secretwave101

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As I approach the completion of residency (FM), I find myself in the enviable position of needing to decide between being a hospitalist and a private family doc. I have offers from both.

The private practice opportunity is backed by the local hospital, which offers a guaranteed salary of 150k for a year, moderate loan repayment, pretty good signing bonus and a monthly stipend until residency for signing early. Everything must be paid back if I leave prior to 3 years. Practice is one other doc, established 5 years, owns building, 10,000 patients with another part-time doc and a NP. Good payor mix with reasonable exposure to charity care. Sports med emphasis.

The hospitalist job isn't set in stone, and currently is funded only such that I can pick up shifts - likely adding up to around 200k/year. The group is very focused on getting me to come on board with them, and eventually they will have a spot funded for me. Pay would be around 200k, off every other week. Small community hospital. Frequent low-acuity ICU exposure. LOVE the docs in this group.

There is a second hospitalist job in town offering me 180k with benefits and 10-20k signing bonus. Would require a longer commute than the others.

I'm gnawin' my fingernails off. I really don't know which one I'd like best. I really enjoy hospital medicine, but only 2 weekends a month with my kids isn't too pretty. The pay is better, though. Also, if the economy gets worse, I'm not sure which type of job is safer.
 

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As I approach the completion of residency (FM), I find myself in the enviable position of needing to decide between being a hospitalist and a private family doc. I have offers from both.

The private practice opportunity is backed by the local hospital, which offers a guaranteed salary of 150k for a year, moderate loan repayment, pretty good signing bonus and a monthly stipend until residency for signing early. Everything must be paid back if I leave prior to 3 years. Practice is one other doc, established 5 years, owns building, 10,000 patients with another part-time doc and a NP. Good payor mix with reasonable exposure to charity care. Sports med emphasis.

The hospitalist job isn't set in stone, and currently is funded only such that I can pick up shifts - likely adding up to around 200k/year. The group is very focused on getting me to come on board with them, and eventually they will have a spot funded for me. Pay would be around 200k, off every other week. Small community hospital. Frequent low-acuity ICU exposure. LOVE the docs in this group.

There is a second hospitalist job in town offering me 180k with benefits and 10-20k signing bonus. Would require a longer commute than the others.

I'm gnawin' my fingernails off. I really don't know which one I'd like best. I really enjoy hospital medicine, but only 2 weekends a month with my kids isn't too pretty. The pay is better, though. Also, if the economy gets worse, I'm not sure which type of job is safer.


Hospitalist at 180K? You should be making more than that, with RVUs and bonuses built in the system. Make sure to ask about that, as well as Loan Repayment.
Hospitalist is not the best job in the world scheduling wise sometimes. I think that its kind of tough sometimes, to have family time -- depending on where and how you work. We do not deal with all of the codes in the Hospital, therefore we are not pressured. Some programs want you to deal with all of codes in the Hospital. At some places, this equates to higher salary. We only have to deal with codes on our own patients -- and we still get backup if we cannot be there right away. You shouldn't work more than 16-18 shifts maximum per month, even a 7 on and 7 off schedule should suffice. We definitely deal with plenty of ICU patients also (10-20% of our census), as we do not have a dedicated ICU doctor.
Dont get suckered into doing more shifts than that.
You won't need extra shifts if its a busy service believe me.
The things that I like about clinic, are several. Most importantly getting to know your patients. Do not sucker punch yourself into doing rounds in the Hospital, and admitting your own, and full day of clinic.
This is exhausting in my opinion, and docs in general do not like it very much.
Clinic is nice, the predictability of it. You are in charge, with virtually no surprises thrown your way.
The problem, as you mention the 150K, is the compensation. With student loans, malpractice, overhead, making everyone happy, it is a tough venture at times. EMR doesn't help things in my opinion at all. I have researched both as well, Hospitalist and Outpatient.
Hospitalist is very very fast paced sometimes, and you have to be good at Medicine, ready to fix problems instantanteously. It is not that bad after a while, but it is tough in the beginning.
The thing I do not miss at all whatsoever about clinic though, is definitely the phone calls. Good grief
2 a.m. "my two month old is constipated"
2:15 a.m. "My doctor forgot to refill my vicodin"
3:15 a.m. "I had a rash yesterday, but its getting much better"
4:15 a.m. "I have had vaginal itching for a few months"

The paperwork at times is insane also, and you do not get paid anything for the large amount of paperwork that you do daily, such as Nursing Home.
Is it all about money?? Well, um er, when you have bills to pay, and you are doing hours of paperwork in a day and not getting paid, isn't that significant? I would venture that the best guess is yes.
this is from residency, I don't know about real life. Real life is much more paperwork I would assume.
Hospitalist is zero paperwork, other than admission orders and progress notes, and orders of course. E-Sign dictations online, put your charges in online.
 
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I can't tell you what you should do, because only you can figure that out.

That being said, office and hospital jobs are quite different, in just about every way that you can imagine. You really have to decide what sort of work and practice environment suits your wants/needs best. What do you enjoy the most? Which would you do if the money was the same? You mentioned that you value your time off, so it's likely that an office-based practice would provide more flexibility in that regard.

It sounds like you'd pretty much be stuck in the outpatient job for three years because of the payback clause. That's unfortunate. We don't do that to our docs. The "iffy" (e.g., unfunded) nature of the hospitalist position should also cause some concern. If you're worried about what could happen in an uncertain economy, that job could be in jeopardy if the hospital cuts back.

The hospital jobs sound like straight salary. In most cases, you're going to be worked harder than you're paid in that situation. Just know that up front. You say the outpatient job has a salary guarantee for only the first year. What happens after that? Make sure you understand how you'll be compensated after your guarantee runs out. Will you be building a practice from scratch? If so, it might take longer than a year to get really busy, although 10,000 patients sounds like a lot for two and a half docs and a mid-level...I suspect that you'll be busy on day one. How's the payer mix? If you're going to be paid based on individual productivity, make sure you don't get stuck with all of the crap (e.g., Medicare/Medicaid patients), or you could find yourself up the creek after your salary guarantee runs out. Ideally, you should have some control over your payer mix, schedule, etc., and be able to tailor your practice to the way you want to do things. Is there a partnership opportunity at some point? If so, make sure you understand exactly how this works.

Have a good contract attorney or consultant review your contracts before you sign. Make sure you fully understand any non-compete clauses, as they will come into play if you decide to leave. Take everything in your contract very seriously, and if you value something, make sure it's in there. Don't take anything on a handshake or promise, even if you trust the people you'll be working with (which you should).
 
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andwhat

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I can't tell you what you should do, because only you can figure that out.

That being said, office and hospital jobs are quite different, in just about every way that you can imagine. You really have to decide what sort of work and practice environment suits your wants/needs best. What do you enjoy the most? Which would you do if the money was the same? You mentioned that you value your time off, so it's likely that an office-based practice would provide more flexibility in that regard.

It sounds like you'd pretty much be stuck in the outpatient job for three years because of the payback clause. That's unfortunate. We don't do that to our docs. The "iffy" (e.g., unfunded) nature of the hospitalist position should also cause some concern. If you're worried about what could happen in an uncertain economy, that job could be in jeopardy if the hospital cuts back
Not sure, I think that it may be the other way around. I have heard of Multispecialty groups with these 'cutbacks', and critically decreased compensation of Family Practice doctors, almost 25% at times. That is insane. Alot of those family docs that this event happened to, turned to Urgent Care and Academics (Residency program)
Hospitalist is not a perfect world either. On the East Coast (NY for instance) Hospitalist programs are 'burnout' (from what I have heard)
It is random, how things turn out sometimes also.
 

secretwave101

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Thanks for the thoughtful replies, mates!

The 'what do you like to do' question is always difficult for me. I hate paperwork and phone calls. I don't like long hours more than every so often, and I don't like a career that doesn't allow me to develop other professional interests and to have quality relationships with family and friends (I'm ok with 60 hrs/week, not 100).

In general, I like the complexity of hospital medicine but lament the lack of variety that you see in clinical practice. Hospitalist hours seem long (12 hrs), but not having to deal with insurance companies, payer mix, office politics and attire (hate dress shoes and ties) is appealing.

Specifically, many of BD's questions about how things will play out after the guaranteed year are hard to really determine. Supposedly I get 50% of all billed gross net (money received after insurance mafia takes their cut). I can buy in as a partner after another year, but I don't really understand how that will work or what to watch for. Buying into a business is something I have ABSOLUTELY no experience with. It will take more time than I feel I have to really understand that aspect of things.

I'll probably go with the office thing, mostly because of all the up-front incentives and the appearance of stability. But I'm not settled about it at the moment.
 
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I like the complexity of hospital medicine but lament the lack of variety that you see in clinical practice. Hospitalist hours seem long (12 hrs), but not having to deal with insurance companies, payer mix, office politics and attire (hate dress shoes and ties) is appealing.

Don't kid yourself. There's at least as much variety in office practice (more, perhaps) than in hospital medicine. Most hospital admissions are for common conditions, and it's very "cookbook." Many hospitals utilize standard protocols and pretty much mandate that you use them. Most hospitals require specialty consultation for certain things. Often times, the admitting doctor ends up doing a bunch of crap like fussing with electrolytes while specialists get paid for managing the main issues (CHF, MI, CVA, GI bleed, etc.) Of course, as the admitting physician, you'll get all of the nurse calls and get stuck handling the discharge. Yippee-skippy.

Payer mix? At least in an office practice, you can control it. In the hospital, you have to take what you get. Dealing with insurance companies? Hospitalists routinely have to beg insurers to approve additional hospital days, and provide justification for why a patient isn't ready for discharge. Length-of-stay is a major sticking point for hospitals, as well, as it's a quality measure. Admitting doctors feel the heat from both directions.

Politics? There's way more politics in the hospital than in the office or community. No comparision.

Attire? Most hospitalists don't usually schlep around in scrubs, especially not during the day. They're not residents, after all. Most dress professionally (shirt and tie).

many of BD's questions about how things will play out after the guaranteed year are hard to really determine. Supposedly I get 50% of all billed gross net (money received after insurance mafia takes their cut). I can buy in as a partner after another year, but I don't really understand how that will work or what to watch for. Buying into a business is something I have ABSOLUTELY no experience with. It will take more time than I feel I have to really understand that aspect of things.

Don't assume anything. Before you accept a job, make sure you know if there's a partnership opportunity and exactly how it's determined. Find out what they buy-in amount will be. I've seen people who basically never got to be partner, and others who were offered partnership but with an outrageous six-figure buy-in. You need to know what you're getting into. If they can't tell you, it's a red flag.
 

secretwave101

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Mis-spoke/wrote about the variety. I was trying to say that although I like how complex hospital medicine can get, I dislike the lack of variety it has compared to opt. practice. Totally agree with you - sometimes hospital medicine seems like about 4 diseases, the only variation is just how sick the pt. is from one of those 4.

SOB, sepsis, renal, CHF...maybe a 5th is cellulitis.
 

andwhat

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Don't kid yourself. There's at least as much variety in office practice (more, perhaps) than in hospital medicine. Most hospital admissions are for common conditions, and it's very "cookbook." Many hospitals utilize standard protocols and pretty much mandate that you use them. Most hospitals require specialty consultation for certain things. Often times, the admitting doctor ends up doing a bunch of crap like fussing with electrolytes while specialists get paid for managing the main issues (CHF, MI, CVA, GI bleed, etc.) Of course, as the admitting physician, you'll get all of the nurse calls and get stuck handling the discharge. Yippee-skippy.

Payer mix? At least in an office practice, you can control it. In the hospital, you have to take what you get. Dealing with insurance companies? Hospitalists routinely have to beg insurers to approve additional hospital days, and provide justification for why a patient isn't ready for discharge. Length-of-stay is a major sticking point for hospitals, as well, as it's a quality measure. Admitting doctors feel the heat from both directions.

Politics? There's way more politics in the hospital than in the office or community. No comparision.

Attire? Most hospitalists don't usually schlep around in scrubs, especially not during the day. They're not residents, after all. Most dress professionally (shirt and tie).



Don't assume anything. Before you accept a job, make sure you know if there's a partnership opportunity and exactly how it's determined. Find out what they buy-in amount will be. I've seen people who basically never got to be partner, and others who were offered partnership but with an outrageous six-figure buy-in. You need to know what you're getting into. If they can't tell you, it's a red flag.

whoaaaaa clarification :D
Hospitalist variety of diseases is very very intriguing, part of why I, as you state, put up with the incessant pages sometimes. That is tough especially at night I will not lie, but you get used to it hopefully one day for me that is
However, this is part of a 'bad' day, which is somewhat fortunately a rarity.
Hospitalist Medicine is anything but 'cookbook'. I have come across the disorders, that I recall from medical school only -- Hemolytic Uremic Syndrome, Salt wasting Nephropathy, Shy Dragger syndrome, Pancoast Syndrome. Also the complexity of medical issues at times is quite quite challenging.
I definitely do go home knowing that I made a difference usually, and moreso than I did in clinic.
Uncontrolled Diabetes, Stroke, and MI at the same time. This is quite challenging -- which one is the most critical? and requires the most urgent intervention? Fortunately Specialists are almost always helpful.
ER is not very helpful at times also. Especially the new people. Some of the newbies are very strong. Others are extremely weak.
Some do not want to get in the middle of Hospitalists and specialists, as far as admission, I would call that 'weak' and not thoroughly handling your responsibilities.
There are complexities in Hospitalist Medicine, however overall it is definitely fun.
You absolutely do not get stuck handling the discharge, that is why it is shift work. The next guy picks it up. Admitting shifts are fun, because you figure it out, order the tests, and can step back if you want to, or follow the patient the next day if you want to.
If the admitting orders are solid, then you will not receive a single call from the nurse.
Actually we discharge patients quite efficiently.
Politics I will not deceive you, it exists. This is why nights are nice, get your work in, and go home.
I am supposed to feel 'sorry' for the overworked specialist?? And call the next doctor who comes on for the consult? That is completely and utterly ridiculous. This is the exception however, and not the rule.
I wear scrubs regularly.
The other thing that I love, is the shift work, I only have to think for 12 hours maximum at a time, and then go home.
 
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Hospitalist variety of diseases is very very intriguing

Common things occur commonly, however, as in any other field.

Hospitalist Medicine is anything but 'cookbook'.

It is if you have a patient on a protocol. There are a lot of protocols in most hospitals nowadays.

I definitely do go home knowing that I made a difference usually, and moreso than I did in clinic.

I'm sorry that you didn't have a better experience in the outpatient setting.

Uncontrolled Diabetes, Stroke, and MI at the same time. This is quite challenging -- which one is the most critical? and requires the most urgent intervention?

The ancient Chinese said, "Superior doctors prevent disease. Mediocre doctors treat early disease. Inferior doctors treat full-blown disease."

Put another way: "Family physicians save lives every day. We just don't wait until the last minute." ;)
 

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just my two cents...but I think it would be incredibly depressing to just do hospital work. What I see in hospitals is a dizzying amount of inefficiency, over-testing, over-reacting, and under-treating what lies at the root of the hospitalized patient's problem, which in many cases relates to lifestyle and economics.

It's not the hospitalists' fault, really, although I have seen some pretty shoddy care going on, I have also seen some excellent care from hospitalists. But the way the hospital is set up just really breeds over-doing things. How many times has an otherwise well patient, who, if you saw them in the clinic, you'd have no problem NOT admitting, is kept an extra day in the hospital for a slightly low potassium, or a cough that got a little worse, so we got another chest x ray....or because cardiology hadn't made it by to write a note that day...or whatever...

To each his own. But I think I'd lose it if I had to spend more than about 2 hours a day in a hospital, or more than one hour rounding. Eternal, never-ending rounding, admissions, and discharges. Ugh...
 

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Uncontrolled Diabetes, Stroke, and MI at the same time. This is quite challenging -- which one is the most critical? and requires the most urgent intervention? Fortunately Specialists are almost always helpful.



Well, let's see. I'd give insulin, either drip or per protocol with lantus and novolog, I'd initiate stroke protocol and check off all the appropriate boxes, consult neuro if they were in the window for tPA after appropriate imaging (per protocol), and I'd consult cardio if it was a STEMI, +/- cardio for an NSTEMI. If it was ischemic, stroke would trump MI if the question was what to do about BP, don't drop too fast or you kill the brain...

Why wouldn't you be able to get all that going at the same time? Help me understand your dilemma? You are saying the specialists are helpful, but it's still a challenge to decide which problem requires the most urgent intervention? Isn't the intervention what the specialists DO (or decide not to do, then it's even easier--you just park them in the ICU and wait it out).

And why wouldn't the specialists already have been called if someone had BOTH an acute MI and an acute CVA? All that is done in the ED, per protocol, before the admitting doc, in the event it's not one of the specialists, gets called. At least that's how it works at our hospitals.
 

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Common things occur commonly, however, as in any other field.



It is if you have a patient on a protocol. There are a lot of protocols in most hospitals nowadays.



I'm sorry that you didn't have a better experience in the outpatient setting.



The ancient Chinese said, "Superior doctors prevent disease. Mediocre doctors treat early disease. Inferior doctors treat full-blown disease."

Put another way: "Family physicians save lives every day. We just don't wait until the last minute." ;)

protocols do exist, I will agree. However, they are seldom used, only maybe perhaps the Stroke Protocol. However, that makes things even more confusing at times, NPO before swallow study? Or Not? Perhaps its up to Neuro, oh wait there is the Dysphagia Protocol.
We are actually lobbying against protocols, they make things much more confusing at times, and literally tons of more paperwork for the nurses.
I had a great outpatient experience actually. I loved figuring things out. I was not so great at Preventive Medicine, Community based Medicine however. Well child examinations, insurance physicals, disability exams. However, most third year residents feared that they would be facing the same things in private practice, and are loving outpatient medicine now.
I would say that I had a very poor outpatient experience only in my preceptorship. I did not like how things were conducted there at all.
EMR, the guys would start at 7-8 a.m., finish clinic around 7 p.m., electronic dictations they did at home.
Wow that is rough at times, the outpatient aspect that I was exposed to.
However, clinic in my residency training was great, outstanding actually. I loved figuring things out, that nobody else had a good handle on.
I actually have tremendous respect for Primary Care docs in the Outpatient setting.
My accumen just falls nearer so to Hospitalist Medicine.
Yes the work is at times unpredictable, and there are occasional ER screwups -- such as having us admit a patient on medical, that was very clearly a Pysch issue. This rarely happens though, and always seems to be that same doc that is driving everyone insane :mad:
There are no significant problems in Hospitalist Medicine, only occasional screwups that I am becoming more and more proficient at correcting.
 

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just my two cents...but I think it would be incredibly depressing to just do hospital work. What I see in hospitals is a dizzying amount of inefficiency, over-testing, over-reacting, and under-treating what lies at the root of the hospitalized patient's problem, which in many cases relates to lifestyle and economics.

It's not the hospitalists' fault, really, although I have seen some pretty shoddy care going on, I have also seen some excellent care from hospitalists. But the way the hospital is set up just really breeds over-doing things. How many times has an otherwise well patient, who, if you saw them in the clinic, you'd have no problem NOT admitting, is kept an extra day in the hospital for a slightly low potassium, or a cough that got a little worse, so we got another chest x ray....or because cardiology hadn't made it by to write a note that day...or whatever...

To each his own. But I think I'd lose it if I had to spend more than about 2 hours a day in a hospital, or more than one hour rounding. Eternal, never-ending rounding, admissions, and discharges. Ugh...

Like I said, its your accumen. I am sure that Blue could blow me away at Inpatient or Outpatient clinical medicine. I am not saying that one is more challenging than the other, or one is better or more important than the other.
I am merely saying, that I prefer practicing Hospitalist Medicine, as opposed to Clinic Outpatient Medicine for the time being.
Usually patients are discharged efficiently and expeditiously. Usually that is.
Discharges are frustrating, I really wish that there were some way to have the Nurse Practioners and P.A.s do more of them. They are of tremendous help, and benefit -- they discharge more patients than the Physicians. We occasionally have to sign orders, but it is a very very nice and efficient system usually. I like admitting and rounding, but not discharging. It is a time hassle, as well as mental energy, and effort spent that I could have spent elsewhere.
However we average 1-4 discharges per shift. That is not that bad.
Some part of your job has to suck ;-))
 

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Well, let's see. I'd give insulin, either drip or per protocol with lantus and novolog, I'd initiate stroke protocol and check off all the appropriate boxes, consult neuro if they were in the window for tPA after appropriate imaging (per protocol), and I'd consult cardio if it was a STEMI, +/- cardio for an NSTEMI. If it was ischemic, stroke would trump MI if the question was what to do about BP, don't drop too fast or you kill the brain...

Why wouldn't you be able to get all that going at the same time? Help me understand your dilemma? You are saying the specialists are helpful, but it's still a challenge to decide which problem requires the most urgent intervention? Isn't the intervention what the specialists DO (or decide not to do, then it's even easier--you just park them in the ICU and wait it out).

And why wouldn't the specialists already have been called if someone had BOTH an acute MI and an acute CVA? All that is done in the ED, per protocol, before the admitting doc, in the event it's not one of the specialists, gets called. At least that's how it works at our hospitals.


Whoa whoa, again -- my point being, is that I have more interest and clinical accumen in Inpatient Medicine, as opposed to Outpatient Medicine for the time being.
I did not mean to come across as meaning one specialty was more meaningful, or beneficial for the patient than the other.
I do not have a dilemma Thank you wholeheartedly for inquiring about me though that was so sweet of you :love:
I wanted to state that the particular case was interesting.
I wish wish wish that things worked like that in our Hospital. It is up to the Hospitalists to decide which intervention is necessary.
This is something that I really really struggled with at first, because I figured that ED Physicians are actually paid to figure things out. However, it is quite a bit of brain work that we have to do also.
Almost like starting over entirely, as if they are triage nurses, some of the Emergency Room Physicians, sad to admit. They actually cringe at the thought of calling a consult if we request, when we are super busy. Some are very good and thorough, others are just plain lazy as can possibly be.
"Abdominal Pain, cum and git it!"
Oh man.... the inadequacies of the Emergency Room, dont even get me started :sleep:
Like I mentioned above, patient clearly a Psych issue, ER doc doesn't want to think about it hard enough, because it is much easier to call Medicine and have them do all of the paperwork, and figure it out.
This happens 2-5% of the time, and I am grilling this concept hardcore when, and surely if this particular ER doc ever calls me again. Speak up or get stepped on, is the rule of Hospital Politics.
I have given up on complaining, because its better to just accept that it will rain sometimes, and not complain about it..... just bring an umbrella... argh...
Sometimes better to deal with the situation yourself, diplomatically... this is something of course I was never taught in residency or medical school....
The fine etiquette of Hospital Politics. Yuck.....
 
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It is up to the Hospitalists to decide which intervention is necessary.

That sounds like lawsuit land to me. The specialist should be involved at the entry level on time-sensitive cases like stroke and MI, that's what they are PAID to do--make those decisions. It should not be up to the hospitalist to decide those things. That's just crazy.
 

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Discharges are frustrating, I really wish that there were some way to have the Nurse Practioners and P.A.s do more of them.

Yes, but a poorly-done or hasty discharge often = bounceback. They don't get their meds, or get the wrong ones, or really weren't ready to go, or had some social or home health or equipment issue unresolved that causes them to get worse and show up in the ED two days later.

And then there is the discharge summary. If hastily or incompletely done, it's sometimes worse than having nothing at all.

Of course, maybe if nurses and PAs did more of them, they'd be done more thoroughly, if they had more time than the docs...
 

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That sounds like lawsuit land to me. The specialist should be involved at the entry level on time-sensitive cases like stroke and MI, that's what they are PAID to do--make those decisions. It should not be up to the hospitalist to decide those things. That's just crazy.

thank you.... yes it is mainly the neuro ones -- I will get a wishy washy sign out that sounds like a Placement issue for instance, and then be expected to run the rest of the show -- could be anything, Stroke, Surgical problem -- I am expected to aggressively dig into it myself..... utterly ridiculous in my opinion... but I have somehow for the most part learned how to accept this...
Thankfully not a huge liability issue has been thrown my way yet.... the Politics are not the best at all here....
The flip side of that, is that you train yourself to think much harder, and be more thorough. This way you know the patient much better also, come signout.
 
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andwhat

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Yes, but a poorly-done or hasty discharge often = bounceback. They don't get their meds, or get the wrong ones, or really weren't ready to go, or had some social or home health or equipment issue unresolved that causes them to get worse and show up in the ED two days later.

And then there is the discharge summary. If hastily or incompletely done, it's sometimes worse than having nothing at all.

Of course, maybe if nurses and PAs did more of them, they'd be done more thoroughly, if they had more time than the docs...


Unfortunately, if it was meant to be a bounceback, it was meant to be... very difficult to predict completely how a patient's outcome will be determined sometimes. Very rarely however. Medicine is not an exact science, as is pretended to be in medical school and during residency.
For instance there is no arbitrary 'cutoff' timepoint, for alcohol withdrawal seizures. They can occur after 72 hours. It is not a cut and dry exact science.
Definitely, the P.A.s and N.P.s have more freetime, and less to do fortunately than the docs.
They are very thorough and meticulous.
Discharges are equally important, or even moreso than admission orders. There are so many complexities and variables sometimes with the discharges, especially nursing home discharges. However, its really not that bad at all after a while. It is time consuming, albeit doable totally.
 
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