Hospitalist Life not as good as it seems?

[CharlesDarnay]

Recent graduate who started a job as an academic hospitalist in a large east coast city. Wasn't in love with hospitalist but thought it would be a good lifestyle and job choice and didn't see myself doing any fellowship or outpatient.

Very surprised to find myself not enjoying it at all despite not being on the job for so long. I enjoyed my ward months during residency but attending life is much less enjoyable. Any other hospitalists with these feelings? Interested in hear other's thoughts. Seems like its an easy job to get burned out.
-Sure, the time off is nice (work about 2/3 of weeks a year and have to come in a couple other days a year for educational stuff, meetings) but having a random tues morning off doesn't make up for the fact that i have to work 13-14 full weekends a year. Thats 1/4 of all weekend at hospital and when I'm there, its usually a solid 12-14 hr days so I'm there much longer pretty much anyone else in hospital (residents, sub specialist attendings). Not to mention that come holidays, I've had to spent 12-14 hr days on while the other attendings in subspecialty come in for 2-3 hours (its academic) or outpatient are off completely. Not to mention, the hours worked doesn't come anywhere close to the salary I receive (150K).

-Other thing that bothers is constantly feeling "dumped on" or being the bottom of barrel in hospital. Both here and other hospitals, the hospitalists get every patient, the social admits, the complicated patients yet the constant argument is hospitalists don't make $$$ for the hospital, so the money goes to the cardiologist who do caths or the surgeons or the GI doing colonoscopies. Maybe its just my area, but hospitalists are seen as glorified residents IMO and i wonder if thats something that other hospitalists are always fighting for their deserved respect and recognition. Thankful for any responses.

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[bronx43]

Recent graduate who started a job as an academic hospitalist in a large east coast city. Wasn't in love with hospitalist but thought it would be a good lifestyle and job choice and didn't see myself doing any fellowship or outpatient.

Very surprised to find myself not enjoying it at all despite not being on the job for so long. I enjoyed my ward months during residency but attending life is much less enjoyable. Any other hospitalists with these feelings? Interested in hear other's thoughts. Seems like its an easy job to get burned out.
-Sure, the time off is nice (work about 2/3 of weeks a year and have to come in a couple other days a year for educational stuff, meetings) but having a random tues morning off doesn't make up for the fact that i have to work 13-14 full weekends a year. Thats 1/4 of all weekend at hospital and when I'm there, its usually a solid 12-14 hr days so I'm there much longer pretty much anyone else in hospital (residents, sub specialist attendings). Not to mention that come holidays, I've had to spent 12-14 hr days on while the other attendings in subspecialty come in for 2-3 hours (its academic) or outpatient are off completely. Not to mention, the hours worked doesn't come anywhere close to the salary I receive (150K).

-Other thing that bothers is constantly feeling "dumped on" or being the bottom of barrel in hospital. Both here and other hospitals, the hospitalists get every patient, the social admits, the complicated patients yet the constant argument is hospitalists don't make $$$ for the hospital, so the money goes to the cardiologist who do caths or the surgeons or the GI doing colonoscopies. Maybe its just my area, but hospitalists are seen as glorified residents IMO and i wonder if thats something that other hospitalists are always fighting for their deserved respect and recognition. Thankful for any responses.

Bro... that's because you're in the East Coast.

I'm in the Midwest and our attendings go home at 3pm. They cover their pagers until 7 pm. They work 55% of the year, and avg income is 220-230k. Obviously there are headaches to being a hospitalist, but subspecialties aren't exactly kicking back and puffing on cigars all day.

And yes, hospitalists are glorified and highly paid residents. But, out there in the real world (not the fantasy world of academics), subspecialists are just highly paid fellows. You don't have lackeys doing all your work for you.

 

[metopic]

Bro... that's because you're in the East Coast.

I'm in the Midwest and our attendings go home at 3pm. They cover their pagers until 7 pm. They work 55% of the year, and avg income is 220-230k. Obviously there are headaches to being a hospitalist, but subspecialties aren't exactly kicking back and puffing on cigars all day.

And yes, hospitalists are glorified and highly paid residents. But, out there in the real world (not the fantasy world of academics), subspecialists are just highly paid fellows. You don't have lackeys doing all your work for you.

This! I'm more out west, and the academic hospitalists have it great. They are 7 on 7 off 12's, but usually are only at work 10am to 3pm. (or like 8am to 1 pm for those that actually listen to the hospital and finish discharges by 10am. some people just ignore the crying from administration) Usually 14 patients, no new admits (teaching team takes all day admits). All their new patients are from overnight where the H&P's have already been done. Plus occasionally they get a junior resident to help out too. Pay is similar.

There is no way in hell I'd do that kind of schedule for 150k. You are crazy to take that little money/hr.

 

[Mad Jack]

Recent graduate who started a job as an academic hospitalist in a large east coast city. Wasn't in love with hospitalist but thought it would be a good lifestyle and job choice and didn't see myself doing any fellowship or outpatient.

Very surprised to find myself not enjoying it at all despite not being on the job for so long. I enjoyed my ward months during residency but attending life is much less enjoyable. Any other hospitalists with these feelings? Interested in hear other's thoughts. Seems like its an easy job to get burned out.
-Sure, the time off is nice (work about 2/3 of weeks a year and have to come in a couple other days a year for educational stuff, meetings) but having a random tues morning off doesn't make up for the fact that i have to work 13-14 full weekends a year. Thats 1/4 of all weekend at hospital and when I'm there, its usually a solid 12-14 hr days so I'm there much longer pretty much anyone else in hospital (residents, sub specialist attendings). Not to mention that come holidays, I've had to spent 12-14 hr days on while the other attendings in subspecialty come in for 2-3 hours (its academic) or outpatient are off completely. Not to mention, the hours worked doesn't come anywhere close to the salary I receive (150K).

-Other thing that bothers is constantly feeling "dumped on" or being the bottom of barrel in hospital. Both here and other hospitals, the hospitalists get every patient, the social admits, the complicated patients yet the constant argument is hospitalists don't make $$$ for the hospital, so the money goes to the cardiologist who do caths or the surgeons or the GI doing colonoscopies. Maybe its just my area, but hospitalists are seen as glorified residents IMO and i wonder if thats something that other hospitalists are always fighting for their deserved respect and recognition. Thankful for any responses.

150k? That's what you get for going academic hospitalist on the East coast.

 

[intmed2014]

Having spoken with many hospitalists who have returned for fellowship, their concerns are similar to yours:
1. Getting dumped on- Basically being hospital's employee to do everything that noone else wants to do. Large portion of the time in admitting/discharging patients/writing notes.
2. Refer to specialist- Consult Cards/GI/Heme-Onc for many simple problems which would usually be worked up by residents in academic center.
3. Time off- Although initially may be nice to have the year off, it is not professionally satisfying to be low man on totem pole. Many previous hospitalists cite boredom as a large reason they left. Working long hours in the week on/week off system means that the off time is spent recovering from long hours.

These are hospitalists in major metropolitan area in South. I'm sure the experiences in smaller environment are much different. From what I have gathered, everyone will be working very hard in modern medicine but the nature of the work can vary vastly.

 

[hallowmann]

Bro... that's because you're in the East Coast.

I'm in the Midwest and our attendings go home at 3pm. They cover their pagers until 7 pm. They work 55% of the year, and avg income is 220-230k. Obviously there are headaches to being a hospitalist, but subspecialties aren't exactly kicking back and puffing on cigars all day.

And yes, hospitalists are glorified and highly paid residents. But, out there in the real world (not the fantasy world of academics), subspecialists are just highly paid fellows. You don't have lackeys doing all your work for you.

This is consistent with all the hospitalists I know. I even know one who went from New Mexico (medium sized city) to inner-city on the east coast. Huge pay cut and much harder work. They loved their hospitalist job in NM and hate the one on the coast, but had to move for personal reasons. If you can stand being on the bottom of the totem pole and what not, its great if you pick the right job.

OP, given that you sound like you picked it more for the lifestyle than the interest, I'd say you picked the wrong job. Consider applying a bit outside of the city, getting away from the academic centers, etc. next year.

 

[CharlesDarnay]

Thanks for the feedback. Keep the comments coming. I do realize there is a huge regional variation in salary and major city on east coast will be at low end of salary but unfortunately, its where my family is at and where i went to school. Even going out into the suburbs, the salary isn't going to go up much in my research. You'd have to go a solid 2-3 hrs away to get away from it. Now, I will say in my group, other academic hospitalists with 5 years experience are closer to 175K but I think the salary tops out around 200K and to be honest, no one has stayed longer than 10 years yet. Community hospitalists where you are seeing 18 patients, usually doing a few nights a month, etc is in the 160-200K range with most in the 170K range. And very little to no increase in yearly salary if you are starting at top end of that range. It is good to hear that things get better away from the big city and I will consider looking there.

With that said, its not just the $70/hr hourly salary that makes hospitalist life not enjoyable for me, it could just be the hospitals I've worked at but as mentioned, its the constant fight for respect. So much easier to be consultant, give orders and then hospitalist has to make sure everything happens. Plus admin is always telling us to do more with less (you must see more patients per day, must get out discharges quicker without giving us resources to do so - not enough ancillary services, social work, PT/OT). They've mentioned about increasing our hours to stay longer yet I haven't heard much on any appropriate increase in salary. It just seems easy for the hospital to take advantage of hospitalists as they are an easy target and undervalued resource in the hospital.

For those who are hospitalists, how do you deal with the weekend days or holidays spent entirely in the hospital? I'm lucky in that we only have to cover 26 weekend days a year but when we are there, it usually means 12-14 hr days on sat and sun while the consultants are there for 2-3 hours on weekends. Its academic world which I realize isn't the same as private but the thought of giving up even a 1/4 of my weekend in 5-10 years doesn't seem very appealing. Maybe thats why a lot of hospitalists where I live go on to do other activities or admin stuff. And during my time in private world, giving up 50% of all weekend (7 on, 7 off) wasn't much better.

Glad to hear others are enjoying hospitalist life. Its interesting to hear perspective on how variable hospitalist life is based on location. The schedule previously mentioned seems much more enjoyable.

 

[mochief2000]

your an academic hospitalist? Don't you have residents who do most of your work? unfortunately, their does not seem to be solution to your problem as you seem restricted geographically and you do not want to do fellowship. Most of the hospitalist I know have the same issues as you, but feel with the time off and better pay (180-210's) their can live with their decision.

You can't have it all. You can't work half the year, expect respect and demand higher pay........wait oh yeah, then their was derm...

 

[metopic]

Mochief academic hospitals have a "non-teaching" service as well which may only rarely or never have a resident on it. So if you are a hospitalist on that service it's like being a community hospitalist with lower volume and pay.

 

[FutureInternist]

I'm doing hospitalist at a private hospital, so no residents etc yet the work load is very manageable
Get there by 7, see everyone (cap of 18) by 11, call consults, write notes, done by 2
Then wait for any new admits (2 per day max) & home by 4-ish
One of the issues is the type of note you need to write in academics vs private (& of course no teaching time 'wasted'), since you can get away w/ just writing

a) Uncontrolled HTN
Increase metoprolol

vs

a) Uncontrolled HTN
Given pt's co-morbidities of X, Y & Z, the ABC study has shown that he will most likely benefit from starting PQR

As far as the dumping.....welcome to IM
This will NEVER change, but if you have a cap then who cares & writing notes on the rocks is easy (copy/paste)
We just started taking <20 weeks pregnant pts at my job

 

[Lawgiver]

hospitalist sounds like the forward button in your email.

 

[efex101]

not sure whey you are working BUT with incentives/bonus many NON academic hospitalists end up making 300K for HALF a YEAR of work, YES you have to work weekends/holidays but USUALLY holidays are split UP so not ONE person is working All the holidays and they rotate. There are literally thousands of positions available but YOU have to search and may need to move. Academia is not for me, the pay ks MUCH less but they also tend to work LESS meaning more cush hours, lower cap, etc. I love my job would not change it for the world and I do NOT have BS meetings on my week off, my week off is OFF and most places are like this. IT seems that you are in a malignant program and need to move on. Look at the midwest/south for good solid programs and ASK the right questions and get everything in writing. I do not feel like a DUMP from subspecialists and ask any consultant how they love their consults which at times are asinine. Yes, we do admit for almost everyone but for the most part it is because WE should be involved as sorry to say this subspecialties are not looking at big picture and only care about their organ system.

 

[Hospitalist MD]

Dear Charles:
I think you are being abused at your job. I am a fresh graduate, I started working as a hospitalist on September 2014, I work 7 on/ 7 off, no matter if there is a Holiday or not, my week off is OFF, I do not have to attend meetings or do paperwork, my census is 15 to 20 patients per day including new admits, I have to work some nights ( one week of nights every 2 months ) and my salary is 250,000. My friends doing locum on top of this job are easily pulling out 350 K, and still have one week off per month. Sub-specialties also work a lot. Believe, I see the cardiologists in my hospital, or the pulmonary people.... they work more than me.... I think they make more money but I work only 2 weeks per month...so far I am happy. I would advise you to look for another program. By the way, I work in northwest Florida. You should move South, work 15 days in a row and go back to your family in the East coast. Best of luck

 

[Bostonredsox]

Forget about respect and not being dumped on. That's what being a Hospitalist is. We're treated like 4th year residents.

But for my base 15 a month seeing about 14 a day on non teaching or 18 a day teaching, I make 250k. With my 8-9 nights I moonlight a month I make another 200k. For 22 shifts and 450k they can dump all the **** on me they want, I just smile on my way to the bank. I have just out of fellowship cardio friends working m-f 7-5 plus a weekend a month and stemi call that make less than I do. Our work sucks. It's boring, repetitive, under appreciated and we're constantly treated like a resident, but I can live with it for that kind of cash and flexibility

 

[Postictal Raiden]

I just read a post on the Anesthesiology forum that some hospitals are replacing their hospitalists with NPs. Are these isolated incidents or is this a trend?

 

[bronx43]

I just read a post on the Anesthesiology forum that some hospitals are replacing their hospitalists with NPs. Are these isolated incidents or is this a trend?

This is NOT happening in my city. Our hospital medicine department has zero midlevels. The private institutions have 5% mid-levels that really do not add much value, and MDs are still more efficient and cost effective. Maybe this is happening elsewhere, but I've not heard of any sort of trend.

 

[aka_tigerj]

I just read a post on the Anesthesiology forum that some hospitals are replacing their hospitalists with NPs. Are these isolated incidents or is this a trend?

Haven't heard of that ... YET

 

[Gpan]

How about a program where A Hospitalist managing 10 NPs hospitalists just like in Anesthesiology. That would cut down the cost, but the salary of that REAL MD/DO need to be amazing. I don't know if that is possible in Hospitalist field. But if it were to happen I would be really scared to come to that hospital as a patient.

 

[aka_tigerj]

How about a program where A Hospitalist managing 10 NPs hospitalists just like in Anesthesiology. That would cut down the cost, but the salary of that REAL MD/DO need to be amazing. I don't know if that is possible in Hospitalist field. But if it were to happen I would be really scared to come to that hospital as a patient.

Hospitalists already get like 15-20 minutes to see, and workup the patient...

How could that doc manage that many NP hospitalists w/o cutting corners?

 

[Taurus]

Of course it is happening and will become more common in the future. Ask yourself, what can you do that an NP can't? For $250k, you could hire 3-4 NP's. It will be like the team model used in anesthesia where one physician to 4 NP's. This will drive down demand and salaries of hospitalists. That's inevitable consequence when you have no special skills that can differentiate from an NP. Look at what happened in anesthesia. I would argue that life and death decision makng in anesthesia is even smaller time window than in general medicine. Anyone who doesn't think that this will happen is in denial.

 

[bronx43]

Of course it is happening and will become more common in the future. Ask yourself, what can you do that an NP can't? For $250k, you could hire 3-4 NP's. It will be like the team model used in anesthesia where one physician to 4 NP's. This will drive down demand and salaries of hospitalists. That's inevitable consequence when you have no special skills that can differentiate from an NP. Look at what happened in anesthesia. I would argue that life and death decision makng in anesthesia is even smaller time window than in general medicine. Anyone who doesn't think that this will happen is in denial.

It's not about what you can do that an NP can't. It's not about special skills. Wasn't intubating, procedures, and keeping a patient alive during surgery not a special skill before anesthesiologists sold out their own field to make a quick buck? Most of medicine doesn't take much IQ to feign competence, so you can teach any monkey to perform the basic tasks of any specialty. The key is for physicians to see the forest for the trees and not throw the younger generation under a bus. The problem is that many are doing it without even realizing it. The rest are doing it knowingly.

 

[Taurus]

It's the MBA's in the hospital administration who will make these decisions. When you have no special skill that differentiates you from experienced NP's, then you are interchangeable for the most part. You still need physicians but maybe in a 1 to 4 ratio. Definitely not all physician hospitalist groups. You are even more at risk because you are employed by the hospital. They will focus on the bottom line and not what is best for physicians or patients. I believe that a part of you agrees with me and sees where it will eventually lead. It's inevitable. Just follow the logic and money trail. So hospitalists is not a viable long term career for most.

 

[bashwell]

But aren't many if not most specialists also gradually becoming employees?

 

[Taurus]

Most medicine specialists cannot be replaced by NP's, ie, cards, GI, heme/onc, etc. They are more secure than hospitalists.

I think many people have been lured into being hospitalists because of the high salaries and plentiful job opportunities that exist now. I doubt it will last. At some point, the hospitals will realize that they can save money by using a hybrid team model.

I've always believed that if you do something make sure that no other can provide the same service. If they can, then it's a race to the bottom.

 

[Gpan]

So basically any specialties can sell out and hire a bunch of NPs like Anesthesiology has been doing. You can teach a monkey how to operate, how to write a script. It's the matter of not letting these "Doctors" of nursing become more than what they should be...Sounds harsh but it is what it is

 

[Gpan]

Most medicine specialists cannot be replaced by NP's, ie, cards, GI, heme/onc, etc. They are more secure than hospitalists.

Have you never worked with Neuro Surgery PAs and such? They think they were THE ones in charge

 

[Taurus]

Have you never worked with Neuro Surgery PAs and such? They think they were THE ones in charge

Surgical PA's/NP's will never replace the surgeon. Surgery has done a marvelous job of differentiating themselves from mid levels.

That is what is lacking in primary care and hospital medicine and to a lesser extent EM. How do you differentiate yourself from an NP? You can't. That is why eventually all 50 states will give NP's complete autonomy. The question is not if it will happen but when. I don't believe that physicians will be shoved out from those fields but you will be managing 4 NP's. This will decrease job opportunities and salaries. Of course it will.

 

[laserbeam]

Surgical PA's/NP's will never replace the surgeon. Surgery has done a marvelous job of differentiating themselves from mid levels.

That is what is lacking in primary care and hospital medicine and to a lesser extent EM. How do you differentiate yourself from an NP? You can't. That is why eventually all 50 states will give NP's complete autonomy. The question is not if it will happen but when. I don't believe that physicians will be shoved out from those fields but you will be managing 4 NP's. This will decrease job opportunities and salaries. Of course it will.

Why would NPs need supervision if they have their own license? I would not supervise them. If they think MD's job is fun and they want the money but not the risk, no way. They should make their own medical decisions, claim their responsibilities and face their own risk of lawsuits, like any MD.

 

[Mad Jack]

Of course it is happening and will become more common in the future. Ask yourself, what can you do that an NP can't? For $250k, you could hire 3-4 NP's. It will be like the team model used in anesthesia where one physician to 4 NP's. This will drive down demand and salaries of hospitalists. That's inevitable consequence when you have no special skills that can differentiate from an NP. Look at what happened in anesthesia. I would argue that life and death decision makng in anesthesia is even smaller time window than in general medicine. Anyone who doesn't think that this will happen is in denial.

The 1:4 model for anesthesia works because that's a maximum of 4 patients being overseen at a given time. Many hospitalists have 15-25 or so patients- one physician can't be expected to properly oversee 60-100 patients. It's not even close to feasible, and every liability lawsuit would hit the hospital for being negligent enough to implement such standards.

You have to remember, the biggest reason we're kept around isn't because we're the cheapest labor, it's because we're the cheapest labor that can reasonably be blamed when something goes wrong. NPs are usually the third or fourth claimants in a lawsuit, hence hospital's reluctance to give them free reign in most areas. They may like saving some money here and there, but, at the end of the day, ever single complication under NP care could cost them hundreds of thousands to millions of dollars, while any complications caused by a physician will generally cost them nothing.

The price differential is also greatly exaggerated- most hospitalists in the Northeast are getting 200k around where I live, while then NPs are getting 100k for being far less productive and working 25% less hours, while also requiring extra money to be spent for physician oversight. The hospitalist services that utilize them usually just have them pre-round and hold down the fort while the physicians are away rather than as independent hospitalists.

 

[bronx43]

Most medicine specialists cannot be replaced by NP's, ie, cards, GI, heme/onc, etc. They are more secure than hospitalists.

I think many people have been lured into being hospitalists because of the high salaries and plentiful job opportunities that exist now. I doubt it will last. At some point, the hospitals will realize that they can save money by using a hybrid team model.

I've always believed that if you do something make sure that no other can provide the same service. If they can, then it's a race to the bottom.

It's a funny thing when "logical conclusions" don't actually line up with reality.

Sorry, but you don't know what you're talking about. Mid-levels are hoarding into specialties like critical care, heme/onc, GI, cards at a FAR faster rate than primary care or hospital medicine. What some people fail to understand is that it is far easier to learn the ropes for one very specific field than it is for a broad field, even if your understanding doesn't have to be very deep. Are midlevels going to replace oncologists or cardiologists? Obviously not, but they can definitely squeeze the job market for new grads. At my institution, every single new NP grad is going into a specialty that ranges from heme/onc, critical care, GI, cards. Not a single one in the hospital medicine department. Why? Because the price differential simply isn't there for NPs when it comes to hospital medicine. Hospitalists make $200k and NPs make $100k. Hospitalists can easily see double the volume of the NP, which more than makes up for the money. NPs also don't want to enter the hospital medicine realm, because it's tougher work than the others where they just sit in clinic, see 10 pts a day, and present those to the attending.

 

[Taurus]

Why would NPs need supervision if they have their own license? I would not supervise them. If they think MD's job is fun and they want the money but not the risk, no way. They should make their own medical decisions, claim their responsibilities and face their own risk of lawsuits, like any MD.

NP's will argue they don't need supervision. Soon all 50 states will allow that.

From a medico legal point of view, hospitals will want a team model with a physician supervising. I don't see all physician hospitalist groups being all that common in the future because they won't be cost advantageous.

Smaller hospitals may have only NP's as their hospitalists. Even bigger hospitals or academic hospitals may have an NP only hospitalist service for lower complexity cases. My hospital where I did medical school had such a service.

Again, if you can't be differentiated from an NP, the hospital administrators will look at cost very closely and think about if they can replace you.

 

[Taurus]

It's a funny thing when "logical conclusions" don't actually line up with reality.

Sorry, but you don't know what you're talking about. Mid-levels are hoarding into specialties like critical care, heme/onc, GI, cards at a FAR faster rate than primary care or hospital medicine. What some people fail to understand is that it is far easier to learn the ropes for one very specific field than it is for a broad field, even if your understanding doesn't have to be very deep. Are midlevels going to replace oncologists or cardiologists? Obviously not, but they can definitely squeeze the job market for new grads. At my institution, every single new NP grad is going into a specialty that ranges from heme/onc, critical care, GI, cards. Not a single one in the hospital medicine department. Why? Because the price differential simply isn't there for NPs when it comes to hospital medicine. Hospitalists make $200k and NPs make $100k. Hospitalists can easily see double the volume of the NP, which more than makes up for the money. NPs also don't want to enter the hospital medicine realm, because it's tougher work than the others where they just sit in clinic, see 10 pts a day, and present those to the attending.

If you take your logic to the next level, then the inference you can draw is that there is some income ceiling of physician hospitalist or salary ratio between physician and NP where financially it makes sense to have NP's as hospitalists. Maybe not at 2 to 1 ratio. What about 2.5 or 3 to 1 ratio? At some point, it doesn't make financial sense to have all physician hospitalist groups.

It comes down to the same problem. You can't differentiate yourself from an NP enough. That is a risky position to be in long term.

 

[Mad Jack]

NP's will argue they don't need supervision. Soon all 50 states will allow that.

If you take your logic to the next level, then the inference you can draw is that there is some income ceiling of physician hospitalist or salary ratio between physician and NP where financially it makes sense to have NP's as hospitalists. Maybe not at 2 to 1 ratio. What about 2.5 or 3 to 1 ratio? At some point, it doesn't make financial sense to have all physician hospitalist groups.

It comes down to the same problem. You can't differentiate yourself from an NP enough. That is a risky position to be in long term.

From a medico legal point of view, hospitals will want a team model with a physician supervising. I don't see all physician hospitalist groups being all that common because they won't be cost advantageous.

Smaller hospitals may have only NP's as their hospitalists. Even bigger hospitals or academic hospitals may have an NP only hospitalist service for lower complexity cases. My hospital where I did medical school had such a service.

Again, if you can't be differentiated from an NP, the hospital administrators will look at cost very closely and think about if they can replace you.

NPs and hospitals don't want the liability of an NP-only group, nor will physicians find it amenable to oversee 100 patients that are being haphaxardly cared for by NPs. If you've ever looked at the relative productivity of NPs versus physicians, even factoring out the whole liability issues, having more than a 1:1 ratio of midlevels to physicuabs just doesn't make sense in hospital medicine. There's also the issue of midlevels not really finding hospital medicine desirable when they could be doing outpatient or specialty work, seeing half the patients for the same amount of money. If you want cash, you do urgent care, surgical, or EM, if you want lifestyle you do outpatient, onc, derm, allergy, etc. Hospitalist medicine is just undesirable overall, and the inly way to make it moreso would be to increase pay or decrease patient load, both of which decrease the advantages that midlevels provide over physicians. I've yet to see a single urban or suburban hospital employ midlevels as unsupervised providers of hospitalist care for the myriad of reasons listed above. Sometimes quality and productivity are enough for physicians to be successful in defeating midlevels, and hospitalist medicine provides an excellent example of that.

 

[bronx43]

If you take your logic to the next level, then the inference you can draw is that there is some income ceiling of physician hospitalist or salary ratio between physician and NP where financially it makes sense to have NP's as hospitalists. Maybe not at 2 to 1 ratio. What about 2.5 or 3 to 1 ratio? At some point, it doesn't make financial sense to have all physician hospitalist groups.

It comes down to the same problem. You can't differentiate yourself from an NP enough. That is a risky position to be in long term.

Your argument makes no sense in reality. The income ceiling of a hositalist has nothing to do with mid-levels or anything of the sort. It has everything to do with hospital capacity, reimbursement, and number of hospitalists in the market. If anything, I suspect that, in the future, hospital medicine may get squeezed into less money because of these other factors, which would then make them even more cost effective than NPs. And NPs are not going to take less money than they are currently to do hospital medicine.

I'm not going to be a hospitalist long-term for a variety of reasons, but midlevel takeover is NOT one of them.

 

[Taurus]

Just do a google search for "NP hospitalist"

http://www.indeed.com/m/jobs?q=Nurse+Practitioner+Hospitalist

Apparently many people in the position to hire are thinking along the same lines as I am.

There are plenty of jobs listed for them. There are plenty of jobs for physician hospitalists too. It's an open question as to how the market will always be like this.

So don't shoot the messenger because you don't like the message. I'm just stating the logical and financial conclusion. You can fight it or be in denial about it, but just like anesthesia it is inevitable as long as you can't differentiate yourself from NP's.

 

[Mad Jack]

Just do a google search for "NP hospitalist"

http://www.indeed.com/m/jobs?q=Nurse Practitioner Hospitalist

Apparently many people in the position to hire are thinking along the same lines as I am.

There are plenty of jobs listed for them. There are plenty of jobs for physician hospitalists too. It's an open question as to how the market will always be like this.

So don't shoot the messenger because you don't like the message. I'm just stating the logical and financial conclusion. You can fight it or be in denial about it, but just like anesthesia it is inevitable as long as you can't differentiate yourself from NP's.

Here's a look at every job on the first page:

http://www.indeed.com/m/viewjob?jk=ede10e8239e25e44
"Under the direction of a supervising physician"

http://www.indeed.com/m/viewjob?jk=578e4fd2b2ca01b9
"Under the direction of the Chief of the Hospitalist Program, the Nurse Practitioner will assist the primary care attending physician"

http://www.indeed.com/m/viewjob?jk=289e07b267eb7929
"selective medical services under the direction of physicians"

http://www.indeed.com/m/viewjob?jk=d8344b04bbaf0cc1
"assignment of pediatric patients to the appropriate specialty physician based on established protocols."

http://www.indeed.com/m/viewjob?jk=c7066430916dfcd6
"work directly with a physician at all times."

http://www.indeed.com/m/viewjob?jk=ec096d9a51a762dc

• 8 hour shifts in length from 4p-12a
  
• Perform dictation of H&P examinations
• Cross cover for the hospitalist team
• Perform dictation of Discharge Summary and Procedure reports
  
  Basically just an off-shift coverage body that calls out to physicians for anything reasonable, from what the job looks like.

http://www.indeed.com/m/viewjob?jk=ff01f56456f919c6
"under direct supervision of attending Physician."

http://www.indeed.com/m/viewjob?jk=cdd8cff3220439cd
" join an existing team of 6 physicians/3 ACP's"
"The ACP would be working with an attending along with the Internal Medicine Residents."

http://www.indeed.com/m/viewjob?jk=143bf3d8770d137a
"To perform, under the responsibility and supervision of physicians"

The last listing had no role description provided. The highest ratio I've seen of hospitalists to midlevels is teams of 1:1, and I'm sure that would have been stretched somewhere if it were safe and feasible. These teams do not have midlevels operating independently, but rather writing notes and having tasks delegated by the physician to improve their productivity. You make it sound as if midlevels are taking independent patients left and right and pushing hospitalists out of practice, which is hardly the case. The only reason my old hospital picked up using midlevels was because of the restriction of resident hours- they're standing in for residents, not attending physicians, and only there to do the mundane crap that residents used to do when they could work them far more hours a week.

 

[Taurus]

And your point is what? I have been saying hybrid team model with physician supervising 3-4 NP's. Hospitals will want this for medico legal reasons.

Let's think about this. Even if those NP's are being supervised, it means fewer jobs for physician hospitalists. You won't need as many of them.

I don't think this is rocket science. This is Econ 101.

Most of you guys are missing the most important argument and to which you have no solution for. You can't differentiate yourself enough from an NP. Very risky position to be in the future when all 50 states allow NP autonomy and NP's demand more and more autonomy in the hospital.

 

[RustBeltOnc]

Surgical PA's/NP's will never replace the surgeon. Surgery has done a marvelous job of differentiating themselves from mid levels.

That is what is lacking in primary care and hospital medicine and to a lesser extent EM. How do you differentiate yourself from an NP? You can't. That is why eventually all 50 states will give NP's complete autonomy. The question is not if it will happen but when. I don't believe that physicians will be shoved out from those fields but you will be managing 4 NP's. This will decrease job opportunities and salaries. Of course it will.

Finally, yes.
Other issue: hospitals are closing, another way hospitalists will get squeezed.

 

[YankeeCandle1141]

And your point is what? I have been saying hybrid team model with physician supervising 3-4 NP's. Hospitals will want this for medico legal reasons.

Let's think about this. Even if those NP's are being supervised, it means fewer jobs for physician hospitalists. You won't need as many of them.

I don't think this is rocket science. This is Econ 101.

Most of you guys are missing the most important argument and to which you have no solution for. You can't differentiate yourself enough from an NP. Very risky position to be in the future when all 50 states allow NP autonomy and NP's demand more and more autonomy in the hospital.

What is to say that your radiology job couldn't be done by 3-4 NPs and reports exported to an attending in Korea to sign off on.

......other than the fact that it currently isn't/never will happen?

 

[Taurus]

What is to say that your radiology job couldn't be done by 3-4 NPs and reports exported to an attending in Korea to sign off on.

......other than the fact that it currently isn't/never will happen?

Because Medicare won't pay for final reads not done on US soil and not to mention the legal implications of foreign teleradiology. That's why it hasn't taken off and won't. NP's are not trained formally to read imaging studies like radiologists. There's no concern about mid level encroachment in radiology. In addition, I specialize in an area of radiology that requires my physical presence. As I was pondering which residency and then which subspecialty to do, I did consider those possibilities and many others very carefully.

What is my point? If you pick a field, make sure that no one else can do your job. Need brain surgery? Only neurosurgeon can do it. Need a CT of abdomen and pelvis? Only radiologist can read it. Etc.

When it comes to primary care and hospital medicine, NP's feel they are trained adequately and ideally suited for it. Why do you think states are giving them full autonomy? It's up to the hospital how much autonomy they actually allow. Most would want a team model with physician leading. Just google NP hospitalist or primary care jobs. Obviously, it's no secret that groups and hospitals see them as cost saving.

There are certainly turf battles between specialties but I would rather fight another specialty than with a cheaper, less trained NP groups.

 

[YankeeCandle1141]

Because Medicare won't pay for final reads not done on US soil. NP's are not trained formally to read imaging studies like radiologists. There's no concern about mid level encroachment in radiology. In addition, I specialize in an area of radiology that requires my physical presence. As I was pondering which residency and then which subspecialty to do, I did consider those possibilities and many others very carefully.

What is my point? If you pick a field, make sure that no one else can do your job. Need brain surgery? Only neurosurgeon can do it. Need a CT of abdomen and pelvis? Only radiologist can read it. Etc.

When it comes to primary care and hospital medicine, NP's feel they are ideally suited for it. Why do you think states are giving them full autonomy? It's up to the hospital how much autonomy they actually allow. Most would want a team model with physician leading. Just google NP hospitalist or primary care jobs. Obviously, it's no secret that groups and hospitals see them as cost saving.

There are certainly turf battles between specialties but I would rather fight another specialty than with a cheaper, less trained NP groups.

My argument is that NPs think they can do anything, every specialty thinks the other specialties are at risk, and in reality there is no replacement for a physician.


I think this issue is really really overblown. And the reason you dont see midlevels in the OR unsupervised is the same reason you wont ever see them take over any specialty. Its just more obvious in the OR.

You dont need a surgeon to take out a routine gall bladder. If we are being honest with ourselves, any PA with 6 months training could do routine lap choles. You need a surgeon to know when its time to convert to an open procedure, how to identify abnormal anatomy, and what to do when **** hits the fan and the hepatic artery starts leaking.

You dont need a radiologist to find lobar pneumonia. You need a radiologist to never miss the cavitary lesion hiding behind the clavicle.


You dont need a hospitalist to manage COPD exacerbations, but you do need one when they have MS, HTN, HLD, CKD, and a concomitant DVT.


This applies to every specialty. The easy stuff is easy, but knowing what the complications might look like, what to test for, and how to manage them........ Thats why I think we are safe in every speciality.


Maybe I am too naive, but I dont think there is any replacement for medical school/ residency.

 

[Mad Jack]

Because Medicare won't pay for final reads not done on US soil and not to mention the legal implications of foreign teleradiology. That's why it hasn't taken off and won't. NP's are not trained formally to read imaging studies like radiologists. There's no concern about mid level encroachment in radiology. In addition, I specialize in an area of radiology that requires my physical presence. As I was pondering which residency and then which subspecialty to do, I did consider those possibilities and many others very carefully.

What is my point? If you pick a field, make sure that no one else can do your job. Need brain surgery? Only neurosurgeon can do it. Need a CT of abdomen and pelvis? Only radiologist can read it. Etc.

When it comes to primary care and hospital medicine, NP's feel they are trained adequately and ideally suited for it. Why do you think states are giving them full autonomy? It's up to the hospital how much autonomy they actually allow. Most would want a team model with physician leading. Just google NP hospitalist or primary care jobs. Obviously, it's no secret that groups and hospitals see them as cost saving.

There are certainly turf battles between specialties but I would rather fight another specialty than with a cheaper, less trained NP groups.

If doing a 4:1 supervision model were possible while maintaing an acceptable level of both performance-per-dollar and medicolegal protection, more hospitals would be doing it. No one does it because, as I said before, this isn't anesthesia where you're overseeing 4 CRNAs working with 4 patients. You're overseeing way more- you'd have a minimum of 60 patients at a time, an impossible census to reasonably oversee. I just think it isn't reasonably feasible, nor is there enough demand from midlevels to reasonably compete with physicians in the near future. You're really stretching a hypothetical. Mayo tried to do an independent midlevel model, where it was a physician-midlevel pair, with the midlevel managing the less complex patients, and each managed their own patients, but it simply didn't work, as the mix of complex and simple patients was never right, thus making it inefficient. They ultimately settled on a 1:1 collaborative arrangement where the physician and midlevel work together to manage the same group of patients, with the PA doing most of the admission and discharge paperwork, while the physician does most of the case management (last I saw, such a model increased productivity overall by 20% relative to cost). Another big name hospital I used to work for uses the exact same model for all of their patients on the non-academic hospitalist service. They, too, tried all sorts of things out, and ultimately found the 1:1 worked best. If bloodsucking consultants that want to scrounge every dollar and some of the brightest management minds in medicine both seem to agree that you can't push beyond the 1:1 ratio or give the midlevels free reign of their own patients, I'm going to side with them on the matter, rather than some random fear monger on the internet that's afraid of the midlevel boogeyman.

Also keep in mind that medicine moves at a snail's pace- anesthesia has been saying that the sky is falling since the early 90s, and yet, here we are, and I know exactly zero unemployed anesthesiologists 25 years later. And that's a field with directly trained, competing providers that have been pumped in to compete for decades. Midlevels haven't even begun to scratch the surface of "taking over" hospitalist services, and all I need is 25 years out of my career before I retire, so I'm pretty sure I'll be fine going the hospitalist route. I doubt we'll be seeing unemployed internists within our working lifetimes, for numerous reasons.

http://www.todayshospitalist.com/index.php?b=articles_read&cnt=35

 

[Taurus]

My argument is that NPs think they can do anything, every specialty thinks the other specialties are at risk, and in reality there is no replacement for a physician.


I think this issue is really really overblown. And the reason you dont see midlevels in the OR unsupervised is the same reason you wont ever see them take over any specialty. Its just more obvious in the OR.

You dont need a surgeon to take out a routine gall bladder. If we are being honest with ourselves, any PA with 6 months training could do routine lap choles. You need a surgeon to know when its time to convert to an open procedure, how to identify abnormal anatomy, and what to do when **** hits the fan and the hepatic artery starts leaking.

You dont need a radiologist to find lobar pneumonia. You need a radiologist to never miss the cavitary lesion hiding behind the clavicle.


You dont need a hospitalist to manage COPD exacerbations, but you do need one when they have MS, HTN, HLD, CKD, and a concomitant DVT.


This applies to every specialty. The easy stuff is easy, but knowing what the complications might look like, what to test for, and how to manage them........ Thats why I think we are safe in every speciality.


Maybe I am too naive, but I dont think there is any replacement for medical school/ residency.

Are there NP only outpatient primary care clinics? Are there CRNA's doing and billing their own cases? Are there small hospitals where the hospitalist is an independent NP? Yes.

Are there any PA's/NP's doing their own surgeries? Are there any NP's reading CT's on their own? Are there any NP's doing their own heart caths? Highly unlikely.

If you have to pick a long term career, which camp do you want to be in?

You have to differentiate between what a group says they can do versus what the state/insurance companies/hospital credentialing allows them to do. The trend in this country is to give NP's the same autonomy and privileges as general medicine providers. That in the end is what matters.

 

[Taurus]

If doing a 4:1 supervision model were possible while maintaing an acceptable level of both performance-per-dollar and medicolegal protection, more hospitals would be doing it. No one does it because, as I said before, this isn't anesthesia where you're overseeing 4 CRNAs working with 4 patients. You're overseeing way more- you'd have a minimum of 60 patients at a time, an impossible census to reasonably oversee. I just think it isn't reasonably feasible, nor is there enough demand from midlevels to reasonably compete with physicians in the near future. You're really stretching a hypothetical. Mayo tried to do an independent midlevel model, where it was a physician-midlevel pair, with the midlevel managing the less complex patients, and each managed their own patients, but it simply didn't work, as the mix of complex and simple patients was never right, thus making it inefficient. They ultimately settled on a 1:1 collaborative arrangement where the physician and midlevel work together to manage the same group of patients, with the PA doing most of the admission and discharge paperwork, while the physician does most of the case management (last I saw, such a model increased productivity overall by 20% relative to cost). Another big name hospital I used to work for uses the exact same model for all of their patients on the non-academic hospitalist service. They, too, tried all sorts of things out, and ultimately found the 1:1 worked best. If bloodsucking consultants that want to scrounge every dollar and some of the brightest management minds in medicine both seem to agree that you can't push beyond the 1:1 ratio or give the midlevels free reign of their own patients, I'm going to side with them on the matter, rather than some random fear monger on the internet that's afraid of the midlevel boogeyman.

Also keep in mind that medicine moves at a snail's pace- anesthesia has been saying that the sky is falling since the early 90s, and yet, here we are, and I know exactly zero unemployed anesthesiologists 25 years later. And that's a field with directly trained, competing providers that have been pumped in to compete for decades. Midlevels haven't even begun to scratch the surface of "taking over" hospitalist services, and all I need is 25 years out of my career before I retire, so I'm pretty sure I'll be fine going the hospitalist route. I doubt we'll be seeing unemployed internists within our working lifetimes, for numerous reasons.

http://www.todayshospitalist.com/index.php?b=articles_read&cnt=35

Eventually an ideal ratio will be settled on. Even 1 to 1 ratio means you need fewer physician hospitalists. I think something like 2 to 1 would be optimal. I would never want to put my fate in the hands of hospital administrators who have ulterior motives. If there is high churn of hospitalist staff, there's even less reason to keep you guys happy. It will be more about the bottom line.

 

[YankeeCandle1141]

Eventually an ideal ratio will be settled on. Even 1 to 1 ratio means you need fewer physician hospitalists. I think something like 2 to 1 would be optimal. I would never want to put my fate in the hands of hospital administrators who have ulterior motives. If there is high churn of hospitalist staff, there's even less reason to keep you guys happy. It will be more about the bottom line.

.....and when it becomes strictly about the bottom line, any hospital who staffs independent midlevels will be dealing with 30% of their beds full of patients who are readmits. The lab would be running pan cultures on every patient. The rads dept would be reading 2x as many CTs, and every consultant would be capped because the NP doesnt know the difference between dehydration and kidney failure.

 

[Taurus]

.....and when it becomes strictly about the bottom line, any hospital who staffs independent midlevels will be dealing with 30% of their beds full of patients who are readmits. The lab would be running pan cultures on every patient. The rads dept would be reading 2x as many CTs, and every consultant would be capped because the NP doesnt know the difference between dehydration and kidney failure.

Well, not every tiny hospital out there can attract physicians to their community. Hence, why they have services run by independent NP's and CRNA's. However tiny the hospital, there's no mid level doing surgery independently. That's the difference between a specialty that has protected itself from mid levels and one that has not.

 

[Mad Jack]

Well, not every tiny hospital out there can attract physicians to their community. Hence, why they have services run by independent NP's and CRNA's. However tiny the hospital, there's no mid level doing surgery independently. That's the difference between a specialty that has protected itself from mid levels and one that has not.

Do you honestly believe we'll be seeing unemployed hospitalists in the next 20 years? I mean, every study of hospital medicine demand conducted disagrees with your grim outlook, with predictions of massive service growth.

Radiology is a legislative penstroke away from being wiped off the map, and already suffers from saturation with no end in sight. Pathology destroyed itself. Technological changes made the demand for skilled open heart surgeons plummet. And worst of all, the government is looking to eliminate FFS and bundle all care into one payment, with no additional cash doled out for wasted tests and procedures, in which case the most valuable physician becomes the one that minimizes your use of resources- exactly the sort of thing a hospitalist and not a midlevel excels at. You don't need midlevel competition to destroy a specialty.

 

[YankeeCandle1141]

Well, not every tiny hospital out there can attract physicians to their community. Hence, why they have services run by independent NP's and CRNA's. However tiny the hospital, there's no mid level doing surgery independently. That's the difference between a specialty that has protected itself from mid levels and one that has not.

There are small hospitals where NPs can do I+Ds, suture lacerations and other small stuff. I guess those are the chest-pain/rule-out of surgical procedures.

I just think when the average cost to readmit a patient is 10k, hospitals dont save any money by hiring midlevels. Hospitals can only bill insurance 80% when a midlevel is primary anyway. Its not like anesthesia where the hospital can save 150k every time they bring on a CRNA.

 

[Taurus]

In a bundled care model where an ACO gets X dollars per year per patient, do you think it's less or more risky for a specialty that is interchangeable with a nursing group? Think about that.

I don't think hospitalists will disappear, but it will evolve to include more supervision. You will have decreased job security, job opportunities, and lower salaries. That's the consequence of not being able to differentiate yourself from NP's. Anesthesia recognizes this and is trying to transform into periop specialists. They know the future is not on stool sitting.

 

[YankeeCandle1141]

In a bundled care model where an ACO gets X dollars per year per patient, do you think it's less or more risky for a specialty that is interchangeable with a nursing group? Think about that.

I don't think hospitalists will disappear, but it will evolve to include more supervision. You will have decreased job security, job opportunities, and lower salaries. That's the consequence of not being able to differentiate yourself from NP's. Anesthesia recognizes this and is trying to transform into periop specialists. They know the future is not on stool sitting.

. In an ACO its about efficiency of care, and that is exactly why midlevels aren't exchangeable with hospitalists. By far the most fundamental part of an ACO is preventing unnecessary consults and tests. You want the most highly trained providers to be your quarterbacks in that system.

When a group gets payed a fixed amount per patient, the absolute last thing you want is a patient who is seeing your endocrinologist for DM, cardiologist for afib, rheum for lupus, and pulm for COPD.

You plop a hospitalist in that system, and all the sudden that patient only sees one doctor, and the service gets paid the exact same amount.

Edit: versus putting an NP in that role who has no idea how to manage an insulin regimen in the context of comorbidities, and your one billable patient has to be seen by 3 doctors.