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Hospitalist job offer for a new grad. What are your thoughts?

fullmetal

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    I am graduating an FM residency program with a strong inpatient training component.

    The offer:

    Hospitalist at a small community hospital (100 beds) in a small town (30,000) 45 minutes outside of a small city (150,000)
    7 on 7 off 7am to 7pm (days only, no nights, no call). Two weeks vacation.
    Census is apparently between 5 and 20 but I am told the average is around 12 each.
    There are only two hospitalists working at a time during the day. We cover codes.
    Admissions are rotated between the two hospitalists.
    It is an open ICU with an intensivist on call.
    Complicated / difficult to manage cases get sent to the city hospital.
    Compensation is $226,000 base + $30,000 based on quality measures.
    There is a pretty okay employee benefit package (I think its 6% match) and all the regular stuff medical, dental, vision, disability, malpractice with tail coverage.
    Sign on bonus of $10,000
    The EMR is not terrible but not great (its not Epic)

    I am Canadian and need a J1 waiver / H1B visa which they have agreed to sponsor (and pay for).

    My impression is that, for an FM grad, it is an average-difficulty job with average compensation which considering I need the visa is pretty good.

    What do you guys think?

    Edit: Oh, and procedures not required
     
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    IMGASMD

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      I think for the amount of work, it’s probably not bad. But only two weeks of vacation is a little rough. They will say, you’re essentially off every other week. Are you though? You’re working 84 hours/week.
      It sounds like a stopgap job. When you don’t need the visa anymore, you may have better prospects.
      And yes, figure out OT pay.
       
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      jurassicpark

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        If you're covering codes, does this mean you are also doing procedures and intubations? Also if it's an open ICU, what are their expectations? That you're managing the ICU patients (including procedures) with the intensivist as backup?

        Also, if it's a 100 bed hospital and there are only two hospitalists, could you theoretically have to cover 50 patients?
         

        fullmetal

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          OT pay? Do you mean ask if I get paid extra if I end up having to work past 7? Or do you mean if I pick up extra shifts?

          I doubt I’d decide to pick up extra shifts at all. I value my time off.
           

          tantacles

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            I would want a hard cap on my census. I’d also want at least another week off

            I agree with this. Totally ok to cover 50 patients at night, but during the day, 50 patients is an impossible task.

            Also, open ICU, but when does ICU start getting covered by the hospitalists?
             

            Egghead34

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              My buddy’s first contract out of residency was as an FM hospitalist at a community hospital In a small town. He gets $330K guaranteed. However, same deal as you: no cap, open ICU (though he does have NP support), week on-week off. His average census is 24-28 patients, and after just under 2 years of practice he is handing in his 2 weeks notice. 20+ patients with ICU responsibility means writing notes til midnight every day. Half his week off is spent recovering, before gathering his strength to start all over again. And heaven help you if you have a family meeting to suck away the hours.

              I am at an academic center where the hospitalist cap is 10. Base pay is $220K. I’d take the lower pay every time over the lucrative hell he lives.
               
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                My buddy’s first contract out of residency was as an FM hospitalist at a community hospital In a small town. He gets $330K guaranteed. However, same deal as you: no cap, open ICU (though he does have NP support), week on-week off. His average census is 24-28 patients, and after just under 2 years of practice he is handing in his 2 weeks notice. 20+ patients with ICU responsibility means writing notes til midnight every day. Half his week off is spent recovering, before gathering his strength to start all over again. And heaven help you if you have a family meeting to suck away the hours.

                I am at an academic center where the hospitalist cap is 10. Base pay is $220K. I’d take the lower pay every time over the lucrative hell he lives.
                28 is completely absurd
                 

                chessknt

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                  And how would the hospital logistically cover a hard cap? Transfer patients out after you reach it because even though they have beds the patients wont be taken care of by their employee? Fat chance of any admin signing off on that.
                   
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                  rokshana

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                    I agree with this. Totally ok to cover 50 patients at night, but during the day, 50 patients is an impossible task.

                    Also, open ICU, but when does ICU start getting covered by the hospitalists?
                    Open Icu usually means that the hospitalist is covering the icu and has a pulm/cc as a consult available.

                    Unless you have significant ICU experience, I wouldn’t take this job...one crumping icu pt can take over your day.
                     
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                    tantacles

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                      Open Icu usually means that the hospitalist is covering the icu and has a pulm/cc as a consult available.

                      Unless you have significant ICU experience, I wouldn’t take this job...one crumping icu pt can take over your day.

                      I meant at OP's specific institution. At mine, the critical care attending is THE attending during the day and only cedes the ICU at night (but must come in if patients are crashing and need to be intubated or require critical procedures.
                       

                      Jinxapotato

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                        I am graduating an FM residency program with a strong inpatient training component.

                        The offer:

                        Hospitalist at a small community hospital (100 beds) in a small town (30,000) 45 minutes outside of a small city (150,000)
                        7 on 7 off 7am to 7pm (days only, no nights, no call). Two weeks vacation.
                        Census is apparently between 5 and 20 but I am told the average is around 12 each.
                        There are only two hospitalists working at a time during the day. We cover codes.
                        Admissions are rotated between the two hospitalists.
                        It is an open ICU with an intensivist on call.
                        Complicated / difficult to manage cases get sent to the city hospital.
                        Compensation is $226,000 base + $30,000 based on quality measures.
                        There is a pretty okay employee benefit package (I think its 6% match) and all the regular stuff medical, dental, vision, disability, malpractice with tail coverage.
                        Sign on bonus of $10,000
                        The EMR is not terrible but not great (its not Epic)

                        I am Canadian and need a J1 waiver / H1B visa which they have agreed to sponsor (and pay for).

                        My impression is that, for an FM grad, it is an average-difficulty job with average compensation which considering I need the visa is pretty good.

                        What do you guys think?

                        Edit: Oh, and procedures not required
                        Just a PGY 1 here but I'm also a Canuck on J1! Just wanna ask your general opinion, how hard is it to find waiver jobs? Especially in small-mid sized cities? Best of luck in job hunt!
                         

                        Splenda88

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                          Wow 225k base is depressingly low.


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                          It's low for that type of job... But 225k is not too low when it's a close ICU, no code, census ~15 and the job is located in a nice city/suburb.

                          OP should get at least 300k/yr and 3-4 wks vacation for that job...
                           
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                          MedicineZ0Z

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                            Why are codes, procedures etc. viewed as such a "bad" thing to have to do for hospitalists? I agree there should be a bit more financial incentive to do them (or jobs needing them should pay more) but it's kind of sad if physicians can't run a code or do inpatient procedures.
                             
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                            CCM-MD

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                              Why are codes, procedures etc. viewed as such a "bad" thing to have to do for hospitalists? I agree there should be a bit more financial incentive to do them (or jobs needing them should pay more) but it's kind of sad if physicians can't run a code or do inpatient procedures.

                              #1 $
                              #2 liability
                              #3 $


                              I meant at OP's specific institution. At mine, the critical care attending is THE attending during the day and only cedes the ICU at night (but must come in if patients are crashing and need to be intubated or require critical procedures.

                              Agrees to cover the ICU at night. Expects someone else to come in from home to take care of a crashing patient. Good luck with that set up. It makes total sense. I am sure the crashing patient will be totally fine until your critical care consultant gets out of bed and comes in. I’m sure the outcomes are gonna be great and liability is gonna be low, while you get paid top dollar.
                               
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                              Egghead34

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                                Why are codes, procedures etc. viewed as such a "bad" thing to have to do for hospitalists? I agree there should be a bit more financial incentive to do them (or jobs needing them should pay more) but it's kind of sad if physicians can't run a code or do inpatient procedures.

                                they are a huge time sink. Your average hospitalist is seeing 20+ patients. In a standard shift that’s roughly 30 minutes per patient if you want to get out on time...an many don't; writing notes til midnight. It’s so bad for lifestyle. So draining.

                                Throw in a central line and your day is extended by an hour. Throw in a code, day extended another hour or more. Same reason family meetings are so terrible when the census is busy.

                                Open ICUs can be a death knell. I’d venture that many of us enjoyed the ICU during residency, but those patients can be major major time sinks. Even one or (heaven forbid) two active patients and your day is ruined...even with mid level support.

                                As we get older, the ability to go in and get out on time becomes all the more valuable. Anything that doesn’t involve seeing patients, pounding out a SOAP note, and putting in a few orders will disrupt the routine.

                                Last thing: use it or lose it. If you’re not doing a couple of procedures each month (which most hospitalist are not), you’ll lose technical proficiency. That means longer procedure times, more complications, more liability, and more stress. Not worth it when you can just tap the intensivist to do it for you.

                                Big reason why I’m subspecializing.
                                 
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                                MedicineZ0Z

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                                  Agrees to cover the ICU at night. Expects someone else to come in from home to take care of a crashing patient. Good luck with that set up. It makes total sense. I am sure the crashing patient will be totally fine until your critical care consultant gets out of bed and comes in. I’m sure the outcomes are gonna be great and liability is gonna be low, while you get paid top dollar.

                                  A decade of schooling and training isn't enough to do high acute patient care. Better get the NP to do it instead.

                                  they are a huge time sink. Your average hospitalist is seeing 20+ patients. In a standard shift that’s roughly 30 minutes per patient if you want to get out on time...an many don't; writing notes til midnight. It’s so bad for lifestyle. So draining.

                                  Throw in a central line and your day is extended by an hour. Throw in a code, day extended another hour or more. Same reason family meetings are so terrible when the census is busy.

                                  Open ICUs can be a death knell. I’d venture that many of us enjoyed the ICU during residency, but those patients can be major major time sinks. Even one or (heaven forbid) two active patients and your day is ruined...even with mid level support.

                                  As we get older, the ability to go in and get out on time becomes all the more valuable. Anything that doesn’t involve seeing patients, pounding out a SOAP note, and putting in a few orders will disrupt the routine.

                                  Last thing: use it or lose it. If you’re not doing a couple of procedures each month (which most hospitalist are not), you’ll lose technical proficiency. That means longer procedure times, more complications, more liability, and more stress. Not worth it when you can just tap the intensivist to do it for you.

                                  Big reason why I’m subspecializing.
                                  Waiting on IR to do a procedure for you can delay patient care. And running your patient's codes/rapids should improve outcomes since you know the patient best. Unless we want to say that knowledge of the patient's history is irrelevant?

                                  I still think it's crappy if physicians train for so long and cannot do routine inpatient procedures. Not the case in most countries.
                                   
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                                  Egghead34

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                                    A decade of schooling and training isn't enough to do high acute patient care. Better get the NP to do it instead.


                                    Waiting on IR to do a procedure for you can delay patient care. And running your patient's codes/rapids should improve outcomes since you know the patient best. Unless we want to say that knowledge of the patient's history is irrelevant?

                                    I still think it's crappy if physicians train for so long and cannot do routine inpatient procedures. Not the case in most countries.

                                    by all means, be that super physician who does everything. I’m not being facetious; I applaud it. My good friend is that person. He’s FM trained hospitalist who does more lines than the intensivist. In fact, in his small hospital he has become THE person to call for procedures.

                                    that said, he goes to sleep each night at 1am and is burnt out two years into his job. If you’re going to be that physician, you better have a lot of willpower or a low cap
                                     
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                                    throwaway1000000

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                                      by all means, be that super physician who does everything. I’m not being facetious; I applaud it. My good friend is that person. He’s FM trained hospitalist who does more lines than the intensivist. In fact, in his small hospital he has become THE person to call for procedures.

                                      that said, he goes to sleep each night at 1am and is burnt out two years into his job. If you’re going to be that physician, you better have a lot of willpower or a low cap

                                      Does he get paid a lot more? Or is he a victim to our stupid reimbursement policies.

                                      I would love to be this all-around physician but if I am going to be paid the same or marginally more, I would be better off picking up a cush job and working ton of locums. What I do hate is giving up these procedures to an ICU midlevel.
                                       
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                                      throwaway1000000

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                                        A decade of schooling and training isn't enough to do high acute patient care. Better get the NP to do it instead.


                                        Waiting on IR to do a procedure for you can delay patient care. And running your patient's codes/rapids should improve outcomes since you know the patient best. Unless we want to say that knowledge of the patient's history is irrelevant?

                                        I still think it's crappy if physicians train for so long and cannot do routine inpatient procedures. Not the case in most countries.

                                        I completely agree with you but also agree with the person above. Unfortunately seems to be a byproduct of the reimbursement system.

                                        As US physicians, we go through more education that most countries and IM grads can easily get proficient in procedures if that is a job requirement. But with the specialized nature of medicine, unfortunately an hospitalist will make probably more money seeing easy admits than running codes and doing procedures like central lines or stabilizing a crashing patient (in the same amount of time).
                                         
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                                        CCM-MD

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                                          It’s not about lack of training. With a full license one has the ability to do everything. There’s no legal constraints. And all kinds of desperate places out there that will let one take on all kinds of liability for $.

                                          Not gonna make ‘mad dough’ from lines and codes, but easy to get sued. Lawsuits are for bad outcomes, not mistakes. Can do everything right and still get sued. And many end up settled, regardless of the absence of physician error. Lots of better avenues for $, look into ketamine and botox, much better liability to compensation ratio.
                                           
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                                          MedicineZ0Z

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                                            by all means, be that super physician who does everything. I’m not being facetious; I applaud it. My good friend is that person. He’s FM trained hospitalist who does more lines than the intensivist. In fact, in his small hospital he has become THE person to call for procedures.

                                            that said, he goes to sleep each night at 1am and is burnt out two years into his job. If you’re going to be that physician, you better have a lot of willpower or a low cap
                                            You don't have to be a super physician and you don't always have to do everything. But doing routine procedures for your patients is a good thing regardless of how you put it. No one is asking you to do bronchs alone at 2am as a hospitalist.

                                            No one has addressed why running codes are a bad thing?? That's the one thing, hands down, that you should be doing when it's your patient.

                                            Does he get paid a lot more? Or is he a victim to our stupid reimbursement policies.

                                            I would love to be this all-around physician but if I am going to be paid the same or marginally more, I would be better off picking up a cush job and working ton of locums. What I do hate is giving up these procedures to an ICU midlevel.

                                            Although, it does feel insulting that the midlevel is able to do it but here I am not able to due to whatever constraints even when I am more trained.
                                            Not sure what's more insulting - the IR PA doing a paracentesis for your patient or an ICU midlevel doing a line for you.
                                             

                                            throwaway1000000

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                                              You don't have to be a super physician and you don't always have to do everything. But doing routine procedures for your patients is a good thing regardless of how you put it. No one is asking you to do bronchs alone at 2am as a hospitalist.

                                              No one has addressed why running codes are a bad thing?? That's the one thing, hands down, that you should be doing when it's your patient.


                                              Not sure what's more insulting - the IR PA doing a paracentesis for your patient or an ICU midlevel doing a line for you.

                                              Oh, I feel insulted at both of those things. I think IM grads should be really good (not just oh i might be able to do it) in doing lines, intubations, paracentesis and other appropriate procedures.

                                              I just see the other side of the argument regarding reimbursement and time constraints.
                                               
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                                              Egghead34

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                                                You don't have to be a super physician and you don't always have to do everything. But doing routine procedures for your patients is a good thing regardless of how you put it. No one is asking you to do bronchs alone at 2am as a hospitalist.

                                                No one has addressed why running codes are a bad thing?? That's the one thing, hands down, that you should be doing when it's your patient.


                                                Not sure what's more insulting - the IR PA doing a paracentesis for your patient or an ICU midlevel doing a line for you.

                                                Your post history suggests you have a bone to pick with mid levels, which makes me feel that you are trying to prove a point rather than have a meaningful discussion. And I absolutely did answer why running codes is “a bad thing”.

                                                Again, if you want to be Mr Do-it-all then by all means go do it. You’ll just wear yourself really thin. Running a code can take over an hour, and then you should be the one to oversee the patients transfer to ICU and resumption of their care. Are you competent enough in managing vents, pressors, intubation, lines? Do you have the hours to spare when you also need to admit three patients, discharge four, and round on 16? Or should you Turf it to the intensivist who does this all day, every day and can do it all faster, safer, and more efficiently?

                                                Are you FM? If so, you May have gone into the wrong specialty. Or you need to find yourself a small, rural hospital in the country and rule supreme.
                                                 
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                                                MedicineZ0Z

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                                                  Oh, I feel insulted at both of those things. I think IM grads should be really good (not just oh i might be able to do it) in doing lines, intubations, paracentesis and other appropriate procedures.

                                                  I just see the other side of the argument regarding reimbursement and time constraints.
                                                  That's why you don't always have to be doing them. This notion that hospitalists are constantly overwhelmed is nonsense. You have "downtime" throughout a week where you can do these things and other times when you can't .
                                                   

                                                  MedicineZ0Z

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                                                    Your post history suggests you have a bone to pick with mid levels, which makes me feel that you are trying to prove a point rather than have a meaningful discussion. And I absolutely did answer why running codes is “a bad thing”.

                                                    Again, if you want to be Mr Do-it-all then by all means go do it. You’ll just wear yourself really thin. Running a code can take over an hour, and then you should be the one to oversee the patients transfer to ICU and resumption of their care. Are you competent enough in managing vents, pressors, intubation, lines? Do you have the hours to spare when you also need to admit three patients, discharge four, and round on 16? Or should you Turf it to the intensivist who does this all day, every day and can do it all faster, safer, and more efficiently?

                                                    Are you FM? If so, you May have gone into the wrong specialty. Or you need to find yourself a small, rural hospital in the country and rule supreme.
                                                    Yeah bro better to have a hyperspecialized system where you consult for dumb stuff. Ever wonder why we stand out in the world for our healthcare and its expenses?
                                                     

                                                    wjs010

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                                                      You don't have to be a super physician and you don't always have to do everything. But doing routine procedures for your patients is a good thing regardless of how you put it. No one is asking you to do bronchs alone at 2am as a hospitalist.

                                                      No one has addressed why running codes are a bad thing?? That's the one thing, hands down, that you should be doing when it's your patient.


                                                      Not sure what's more insulting - the IR PA doing a paracentesis for your patient or an ICU midlevel doing a line for you.

                                                      Are you in school, residency, or attending?


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                                                        Agrees to cover the ICU at night. Expects someone else to come in from home to take care of a crashing patient. Good luck with that set up. It makes total sense. I am sure the crashing patient will be totally fine until your critical care consultant gets out of bed and comes in. I’m sure the outcomes are gonna be great and liability is gonna be low, while you get paid top dollar.

                                                        It's the setup. ED is expected to intubate in a code situation. It's not ideal, but is any job ideal, really?
                                                         

                                                        Egghead34

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                                                          Yeah bro better to have a hyperspecialized system where you consult for dumb stuff. Ever wonder why we stand out in the world for our healthcare and its expenses?

                                                          lol, I’m not telling you how things should be; I’m telling you how they are. Be the doctor you wish to be or go howl at the moon in frustration. Makes no difference to me.
                                                           
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                                                          MedicineZ0Z

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                                                            Are you in school, residency, or attending?


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                                                            We have these little things under our names on the left side that say what we are.

                                                            Also I'm not bringing up some new revelation. My point has been brought up extensively and you'll find most pieces online highly criticize the model of a hospitalist not doing anything beyond rounding and writing notes. It's literally a system only exclusive to suburban and majority suburban USA, and basically nowhere else in the world.
                                                             

                                                            drimo786

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                                                              I am graduating an FM residency program with a strong inpatient training component.

                                                              The offer:

                                                              Hospitalist at a small community hospital (100 beds) in a small town (30,000) 45 minutes outside of a small city (150,000)
                                                              7 on 7 off 7am to 7pm (days only, no nights, no call). Two weeks vacation.
                                                              Census is apparently between 5 and 20 but I am told the average is around 12 each.
                                                              There are only two hospitalists working at a time during the day. We cover codes.
                                                              Admissions are rotated between the two hospitalists.
                                                              It is an open ICU with an intensivist on call.
                                                              Complicated / difficult to manage cases get sent to the city hospital.
                                                              Compensation is $226,000 base + $30,000 based on quality measures.
                                                              There is a pretty okay employee benefit package (I think its 6% match) and all the regular stuff medical, dental, vision, disability, malpractice with tail coverage.
                                                              Sign on bonus of $10,000
                                                              The EMR is not terrible but not great (its not Epic)

                                                              I am Canadian and need a J1 waiver / H1B visa which they have agreed to sponsor (and pay for).

                                                              My impression is that, for an FM grad, it is an average-difficulty job with average compensation which considering I need the visa is pretty good.

                                                              What do you guys think?

                                                              Edit: Oh, and procedures not required


                                                              As a J1 candidate I would say that this offering is fair. Please reach out to someone directly working at the facility to get an idea of how experiences for their previous J1 hospitalists have been. You are signing a relatively firm agreement and switching jobs after agreeing to this one would be difficult (I have a friend in this situation, ended up at an abusive hospital).

                                                              Otherwise, if all checks out with people at the institution and you are happy with the geographical location the job seems like a slightly above average offering and well balanced. I would consider it strongly.

                                                              For reference, I am an IM PGY3 going into Hospitalist medicine this Summer.
                                                               

                                                              wamcp

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                                                                I am graduating an FM residency program with a strong inpatient training component.

                                                                The offer:

                                                                Hospitalist at a small community hospital (100 beds) in a small town (30,000) 45 minutes outside of a small city (150,000)
                                                                7 on 7 off 7am to 7pm (days only, no nights, no call). Two weeks vacation.
                                                                Census is apparently between 5 and 20 but I am told the average is around 12 each.
                                                                There are only two hospitalists working at a time during the day. We cover codes.
                                                                Admissions are rotated between the two hospitalists.
                                                                It is an open ICU with an intensivist on call.
                                                                Complicated / difficult to manage cases get sent to the city hospital.
                                                                Compensation is $226,000 base + $30,000 based on quality measures.
                                                                There is a pretty okay employee benefit package (I think its 6% match) and all the regular stuff medical, dental, vision, disability, malpractice with tail coverage.
                                                                Sign on bonus of $10,000
                                                                The EMR is not terrible but not great (its not Epic)

                                                                I am Canadian and need a J1 waiver / H1B visa which they have agreed to sponsor (and pay for).

                                                                My impression is that, for an FM grad, it is an average-difficulty job with average compensation which considering I need the visa is pretty good.

                                                                What do you guys think?

                                                                Edit: Oh, and procedures not required

                                                                103/hr base for open icu, days only position is not great, if you are outside of a saturated metro job market. In general 125/hr base pay would be fair for this kind of position.
                                                                 
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                                                                wamcp

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                                                                  My buddy’s first contract out of residency was as an FM hospitalist at a community hospital In a small town. He gets $330K guaranteed. However, same deal as you: no cap, open ICU (though he does have NP support), week on-week off. His average census is 24-28 patients, and after just under 2 years of practice he is handing in his 2 weeks notice. 20+ patients with ICU responsibility means writing notes til midnight every day. Half his week off is spent recovering, before gathering his strength to start all over again. And heaven help you if you have a family meeting to suck away the hours.

                                                                  I am at an academic center where the hospitalist cap is 10. Base pay is $220K. I’d take the lower pay every time over the lucrative hell he lives.

                                                                  330k for open icu 28 census days? F that, that is slave wages not lucrative whatsoever. Need 600k minimum to make it fair
                                                                   
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                                                                  wamcp

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                                                                    Why are codes, procedures etc. viewed as such a "bad" thing to have to do for hospitalists? I agree there should be a bit more financial incentive to do them (or jobs needing them should pay more) but it's kind of sad if physicians can't run a code or do inpatient procedures.

                                                                    it is bad if you aren’t being fairly compensated for the extra responsibilities
                                                                     

                                                                    wjs010

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                                                                      We have these little things under our names on the left side that say what we are.

                                                                      Also I'm not bringing up some new revelation. My point has been brought up extensively and you'll find most pieces online highly criticize the model of a hospitalist not doing anything beyond rounding and writing notes. It's literally a system only exclusive to suburban and majority suburban USA, and basically nowhere else in the world.

                                                                      I am not able to see that on my screen. Maybe it’s because I only use mobile. But you have to think, what is the most litigious society in the world? Here In the USA. That’s the problem you run into when you do things outside of your comfort zone.


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                                                                      CCM-MD

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                                                                        I am not able to see that on my screen. Maybe it’s because I only use mobile. But you have to think, what is the most litigious society in the world? Here In the USA. That’s the problem you run into when you do things outside of your comfort zone.


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                                                                        Pretty much everything is in his comfort zone though, so he will be fine.
                                                                         
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                                                                        NITRAS

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                                                                          You don't have to be a super physician and you don't always have to do everything. But doing routine procedures for your patients is a good thing regardless of how you put it. No one is asking you to do bronchs alone at 2am as a hospitalist.

                                                                          No one has addressed why running codes are a bad thing?? That's the one thing, hands down, that you should be doing when it's your patient.


                                                                          Not sure what's more insulting - the IR PA doing a paracentesis for your patient or an ICU midlevel doing a line for you.

                                                                          Being responsible for codes means you have to be in house at all times. Running a code isn't rocket science, but the patients need an ICU doc ASAP.
                                                                          I do a lot of my own para's and LP's (when I have a little bit of time) because I like to do them. I haven't done a central line in years. You might realize that central lines are a high risk procedure. If you haven't seen a ton of complications, you haven't done them. Each of these procedures adds about an hour to my time at the hospital. They add minimal billing, and frankly, its not like it takes much brain power to do, either. I don't place peripheral IV's (other than the odd EJ) nor do I place foleys, nor start my own antibiotics.
                                                                           
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                                                                          DrSnips

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                                                                            And how would the hospital logistically cover a hard cap?

                                                                            If you're actually wondering, there are a few ways to logistically do hard caps:

                                                                            1) When the hospitalist service reaches the cap, a non-hospitalist service takes some patients that they are totally capable of taking care of (e.g. family med takes a patient who is not followed by them as outpatient, or peds takes a patient 2 years above their age cutoff who has only sickle cell, or neuro takes someone who can't walk due to radicular pain)

                                                                            2) Have hospitalist(s) on call for when the cap is reached

                                                                            3) Have an ED obs unit that cares for medicine patients who would otherwise have been admitted and discharges them directly in the next couple days (yes, this is an actual thing and requires a good triage system)
                                                                             

                                                                            aafisahar

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                                                                              Oh, I feel insulted at both of those things. I think IM grads should be really good (not just oh i might be able to do it) in doing lines, intubations, paracentesis and other appropriate procedures.

                                                                              I just see the other side of the argument regarding reimbursement and time constraints.
                                                                              Bro, **** the airway. I intubated a handful of people in residency (<10) and it's probably the most stressful procedure that non surgeons can do. Sure, when you have three levels of backup (fellow, attending, anesthesia) at an academic center, a bad outcome is less likely. When you are the only guy in house and you have a crashing airway? **** that. Every year, there's always a bunch of malpractice cases where some idiot who had no business intubating ended up intubating and ****ing it up good.
                                                                               
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                                                                              throwaway1000000

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                                                                                Bro, **** the airway. I intubated a handful of people in residency (<10) and it's probably the most stressful procedure that non surgeons can do. Sure, when you have three levels of backup (fellow, attending, anesthesia) at an academic center, a bad outcome is less likely. When you are the only guy in house and you have a crashing airway? **** that. Every year, there's always a bunch of malpractice cases where some idiot who had no business intubating ended up intubating and ****ing it up good.

                                                                                Yeah. It is definitely a skill that you have to do a lot do get good at but it is definitely not rocket science. EM residents learn to do it in 3 years. CRNAs learn it.

                                                                                IM grads could learn it too if we put our mind to it and designed the residency curriculum to accommodate for that.

                                                                                But...the bottom line is it's a nice ego boost to be able to intubate your crashing patient but I doubt it changes your pay as a hospitalist. Like others said in this thread, managing a crashing patient is probably a time sink/liability issue without significant increase in pay for a hospitalist. In fact, you can probably bill more seeing 2-3 easy admits than spending an hour on a crashing patient.

                                                                                If my pay as an hospitalist is tied significantly to these procedures like the EM/ICU attendings pay is, I would advocate much more strongly to master it but in the current scenario, doesn't seem to matter much.
                                                                                 

                                                                                MedicineZ0Z

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                                                                                  Bro, **** the airway. I intubated a handful of people in residency (<10) and it's probably the most stressful procedure that non surgeons can do. Sure, when you have three levels of backup (fellow, attending, anesthesia) at an academic center, a bad outcome is less likely. When you are the only guy in house and you have a crashing airway? **** that. Every year, there's always a bunch of malpractice cases where some idiot who had no business intubating ended up intubating and ****ing it up good.
                                                                                  There are lots of EDs and also even ICUs in the country where midlevels (PA/NP, not CRNA) is independently intubating with no one else in house.
                                                                                   

                                                                                  chessknt

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                                                                                    If you're actually wondering, there are a few ways to logistically do hard caps:

                                                                                    1) When the hospitalist service reaches the cap, a non-hospitalist service takes some patients that they are totally capable of taking care of (e.g. family med takes a patient who is not followed by them as outpatient, or peds takes a patient 2 years above their age cutoff who has only sickle cell, or neuro takes someone who can't walk due to radicular pain)

                                                                                    2) Have hospitalist(s) on call for when the cap is reached

                                                                                    3) Have an ED obs unit that cares for medicine patients who would otherwise have been admitted and discharges them directly in the next couple days (yes, this is an actual thing and requires a good triage system)

                                                                                    I worked at a 100 bed hospital. There was no family med service and they were so strapped for hospitalitists we running a skeleton crew. Apps not legally allowed to practice independently. Profit margins were razor thin.

                                                                                    How does this hospital do a hard cap? Its all nice when the hospital has cash to pay people for calls or units they only need to use in rare scenarios to make their contract look more appealing but the fiscal reality is that having a cap is a huge money sinkhole unless there is a large pool of salaried labor that can be tapped at will (ie academics).
                                                                                     
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