1.5 years. With the shutdown in March and decreased patient volume during the initial stage of the pandemic, I was not able to hit my incentive the first year. I am expecting ~$275k during my second year (this year). Most physicians in the group are making more than this.