gerlawz

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How common is it for hospitalists to cover the ICU?

I was looking at some hospitalist positions and a couple of them require ICU coverage -- e.g. managing vent, performing procedures, etc.. This sounds more like critical care rather than internal medicine. Has anyone worked in a hospital like this?
 

Bobblehead

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In institutions where there isn't 24/7 critical care coverage, especially at night when it's usually quieter it can be common for a hospitalist to cover the ICU. Not all hospitals use closed ICUs due to their patient mix, cost savings, etc.
 
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rokshana

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How common is it for hospitalists to cover the ICU?

I was looking at some hospitalist positions and a couple of them require ICU coverage -- e.g. managing vent, performing procedures, etc.. This sounds more like critical care rather than internal medicine. Has anyone worked in a hospital like this?
not uncommon at smaller and more rural hospitals...usually they are not crazy crazy sick...if they are they usually get transferred to a higher level hospital.
 

DrMetal

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Curious..... So what happens if you're asked to do something, like intubating a patient or placing an A-line and you're not comfortable doing it because you haven't done it in a while? Is there at least some kind of on the job training or apprenticeship?
 

rokshana

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Curious..... So what happens if you're asked to do something, like intubating a patient or placing an A-line and you're not comfortable doing it because you haven't done it in a while? Is there at least some kind of on the job training or apprenticeship?
no...you don't take that job...during credentialing you will have to show that you are able to do the procedures required (of course you are not necessarily going to BE required to do some of those procedures...many times anesthesia or surgery will do intubations and lines respectively).
 
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How common is it for hospitalists to cover the ICU?

I was looking at some hospitalist positions and a couple of them require ICU coverage -- e.g. managing vent, performing procedures, etc.. This sounds more like critical care rather than internal medicine. Has anyone worked in a hospital like this?
This is probably a rural spot, its probably going to be ok. I would clarify the details and be careful. I know of one person who got stuck in some malpractice litigation after the death of a young asthmatic. He was in a high paying hospitalist position where he was required to manage admits in an open ICU for the "first 24 hours" before a critical care consult saw the patient. The ED provider was doing his lines and tubes.
 
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Bobblehead

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Curious..... So what happens if you're asked to do something, like intubating a patient or placing an A-line and you're not comfortable doing it because you haven't done it in a while? Is there at least some kind of on the job training or apprenticeship?
You mean like a residency?

Joking aside, your partners/colleagues may be able to help you relearn certain things you've once known and forgotten or never learned but bear in mean the transition into practice already has a steep enough learning curve with regards to the administrative aspects. You may not want to learn/relearn technical aspects and your partners/colleagues may not want to teach you and opt for someone already competent in those aspects. That being said there is some on the job training once you're out of formal training. You'll generally work with the device/manufacturer's rep, they may even have a formal course. You may also have the opportunity to observe others in your institution. But that's all self-taught/self-started so expect to inquire about it, spend a lot of extra unpaid time and some of your own money. Also realize that since you're no longer in formal training everyone, patients and other professionals will expect you to be competent to a certain degree.

If you're set on a specific practice with specific requirements you may want to spend your last year of residency learning those specific skills.
 

DrMetal

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You mean like a residency?
.
Yeah the residency you did X years ago? and your ICU rotation might be even more distant in the past....how many of us internists are comfortable intubating a decompensated cirrhotic with a BMI >40, under minimal visualization and by ourselves?!

Joking aside, your partners/colleagues may be able to help you relearn certain things you've once known and forgotten or never learned but bear in mean the transition into practice already has a steep enough learning curve with regards to the administrative aspects. You may not want to learn/relearn technical aspects and your partners/colleagues may not want to teach you and opt for someone already competent in those aspects.
Oh I agree, I was sort of asking my question above rhetorically. In any case, I think the open ICU model is very dangerous and I'm surprised they still exist (even in a rural setting....if the hospital is that rural, best to transfer the patient)
 

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How common is it for hospitalists to cover the ICU?

I was looking at some hospitalist positions and a couple of them require ICU coverage -- e.g. managing vent, performing procedures, etc.. This sounds more like critical care rather than internal medicine. Has anyone worked in a hospital like this?
It is quite common to be honest. Simply stated, there are not enough intensivists to cover our ICUs. Most ICU patients can probably be managed by IM - run off the mill septic shock, COPDer who needs a few days on the vent, DKA, etc. I did it for two years. However, I think it is less than ideal. After all, we are internists, not intensivists.

The model is a recipe for disaster. ICU patients often require you to be in the unit for hours at a time. That is not compatible with rounding on patients with mild pancreatitis getting IVF in the wards, doing admissions, discharging patients, rounding with case management, social workers, fielding calls from the nurses, etc.

My personal experience is that you shouldn't count on being able to transfer your patients to a tertiary hospital. Once you admit a patient, you own that patient and no one has to accept a transfer. Further, academic centers are often working at capacity and it can take days for a transfer to take place.

Bear in mind that if you find yourself in an adverse medico legal situation you will be judged compared to the standard of care provided by intensivists. Saying that "you didn't know better because you are not an intensivist" is not going to fly.

Beware of hospitals that entice you to join them by telling you that you will not be required to do procedures. If you are not comfortable with common ICU procedures such as central lines and arterial lines you need to ask very carefully who is responsible for doing the procedures. I guess intubations can be managed by the ER doc or GAS. However, asking your colleagues to place a central line for you on a daily basis will not fly.

And I wouldn't be overconfident about intubating anyone. I had to do it emergently a few times but I wish I didn't have to do it.

IR is pretty much ubiquitous in large hospitals, often seven days a week. They can definitely help you out with common bedside procedures. I wouldn't count on this in a small hospital in a rural setting, particularly during the weekends.

If you have been in the outpatient setting for long, transitioning into hospital medicine is harder than you think. I don't remember the last central line or A-line that I placed, or the last paracentesis. I can probably do it but I have not done one in over a year. The more time I spend out of the hospital the harder it is to be competent as a hospitalist and vice versa.

I remember a primary care physician that joined our hospitalist group after more than 20 years in the office. He had to settle for the job due to a non compete clause that he had. To make the story short, he was let go after roughly five days for gross incompetence. I'm sure he was a great primary care doctor though.

I think that IM needs to be split between hospital medicine tracks and primary care tracks. They really are different specialties.

In summary, I think it can be done but ICU care requires emergency procedures and you should be confident doing them or you should have a procedural team available to you 24/7. If this is not clearly available, I wouldn't take the job. You should be confident to do critical procedures in a timely fashion if you are going to provide critical care.

LPs, paracentesis, and thoracentesis, are also common inpatient procedures although often not emergent (meaning you can punt to IR if available). I wouldn't worry too much about these because you have time to find someone that can help you out if you are unable to do them yourself.

PS: Don't believe for a second that because the hospital is rural all you will see are soft cases. The acuity is going to be there wherever you go. Whether the hospital has the capability to care for those patients is the real question here.
 

DrMetal

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It is quite common to be honest.
Excellent post, many good points.

Ya know, I can't help but wonder: With such a shortage of intensivists.....do you think there will every be a way for hospitalists to become trained/credentialed in intensive care, without having to go back and do a formal fellowship?

For instance, say you have a hospitalist---and I would only suggest a hospitalist, not someone who's been doing outpatient primary care for the last decade---And suppose said hospitalist is good at his/her job, she's 50-yo, has kids and a mortgage (so little desire incentive to go back to formal training, making $40-50K per year). But if she could get some intense on-the-job training over the next few years while working in a unit (and still keeping her hospitalist paycheck), could she not then challenge the boards and certify/practice as a critical care physician? I can think of at least a dozen practicing hospitalists that would gladly do this (but don't because they don't want to/or cant go back to formal training). Just a thought.....I know it goes against the norm.
 
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Bobblehead

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Most board exams are designed to be a competitive moat. You're arguing to drain the moat which is unlikely to happen. Generally the only times that practice pathways exist are for new certifications (see the practice pathway for sleep medicine which was only available for the 2007, 09, 11 exams).
 
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PlutoBoy

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Excellent post, many good points.

Ya know, I can't help but wonder: With such a shortage of intensivists.....do you think there will every be a way for hospitalists to become trained/credentialed in intensive care, without having to go back and do a formal fellowship?

For instance, say you have a hospitalist---and I would only suggest a hospitalist, not someone who's been doing outpatient primary care for the last decade---And suppose said hospitalist is good at his/her job, she's 50-yo, has kids and a mortgage (so little desire incentive to go back to formal training, making $40-50K per year). But if she could get some intense on-the-job training over the next few years while working in a unit (and still keeping her hospitalist paycheck), could she not then challenge the boards and certify/practice as a critical care physician? I can think of at least a dozen practicing hospitalists that would gladly do this (but don't because they don't want to/or cant go back to formal training). Just a thought.....I know it goes against the norm.
If I recall correctly there was some discussion about this between the Society of Hospital Medicine and the Society of Critical Care Medicine a few years ago. I wouldn't count on it happening, though.

There are a few centers offering a one year Hospital Medicine fellowship designed to train you to do the most common inpatient procedures including intubations.

If you are serious about this I would look into it. It's a safe way to get back in the game, get reacquainted with the most common inpatient problems and have a chance to practice the procedures that you may need.

It's worth a shot.

Hospitalist Fellowship | Education | Society of Hospital Medicine
 
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KnuxNole

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I work at an open ICU, and we are responsible for ICU patients. Usually, we have GAS in house to assist with intubations and a-lines/central lines. I've asked general surgery to throw in a central line, depending on who is on call(some are more receptive and prefer to be called vs. gas). In regards to vents, a lot of the older hospitalists manage it on their own, but the younger ones get pulm to assist. Basically, you practice within your comfort level, which is what I like. Honestly, as a hospitalist, putting in lines would take forever and I would get 15 pages while doing one. We don't have a separate admitter so I could be rounding on 10-14 ICU patients, take 3-4 admissions, and field calls.
 

Raryn

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I moonlight in a hospital without intensivist coverage in house at night. Procedures are done by the ED doc or a general surg PA. There's a CRNA on call for intubations.

I'm technically credentialed for lines/thoras/paras/everything but tubes as I did plenty of them as a resident, but every single one for a patient I've admitted in the various shifts I've done so far has been done by the ED before I see them or by IR the next day. I have no particular desire to start doing lines again, so I'm OK with that.

The actual typical ICU management in the community isn't that hard, just a time-suck. At least right now, I can manage sepsis just as easily as I can manage any random floor concern, and everything is easy compared to covering 20+ ICU patients while doing a half dozen admissions on my own in between doing lines as a PGY3.
 
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The tough thing about critical care is that it really is a game of inches. Sure, you can manage the vent and volume status, etc, but the subtleties that come with living in an icu for month after month is what seems to drive outcomes. Where I used to moonlight in a rural ED, the hospitalist who admitted to the ICU said he felt comfortable with managing vents, pressors, etc but was practicing significantly outdated medicine and didn't know it.
 
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Honestly I don't really see a big difference between a close academic unit vs a open community.

Closed academic - most places the unit is run by a PGY2 or PGY3 overnight with a fellow either available by phone or in house to help with questions/tubes.

Open - Attending hospitalist overnight with CC attending available by phone as backup.

Both models have a critical care attending during the day to mop up.

Sometimes I wonder how evidence based what we really do in CC is anyway. I mean it's a game of inches... but in what direction.
 

PlutoBoy

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Honestly I don't really see a big difference between a close academic unit vs a open community.

Closed academic - most places the unit is run by a PGY2 or PGY3 overnight with a fellow either available by phone or in house to help with questions/tubes.

Open - Attending hospitalist overnight with CC attending available by phone as backup.

Both models have a critical care attending during the day to mop up.

Sometimes I wonder how evidence based what we really do in CC is anyway. I mean it's a game of inches... but in what direction.
I think the value of an intensivist increases exponentially the higher the complexity of the patient.

Sure. I can start levophed and put someone on volume controlled ventilation. One does not need to be very smart to know what to do for a patient with simple septic shock (if such a thing exists) or respiratory failure 2/2 COPD, for example.

The value of the intensivist comes into play when you need advanced modes of ventilation, bronchs, etc.

Most patients can be handled by internal medicine. But oh boy, when you need CC it is a blessing to have them in house.
 
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Everyone thinks they can do critical care, doesn't mean they are doing it right. It has been shown over and over again that high intensity intensivist staffing changes outcomes and reduces costs. I'm in a medium sized midwestern city and in the entire metro almost all the hospitals have ICUs staffed by intensivists. If you're not trained, but willing to take on the liability, and can find a place desperate enough to hire you, go for it. Don't expect to be paid the same though.
 

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Critical care is so very nuanced. You will likely miss this distinction outside of the formal training. Patients usually really drive the care they get not the internist or intensivist. Which is why you see so often "I can manage a septic shock on a vent". It's neat patients can and do often get better with just the small pushes and interventions we do bring to the table like initiating abx and pressor. I deal with a lot of transfers from guys who are trying to manage ICU patients in smaller hospitals as internists. I never ever say no to a transfer provided I have physical space for the patient. In almost every case of transfer the internist is in way over their heads. This is clearly a confirmation bias on my end because it doesn't account for the cases where the internist did it all correctly but just the cases where I become involved. Patients are getting more complicated not less these days. Rural patients have a tendency to be more chronically ill overall in my experience. I have reasons why I suspect this is the case that is cultural and socioeconomic. But also access to the healthcare in general.

I wouldn't recommend taking any job that asked you to be an intensivist outside of very specific and clearly defined parameters as set forth in your contract with known ability to transfer without trouble to higher level of care. And agreeable help from other services for procedure that you can't or won't do that they can and *will* do by formal agreement. Outside of this I think an internist is playing with fire.