Hospitalist confused about what to do next

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There are a lot of pros and cons to being a Hospitalist, but this is true for any specialty. I feel like people tend to discuss more of what they do not like then what they do like about their fields. If you are interested in sub specializing then you should consider speaking to them about their thoughts and opinions.

I do tend to agree with some of the things being said here but that's just the nature of medicine now. For instance, if you sub specialize and work at a place with your own primary service, chances are that you will be consulting just as often as a Hospitalist for different issues, maybe even for lesser reasons because you're no longer comfortable with certain medical issues. Some of the most awkward consults are the ones from Medicine specialists to Hospitalists to help with care. There is also an aspect of sub specialty dumping on other specialties. Also consider that to specialize is to spend >50 percent of your clinical time in clinic. The best sub specialists here round early in the morning (notes in by 7am), go to clinic (finish around 4-6pm), then come back in the afternoon to do consults or procedures (consult/follow up notes in around 8 pm).

I think some of the complaints about feeling looked down upon comes from academic settings more often. In the community, if a consultant is not playing nice or you don't feel like they're providing good patient care, you can always consult someone else. Being on call usually means the only person you can call after 5pm. Just because someone is on call, doesn't mean you have to consult them necessarily. There are plenty of consultants that are extremely thankful for any consults, because they're trying to build their patient base and get their name out. There was a specialist here that was really disrespectful and inappropriate to our group so we just stopped consulting this person altogether. I don't have experience to say what the consequences or effects on a sub specialist are when this happens.

A Hospitalist role is kind of plug and play too. Sometimes this is good depending on your personal desire of involvement but it also does mean you're just a cog and replaceable. It is much harder for a sub specialist to change jobs because it means starting completely over, being the new person with the worst schedule and calls, and hustling to get your name and referrals out.

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[alicealicealice]

Sorry for the late reply. It's great that you take pride in your work and enjoy general medicine, we need more hospitalists (and doctors in general) like you. I enjoyed being a traditionalist, especially the long-term relationships with patients. Like you, I learned quickly not to push people out, because if you're seeing them in clinic, it'll come back to bite you. As I worked in a rural area, I lacked the ability to consult specialists for many patients and had to take care of many subspecialty problems myself - this was stimulating and rewarding. However I would imagine depending where you worked, this would not be feasible. Eventually got burned out taking too much overnight and weekend calls which was also a function of the rural setting. There was a nearby larger town where our patients would sometimes end up if they needed dialysis, cath, etc. The doctors there were often terrible but looked down on me for working at the rural hospital - I also got tired of dealing with them also.

I actually disagree that PCPs are not respected by other doctors (not sure if that's exactly what you meant) - in my experience as a subspecialist, PCPs are treated no differently than the patient's other outpatient physicians and a good one is worth their weight in gold. The impression of the lay public is variable, I think depending on the nature of the patient's issues and the PCP. I would probably have become a PCP if I hadn't specialized.

I'm happy with my current job. I'm an attending at a large referral center (similar to where I trained for IM). I have about 24-28 weeks of service a year (ICU, consults), and 2-3 clinics per week. I work 1 out 5-6 weekends (not overnight thought) and a few nights a month. Was worth it to me (although finances were rough on a fellow salary with young kids) and I like being a subspecialist. Also have some time to do research, although it's more of a hobby than a required part of my job.

If we could somehow go back to a system where internists rounded on their own patients in the hospital (or took turns) and did clinic, I think job satisfaction and patient satisfaction would be much higher...just my 2 cents. That seems unlikely to happen though.

To be clear I agree that pcps are not looked down upon as much as hospitalists are. And it almost doesn’t matter because in my mind there is no question of a pcps value and hard work...if you’re good your patients like you, stick by you and other doctors tend to respect you as well. Or At least appreciate your role is important

It seems to me you said you were a traditionalist but it burned you out hence the transition to fellowship.

I do have the opportunity to be a traditionalist within our system, meaning be a pcp and also be attending of record for my patients who are hospitalized, overseeing care and writing the discharge summary, however the pager coverage and orders always fall to a hospitalist, np, or house staff depending on my patients physical location in the hospital 24/7. The group then takes turn covering as attending of record over the weekend.

So it’s between this and specializing in PulmCC. People think It’s weird that I’m attracted to both ends of the severity spectrum but both have aspects that appeal to me. I like dotting is and crossing Ts. Sick medical patients as well as stable medical patients who clearly have something wrong but are either as yet undiagnosed or not yet optimally managed both are challenging and exciting. The worried well do not piss me off—I think it’s better that someone gets to know them so they can tell when something actually develops that needs more work up.

I do get concerned that I will get bored with the medicine of primary care though I never felt that way as a resident...also people who say they get bored in my Limited experience tend to be the ones who refuse to think beyond the 20 most common treatments for the 20 most common presentation... if you think that giving another z pack the third time the patient re-presents with a non resolving cough then yes you will be bored not working up pathology that deserves more work up. Finding a few cancers in my primary panel early were huge wins for me...while of course it was the oncologist or rad onc it surgeon who cured them, they greatly valued the initial diagnosis

I also get worried about burnout and just being demoralized by the system no matter how I feel now. There is no question that the pcp position is the most soulcrushing from the insurance/paperwork / prior authorization /social work perspective. Again, for better or for worse In Our system a doctor needs to be involved to get some people services and meds they need to actually have a quality of life —specialists in my experiences often will not do this or focus only on the “medicine” to the detriment of the actual patient—leaving the task of setting up home o2, securing transportation to pulmonary rehab, the stuff that the patient actually needs to have a fighting chance—to the pcp.

 

[lulu09]

Here's a niche to consider... The hospitalist who works in the free standing psych hospital. The psychiatrist is likely the primary and you are the consultant. Most of the patients you see will be the obligatory, straight forward consult and a quick sign off. Some will be the usual long med list, long problem list you are accustomed to. But you will be cherished and valued even for something as simple as a UTI or skin rash. When you keep your eyes open and listen to the patients, you will find things that were missed by many other physicians because it is a psychiatric patient the others likely didn't spend the time to fully assess. More severe mental illness with floridly psychotic or manic patients, you will be valued for your efforts to get the consult done - but if you can't, you can't. Furthermore, with psychiatry typically being the primary, you won't have to do discharge summaries! You'll get to wear fun hats like be on the microbial stewardship committee for the hospital, too. Not exactly the CHF, COPD, AKI, DKA grind you are used to and fully capable of but when those things sneak through the doors you will be cherished for helping to spot and transfer out. Or when you speak and say, 'hey, this needs to get done' or this patient needs this test while here (sadly, you'll likely have to spend time coordinating for the test at the outside facility) you will have the satisfaction of knowing you helped a patient who probably wouldn't have gotten that test otherwise. Some of the more severe mental illness have poorer life expectancy, and health outcomes - so your knowledge and personal investment and drive for advocacy really could make the difference in a patient's life. Ex: getting the biopsy on lesion for likely cancer in transient schizophrenic who just showed up in your town from across country.

Its also possible to carve out this set up in a general hospital that has an attached psych unit. My experience has been most of the IM hospitalists loathed setting foot on the psych unit, and if you volunteer in the group to be the designated psych consultant, your IM group will praise you for jumping on the landmine, the psych group will be grateful for quality and consistency.

Good for you.

I'm part of the hospitalist contingent that wants to stay the heck away from the inpatient psych unit. Psych unit consults in our group are handled on a weekly rotating basis (a hospitalist covers the ward for 7 days, then switch off). I commend you on seeing the positives of their consults but my patience has been sorely tested with automatic, brainless consults from psychiatrists for "urine feels funny" (no UA sent, on my interview patient denies all symptoms) or constipation (yes! constipation! "erm...try miralax?"). I would literally go insane myself if I had to cover the psych ward for a whole year.

Yes, it is supremely rewarding to be the one diagnosing someone who is actually medically sick on the psych floor (previously undiagnosed CHF, unexplained PE which turned out to be 2/2 diffuse metastatic cancer), but unfortunately I would have to see about 30-50 brainless consults to get one of those consults :/

 

[Sushirolls]

Some of those issues should be amendable with communication. Granted some places, some docs just don't care, or some ARNPs need every ounce of help they can get from consultants. I've done curbsides for hospitalists on try X, Try Y, then consult psych. Hopefully communication lines are open to provide a similar feedback to cut down on that. I've been told over the years "order X" and if findings positive, then call for consult. Open, collegiate communication really helps to reduce consults, and those curbsides help to nudge people in the right direction.

 

[lulu09]

Some of those issues should be amendable with communication. Granted some places, some docs just don't care, or some ARNPs need every ounce of help they can get from consultants. I've done curbsides for hospitalists on try X, Try Y, then consult psych. Hopefully communication lines are open to provide a similar feedback to cut down on that. I've been told over the years "order X" and if findings positive, then call for consult. Open, collegiate communication really helps to reduce consults, and those curbsides help to nudge people in the right direction.

Yeah, definitely. Part of the problem is that where I practice automatic consults are very much of a thing (if you get consulted you have to write a note, very little "curbside" culture here, also often difficult to get hold of the consulting person who is also often not a doc that can be more easily reasoned with "attending to attending"...etc.) -- to not see a consult basically the consulting team will have to take the consult out and sometimes it's faster to see the consult than to find the consulting team and to reason with them about why the consult is inappropriate.

It's ironic in the sense that I think yes the overall situation would be better if there was consistency so that the psych team is only ever dealing with one hospitalist (to build trust and rapport...etc. like you said), but no one wants to take on that role, lol. So yes, the culture needs to change big time, and maybe we are just perpetuating the problem and the culture by continuing to do what we're doing. Perhaps we just need more people like you

 

[Sushirolls]

I got tired of hospital politics and bureaucracy of hospitals whether it was a health system or free standing psych facility. I'm keeping it simple in a solo private outpatient practice now. Sorry your places has a draconian 'do the consult' culture, that's a beast to change, good luck if you attempt to change it.

 

[DolphInternist]

I've been a general internist for 11 years. The truth is that you already screwed up just doing internal medicine. You have no choices at this point but to somehow get into a subspecialty, quit medicine, or be a general internist/hospitalist serf for the remainder of your working career.

Just the facts man. We are nothing. One step above nurses, pharmacists, and physical therapists. They'll replace us all with midlevels eventually. That or immigrants.

 

[bronx43]

I've been a general internist for 11 years. The truth is that you already screwed up just doing internal medicine. You have no choices at this point but to somehow get into a subspecialty, quit medicine, or be a general internist/hospitalist serf for the remainder of your working career.

Just the facts man. We are nothing. One step above nurses, pharmacists, and physical therapists. They'll replace us all with midlevels eventually. That or immigrants.

Not sure if srs...

You were never more than one step above nurses, pharmacists, and therapists. The fact that you think you should be is part of the problem.

 

[Colorado outliers]

To be clear I agree that pcps are not looked down upon as much as hospitalists are. And it almost doesn’t matter because in my mind there is no question of a pcps value and hard work...if you’re good your patients like you, stick by you and other doctors tend to respect you as well. Or At least appreciate your role is important

It seems to me you said you were a traditionalist but it burned you out hence the transition to fellowship.

I do have the opportunity to be a traditionalist within our system, meaning be a pcp and also be attending of record for my patients who are hospitalized, overseeing care and writing the discharge summary, however the pager coverage and orders always fall to a hospitalist, np, or house staff depending on my patients physical location in the hospital 24/7. The group then takes turn covering as attending of record over the weekend.

So it’s between this and specializing in PulmCC. People think It’s weird that I’m attracted to both ends of the severity spectrum but both have aspects that appeal to me. I like dotting is and crossing Ts. Sick medical patients as well as stable medical patients who clearly have something wrong but are either as yet undiagnosed or not yet optimally managed both are challenging and exciting. The worried well do not piss me off—I think it’s better that someone gets to know them so they can tell when something actually develops that needs more work up.

I do get concerned that I will get bored with the medicine of primary care though I never felt that way as a resident...also people who say they get bored in my Limited experience tend to be the ones who refuse to think beyond the 20 most common treatments for the 20 most common presentation... if you think that giving another z pack the third time the patient re-presents with a non resolving cough then yes you will be bored not working up pathology that deserves more work up. Finding a few cancers in my primary panel early were huge wins for me...while of course it was the oncologist or rad onc it surgeon who cured them, they greatly valued the initial diagnosis

I also get worried about burnout and just being demoralized by the system no matter how I feel now. There is no question that the pcp position is the most soulcrushing from the insurance/paperwork / prior authorization /social work perspective. Again, for better or for worse In Our system a doctor needs to be involved to get some people services and meds they need to actually have a quality of life —specialists in my experiences often will not do this or focus only on the “medicine” to the detriment of the actual patient—leaving the task of setting up home o2, securing transportation to pulmonary rehab, the stuff that the patient actually needs to have a fighting chance—to the pcp.

Traditionalist was a good gig, I'd recommend it. I got burned out because I was taking overnight call once a week (then working the entire next day) and doing 1 in 4-5 weekends (36 hour call) as well as providing some ICU level care. However, if you can avoid this in your job, I think the job would be sustainable, IMO. I really liked seeing patients in and out of the hospital, it's very rewarding.

I find that as a pulmonologist I am also often the 'de facto' PCP for many chronic lung patients...they don't have easy access to their PCP and many of the mundane tasks you described still fall to me. I think the same is true for any doctor that really cares about their patients and takes ownership of their care, unfortunately. I'm not sure how to avoid that unless you're in a completely procedural subspecialty.

Being an intensivist, in some ways, is not that different than being a hospitalist...in the sense you are a generalist and consulting other specialties when needed. However, if you're pulm-trained at least you are in charge of the lungs/vent...lol. Obviously the acuity/stress of the ICU is challenging, not for everyone, and makes for high levels of burnout.

 

[Colorado outliers]

I've been a general internist for 11 years. The truth is that you already screwed up just doing internal medicine. You have no choices at this point but to somehow get into a subspecialty, quit medicine, or be a general internist/hospitalist serf for the remainder of your working career.

Just the facts man. We are nothing. One step above nurses, pharmacists, and physical therapists. They'll replace us all with midlevels eventually. That or immigrants.

Lol. Maybe you should change careers.

 

[jurassicpark]

It may be the individual place you are working and the general culture of that area.

PCPs are definitely not looked down where I work. They are the GODS of consults. Since they usually control the well-insured patient population, I have to tailor who I consult based off of the PCP preference, and the consultants are always hungry for more work (especially ones that end up with procedures). As the hospitalist, I get the trickle down effect. I get to still eventually decide which consultant to use in the end if they are in the hospital within reason and unassigned patients get distributed by me.

The hospitalist gig is definitely demanding, your schedule seems fairly cush though. Right now I'm in a 7 day stretch, one day off then another 6 days on. But this is all individual, there are plenty of hospital gigs that have varying demands of patient population/demographics/amount/days on etc, you just have to find the right one. And if the atmosphere where you are at looks down at you and you love what you are doing, get out and find a new place.

 

[IMreshopeful]

I've been a general internist for 11 years. The truth is that you already screwed up just doing internal medicine. You have no choices at this point but to somehow get into a subspecialty, quit medicine, or be a general internist/hospitalist serf for the remainder of your working career.

Just the facts man. We are nothing. One step above nurses, pharmacists, and physical therapists. They'll replace us all with midlevels eventually. That or immigrants.

Had to sprinkle in a touch of racism eh?

Sounds like maybe you should change your career as someone said

 

[bronx43]

It may be the individual place you are working and the general culture of that area.

PCPs are definitely not looked down where I work. They are the GODS of consults. Since they usually control the well-insured patient population, I have to tailor who I consult based off of the PCP preference, and the consultants are always hungry for more work (especially ones that end up with procedures). As the hospitalist, I get the trickle down effect. I get to still eventually decide which consultant to use in the end if they are in the hospital within reason and unassigned patients get distributed by me.

The hospitalist gig is definitely demanding, your schedule seems fairly cush though. Right now I'm in a 7 day stretch, one day off then another 6 days on. But this is all individual, there are plenty of hospital gigs that have varying demands of patient population/demographics/amount/days on etc, you just have to find the right one. And if the atmosphere where you are at looks down at you and you love what you are doing, get out and find a new place.

Why would you have to choose the consultant of the PCP’s preference? If they care so much maybe they should manage their own patients in the hospital.

 

[deleted941485]

Why would you have to choose the consultant of the PCP’s preference? If they care so much maybe they should manage their own patients in the hospital.

Oh those pre hospitalist bygone years.

I always found it funny any time someone would talk about continuity of care. I’m like but my pcp used to follow me into the hospital. What’s more continuous than that?

Oh I know an overworked hospitalist with a million patient census most of whom will undoubtedly look to transition to strictly the outpatient setting or fantasize about being a consultant. Who transitions your care via handoff to another hospitalist every 8-12 hours lol.

Granted being a pcp and following patients into the hospital was likely just as much of a grind. Maybe things have changed but the challenge remains the same.

 

[kaycee18]

There are a lot of pros and cons to being a Hospitalist, but this is true for any specialty. I feel like people tend to discuss more of what they do not like then what they do like about their fields. If you are interested in sub specializing then you should consider speaking to them about their thoughts and opinions.

I do tend to agree with some of the things being said here but that's just the nature of medicine now. For instance, if you sub specialize and work at a place with your own primary service, chances are that you will be consulting just as often as a Hospitalist for different issues, maybe even for lesser reasons because you're no longer comfortable with certain medical issues. Some of the most awkward consults are the ones from Medicine specialists to Hospitalists to help with care. There is also an aspect of sub specialty dumping on other specialties. Also consider that to specialize is to spend >50 percent of your clinical time in clinic. The best sub specialists here round early in the morning (notes in by 7am), go to clinic (finish around 4-6pm), then come back in the afternoon to do consults or procedures (consult/follow up notes in around 8 pm).

I think some of the complaints about feeling looked down upon comes from academic settings more often. In the community, if a consultant is not playing nice or you don't feel like they're providing good patient care, you can always consult someone else. Being on call usually means the only person you can call after 5pm. Just because someone is on call, doesn't mean you have to consult them necessarily. There are plenty of consultants that are extremely thankful for any consults, because they're trying to build their patient base and get their name out. There was a specialist here that was really disrespectful and inappropriate to our group so we just stopped consulting this person altogether. I don't have experience to say what the consequences or effects on a sub specialist are when this happens.

A Hospitalist role is kind of plug and play too. Sometimes this is good depending on your personal desire of involvement but it also does mean you're just a cog and replaceable. It is much harder for a sub specialist to change jobs because it means starting completely over, being the new person with the worst schedule and calls, and hustling to get your name and referrals out.

I currently work as a nocturnist and I am burnt out. One of the ways I have been trying to fight burn out is by practicing mindfulness. It does not help with the fatigue but it helps me to feel less bitter when other subspecialties look down on me or when dealing with nursing staff and the frequent calls through out the night. Of course, I am working on leaving the job as I don't think I'll survive it till the end of my contract and it is not a sustainable career especially in a busy hospital. But mindfulness is helping for now.

 

[Anicetus]

I currently work as a nocturnist and I am burnt out. One of the ways I have been trying to fight burn out is by practicing mindfulness. It does not help with the fatigue but it helps me to feel less bitter when other subspecialties look down on me or when dealing with nursing staff and the frequent calls through out the night. Of course, I am working on leaving the job as I don't think I'll survive it till the end of my contract and it is not a sustainable career especially in a busy hospital. But mindfulness is helping for now.

If we have no choice but to be banished into the lost sea that is hospitalist medicine, what are things to look out for when choosing a hospital to work at generally? Is it better to work at a smaller richer hospital with not as sick patients with better case managers?

 

[kaycee18]

If we have no choice but to be banished into the lost sea that is hospitalist medicine, what are things to look out for when choosing a hospital to work at generally? Is it better to work at a smaller richer hospital with not as sick patients with better case managers?

- the most important thing is knowing yourself and what is most important to you at this stage of your career.
- When I signed up initially, I was interested in seeing interesting pathophysiology given that I was a new physician. My current position provides that. But now, I realize that money is equally as important given the student loans we have to pay off. It is important that at the end of the month, you have enough to pay bills and safe for the future.
- Frankly, unless you are interested in pursuing a fellowship or academic, a smaller hospital would be preferable especially if the pay is great.
- I would not depend so much on productivity RVUs or even quality bonus as they are barely attainable. So, it is better to determine your income based on the base salary.
- Taking enough time to search for a position is also important. Getting a decent job off season is much harder. I did not start applying until i had completed residency.

 

[kaycee18]

If we have no choice but to be banished into the lost sea that is hospitalist medicine, what are things to look out for when choosing a hospital to work at generally? Is it better to work at a smaller richer hospital with not as sick patients with better case managers?

- Also look at the turn over of physicians. If a facility is always advertising for a new position, it is because physicians are not satisfied.