Hospitalist Questions

[KeikoTanaka]

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Hello,

I am very interested in IM because I hear these are the "Master Diagnosticians" who basically know everything (Hyperbole). My current Clinical Systems instructor is an IM trained Physician and she's amazing, she just knows everything, and I really look up to her.

I'm a 2nd year so obviously I have a lot of experience to gain in the realm of rotating through IM services on the floors next year, but I have some questions pertaining to the role of Hospitalists that I was wondering if people could discuss.

1. How involved is the Hospitalist in patient care? What I mean by this is - Let's pretend you have a patient come in for an Endocrine disorder (Let's say Adrenal Insufficiency, I like this example because I just finished my Endocrine module in school) - Do you wait for the Endocrinologist to consult the patient, or can the Hospitalist go ahead and do the ACTH Stimulation Test, and basically whatever test is needed, until they get "stuck" and have to have the specialist come in? What other tests do you find yourself often doing? What is something you basically 100% always wait for a specialist to come in and do? If a problem is pretty severe and the patient basically needs to be consulted by 3 different specialists - How often do you see the patient between all their surgeries and consults?

2. How often are you getting new patients? How long max do you typically hold onto a patient for? What's the shortest you'll receive a patient for?

3. Do you ALWAYS have a well-planned out therapy goal for a patient to follow for their discharge, assuming they have a new diagnosis or poorly treated diagnosis prior to admission? And is this plan always conveyed to the patient's primary care physician? How do you go about alerting their primary that they have a new treatment plan?

4. During a single week, do you feel the clinical presentation of the patients is diverse enough to keep you interested and keep you on your toes? I want a job where I'll be constantly learning new things (at least for a while) - I would hate for example to be on the wards solely for stroke patients where everyone comes in with the same kind of disease presentation. How are patients organized typically in a hospital?

5. How does working with Nurse Practitioners and PAs work as a hospitalist? Do they do the night shifts? Are you on call during your week that you're on, and these NPs and PAs are there with you, monitoring your patients? How often will they get involved? What kinds of things do they do while we're not exactly present in the hospital during an "on week"?

6. Speaking of Night Shifts, I know a lot of EM Physicians complain about the ever-changing schedule and circadian rhythm mess ups - But how do IM doctors deal with this? Is there high burn out due to night shift week as a hospitalist? How often will you typically work a week of all nights?

7. If you had to go back and do it again - Would you choose to be a hospitalist again? If not, what would you change about the job to make it more enjoyable?

8. On your off weeks, do you find yourself - at least more in the beginning, doing a lot of home-reading from journals such as Nature, or JAMA? Do you find these weeks off beneficial to your practice as you're able to read up about certain things that maybe you were a bit uneasy with during your week on that maybe stumped you?

9. How often, during your shift, are you looking up information because a patient stumps you, or comes in with something rare?

Thanks, sorry for the wall of text!

 

[pgy0246]

It depends on the complexity of your patients, the culture of your hospital, and your census load;
On the day I have 20 new patients, and I have 3-4 crashing patients
I will tend to consult endocrine in order for following up the stable DKA patients.

If I am in the ICU admitting a patient with A-fib with RVR; I do all the initial stabilizing, amiodarone drip.
I don't always wait for a specialist before getting the initial test.
the hospitalist can feel like glorified residents at time, and you will look down by consultant who scores 20 points lower than you on the usmle.


I enjoy my hospitalist shift for now, but I won't recommend m3/m4 to pick IM as a specialty so they can become a hospitalist, it is not a sustainable career. I would have done anesthesia and then critical care if you enjoy inpatient medicine; more clinical and less social worker.

 

[KeikoTanaka]

It depends on the complexity of your patients, the culture of your hospital, and your census load;
On the day I have 20 new patients, and I have 3-4 crashing patients
I will tend to consult endocrine in order for following up the stable DKA patients.

If I am in the ICU admitting a patient with A-fib with RVR; I do all the initial stabilizing, amiodarone drip.
I don't always wait for a specialist before getting the initial test.
the hospitalist can feel like glorified residents at time, and you will look down by consultant who scores 20 points lower than you on the usmle.


I enjoy my hospitalist shift for now, but I won't recommend m3/m4 to pick IM as a specialty so they can become a hospitalist, it is not a sustainable career. I would have done anesthesia and then critical care if you enjoy inpatient medicine; more clinical and less social worker.

What about emergency into critical care?

 

[jurassicpark]

That's a lot of questions and I don't read no good no mores!

Let me tackle it. Every single hospitalist and group policy or unofficial policy is different.

- A hospitalist can tackle essentially whatever they want within their scope of practice without ever having to consult a specialist as long as it's SAFE to do so. Can I handle a simple r/o ACS without calling cardiology, absolutely. Should I handle that troponin of 2 without calling them? No. Can I take care of simple thyroid, adrenal, endocrine stuff without bothering endocrine? For sure. But in almost all cases I make sure patients have appropriate followup. There are many cases I handle A-Z and discharge. The hospitalist IS the primary care physician while in the hospital. You will round and see on the patient as many times as you feel needed per day. Most of the time I will just see them once, but it is not uncommon that I may have to pay them a visit 2 or 3 times in the day to make sure they're tucked away or family is hounding me.

- Oftentimes it will be a surgical issue that I need to wait for my consultant. Because what am I going to do, go rip open their abdomen by myself? Sounds fun, but no.

- New patients depends on how your group/practice/hospital is set up. I am on-call every day I am working. So I will get new consults daily plus whatever was admitted at night. It is a CONSTANT revolving door. Their PMDs are often notified by their discharge summary or quick phone call. Depends.

- The breadth of patients you will see depends where you practice. Some community hospitalists will primarily see bread and butter stuff like pna, DKA, CHF, etc. Universities you may see more zebras. Where I work I get a good diversity of patients where even former highbrow academics who decided they wanted more money come and say, "sweet jesus, I only read about this type of stuff!!" But I also take shifts at a rural hospital, and while we see cool stuff through the ER the hospital is not physically equipped for much more than simple bread and butter cases and we have to ship them out. In terms of stroke units, etc.. once again, depends on where you work.

- NP/PA are all dependent on individual hospital/group policy in whether they can work at all and how they work.

- Some doctors for personal reason request night float. I personally hate it, my wife hates it, my dog hates it. There's not enough coffee, and I only do it when there's nobody else to fill a shift.. but otherwise you gotta pay me big $$$ to do it.

- Week offs if able to I run far far away. Vegas. Hawaii. Whatever else I can do. It's not like med school or residency where you're reading every free moment you have. I will be drinking something very very expensive in a place that was very expensive to get too when I can. I understand the crux of the question, even after residency you have NOT seen it all and it's always a continual learning process. But that week off is not meant to be a cram-fest, you're supposed to recharge, moonlight, take care of your family, etc. But for sure, keeping up is important too..

- I am ALWAYS looking stuff up regarding my patients. I try to make sure I am "uptodate," and making sure I am on the right path for patients with disease processes I may not see that often. I do not have a photographic mind as much as I wish I did.

 

[KeikoTanaka]

That's a lot of questions and I don't read no good no mores!

Let me tackle it. Every single hospitalist and group policy or unofficial policy is different.

- A hospitalist can tackle essentially whatever they want within their scope of practice without ever having to consult a specialist as long as it's SAFE to do so. Can I handle a simple r/o ACS without calling cardiology, absolutely. Should I handle that troponin of 2 without calling them? No. Can I take care of simple thyroid, adrenal, endocrine stuff without bothering endocrine? For sure. But in almost all cases I make sure patients have appropriate followup. There are many cases I handle A-Z and discharge. The hospitalist IS the primary care physician while in the hospital. You will round and see on the patient as many times as you feel needed per day. Most of the time I will just see them once, but it is not uncommon that I may have to pay them a visit 2 or 3 times in the day to make sure they're tucked away or family is hounding me.

- Oftentimes it will be a surgical issue that I need to wait for my consultant. Because what am I going to do, go rip open their abdomen by myself? Sounds fun, but no.

- New patients depends on how your group/practice/hospital is set up. I am on-call every day I am working. So I will get new consults daily plus whatever was admitted at night. It is a CONSTANT revolving door. Their PMDs are often notified by their discharge summary or quick phone call. Depends.

- The breadth of patients you will see depends where you practice. Some community hospitalists will primarily see bread and butter stuff like pna, DKA, CHF, etc. Universities you may see more zebras. Where I work I get a good diversity of patients where even former highbrow academics who decided they wanted more money come and say, "sweet jesus, I only read about this type of stuff!!" But I also take shifts at a rural hospital, and while we see cool stuff through the ER the hospital is not physically equipped for much more than simple bread and butter cases and we have to ship them out. In terms of stroke units, etc.. once again, depends on where you work.

- NP/PA are all dependent on individual hospital/group policy in whether they can work at all and how they work.

- Some doctors for personal reason request night float. I personally hate it, my wife hates it, my dog hates it. There's not enough coffee, and I only do it when there's nobody else to fill a shift.. but otherwise you gotta pay me big $$$ to do it.

- Week offs if able to I run far far away. Vegas. Hawaii. Whatever else I can do. It's not like med school or residency where you're reading every free moment you have. I will be drinking something very very expensive in a place that was very expensive to get too when I can. I understand the crux of the question, even after residency you have NOT seen it all and it's always a continual learning process. But that week off is not meant to be a cram-fest, you're supposed to recharge, moonlight, take care of your family, etc. But for sure, keeping up is important too..

- I am ALWAYS looking stuff up regarding my patients. I try to make sure I am "uptodate," and making sure I am on the right path for patients with disease processes I may not see that often. I do not have a photographic mind as much as I wish I did.

Thanks for the insight and the long response! I appreciate it.

Obviously I'm not thinking I'm going to be doing it ALL myself, but, I want to see EVERYTHING. I don't think i'll mind at all having a specialist consult a patient, I'd love for the opportunity to learn! Maybe next time I'll know what to do different to have the patient even more ready for the specialist or what not. Thanks though, it really seems like if I can find a good hospital, Hospitalist really does offer a little bit of "everything" in medicine, all with the possibility of moving outpatient if the hospital stress gets too burdensome. This is my fear with choosing EM as a specialty, I would become exhausted of the ED but only be able to move out of the hospital to something like an urgent care, which is not something I ever really care to work in.

 

[iforget2]

It depends on the complexity of your patients, the culture of your hospital, and your census load;
On the day I have 20 new patients, and I have 3-4 crashing patients
I will tend to consult endocrine in order for following up the stable DKA patients.

If I am in the ICU admitting a patient with A-fib with RVR; I do all the initial stabilizing, amiodarone drip.
I don't always wait for a specialist before getting the initial test.
the hospitalist can feel like glorified residents at time, and you will look down by consultant who scores 20 points lower than you on the usmle.


I enjoy my hospitalist shift for now, but I won't recommend m3/m4 to pick IM as a specialty so they can become a hospitalist, it is not a sustainable career. I would have done anesthesia and then critical care if you enjoy inpatient medicine; more clinical and less social worker.

Could you elaborate on why being a hospitalist is not sustainable? I have an interest in the field, and the 7 on/7 off model makes me even more interested in it. I'm more than open to be dissuaded though.

 

[rokshana]

Could you elaborate on why being a hospitalist is not sustainable? I have an interest in the field, and the 7 on/7 off model makes me even more interested in it. I'm more than open to be dissuaded though.

Kids...and getting old.

 

[jurassicpark]

Kids...and getting old.

No kids yet, but the getting old part. I don't mind it so much, been doing it for so long the hours don't bother me. But bothers the heck out of my wife, the having kids part worries my wife if I'm gone 12-15 hours a day for 20-22 days of the month.

 

[xoggyux]

1. How involved is the Hospitalist in patient care? What I mean by this is - Let's pretend you have a patient come in for an Endocrine disorder (Let's say Adrenal Insufficiency, I like this example because I just finished my Endocrine module in school) - Do you wait for the Endocrinologist to consult the patient, or can the Hospitalist go ahead and do the ACTH Stimulation Test, and basically whatever test is needed, until they get "stuck" and have to have the specialist come in? What other tests do you find yourself often doing? What is something you basically 100% always wait for a specialist to come in and do? If a problem is pretty severe and the patient basically needs to be consulted by 3 different specialists - How often do you see the patient between all their surgeries and consults?

Will it surprise you if I tell you that "it depends"? Well, it does depend. Short of doing a surgical/semi-surgical procedure that you don't have expertise/privileges to do and sometimes ordering a handful of medications that pharmacy will put under a great deal of bureaucracy (e.g. Ceftaroline, Rituximab, Tolvaptan) that might require their respective consultants to order it, you can technically do anything and everything you need to do for your patient. In practice, I have found this is far from the case. Whether it is out of laziness, convenience, ignorance, "cover your ass", incompetence, optimizing care for your patients, facilitating follow up (aka, I consult cardio inpatient so that they establish a relationship and patient is more likely to follow up), or any of a billion possible reasons, the reality is that the majority of the admissions that deviate from your "bread and butter" will likely carry a consult. Many times I realize consultant X actually does a ****tier job that I do or basically says "agree with this and this" all of which has all been done and they just babysit. This is kind of the reality for most places that I have seen, some variation (where I trained there was high ## of litigation and as such people practiced a lot of covers your ass medicine, so young people would often get admitted with diarrhea/mild pneumonia/etc despite not needing for example. So, while technically you can do a lot, practice does place an artificial limit.

2. How often are you getting new patients? How long max do you typically hold onto a patient for? What's the shortest you'll receive a patient for?

Varies a lot. Admission ## will vary significantly depending on how busy the hospital is, how many other people are taking admission, how aggressive is the ED to admit someone. Same thing with "how long to hold onto a patient". The alcoholic guy can go early the next morning when he is sobered off so long as he/she was not baker acted for saying he/she is suicidal. The homeless demented guy that one-time police snatched off the street could very well live months if not years in the hospital. I have seen a handful of patients that have been in the hospital for ~4 years unable to be placed anywhere else. Then there are the "vegetative state" patients, sometimes vent-dependent that are basically dumped in the hospital by family, who refuses to take any end-of-life measures and a patient simply stays in the hospital getting pneumonia every 2-3 weeks until eventually they are resistant to everything and they die after the 12th of 14th code blue. You should get a decent taste of this when you do wards, certainly during residency.

3. Do you ALWAYS have a well-planned out therapy goal for a patient to follow for their discharge, assuming they have a new diagnosis or poorly treated diagnosis prior to admission? And is this plan always conveyed to the patient's primary care physician? How do you go about alerting their primary that they have a new treatment plan?

No. If you use the word "ALWAYS" the answer is going to be no.

4. During a single week, do you feel the clinical presentation of the patients is diverse enough to keep you interested and keep you on your toes? I want a job where I'll be constantly learning new things (at least for a while) - I would hate for example to be on the wards solely for stroke patients where everyone comes in with the same kind of disease presentation. How are patients organized typically in a hospital?

Again, depends. I think for all hospitals, 80%+ will be a handful of common diagnosis (CHF, ACS, COPD, Asthma, Kidney stone, Stroke, HTN Emergency, Syncope, Pneumonia, Septic UTI/pyelo, Abscess, SBO, Dehydration (various causes), Renal failure, Psych issues). If you go to a rural area, chances are thats pretty much everything you will see with a very rare exception, and when that exeption happens, if its a severe case, chances are you will end up transfering. If you practice next to a busy metropolitan area (NY, LA, Chicago, Miami, Atlanta, etc...) chances are that given diversity, immigration and cheer number of people you will have a more diverse patient population even if not practicing in an "university program". Still, rare cases are rare. Even in places where you do get to see the rare stuff, you will see 80+% of the common stuff.

5. How does working with Nurse Practitioners and PAs work as a hospitalist? Do they do the night shifts? Are you on call during your week that you're on, and these NPs and PAs are there with you, monitoring your patients? How often will they get involved? What kinds of things do they do while we're not exactly present in the hospital during an "on week"?

It depends on the model. Sometimes they will function as your personal, slightly more efficient, intern. They will write **** for you, will put the orders, will be doing the calls to the family, nursing home, etc while you supervise that he/she does not kill the patient and you lose your license or go to jail (kidding!). Sometimes they are the only presence in the hospital and their "supervising doc" is sleeping comfortably at home (as nice as this may sound to you, this obviously carries significant liability!). They can be very helpful/asset or the bane of your existence.

6. Speaking of Night Shifts, I know a lot of EM Physicians complain about the ever-changing schedule and circadian rhythm mess ups - But how do IM doctors deal with this? Is there high burn out due to night shift week as a hospitalist? How often will you typically work a week of all nights?

Another "depends". You can be a dedicated nocturnist. And basically it would be exacly the way it sounds, you work only at night, you sleep during the day. You get a week off that you can either switch your schedule or not if you don't care! For instance, if you want to travel alot around the word, this type of schedule might not be as disruptive to your life as you might first think. In the other hand, if you have a wife/husband and 3 children chances are that your first salary will include some money set aside for the rope you will need to hang yourself =). In other words, tough.

7. If you had to go back and do it again - Would you choose to be a hospitalist again? If not, what would you change about the job to make it more enjoyable?

Yes.

8. On your off weeks, do you find yourself - at least more in the beginning, doing a lot of home-reading from journals such as Nature, or JAMA? Do you find these weeks off beneficial to your practice as you're able to read up about certain things that maybe you were a bit uneasy with during your week on that maybe stumped you?

Reading only while in the hospital unless I get a paper title with a really nice provocative tittle that I cannot wait to read right now. During a week I get a few hours of downtime in the hospital that I can use to read, catch up.

9. How often, during your shift, are you looking up information because a patient stumps you, or comes in with something rare?

Looking up information for me is a daily thing but not always because "it is something rare I need to find out". The vast majority of information I look is a medication patient is taken that I am not familiar with, side effects of a recent treatment/surgery that patient had that I am not sure if its contributing to the current presentation, dosages of some meds I don't use on a daily basis. If I have time, I make a habit of reading the uptodate page relevant to a patient with the admitting diagnosis that I don't see on a weakly basis.

The breadth of patients you will see depends where you practice. Some community hospitalists will primarily see bread and butter stuff like pna, DKA, CHF, etc. Universities you may see more zebras. Where I work I get a good diversity of patients where even former highbrow academics who decided they wanted more money come and say, "sweet jesus, I only read about this type of stuff!!" But I also take shifts at a rural hospital, and while we see cool stuff through the ER the hospital is not physically equipped for much more than simple bread and butter cases and we have to ship them out. In terms of stroke units, etc.. once again, depends on where you work.

Exactly.

Could you elaborate on why being a hospitalist is not sustainable? I have an interest in the field, and the 7 on/7 off model makes me even more interested in it. I'm more than open to be dissuaded though.

I don't see how that could be the case. Burnout is the typical answer, but keep in mind this sort of schedule has come about due to convenience, mostly because a lot of people actually prefer this. The pay is certainly good, between 250-350k is pretty good, especially if you consider that the number of hours worked is actually much less for a hospitalist. 182 shifts in the 7on 7off seem typical, while if you have a regular 9-5 job that's like ~250. Not to mention you skip anywhere between 2-7 years of fellowship which translates into a lot of work and $$ (cost opportunity). The only way it is not sustainable is if you don't actually enjoy it. I for one would hate spending 90% of my time in the cath lab standing doing exactly the same two or three procedures.

 

[KeikoTanaka]

Will it surprise you if I tell you that "it depends"? Well, it does depend. Short of doing a surgical/semi-surgical procedure that you don't have expertise/privileges to do and sometimes ordering a handful of medications that pharmacy will put under a great deal of bureaucracy (e.g. Ceftaroline, Rituximab, Tolvaptan) that might require their respective consultants to order it, you can technically do anything and everything you need to do for your patient. In practice, I have found this is far from the case. Whether it is out of laziness, convenience, ignorance, "cover your ass", incompetence, optimizing care for your patients, facilitating follow up (aka, I consult cardio inpatient so that they establish a relationship and patient is more likely to follow up), or any of a billion possible reasons, the reality is that the majority of the admissions that deviate from your "bread and butter" will likely carry a consult. Many times I realize consultant X actually does a ****tier job that I do or basically says "agree with this and this" all of which has all been done and they just babysit. This is kind of the reality for most places that I have seen, some variation (where I trained there was high ## of litigation and as such people practiced a lot of covers your ass medicine, so young people would often get admitted with diarrhea/mild pneumonia/etc despite not needing for example. So, while technically you can do a lot, practice does place an artificial limit.

Thank you so much for your reply! This definitely opens my eyes to more of the role of the hospitalist. Could you speak about this response though, about the "artificial limit" that is placed on Hospitalists.

Do you find this to be the case in EM, or with Primary Care? Do you feel like you have more "control" over your patients in these other settings?

Do you ever plan on moving OP and doing PCP work, or do you plan on doing Hospitalist work indefinitely? One of the things holding me back from doing EM is that I will never have the luxury to move out of the hospital to an environment I can have more control over. Hospitalist seems to still always offer said pathway.

 

[PugsAndHugs]

Will it surprise you if I tell you that "it depends"? Well, it does depend. Short of doing a surgical/semi-surgical procedure that you don't have expertise/privileges to do and sometimes ordering a handful of medications that pharmacy will put under a great deal of bureaucracy (e.g. Ceftaroline, Rituximab, Tolvaptan) that might require their respective consultants to order it, you can technically do anything and everything you need to do for your patient. In practice, I have found this is far from the case. Whether it is out of laziness, convenience, ignorance, "cover your ass", incompetence, optimizing care for your patients, facilitating follow up (aka, I consult cardio inpatient so that they establish a relationship and patient is more likely to follow up), or any of a billion possible reasons, the reality is that the majority of the admissions that deviate from your "bread and butter" will likely carry a consult. Many times I realize consultant X actually does a ****tier job that I do or basically says "agree with this and this" all of which has all been done and they just babysit. This is kind of the reality for most places that I have seen, some variation (where I trained there was high ## of litigation and as such people practiced a lot of covers your ass medicine, so young people would often get admitted with diarrhea/mild pneumonia/etc despite not needing for example. So, while technically you can do a lot, practice does place an artificial limit.

Varies a lot. Admission ## will vary significantly depending on how busy the hospital is, how many other people are taking admission, how aggressive is the ED to admit someone. Same thing with "how long to hold onto a patient". The alcoholic guy can go early the next morning when he is sobered off so long as he/she was not baker acted for saying he/she is suicidal. The homeless demented guy that one-time police snatched off the street could very well live months if not years in the hospital. I have seen a handful of patients that have been in the hospital for ~4 years unable to be placed anywhere else. Then there are the "vegetative state" patients, sometimes vent-dependent that are basically dumped in the hospital by family, who refuses to take any end-of-life measures and a patient simply stays in the hospital getting pneumonia every 2-3 weeks until eventually they are resistant to everything and they die after the 12th of 14th code blue. You should get a decent taste of this when you do wards, certainly during residency.



No. If you use the word "ALWAYS" the answer is going to be no.

Again, depends. I think for all hospitals, 80%+ will be a handful of common diagnosis (CHF, ACS, COPD, Asthma, Kidney stone, Stroke, HTN Emergency, Syncope, Pneumonia, Septic UTI/pyelo, Abscess, SBO, Dehydration (various causes), Renal failure, Psych issues). If you go to a rural area, chances are thats pretty much everything you will see with a very rare exception, and when that exeption happens, if its a severe case, chances are you will end up transfering. If you practice next to a busy metropolitan area (NY, LA, Chicago, Miami, Atlanta, etc...) chances are that given diversity, immigration and cheer number of people you will have a more diverse patient population even if not practicing in an "university program". Still, rare cases are rare. Even in places where you do get to see the rare stuff, you will see 80+% of the common stuff.

It depends on the model. Sometimes they will function as your personal, slightly more efficient, intern. They will write **** for you, will put the orders, will be doing the calls to the family, nursing home, etc while you supervise that he/she does not kill the patient and you lose your license or go to jail (kidding!). Sometimes they are the only presence in the hospital and their "supervising doc" is sleeping comfortably at home (as nice as this may sound to you, this obviously carries significant liability!). They can be very helpful/asset or the bane of your existence.


Another "depends". You can be a dedicated nocturnist. And basically it would be exacly the way it sounds, you work only at night, you sleep during the day. You get a week off that you can either switch your schedule or not if you don't care! For instance, if you want to travel alot around the word, this type of schedule might not be as disruptive to your life as you might first think. In the other hand, if you have a wife/husband and 3 children chances are that your first salary will include some money set aside for the rope you will need to hang yourself =). In other words, tough.


Yes.


Reading only while in the hospital unless I get a paper title with a really nice provocative tittle that I cannot wait to read right now. During a week I get a few hours of downtime in the hospital that I can use to read, catch up.


Looking up information for me is a daily thing but not always because "it is something rare I need to find out". The vast majority of information I look is a medication patient is taken that I am not familiar with, side effects of a recent treatment/surgery that patient had that I am not sure if its contributing to the current presentation, dosages of some meds I don't use on a daily basis. If I have time, I make a habit of reading the uptodate page relevant to a patient with the admitting diagnosis that I don't see on a weakly basis.

Exactly.


I don't see how that could be the case. Burnout is the typical answer, but keep in mind this sort of schedule has come about due to convenience, mostly because a lot of people actually prefer this. The pay is certainly good, between 250-350k is pretty good, especially if you consider that the number of hours worked is actually much less for a hospitalist. 182 shifts in the 7on 7off seem typical, while if you have a regular 9-5 job that's like ~250. Not to mention you skip anywhere between 2-7 years of fellowship which translates into a lot of work and $$ (cost opportunity). The only way it is not sustainable is if you don't actually enjoy it. I for one would hate spending 90% of my time in the cath lab standing doing exactly the same two or three procedures.

Thank you very much for this extensive reply! MS4 applying for IM hoping to do academic hospitalist!

 

[wamcp]

Could you elaborate on why being a hospitalist is not sustainable? I have an interest in the field, and the 7 on/7 off model makes me even more interested in it. I'm more than open to be dissuaded though.

Hospitalist medicine is not for everyone. If you agree with the below then it is probably right for you:

-don’t want to waste extra 2-5 years in fellowship or other longer residencies
-don’t want to do any clinic or answer clinic phone calls
-prefer shift work, no one can bother you when you are off
-you view your job as just a job, i.e you could care less if the routine postop patient regards you lesser than their surgeon, as long as you get a paycheck for popping into the room for 5 seconds to make sure they’re alive when rounding.
-you love it when the ER doc is the one screening out 80% of the b.s. walking into the ER, sure you get stupid admits of the 20% but at least i don’t see 3 patients per hour in the pit and have to deal with EVERY SINGLE druggie, drunk or kid with the sniffles and the continual screams down there and constant interruptions
-hate doing anything surgical or don’t care that you are never going to do procedure heavy things
-hate dealing with pediatrics (i absolutely hated dealing with the parents)
-despise anything OB or gyn related
-when encountered with a suicidal or manic patient, prefer to say ‘let’s consult psych and walk away’ during rounds than actually putting up with it

 

[IMreshopeful]

At least among my classmates from medical school and residency even three years out there’s been a pretty high attrition rate in folks who are hospitalists - many have done a fellowship or switched to outpatient or joined an academic center where the workload is perhaps less burdensome. There are folks who do it lifelong but it’s common for people to get burned out.

I spent another four years doing fellowship but would never become a hospitalist because I hated it - i enjoy being a consultant and not having to deal with the minutiae of admitting and discharging, orders, endless H&P/progress note/discharge summaries, social admits, and so forth. There’s always two sides obviously - we will have to deal with stupid consults (the anemic septic guy with a trop of 0.5? You couldn’t figure that out Mr. Or Ms. Hospitalist?) but those pay the bills as it stands and I prefer it to seeing lots of admits for alcohol withdrawal and UTI.

 

[xoggyux]

Thank you so much for your reply! This definitely opens my eyes to more of the role of the hospitalist. Could you speak about this response though, about the "artificial limit" that is placed on Hospitalists.

Do you find this to be the case in EM, or with Primary Care? Do you feel like you have more "control" over your patients in these other settings?

Do you ever plan on moving OP and doing PCP work, or do you plan on doing Hospitalist work indefinitely? One of the things holding me back from doing EM is that I will never have the luxury to move out of the hospital to an environment I can have more control over. Hospitalist seems to still always offer said pathway.

I'd say this artificial limit is more of a systemic issue rather than "IM trained people don't do that". I don't have first-hand experience in other specialties but as an outsider, I think it is about the same for all specialties. It is for good also, I have found when doctors start to deviate too much from the few dozen diagnoses that we are very comfortable with we don't really perform that well. I think this applies to EM, cardiology, critical family medicine and all others that I have seen. This idea that some people get from watching TV series such as House, ER and such is completely unrealistic. The ED doc spends 80%+ of their time catering to drunk people, freak out moms of kids with the cold, people that have chronic shoulder pain, etc. I am still young but I have not seen, nor heard of a bedside pericardiocentesis, the few patients that I have seen ended going to cath lab or OR and done by a specialist and not the IM or ED doc. In my hospital if an LP does not get done in the ED, it almost always ends up being done by Neuro IR (sometimes critical care do them, but neither IM, ID, Neuro or even "regular" IR does them). Maybe your expectations are not that realistic.

 

[iforget2]

Hospitalist medicine is not for everyone. If you agree with the below then it is probably right for you:

-don’t want to waste extra 2-5 years in fellowship or other longer residencies
-don’t want to do any clinic or answer clinic phone calls
-prefer shift work, no one can bother you when you are off
-you view your job as just a job, i.e you could care less if the routine postop patient regards you lesser than their surgeon, as long as you get a paycheck for popping into the room for 5 seconds to make sure they’re alive when rounding.
-you love it when the ER doc is the one screening out 80% of the b.s. walking into the ER, sure you get stupid admits of the 20% but at least i don’t see 3 patients per hour in the pit and have to deal with EVERY SINGLE druggie, drunk or kid with the sniffles and the continual screams down there and constant interruptions
-hate doing anything surgical or don’t care that you are never going to do procedure heavy things
-hate dealing with pediatrics (i absolutely hated dealing with the parents)
-despise anything OB or gyn related
-when encountered with a suicidal or manic patient, prefer to say ‘let’s consult psych and walk away’ during rounds than actually putting up with it

I mean this sounds pretty great lol. I'm sure there's a side that I won't understand until I get there. Do most places require you to stay the whole shift or are there more places where you can round and go?

 

[xoggyux]

It varies by practice. That's the time you are expected to be responsible for the patient, whether you can be "responsible" over the phone with the PA in the hospital or perhaps someone else from your group inhouse etc that's a different question. How much a group goes out of their way to enforce this also varies.

 

[deleted746658]

how hard is it to crack 300k as a hospitalist?

 

[jurassicpark]

how hard is it to crack 300k as a hospitalist?

Not very. It really all depends on where you work, how much you want to work.

 

[deleted746658]

Not very. It really all depends on where you work, how much you want to work.

can u crack in coastal city? how much extra work can be picked up?

 

[NITRAS]

In my hospital if an LP does not get done in the ED, it almost always ends up being done by Neuro IR (sometimes critical care do them, but neither IM, ID, Neuro or even "regular" IR does them). Maybe your expectations are not that realistic.

It takes me an hour to do an LP. Small procedures like LP, paracentesis, thoracentesis are not compensated much, and the trend is for these things to be done by proceduralists (aka IR) where it takes 5-10 minutes of their time. We have a procedure team of IM residents that also co-manage some ortho patients. I really do like doing the small procedures, but it isn't practical when I am running of team of 16 patients doing all the calls, writing the notes, following up on this or that. I feel teaching team should do their base IM procedures, but even our teaching teams tend to farm it out to IR depending on the staff.

My group has good retention, but our census isn't crazy, have a dedicated team for admissions, cross cover, and dedicated nocturnists.

 

[tantacles]

can u crack in coastal city? how much extra work can be picked up?

The offer I just got in SF is essentially $260000 for 12 NIGHT shifts per month. $1800 for an extra shift. So doing 2-3 extra shifts per month (2.22 if you like averaging, so an extra every 5 months), cracking $300,000 is pretty reasonable and much less work than we ever did in residency.

 

[Splenda88]

The offer I just got in SF is essentially $260000 for 12 NIGHT shifts per month. $1800 for an extra shift. So doing 2-3 extra shifts per month (2.22 if you like averaging, so an extra every 5 months), cracking $300,000 is pretty reasonable and much less work than we ever did in residency.

How is the 12 nights distribution like for the month?

 

[tantacles]

How is the 12 nights distribution like for the month?

Mine seems somewhat flexible, but it's just an offer. No idea what it looks like in practice.

 

[jurassicpark]

much less work than we ever did in residency.

Careful there young Jedi. Make sure you know what the score is. Some places, night floats are a real cluster. All the patients like coming in mid-afternoon, worksup are not done until 7-9pm, so the admissions come pouring in at night time. Most specialists don't want to be bothered at night so you gotta keep your patients on ice. Floor calls are flooding in Q4h or whichever frequency nurses check their patients. Brand new nurses are calling you at 3am because they went through the chart and found their sleeping patient hasn't pooped for 2 days. 6am you'll get another deluge of calls requesting electrolyte coverage, slight deviance in lab values, etc. Then 6:15am the ER will ask you to admit one or two last patients. 10-15 admissions later you're ready to call it a morning!

 

[rokshana]

Careful there young Jedi. Make sure you know what the score is. Some places, night floats are a real cluster. All the patients like coming in mid-afternoon, worksup are not done until 7-9pm, so the admissions come pouring in at night time. Most specialists don't want to be bothered at night so you gotta keep your patients on ice. Floor calls are flooding in Q4h or whichever frequency nurses check their patients. Brand new nurses are calling you at 3am because they went through the chart and found their sleeping patient hasn't pooped for 2 days. 6am you'll get another deluge of calls requesting electrolyte coverage, slight deviance in lab values, etc. Then 6:15am the ER will ask you to admit one or two last patients. 10-15 admissions later you're ready to call it a morning!

Absolutely agree!

And a place that only requires 12 shifts/month? Probably because when you are there you are slammed!

If it sounds too good to be true...it probably is!

 

[Splenda88]

Absolutely agree!

And a place that only requires 12 shifts/month? Probably because when you are there you are slammed!

If it sounds too good to be true...it probably is!

12 shifts/month nocturnist is commensurate with the 260k/year... Every single person in my program who signed nocturnist contracts got above 300k for 14 shifts/month.

12 shifts/month for 260k is not that a great deal when one looks at the totality of everything...

 

[DrSnips]

12 shifts/month for 260k is not a that great deal when one looks at the totality of everything...

For a big city in the northeast that's not too bad, but yeah, just about anywhere else I agree.

 

[aafisahar]

The offer I just got in SF is essentially $260000 for 12 NIGHT shifts per month. $1800 for an extra shift. So doing 2-3 extra shifts per month (2.22 if you like averaging, so an extra every 5 months), cracking $300,000 is pretty reasonable and much less work than we ever did in residency.

260k in the bay area is like 110K in Indianapolis, probably even worse as you can buy a pretty sweet home in Indy with a salary of 120k. You can't buy a home in San Fran on a salary of 260k.

 

[tantacles]

260k in the bay area is like 110K in Indianapolis, probably even worse as you can buy a pretty sweet home in Indy with a salary of 120k. You can't buy a home in San Fran on a salary of 260k.

Yeah, and if you buy that sweet home in Indianapolis, you have to live in Indianapolis (or maybe even the suburbs, which is even worse), which is a completely repulsive idea to me.

I'll leave the midwest to people who like it. You get what you pay for, and I'm willing to pay more to be happy.

On the flipside as well, many of us prefer smaller homes; having a big house does little for us.

 

[tantacles]

For a big city in the northeast that's not too bad, but yeah, just about anywhere else I agree.

Yeah, it's commensurate with other jobs in the bay area, though.

 

[tantacles]

12 shifts/month nocturnist is commensurate with the 260k/year... Every single person in my program who signed nocturnist contracts got above 300k for 14 shifts/month.

12 shifts/month for 260k is not that a great deal when one looks at the totality of everything...

To be fair, this job is in a 44 bed + 8 ICU bed community hospital, so the shifts don't seem incredibly taxing. For what the job is, it seems to pay pretty well.

Also to be fair, I'm hoping to get one of the other two jobs I interviewed for; they pay better and have even fewer shifts, but are almost certainly more intense in terms of the work you do while on duty.

 

[Splenda88]

To be fair, this job is in a 44 bed + 8 ICU bed community hospital, so the shifts don't seem incredibly taxing. For what the job is, it seems to pay pretty well.

Also to be fair, I'm hoping to get one of the other two jobs I interviewed for; they pay better and have even fewer shifts, but are almost certainly more intense in terms of the work you do while on duty.

I would definitely take a less intense job, which will allow me to work extra shifts than an intense job. That is my take.

 

[tantacles]

I would definitely take a less intense job, which will allow me to work extra shifts than an intense job. That is my take.

I think it depends on what you're looking for. If you're working, say, 8 shifts per month in your job, and they're mostly pretty intense, you could, say, work 4 on 2 off 4 on, which gives you 2.5 weeks of vacation. During that time, you can work more or just take the time if you need it. The flexibility is something I value. Some people value a higher base salary with more shifts, and some people value a lower base salary with fewer shifts and the ability to work more if they desire to.

 

[Splenda88]

I think it depends on what you're looking for. If you're working, say, 8 shifts per month in your job, and they're mostly pretty intense, you could, say, work 4 on 2 off 4 on, which gives you 2.5 weeks of vacation. During that time, you can work more or just take the time if you need it. The flexibility is something I value. Some people value a higher base salary with more shifts, and some people value a lower base salary with fewer shifts and the ability to work more if they desire to.

It would be nice to find a full time (with benefits) hospitalist/nocturnist job that is 8-10 shifts/month.

 

[tantacles]

It would be nice to find a full time (with benefits) hospitalist/nocturnist job that is 8-10 shifts/month.

They exist. That's 2/3 of the positions I applied for.

 

[Splenda88]

They exist. That's 2/3 of the positions I applied for.

Good to know... I thought only EM docs had these opportunities.

What is the salary range for these positions?

 

[tantacles]

Good to know... I thought only EM docs had these opportunities.

What is the salary range for these positions?

245,000 for one with $1900 for each extra shift
Not sure about the pay for the other one.

 

[Splenda88]

245,000 for one with $1900 for each extra shift
Not sure about the pay for the other one.

This is an extremely good salary for 10 shifts/month...

 

[wamcp]

245,000 for one with $1900 for each extra shift
Not sure about the pay for the other one.

Huh...Extra shift pays less than the base salary shift? That makes no sense

 

[tantacles]

Huh...Extra shift pays less than the base salary shift? That makes no sense

Meh, whatever. I would have the option to do per diem shifts elsewhere if I desired. The base salary is what I'm looking at for this particular job.

 

[tantacles]

This is an extremely good salary for 10 shifts/month...

I have no complaints about it. Just wondering if it'll be the best offer I get.

 

[tantacles]

Careful there young Jedi. Make sure you know what the score is. Some places, night floats are a real cluster. All the patients like coming in mid-afternoon, worksup are not done until 7-9pm, so the admissions come pouring in at night time. Most specialists don't want to be bothered at night so you gotta keep your patients on ice. Floor calls are flooding in Q4h or whichever frequency nurses check their patients. Brand new nurses are calling you at 3am because they went through the chart and found their sleeping patient hasn't pooped for 2 days. 6am you'll get another deluge of calls requesting electrolyte coverage, slight deviance in lab values, etc. Then 6:15am the ER will ask you to admit one or two last patients. 10-15 admissions later you're ready to call it a morning!

Right, I don't think I said it was paradise, but when residency for me was doing all of this with ~90 patients per night at a tertiary care teaching hospital with a substandard EMR with extremely hostile fellows on the other end of the line, no in-house attending, an average of 20 pages per hour (sometimes more, including the constipation ones) and, on top of all of that, working 12 days in a two week block rather than 10 in a 1 month block, I feel pretty confident in saying that my experience doing nocturnist work at this hospital will be less rigorous than my experience in residency. Can I predict every nuance of this job? Absolutely not. Can I predict the difference between being the resident on night float and the attending on nights permanently? No. But this is why I've spent a significant amount of this year doing nights, both as a moonlighter and during my normal resident work.

You say know what the score is, but frankly, there's no way to ever know what the score is. It doesn't matter if you talk to someone who works there, work one night there as a sample, grill your interviewer, or do anything else. I know absolute numbers, and I know that I can hold admissions off until morning it's truly an overwhelming night.

But, most importantly, I know that I can leave this job if I need to. I won't be stuck in a ****ty contract that basically says I can't work if I don't finish, so while you're certainly beholden to administration, the difference is now that I get to choose. For me, that makes all the difference.

Don't worry. I'm not expecting to sleep 6 hours each night shift or anything.

 

[tantacles]

Absolutely agree!

And a place that only requires 12 shifts/month? Probably because when you are there you are slammed!

If it sounds too good to be true...it probably is!

12 night shifts per month is pretty standard for a nocturnist. I'm far more worried about the place that requires 10!

 

[jurassicpark]

Right, I don't think I said it was paradise, but when residency for me was doing all of this with ~90 patients per night at a tertiary care teaching hospital with a substandard EMR with extremely hostile fellows on the other end of the line, no in-house attending, an average of 20 pages per hour (sometimes more, including the constipation ones) and, on top of all of that, working 12 days in a two week block rather than 10 in a 1 month block, I feel pretty confident in saying that my experience doing nocturnist work at this hospital will be less rigorous than my experience in residency. Can I predict every nuance of this job? Absolutely not. Can I predict the difference between being the resident on night float and the attending on nights permanently? No. But this is why I've spent a significant amount of this year doing nights, both as a moonlighter and during my normal resident work.

You say know what the score is, but frankly, there's no way to ever know what the score is. It doesn't matter if you talk to someone who works there, work one night there as a sample, grill your interviewer, or do anything else. I know absolute numbers, and I know that I can hold admissions off until morning it's truly an overwhelming night.

But, most importantly, I know that I can leave this job if I need to. I won't be stuck in a ****ty contract that basically says I can't work if I don't finish, so while you're certainly beholden to administration, the difference is now that I get to choose. For me, that makes all the difference.

Don't worry. I'm not expecting to sleep 6 hours each night shift or anything.

Good that you're looking at it realistically. When someone says easier than residency, its sets my spidey-senses tingling. Likewise, I too did a pretty demanding county hospital residency.. but it was nothing compared to what I had to do as an Attending. Granted, we were building up our group at that time and it certainly was not the norm what I was doing (covering 5 hospitals and probably should not disclose how many patients).. but I've heard of much much worse (like New York), where you're slammed beyond crazy for minimal pay.

 

[fldoctorgirl]

245,000 for one with $1900 for each extra shift
Not sure about the pay for the other one.

I know you mentioned this is $245,000 base for 10 shifts/month. Day or night? 12 hour shifts?

 

[tantacles]

I know you mentioned this is $245,000 base for 10 shifts/month. Day or night? 12 hour shifts?

Night. 11's (weekends are 13 with no shift differential, but as a nocturnist I get first pick of which shifts I do.)