IM residency vs Hospitalist fellowship after FM res, for hospital jobs in competitive areas?

[Fococoroco22]

Hi SDN-IM. Thanks for your time.
*Posted in IM as well but I truly need advice and insight from my FM colleagues. So if a mod reads this, please don't delete. If you need to delete then please remove the post in IM.

I'm a rising PGY3 FM resident on a hospitalist training track wanting to do hospital medicine after graduation. I will graduate with approx 10 months of adult hospital medicine, 2 of which will be ICU. That's mod-high for FM, pretty low for IM, I believe.

My family live in two of the most competitive areas in the US: S. FL and S. CA. I've been away for a long time and my main goal is to be closer to them after training-- aging parents, brother and his kids, friends, etc. I know the issue of finding a job would be less difficult if they lived in more rural areas

Questions:

1. Is it UNreasonable to think that finding a solid hospitalist job, as an FM-trained freshly-minted grad, in or around LA/Miami is possible?

- If possible, do you have any job search resources or hunting advice?
- Do any of you commute 2 or more hours for your week on week off schedule? Is it rational to have two homes?
- Any thoughts on doing Locums for the first year out vs a perm job straight off?​

2. FM Hospitalist fellowship: I am strongly considering doing an FM hospitalist fellowship. However, I have no idea how much it will improve my marketability in my desired field and locations. Does it let me compete at the same level as a newly trained IM grad or will many places always hire IM only?

- If anyone here is on the hiring committee of your group would you please share how you view a FM hospitalist vs FM with hospitalist fellowship trained applicant? Would the fellowship open up a significant amount of doors in your opinion?​

3. IM Residency after FM: I am also seriously considering applying to IM residencies after graduation rather than do a 1year fellowship especially since it may be possible to get a year of credit for my FM residency. Is that a smart cost:benefit decision?

4. Second Residency funding: How much of an issue is funding going to be? I know I will only get 50% the usual medicaid/care funding but is that a fatal issue or will many places be able to absorb that cost?

- Can I fund the deficit on my own? Is that legal? Can I sell myself to IM programs as: "Dont pay me just train me?"​

PLEASE feel free to correct any faults in my understanding or expectations regarding what it's like out there for a FM hospitalist.

Thank you all for your time. I appreciate it.

====================
BACKGROUND if interested:
- DO
- Step I: 550, Step II: 605, Step III: 620.
- No fails, or red flags
- All excellent or high pass grades in school/clinical years.
- Fulbright Fellow to South Korea
- Fluent in Spanish
- Some other moderately interesting non-medical stuff.

My medicine attending and I are very close. He's IM BC and has helped me essentially build our program's hospitalist track-- I'll be the first. We run the Step Down Unit and admit/care for our own ICU pts (with CC/Pulm backup). I'm going to ask him these same questions. Still, his is just one opinion and I do honestly appreciate your input.

Briefly, why I didn't apply to IM:
# My FM advisors and mentors all were from a generation or two back where FM really could "do everything except sub-specialize". So I figured It'd be the best of all worlds. Maybe true a decade ago, not now.
# loved my adult medicine rotations the most but also enjoyed EM, OB (NOT anymore though!), some peds and definitely medical mission work. Again, thought FM would be the best fit.
# Critical Care would be the only sub-spec that I'd consider doing but tbh I'm not 100% sure about it yet. I learned a TON managing ICU patients but I still liked my hospitalist months better (we run the SDU floor as well as see our own ICU patients).
# After 2 years of residency I am 100% willing to give my other interests up in order to be a strong hospitalist: EM is cool but not for me long term, OB....never again, peds...go to a pediatrician.

Last edited: 6 minutes ago

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[NITRAS]

I wouldn't do IM residency, unless you want to do medical subspecialty. That's two to three years of lost income.

You can call some of the groups in the area you want to work/live in. They will tell you. There are 40 docs in my hospitalist group, only one is FM. I suspect you will be forced to do hospitalist fellowship to go into competitive areas. I did residency in the boonies (community hospital not in a desirable area) and the hospitalist group was like 66% FM, but most did hospitalist fellowship.

Good luck. I'd also remember most larger hospitals will tend to have closed ICU's, if that is where you want to work.

 

[SqEdSaint]

I'm a 1st year FM in a rural/semi rural area. Was interested in hospitalist work coming in but has since changed my mind. But the advice from the hospital recruiter was this: if you want to work as a FM hospitalist in a big/desirable city, you should work as a hospitalist in a level 2 trauma center (which is a lot of the larger hospitals in a geographically isolated/rural area) for a few years. This will strength your resume for applying to big city hospitals. This beats doing hospitalist fellowship somewhere (most likely in the boonies) and you still get to enjoy attending salary. I would recommend this route if you're able to put off gratification for a few years.

 

[Instatewaiter]

I'm a rising PGY3 FM resident on a hospitalist training track wanting to do hospital medicine after graduation. I will graduate with approx 10 months of adult hospital medicine, 2 of which will be ICU. That's mod-high for FM, pretty low for IM, I believe.

That is very low for IM which tends to be mostly hospital based. I did IM at a very hospital heavy program and my intern year alone involved both more IM hospital time and more ICU time (10.5 months of hospital, 2.5 months of ICU) than your entire residency hospital experience.


Questions:

1. Is it UNreasonable to think that finding a solid hospitalist job, as an FM-trained freshly-minted grad, in or around LA/Miami is possible?

- If possible, do you have any job search resources or hunting advice?
- Do any of you commute 2 or more hours for your week on week off schedule? Is it rational to have two homes?
- Any thoughts on doing Locums for the first year out vs a perm job straight off?​

I think the likelihood of finding a hospitalist job in a competitive area as an FM is going to be tough. The 2 hopistals I was at before my current job didn't have any FM in the hospital. To be honest, I didn't even know this was still a thing. Just thought FM essentially only did outpatient work.

With a week on/week off schedule it could work to commute. You will get paid more outside of the major cities. However, in Miami or LA, you aren't going to be making enough money as a hospitalist to pay for 2 houses. In highly desirable cities, you actually make less not more despite cost of living being higher in the big city.
​

2. FM Hospitalist fellowship: I am strongly considering doing an FM hospitalist fellowship. However, I have no idea how much it will improve my marketability in my desired field and locations. Does it let me compete at the same level as a newly trained IM grad or will many places always hire IM only?

- If anyone here is on the hiring committee of your group would you please share how you view a FM hospitalist vs FM with hospitalist fellowship trained applicant? Would the fellowship open up a significant amount of doors in your opinion?​

Even with a hospitalist fellowship, the places that aren't going to hire an FM are not going to hire you. A fellowship will probably open up some doors but not as much as if you had just done IM.

That leads to the last issue about doing a second residency, this time in IM. The husband of one of my co-residents left his FM Program to go to IM. He only got credit for an intern year. Some places may even make you start over. Let's assume you get credit for intern year- I can't answer whether it would be worth it. Why don't you cold call some hospitals in the areas you might move to and see if they would hire an FM. If no, you have your answer- do IM

If yes, ask if they'd require a fellowship and you may be able to save yourself 250-500K

 

[deleted87716]

It's entirely hospital-dependent. There's often some institutional bias. Most of the hospitalists in my group are FM. We aren't biased one way or the other. We're not in FL/CA, either.

 

[nlax30]

Have you tried contacting any hospital groups in either S FL or S CA to inquire about this? Just look up some of the large hospital systems as they usually have their own recruiters and could probably give some initial advice as to whether they would consider someone BC/BE in FM for a Hospitalist gig.

 

[smq123]

Have you tried contacting any hospital groups in either S FL or S CA to inquire about this? Just look up some of the large hospital systems as they usually have their own recruiters and could probably give some initial advice as to whether they would consider someone BC/BE in FM for a Hospitalist gig.

I would agree with this.

As someone who practices in Miami, I have not heard of any FM hospitalists, but it doesn't mean that they're not out there.

Expand your south Florida search outside of Miami. Miami is a tight market, but there are a lot of hospitals out there in Miramar/Pembroke Pines, Hialeah, Ft. Lauderdale, etc. You could even expand your search to Naples, which is usually considered part of South Florida (just on the Gulf Coast).

If you run into dead ends, feel free to PM me, and I can ask some of the FM residents from the local programs for you.

 

[SLC]

It may be possible you can get a hospitalist job in your target area(s); I know my good friend is starting as a hospitalist in the Boston area right out of FM residency, only 6 months on wards here, and 1 ICU. They’re very thrilled to have her.

I’m going hospital work in the Salt Lake City area, but along with clinic and ED.

My other advice would be to target hospitals connected to FM residencies; they will almost certainly be more likely to snatch you up. Plenty of options like that in Miami and SoCal.

You’ll never know till you ask.

 

[AMEHigh]

You should contact a recruiter and the hospitals in the areas you desire to live to find out. I get a million of those recruiter emails and I'd say 1/10 is looking for a FM hospitalist. I live in a major city with a lot of hospitals and medical schools and there are family med docs as hospitalist all around. 2 of our graduates want to do hospital medicine next year when they finish and it seems highly likely that they will. There's no way I'd do an IM residency, but would consider a fellowship if absolutely necessary.

 

[W19]

As for south FL, Miami-Dade, Broward and Palm Beach county will be tough.... Collier (excluding Naples), Monroe (excluding Key West) and Hendry might be possible...

 

[galactus]

It's doable. My entire residency class (8 of us) still does inpatient medicine. 2 are pure hospitalists, and the rest of us to a combo of outpatient/inpatient

 

[jm192]

I'm FM trained in KY and there are options virtually everywhere in KY. You'll obviously have hold ups in bigger cities. Would being IM trained open more doors--sure.

But, let's be real here. You're 29-30 at a minimum by the time you're out. You likely have debt. You may have family. And surely you're worn out with training/higher education.

Why go take 50K per year to be trained more when you can make 250+ and be your own boss?

I'm not sure how easy it is to get into a second residency. But, I think it's just too much

There are a lot of things that will help you open doors.

1. Experience. You probably won't be able to walk into Big City General day 1 as FM. You may not even get that job day 1 as IM. Maybe they think their patients are that sick and they want experienced docs.

2. DO NOT DO FELLOWSHIPS. Here's the problem with a lot of FM fellowships. There is no governance. A hospital or hospitalist group is going to work you like a resident. They're going to pay you slightly better. You'll get call. You'll be up all night. You'll have someone else calling the shots. And they'll give you a piece of paper saying you completed the program. But it's nothing official. It's not like a nephrologist fellowship where there are core competency requirements or a recognized board. I looked heavily into these and had communicated with "program directors" and I'm fairly certain I had 2 positions locked in before even meeting the people. They seemed very happy to get someone. Why didn't I go with it? People on SDN told me not to. Seriously. If you take a job or if you do the fellowship--you'll be doing inpatient medicine. Same patients, a fraction of the pay. Training the same as what you got before--just now dedicated to wards/ICU.

But since the fellowship doesn't have an organized/recognizing body--who cares? Southwest Jones Memorial says you're certified in Hospital Medicine. Cool.

SHM lists these on their website. My hope is that one day it or someone else can act as an accrediting agency. But right now it's a useless piece of paper.

IM grads have options like Vanderbilt and Johns Hopikins. That probably looks good enough on Your CV that it carries weight, but I'm pretty sure they only take IM grads.

3. There is a maintenance of certification exam from ABFM/ABIM. ABFM | Designation of Focused Practice in Hospital Medicine (DFPHM)

I think you have to be practicing 3-5 years before you can take it. I'm not there yet. That said, even if you want to work in BFE, I think this will become a thing in the very near future. Places are going to start wanting it. And I think it gives (at least apperance wise) more legitamcy to FM hospitalists.

4. Be in SHM and when the time comes consider becoming a fellow. I think the fellow thing looks good on a CV--how much it matters I don't know. But going to conferences will allow you to network and meet people from the areas you want to be working.

 

[shiftingmirage]

I'm going to echo what a lot of people have already said.
- This is employer specific. We have 2 in our group of 24 that are FM trained, the rest are IM (Midwest)
- Can't speak about the locations you are interested in, but I do know someone who is a hospitalists in northern Florida and did FM and went there directly after. Opportunities do exist, but I know she received push back from other programs because she was FM.
- I think doing an IM residency with a goal to be a hospitalists after already doing FM is not worth it. There are places that will take FM directly. Hospitalist fellowship makes more sense to me. Something that I don't think has been mentioned is if you do 1-2 years of hospital medicine at another location, your desired locations may be more interested and not require you to do the fellowship, and you are still making attending salary.
- Medicare only pays for like half the residency programs in the country. At my program, half the slots were paid for via other means, so I don't think that will be a problem, but like I say, I would not recommend repeating a residency for hospitalist.
- You mentioned locums. I don't know about your financial situation and you briefly mentioned your family situation, but LA is crazy expensive, and I bet Miami isn't cheap either. If there are places in your desired area that would accept you with some hospitalists experience, I would recommend going somewhere else for 2-3 years, continue to live like a resident, pocket the money to pay down student loans or save up for the move to LA/Miama, all while adding to your CV. You said you'd be willing to repeat a residency, so I don't think this is that big of a leap.

 

[Fococoroco22]

OP here.
Thank you all for the insight. It’s trully appreciated.

The ratio I’m getting from recruiters is that 1/10 or 1/8 hospitals will consider a FM trained Hospitalist. The others won’t due to medicolegal by-laws and such. And that ratio will likely continue to worsen over time.

The DFPHM recognition JM mentioned seems like an incredible thing on paper. I was looking at it earlier. Tell me if I’m misreading but it’s goal is to provide hiring and insuring bodies an objective way to say that an FM trained hospitalist is equivalent to an IM trained doc when it comes specifically to hospital medicine. Right? ABIM and ABFM built it together for this purpose it seems. Unfortunately none of the recruiters I’ve spoken to have any idea what it is or if having it would allow me to compete at IM only hospitals.

>> I definitely intend on applying for it after the requisite experience and exams. Anyone here have it, plan to have it or know someone with it who benefited job wise from it? Simply, do you think having it will help get better jobs?

>> To recap your advice for clarity, correct if wrong:
- Don’t do a fellowship; get out and work wherever you can even if it’s not close to family;
- Doing IM res, even if they give me a year of credit for FM isn’t worth it, even though it will undoubtedly help land me jobs in my home cities that would otherwise be inaccessible.
- Join SHM
- Get the DFPHM recognition when able
- Knock the “chip” off my shoulder.

================

Lastly, a bit of a soft topic: A part of this frustration is coming from the sense that the medical community at large is saying that as a family medicine trained doc I am sub par and inadequate as a hospitalist. After all this time and training and dedication, to have that notion thrown at me is a pretty big jolt to the system. Without succumbing to hubris, I am certainly not sub par and I am, by all objective and subjective measures, on track to becoming a highly effective, caring and successful doctor.

On the other hand, there’s no question that IM residents get significantly more hospital training. Does that mean that the only truly valid way to be a safe and successful hospitalist is to be IM trained? If so then why would the two boards create that DFPHM recognition? And if that recognition deems someone sufficiently trained for hospitalist medicine, why the continued discrimination afterwards? Perhaps I’m jumping ahead of myself and catastrophizing a bit but the concept of being seen as “inferior” for the rest of my career, or “separate and unequal” despite adequate training is very troubling.

Thank you all again!

 

[cabinbuilder]

One thing I might add: I did hospitalist as an FP doing locums for 5 years. However, I did not learn vents in residency and made that a stipulation for whatever job I did. I have done ICU otherwise. Anyhow. The reason I was able to get a hosptialist job and/or and ER job is I keep very good patient logs - still do. Every patient I see even today I write down in a notebook. Any job you apply for likely will asks for patient logs - if you can prove your numbers I have found it's generally not an issue. Now there will always be places that are closed. Just like I have had applications turned down for being a DO. It's the way of the land these days. Do your homework and maximize your chances and options before you decided on a residency. If you are set on ICU/Critical care, I would do IM.

 

[jm192]

I wouldn't worry about feeling subpar. I don't think half of my group readily identifies that I'm FM.

If you show up and do your part and do it well, no one cares.

As far as opening doors--it is what it is.

I'm not convinced that a fellowship opens anymore doors than the same amount of experience. And until it's some unified recognized thing that you apply through a similar process to other fellowships--I think you risk wasting your time, giving up income for no benefit.

I think the Maintenance of certification will be a big deal. Whether or not it opens every door--I'm sure that it won't. But I do think it will open more. It may be several years down the road, but I think the fact that there's a test--it'll start off as optional and maybe become something that helps and may even one day become mandatory. But I do think if we have a similar/same certification exam to ABIM--it'll be an easier process.

In terms of working away from family--you may have to make a choice. Apply broadly in your area. A lot of smaller/sattelite hospitals will have openings--but be warned that you may have less resources. Are you comfortable starting out with that? I work at 400 bed hospital and have most specialists. It's a nice starting enviornment. I'm ~1 year in.

If you have to go away from family/friends to get a job--is that something you're ok with? You'll likely find urgent care or clinic work anywhere. And you'll make ok $$. But if you're out of the hospital for so long, it becomes harder to get back in.

I took a job 2.5 hours from where I want to be--which obviously isn't a ton. But I've stayed in communication with the hospitals in the area. They probably expect my e-mails at this point. On recruiter said the group didn't want FM. She recently contacted me saying they had openings now and wanted my CV. And as life goes, I've met a girl in the area I work and I'm figuring out geography again.

But, if your goal is to be a hospitalist--I'd say consider going where you can for now--stay in touch with local hospitals and see what happens. If at some point you feel you need to be back home--you can come back home and maybe do something else. But the experience will help open doors.

 

[Fococoroco22]

I wouldn't worry about feeling subpar. I don't think half of my group readily identifies that I'm FM.

If you show up and do your part and do it well, no one cares.

As far as opening doors--it is what it is.

I'm not convinced that a fellowship opens anymore doors than the same amount of experience. And until it's some unified recognized thing that you apply through a similar process to other fellowships--I think you risk wasting your time, giving up income for no benefit.

I think the Maintenance of certification will be a big deal. Whether or not it opens every door--I'm sure that it won't. But I do think it will open more. It may be several years down the road, but I think the fact that there's a test--it'll start off as optional and maybe become something that helps and may even one day become mandatory. But I do think if we have a similar/same certification exam to ABIM--it'll be an easier process.

In terms of working away from family--you may have to make a choice. Apply broadly in your area. A lot of smaller/sattelite hospitals will have openings--but be warned that you may have less resources. Are you comfortable starting out with that? I work at 400 bed hospital and have most specialists. It's a nice starting enviornment. I'm ~1 year in.

If you have to go away from family/friends to get a job--is that something you're ok with? You'll likely find urgent care or clinic work anywhere. And you'll make ok $$. But if you're out of the hospital for so long, it becomes harder to get back in.

I took a job 2.5 hours from where I want to be--which obviously isn't a ton. But I've stayed in communication with the hospitals in the area. They probably expect my e-mails at this point. On recruiter said the group didn't want FM. She recently contacted me saying they had openings now and wanted my CV. And as life goes, I've met a girl in the area I work and I'm figuring out geography again.

But, if your goal is to be a hospitalist--I'd say consider going where you can for now--stay in touch with local hospitals and see what happens. If at some point you feel you need to be back home--you can come back home and maybe do something else. But the experience will help open doors.

This is sage advice. Thank you Jm192. Any pointers on what to look for in a hospitalist job— now that I’m good with a much wider search area? Eg: 20-25 pt a day? Admission cap at 6? Starting salaries? Any things you would have wished someone could have told you before jumping in?

Also, what about doing Locums for a year or so to get an idea of the kinds of practice environments suit me best? Of course some of the recruiters have suggested that starting out.

 

[TableMD]

I think that this invasion of the scope of our practice hurts our specialty. We ARE board certified, in family medicine. That should mean inpatient, outpatient, and if trained, OB.

The FM leadership should understand that if we get pushed out of this work it hurts us all. I personally do primary care and sports, but I told a recruiter that I would not consider their system because they disnt want FM docs doing OB. Its insulting. We worked hard for this.

For the OP, please fight and succeed for your right to practice as you need to, and good luck. F the haters. Sub-specialization creep is a marketing and administration thing that will erode all of our rights to work within our scope. Look at the pediatricians, where they will apparently have to do a two year “hospitalist” fellowship if they want to work in a larger childrens hospital, as if 3 years of wards, PICU, etc isnt enough. Its a good thing stethoscopes werent invented recently, otherwise Id have to do a pulmonary auscultation fellowship, CME, and takea $7000 exam to use that piece of equipment.

 

[Gastrapathy]

Kaiser SoCal has FM hospitalists.

 

[CountryMed]

I know for a fact a large hospital system in SW Florida (1.5 hours from Miami) that has hired newly trained FM docs as hospitalist.

 

[Fococoroco22]

I know for a fact a large hospital system in SW Florida (1.5 hours from Miami) that has hired newly trained FM docs as hospitalist.

Hi.
Would you mind giving me the sites name? PM me if you’d prefer. And these are FM docs without fellowship training?
Thanks a lot!