Hospitalists: could you do clinic?

[glorifiedresident]

---

Members don't see this ad.

I’ve been a hospitalist for 20 years. Just wondering if any of you guys could ever do clinic? I would probably retire or quit and do something else if I had to do outpatient clinic. I just don’t think I could do it, seems so painful without any flexibility and seems like you would be constantly stressed from getting behind and trying to get patients out the door. Whereas a hospitalist has all the control of how long you spend or don’t spend with a patient.

 

[HemeOncHopeful19]

Not gonna lie after 20 years I also don't think you could do clinic 😛.

TBH I have ADHD and I get home on time a lot better in clinic than on my hospital call weeks. The patients being set up on a schedule and constantly needing to get them out the door keeps me on time whereas at the hospital I can always wander around bullsh**ing in the lounge eating Graham Crackers or whatever until I finally sit down to do my notes.

 

[DrMetal]

No way. The problem with outpatient medicine in this country, is that it has now become nothing-burger medicine. From the plethora of psychosomatic complaints (where we diagnose nothing really--BS fibromyalgia, chronic fatigue syndrome, long covid---and we treat with placebos: acupuncture, massage therapy) to the sting of malingering/secondary gain crap . . . I couldn't stand it.

Sadly, those you really need to see in clinic (DMs, asthmatics, HF, COPD) rarely show up. You're sure to find them in the hospital.

 

[dozitgetchahi]

Not gonna lie after 20 years I also don't think you could do clinic 😛.

TBH I have ADHD and I get home on time a lot better in clinic than on my hospital call weeks. The patients being set up on a schedule and constantly needing to get them out the door keeps me on time whereas at the hospital I can always wander around bullsh**ing in the lounge eating Graham Crackers or whatever until I finally sit down to do my notes.

Yeah.

As a 100% outpatient rheumatologist, the question for me is “could/would you ever do inpatient”. And the answer is “hell no”.

I actually love the fact that the clinic is structured and that there are defined visit times. People can’t just show up whenever they want (unless you have a walk in clinic or something, which I would never agree to). I hated the chaos of the hospital - here you go, now you suddenly have a new admit/consult…on top of the 12 you already have. One or two super sick patients can totally monopolize your time, and keep you from getting to other patients who also need your attention.

I also love knowing that John Doe is coming at 9:40am, and that the visit will be 20 minutes. I know that if John Doe happens to have an obnoxious personality (or is excessively needy, etc etc) I have to sit through only 20 minutes of it, and I’m done. I can deal with anything for 20 minutes. Meanwhile, in the hospital, an excessively needy or complex patient can suck up your whole day.

Even in rheumatology, you can screen out the nonsense. You also can have the feeling that you’re really helping folks. In the hospital, I often felt like I was shuffling deck chairs on the Titanic. Here’s patient X, EF of 15%, back for his 4th CHF exacerbation of the year. Here’s a 95 year old with urosepsis, completely delirious and demented, who is for some reason still full code. Etc etc. Personally, I’d rather deal with outpatient “nothing burger” cases than that sort of stuff any day.

 

[PugsAndHugs]

Yeah.

As a 100% outpatient rheumatologist, the question for me is “could/would you ever do inpatient”. And the answer is “hell no”.

I actually love the fact that the clinic is structured and that there are defined visit times. People can’t just show up whenever they want (unless you have a walk in clinic or something, which I would never agree to). I hated the chaos of the hospital - here you go, now you suddenly have a new admit/consult…on top of the 12 you already have. One or two super sick patients can totally monopolize your time, and keep you from getting to other patients who also need your attention.

I also love knowing that John Doe is coming at 9:40am, and that the visit will be 20 minutes. I know that if John Doe happens to have an obnoxious personality (or is excessively needy, etc etc) I have to sit through only 20 minutes of it, and I’m done. I can deal with anything for 20 minutes. Meanwhile, in the hospital, an excessively needy or complex patient can suck up your whole day.

Even in rheumatology, you can screen out the nonsense. You also can have the feeling that you’re really helping folks. In the hospital, I often felt like I was shuffling deck chairs on the Titanic. Here’s patient X, EF of 15%, back for his 4th CHF exacerbation of the year. Here’s a 95 year old with urosepsis, completely delirious and demented, who is for some reason still full code. Etc etc. Personally, I’d rather deal with outpatient “nothing burger” cases than that sort of stuff any day.

Completely agree with you as a sub-specialist, but as a PCP I would agree with OP, I would not be able to do outpatient.

 

[NotAProgDirector]

I was an outpatient doc for 15 years (with inpatient time also), and now a hospitalist. So I have lived both.

As a resident, it's very difficult to really understand how an outpatient practice really feels. You imagine all acute care visits, chronic pain, etc. What actually happens is you build a practice of patients that you know. So once your practice is stable, your schedule each day is a bunch of people you already know well. You can quickly review the chart to see what's changed since the last time you've seen them, and get to work. There's a real pleasure to continuity care that is lost in HM. In general, most visits fit into an appointment time slot easily. Notes are pretty short. Most of what you do is reassure people that they are OK, help manage minor complaints. It's very hard to start - takes 2-3 years until you really know your panel and you get into a groove.

One of the big challenges of switching from HM to OP (or the other way) is that the medicine is different.

 

[glorifiedresident]

I was an outpatient doc for 15 years (with inpatient time also), and now a hospitalist. So I have lived both.

As a resident, it's very difficult to really understand how an outpatient practice really feels. You imagine all acute care visits, chronic pain, etc. What actually happens is you build a practice of patients that you know. So once your practice is stable, your schedule each day is a bunch of people you already know well. You can quickly review the chart to see what's changed since the last time you've seen them, and get to work. There's a real pleasure to continuity care that is lost in HM. In general, most visits fit into an appointment time slot easily. Notes are pretty short. Most of what you do is reassure people that they are OK, help manage minor complaints. It's very hard to start - takes 2-3 years until you really know your panel and you get into a groove.

One of the big challenges of switching from HM to OP (or the other way) is that the medicine is different.

Thank you for this post.

 

[Señor S]

Yeah I think I could and in some ways I'd probably prefer it: regular schedule (not a lot of OP guys working New Year's like I am tomorrow), patients/staff not as tightly wound because the acuity is lower, being able to screen stuff out (something you categorically cannot do as a hospitalist). I agree that residents often get a bad view of outpatient medicine because resident clinics tend to be dumping grounds for difficult (in every sense) patients. Biggest downside for me would probably be boredom.

 

[gutonc]

Yeah I think I could and in some ways I'd probably prefer it: regular schedule (not a lot of OP guys working New Year's like I am tomorrow), patients/staff not as tightly wound because the acuity is lower, being able to screen stuff out (something you categorically cannot do as a hospitalist). I agree that residents often get a bad view of outpatient medicine because resident clinics tend to be dumping grounds for difficult (in every sense) patients. Biggest downside for me would probably be boredom.

Boredom is the best part. I don't want constant excitement on a day to day basis. I want to come to work, deal with routine stuff, occasionally (once a day max) deal with a surprise or acute issue and go home at a planned time every day with all my notes done. The calm and predictability is the draw.

 

[dozitgetchahi]

Boredom is the best part. I don't want constant excitement on a day to day basis. I want to come to work, deal with routine stuff, occasionally (once a day max) deal with a surprise or acute issue and go home at a planned time every day with all my notes done. The calm and predictability is the draw.

Exactly. This is a big part of the appeal in clinic.

That doesn’t mean that I don’t enjoy taking on some complex/unusual cases to get my brain working…but I’m also happy to see a whole lot of bread and butter. I know those patients are going to be a (relatively) easy win, with a straightforward note where I don’t have to parse 3 inches of patient records and dictate the highlights of it…

Residency and fellowship showed me just how brutal medicine could be to your health, family life and sanity. If you don’t try to control it and set some boundaries, medicine will run wild through your life like an unchained beast. A well organized clinic (with firmly established boundaries) is the best way I have found to cage the beast that is modern medicine.

 

[bronx43]

No way. The problem with outpatient medicine in this country, is that it has now become nothing-burger medicine. From the plethora of psychosomatic complaints (where we diagnose nothing really--BS fibromyalgia, chronic fatigue syndrome, long covid---and we treat with placebos: acupuncture, massage therapy) to the sting of malingering/secondary gain crap . . . I couldn't stand it.

Sadly, those you really need to see in clinic (DMs, asthmatics, HF, COPD) rarely show up. You're sure to find them in the hospital.

The thing that makes GIM one of the hardest jobs in medicine is that it's not ALL psychosomatic complaints. It's 99 psychosomatic complaints with 1 real pathology that LOOKS like psychosomatic BS.

Your job is basically sifting through the haystack to try to find the one needle, which is both mind numbing and potentially dangerous (since it can prick your finger if you don't see it). And it literally takes the entirety of our medical training and countless patient encounters to develop the ability to reliably find this needle.

 

[CCM-MD]

My wife was so burnt out of outpatient endocrine because of all the trash she had to see and the continuous grind without a break. For a period of time I thought outpatient subspecialty practice was the sweet spot in medicine but I don’t think so anymore. She only does inpatient consult work and is much happier.

 

[MifflinDunder]

My wife was so burnt out of outpatient endocrine because of all the trash she had to see and the continuous grind without a break. For a period of time I thought outpatient subspecialty practice was the sweet spot in medicine but I don’t think so anymore. She only does inpatient consult work and is much happier.

My inbox is on FIRE everyday in heme onc. Curious to know how bad is it for her in endocrinology.

 

[gutonc]

My inbox is on FIRE everyday in heme onc. Curious to know how bad is it for her in endocrinology.

I'm curious when people say that, what are you actually talking about? I mean, Sure, my inbasket has 30 or 40 things in it every time I look at it. But most of them take <2 seconds and a mouse click to be done with.

 

[HemeOncHopeful19]

I'm curious when people say that, what are you actually talking about? I mean, Sure, my inbasket has 30 or 40 things in it every time I look at it. But most of them take <2 seconds and a mouse click to be done with.

If someone could just come up with a feature (they can call it AI or whatever buzzword they want) where if I review the labs in the lab tab or look at the scan in the imaging tab of the EMR that it automatically gets signed and not sent to my inbox, I’d kiss their feet.

 

[gutonc]

If someone could just come up with a feature (they can call it AI or whatever buzzword they want) where if I review the labs in the lab tab or look at the scan in the imaging tab of the EMR that it automatically gets signed and not sent to my inbox, I’d kiss their feet.

Epic has a new feature that halfway does this. When you're closing an encounter, if the patient has results in your inbasket (viewed or not), it tells you that when you're trying to close the chart. There's a "select all" button that you can check (admittedly one more stupid f)(*^()*&ing click) but then it marks them all done in the InBasket and they're gone. Not exactly what you're asking for, but getting a lot closer.

I can see why the EMR people want to put that liability on us, not themselves. If you have to take a formal action to acknowledge a result, they can disclaim responsibility for any consequences.

 

[HemeOncHopeful19]

I can see why the EMR people want to put that liability on us, not themselves. If you have to take a formal action to acknowledge a result, they can disclaim responsibility for any consequences.

I know that is the argument made but in reality… has an EMR company *ever* been named and lost a malpractice suit?

It would appear from google that the answer is : of course not.

 

[gutonc]

I know that is the argument made but in reality… has an EMR company *ever* been named and lost a malpractice suit?

It would appear from google that the answer is : of course not.

Of course not. But the world is run by lawyers. So here we are.

 

[dozitgetchahi]

I'm curious when people say that, what are you actually talking about? I mean, Sure, my inbasket has 30 or 40 things in it every time I look at it. But most of them take <2 seconds and a mouse click to be done with.

I agree. I mean, as a rheumatologist I certainly have a lot of stuff turn up in my inbox (as a specialty we probably order more labs than anyone else - or at least, we’re near the top), but usually most of it is fairly easy to dispatch.

 

[hotsaws]

If I had to do general IM, I think I'd choose hospitalist work over PCP clinic stuff. Only way I could see outpt clinic is if I had a practice in just the right area (think 65+ in an upscale seniors community area). I practice very close to one now and I'll tell you these are the healthiest seniors you ever seen. They have medicare plus supplement or dual insured. They have taken good care of themselves. They are early to every apt and very compliant. They generally have enough money to manage whatever prescriptions get sent their way. Lots of them have stable chronic issues that seem very easy to manage if they are coming in regularly and following the treatment plans and screening recommendations. They are also a pleasant crowd, generally.

As an allergist, I have a very low maintenance inbox. Biologic approvals and auths are probably the biggest headache for the practice. I still get some moochers trying to get me to tell their HR they should work from home for their mild stable asthma or something but we've started just charging a flat fee for these types of paperwork and I've started telling patients that I will not engage in a "back and forth" with their HR. I will fill out the forms once, how I see fit, and that is final.

 

[dgdg]

No way. The problem with outpatient medicine in this country, is that it has now become nothing-burger medicine. From the plethora of psychosomatic complaints (where we diagnose nothing really--BS fibromyalgia, chronic fatigue syndrome, long covid---and we treat with placebos: acupuncture, massage therapy) to the sting of malingering/secondary gain crap . . . I couldn't stand it.

Sadly, those you really need to see in clinic (DMs, asthmatics, HF, COPD) rarely show up. You're sure to find them in the hospital.

Well, I think everyone's experience and perspective will vary based on, in part, patient population.
I was a hospitalist for a couple years, then moonlit for a couple more. I loved full time hospital work, running codes, complex admissions, etc, but this was when hospital profession was ramping up about 20 years ago. My work schedule in a busy hospital, even at a young age, wore me out. I couldn't move like others did, so I went outpatient. It really depends on your personality and patient population.
Currently I see a lot of (older) kind people, many (not all) are well educated and live a comfortable financial life (not nec rich). Some I have been seeing for 15+ years now. Most complaints/needs are truly organic in nature. Many visits are simply prevention and education, modest management of chronic conditions. Even if what I do sometimes during a patient visit is routine, often they express (or I'm aware) how important it is to them. That has value. There are also still enough (unfortunately) complex diagnoses and management problems that keep me academically stimulated and sharp. You have to be perceptive for the uncommon things your way in order to catch them. So for me, it is fulfilling either practice population.

It's more of an issue, for me, with insurance companies, increasing anti-science, the slow death of physician based primary care as more graduates seek specialties paying much more, and overall witnessing the downward spiral of our health care system as quantified by population quality metrics (compared to other advanced economies) and less than ideal productive and efficient oversight by government entities. While I was in premed, ~85% of primary care practices were independently physician owned, now the same percent corporate owned with ever increasing private equity.
YMMV

 

[AlbinoHawk DO]

I did some clinic locum right after fellowship for primary care in the meantime while getting credentialed for my "real" job. I actually found it to be very pleasant. The system is highly structured. If people come for acute complaints, these are often very straightforward and I don't have to really dig into their other problems. If it's a follow-up, most of it is adjusting things. People wanting opiates and stuff like that are automatic pain medicine referral. I think you're overthinking clinic work. We IM trained folks don't really do procedures, see women's health, or see kids. Our job is not as bad as you may think

 

[Bropranolol]

I did some clinic locum right after fellowship for primary care in the meantime while getting credentialed for my "real" job. I actually found it to be very pleasant. The system is highly structured. If people come for acute complaints, these are often very straightforward and I don't have to really dig into their other problems. If it's a follow-up, most of it is adjusting things. People wanting opiates and stuff like that are automatic pain medicine referral. I think you're overthinking clinic work. We IM trained folks don't really do procedures, see women's health, or see kids. Our job is not as bad as you may think

I second this.

As someone who does inpatient service with our residents, I much prefer clinic. Not sure if it’s bc our hospital has no support staff but one rapid response or GOC discussion deflates me ruins my day.

Also in clinic, we have the Medicare AWV and g code modifiers that make it more financially rewarding..
Running at 99214 mill is fun.

 

[dgdg]

To which G codes do you refer?

If appropriate, we add an E&M visit with a 25 modifier to the AWV. At that point the G2211 code can't be used.

 

[WIFEL585]

I could (and did) but would hate it. Continuity of care can be very rewarding for certain populations but also a massive headache with even a fraction of a panel being filled with Psychiatry and chronic pain drug addicts. Not even including insurance stuff.

With that said, stress level is certainly lower given that you can just turf any acutely ill patient to the ER / hospital.

 

[VA Hopeful Dr]

To which G codes do you refer?

If appropriate, we add an E&M visit with a 25 modifier to the AWV. At that point the G2211 code can't be used.

Incorrect, as of this year you can use the G2211 code in that situation.