IM vs FM inpatient and outpatient stress/lifestyle

[camng22]

How stressful is it to work as a hospitalist compared to outpatient clinics? Obviously, every job is different but in general which route would provide a better lifestyle? I am trying to decide between the two specialties. IM is a bit more competitive and I wanted to choose where I end up in residency so am leaning towards more so FM. It seems like hospitalists have a better time taking time off work for vacation because it's all shift work and they're technically not providing long term care for a pt compared to outpatient. However, it seems like a lot of hospitalists I see seem pretty unhappy whereas outpatient docs seem like theyre less stressed. Would love to hear your thoughts to help me decide on my specialty

My attendings have told me that depending on your job, you can just round see patients, and just be in and out of the hospital within a few hours. They go home and write up notes and are technically "on call" until something happens. Is this a common thing and is it actually appealing as it sounds?

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[CaliforniaAppli]

In my opinion, outpatient work is 10x less stressful but also very mundane. I would rather take the stress of being a hospitalist then have to deal with all the viral URIs , insurance paperwork , EHR messaging of outpatient work though.

As nice as the schedule is for hospitalist work, the work itself is demanding.

 

[mdjo]

I guess I'll be the first one to point out that you can be a hospitalist or a PCP from either an FM or IM background, so that shouldn't be your biggest deciding factor.

I think the only good reasons to pursue FM are if you know for sure you want to live in a more rural area, or if your application stats truly won't allow for IM. Otherwise FM just closes you off from fellowship consideration. I just worked with an FM resident who realized halfway through her residency that she loved rheumatology, but unfortunately she will never be able to pursue this fellowship. It was pretty sad for her!

IM keeps your options open much better than FM does. I've never found the "but I want to do OB and peds too!" argument compelling; if you're working in even a small city, people will have no trouble finding an actual OB or pediatrician so those skills don't add much benefit other than letting indecisive med students put off making career decisions.

 

[Cheeni17]

Not doing ob and peds sounds great! Hence why I did IM not FM

 

[camng22]

Do you guys think hospitalists work is more flexible than outpatient work? I.e. more time for vacation, etc

 

[KeikoTanaka]

Further follow up question: I have read a lot about DPC lately. This seems to make OP less mundane and you get better results and time with patients. Is FM or IM a better field for DPC?

 

[gutonc]

Further follow up question: I have read a lot about DPC lately. This seems to make OP less mundane and you get better results and time with patients. Is FM or IM a better field for DPC?

It probably doesn't matter that much. You can make an argument for both:
- Most of the people willing to pay for DPC will be adults, therefore peds training is probably not that critical. (Point to IM)
- Most of the people willing to pay for DPC will also be willing to pay for specialists for other things, like OB if necessary. (Point to IM)
- Most of the people willing to pay for DPC will want "most" things to be dealt with by their PCP. Like joint injections, skin biopsies, other minor procedures. Stuff that FM does a lot and IM does almost none of. (Point to FM)
- DPC is a niche market most places, so having a broader/deeper skillset/knowledge base may be more useful. (Point to FM)

There is a DPC group in town that has 10 docs in it covering 2 offices. 5 IM, 4FM and 1 psychiatrist. Draw your own conclusions from that.

 

[mszzeta]

How stressful is it to work as a hospitalist compared to outpatient clinics? Obviously, every job is different but in general which route would provide a better lifestyle? I am trying to decide between the two specialties. IM is a bit more competitive and I wanted to choose where I end up in residency so am leaning towards more so FM. It seems like hospitalists have a better time taking time off work for vacation because it's all shift work and they're technically not providing long term care for a pt compared to outpatient. However, it seems like a lot of hospitalists I see seem pretty unhappy whereas outpatient docs seem like theyre less stressed. Would love to hear your thoughts to help me decide on my specialty

My attendings have told me that depending on your job, you can just round see patients, and just be in and out of the hospital within a few hours. They go home and write up notes and are technically "on call" until something happens. Is this a common thing and is it actually appealing as it sounds?

It totally depends on what kind of person you are and there is no absolute right or wrong answers. Both hospitalist and PCP have their pros and cons

pros of hospitalist

7 on and 7 off schedule, which means you can have two mini vacations each month!
Start salary is somewhat higher than PCP. This depends on the geography. And working night shift earns much more
I personally feel working in a big academic center with residents and medical student is very fun with lots of interesting pathology and teaching opportunity


Cons of hospitals
Some people consider this job less rewarding, given that you can do very little about lots of your patients' poor situation (People who takes drugs and will be re-admitted irrespective how you manage them. People who have little insight or responsibility over their health or simply with personality disorder which is challenging to interact. These are the people who are most likely being admitted to the hospital).
Similarly, no continuity of care, which some people say may increase burn out rate in long run

Pros of PCP
Longstanding relationship with patients and can potentially get high job satisfaction depending on what kind of person you are
If run business very successful, may earn more money than hospitalist in the long run

Cons of PCP
5 day on and 2 day off, at most. Some PCP even spend time return patients' email after work
Starting salary often lower than hospitalist

 

[VA Hopeful Dr]

It totally depends on what kind of person you are and there is no absolute right or wrong answers. Both hospitalist and PCP have their pros and cons

pros of hospitalist

7 on and 7 off schedule, which means you can have two mini vacations each month!
Start salary is somewhat higher than PCP. This depends on the geography. And working night shift earns much more
I personally feel working in a big academic center with residents and medical student is very fun with lots of interesting pathology and teaching opportunity


Cons of hospitals
Some people consider this job less rewarding, given that you can do very little about lots of your patients' poor situation (People who takes drugs and will be re-admitted irrespective how you manage them. People who have little insight or responsibility over their health or simply with personality disorder which is challenging to interact. These are the people who are most likely being admitted to the hospital).
Similarly, no continuity of care, which some people say may increase burn out rate in long run

Pros of PCP
Longstanding relationship with patients and can potentially get high job satisfaction depending on what kind of person you are
If run business very successful, may earn more money than hospitalist in the long run

Cons of PCP
5 day on and 2 day off, at most. Some PCP even spend time return patients' email after work
Starting salary often lower than hospitalist

I know very few PCPs who don't take at least a half day per week off in addition. Lots take a full day.

My wife was a hospitalist and one of her main complaints was being treated like a resident by most of the other services: basically an admitting monkey for Ortho, GI, surgery, and cardiology.

 

[DrMetal]

basically an admitting monkey .....

It's interesting: it's a common sentiment in medicine, where we become complacent in our respective specialties (or sub-specialties), and we take on the "monkey-inferiority" complex. I had a GI tell me once he was sick of scoping, being a 'scope monkey' (albeit, this was at a low acuity hospital, where he wasn't getting paid well). I cant help but remember thinking, "Well, scoping is what you do...so yes, monkey away." Cardiologists complain about reading echos all day, hospitalists about admitting patients, etc etc.

Same is true for hospitalists. It's your job to admit and take care of sick people in the hospital. The surgical services love you b/c they can't do the same. Bottom line is do what you like, find it an pursue it.

 

[VA Hopeful Dr]

It's interesting: it's a common sentiment in medicine, where we become complacent in our respective specialties (or sub-specialties), and we take on the "monkey-inferiority" complex. I had a GI tell me once he was sick of scoping, being a 'scope monkey' (albeit, this was at a low acuity hospital, where he wasn't getting paid well). I cant help but remember thinking, "Well, scoping is what you do...so yes, monkey away." Cardiologists complain about reading echos all day, hospitalists about admitting patients, etc etc.

Same is true for hospitalists. It's your job to admit and take care of sick people in the hospital. The surgical services love you b/c they can't do the same. Bottom line is do what you like, find it an pursue it.

And she didn't mind it for patients who were actually sick.

The 60 year old with no medical history who is admitted to fix her broken hip doesn't really need a hospitalist.

General surgery didn't require them to admit their uncomplicated appendectomy patients so there was a lot of frustration when Ortho did require it for similar uncomplicated patients.

 

[DoubleBogey]

In my neck of the woods you can “round and go” most of us have outpt clinic and then have an APC do admits in the afternoon then the hospitalist service takes night admissions and hands off in the morning.

IM trained here, I do outpt, nursing homes/SNFs and home visits, some inpt when time allows. I love what I do and don’t have an ego/complex about what others make and do - I do well from a compensation aspect.

Typical shifts as a hospitalist, in my opinion, would hurt my family/life-balance; miss half the games/practices/bday parties with the burden placed on my wife. Hospitalist pays more per hour in general and usually you can generate more from production standpoint (with proper outpt billing you can match inpt). When you’re off you are off, not having to worry about chronic management and insurance stuff.


I work 4.5d per week in clinic, some docs I know have their practice 3.5d (off Wednesday and half day Friday)
Much better life balance, can work more after work (nursing home admissions, monthly f/ups etc)
The insurance denials, FMLA paperwork, Medicaid psychiatric medical disasters with personality disorders make outpt difficult at times.

I look at work as if it is the Kreb cycle- how do you keep the cycle moving and generate ATP (RVUs) for yourself.
My ideal job, round and go inpt work intermittently (when needed) with 4d clinic and good size nursing home/SNF base. The inpt keeps your skills and acuity in check/supplements production, NH/SNFs supplement production and feed to hospital and clinic work, the clinic is your base salary and feeds the hospital.
I’m currently in my ideal job, some days are better then others, can be stressful, by haven’t missed a baseball game yet due to working

Do what you enjoy and it won’t be work

 

[wjs010]

In my neck of the woods you can “round and go” most of us have outpt clinic and then have an APC do admits in the afternoon then the hospitalist service takes night admissions and hands off in the morning.

IM trained here, I do outpt, nursing homes/SNFs and home visits, some inpt when time allows. I love what I do and don’t have an ego/complex about what others make and do - I do well from a compensation aspect.

Typical shifts as a hospitalist, in my opinion, would hurt my family/life-balance; miss half the games/practices/bday parties with the burden placed on my wife. Hospitalist pays more per hour in general and usually you can generate more from production standpoint (with proper outpt billing you can match inpt). When you’re off you are off, not having to worry about chronic management and insurance stuff.


I work 4.5d per week in clinic, some docs I know have their practice 3.5d (off Wednesday and half day Friday)
Much better life balance, can work more after work (nursing home admissions, monthly f/ups etc)
The insurance denials, FMLA paperwork, Medicaid psychiatric medical disasters with personality disorders make outpt difficult at times.

I look at work as if it is the Kreb cycle- how do you keep the cycle moving and generate ATP (RVUs) for yourself.
My ideal job, round and go inpt work intermittently (when needed) with 4d clinic and good size nursing home/SNF base. The inpt keeps your skills and acuity in check/supplements production, NH/SNFs supplement production and feed to hospital and clinic work, the clinic is your base salary and feeds the hospital.
I’m currently in my ideal job, some days are better then others, can be stressful, by haven’t missed a baseball game yet due to working

Do what you enjoy and it won’t be work

But how do you finish notes in time to go to those games? In my mind, outpatient always seems 9-5 but really it’s get there at 8 to pre chart and leave after your 30 notes are done. Is this not the case?

 

[DoubleBogey]

But how do you finish notes in time to go to those games? In my mind, outpatient always seems 9-5 but really it’s get there at 8 to pre chart and leave after your 30 notes are done. Is this not the case?

For outpt I get about 1/2-3/4 of my notes done that day, then finish them the following day or two. I’m lax with my notes though, but usually get them done before 4d (deficiency notification sent),my contract says they need to be done before 30d, which I’ve never had happen. If I’m ordering a STAT study then I get the note completed with the pt in the room so my staff can send the note.

Outpt notes would never limit me from missing something (would be comical really).
The issue is if I directly admit someone and need to have orders in - I usually give verbal orders, then later login and place them in the chart.

I don’t prechart- some of my colleagues do, if I were seeing 25+ I probably would do so, but I still get no shows and if I open the chart/start the encounter it’s a pain to delete

 

[DolphInternist]

While it's true that both FM and IM have options, that doesn't necessarily make them good fields to go into. Why do you think we have "options"? Precisely because there's a huge demand to get out of general practice. If every internist were practicing traditional, there would in fact be no hospitalists. If doctors were satisfied, there would be no locum tenens, etc. You would not have the progressive and unrelenting career churn. It is what it is.

Most specialties practice for a lifetime without much in the way of complaint. Again, broadly speaking, there are always exceptions.

Pure FM and general IM are the worst fields in medicine....by far, with no contest. With only one exception: emergency medicine. Because in EM, even though they have flex scheduling and reasonable pay, it can really crush a soul beyond repair. Typically happens in late 40s/early 50s.

I bet they don't tell you that in medical school or residency.

 

[NITRAS]

Do you guys think hospitalists work is more flexible than outpatient work? I.e. more time for vacation, etc

I routinely have 2 weeks off, which I can moonlight or go somewhere. I think it will be harder when my kids are in school. I work half the holidays. In our group you are working Christmas or Thanksgiving...no exceptions.

At my current job, I am not required to do nights. I can round and go, and our caps are pretty reasonable.

Some days suck, but I like the variety.

I actually don’t mind babysitting patients. It’s easy. The worst bit is it inflates the bill and I feels it’s a disservice to surgical residents.

 

[SLC]

I've never found the "but I want to do OB and peds too!" argument compelling; if you're working in even a small city, people will have no trouble finding an actual OB or pediatrician so those skills don't add much benefit other than letting indecisive med students put off making career decisions.

FM docs in large cities and suburban areas do Peds all the time.

Less so with OB, but it still happens.

I chose FM for the peds and Gyn work it can bring. I do a lot of family planning/implantable contraception; and that type of thing appeared very lacking in IM training.

I also do hospitalist work on occasion. And yes, where I’m at I go in during the AM, round and then leave. Only go back for acute issues or new admits when they happen. Haven’t been in at all this weekend (it’s a small hospital and there are no current inpatients) so I’ve been getting paid to hang out at home.

 

[DoubleBogey]

While it's true that both FM and IM have options, that doesn't necessarily make them good fields to go into. Why do you think we have "options"? Precisely because there's a huge demand to get out of general practice. If every internist were practicing traditional, there would in fact be no hospitalists. If doctors were satisfied, there would be no locum tenens, etc. You would not have the progressive and unrelenting career churn. It is what it is.

Most specialties practice for a lifetime without much in the way of complaint. Again, broadly speaking, there are always exceptions.

Pure FM and general IM are the worst fields in medicine....by far, with no contest. With only one exception: emergency medicine. Because in EM, even though they have flex scheduling and reasonable pay, it can really crush a soul beyond repair. Typically happens in late 40s/early 50s.

I bet they don't tell you that in medical school or residency.

I’m still young in the field and have time to develop a chaded opinion, but for now I like and would think/add OB to your list. Tough call schedule as you get older

 

[Doctor_Strange]

Can anyone comment on a few prevailing opinions I have read about:

- FM-trained physicians are less equipped to be a hospitalist d/t more outpatient training and bias in credentialing requirements by hospitals?
- hospitalists, in general, is the dumping ground for other services and it can be unfulfilling after some years as an attending?

Also, if anyone can offer insight as to why he or she decided not to pursue a fellowship versus being a hospitalist? I read somewhere that outside of GI/Cards/Pulm/Heme-Onc, that the additional years of training do not provide that much of an increase in compensation. Personally, my number one concern is I just want to end up doing something that I like. Still have a ways to go to figure it out (M3), but I would value the opinions of others!

 

[rokshana]

Can anyone comment on a few prevailing opinions I have read about:

- FM-trained physicians are less equipped to be a hospitalist d/t more outpatient training and bias in credentialing requirements by hospitals?
- hospitalists, in general, is the dumping ground for other services and it can be unfulfilling after some years as an attending?

Also, if anyone can offer insight as to why he or she decided not to pursue a fellowship versus being a hospitalist? I read somewhere that outside of GI/Cards/Pulm/Heme-Onc, that the additional years of training do not provide that much of an increase in compensation. Personally, my number one concern is I just want to end up doing something that I like. Still have a ways to go to figure it out (M3), but I would value the opinions of others!

FM training can be very program dependent and may not have much on the way of inpt training if they are not an unopposed program. There are 1 year hospital medicine fellowship for FM.

In general, non procedural IM subspecialties make the same of less than hospitalists but have other pros to them.

 

[VA Hopeful Dr]

Pure FM and general IM are the worst fields in medicine....by far, with no contest. With only one exception: emergency medicine. Because in EM, even though they have flex scheduling and reasonable pay, it can really crush a soul beyond repair. Typically happens in late 40s/early 50s.

Utter nonsense.

I work bankers hours, 4 weeks vacation/year, no nights/weekends/holidays and get paid 200k+ for it. Also, shortest residency out there. I can get a job literally anywhere in the country tomorrow if I wanted to. Most patients still like their internist/family doctor.

I also happen to enjoy the work, which admittedly is important. Its not perfect, but what is?

Its a good living, with a good schedule, and you can make a pretty big difference.

 

[Splenda88]

Utter nonsense.

I work bankers hours, 4 weeks vacation/year, no nights/weekends/holidays and get paid 200k+ for it. Also, shortest residency out there. I can get a job literally anywhere in the country tomorrow if I wanted to. Most patients still like their internist/family doctor.

I also happen to enjoy the work, which admittedly is important. Its not perfect, but what is?

Its a good living, with a good schedule, and you can make a pretty big difference.

But you are not making 300k+ like psych or derm..😛

 

[VA Hopeful Dr]

But you are not making 300k+ like psych or derm..😛

Ha.

I'm 5 weeks into the job. Give me 15 months...

 

[rokshana]

But you are not making 300k+ like psych or derm..😛

You would be a bad derm if all you are making is 300k...

 

[Sushirolls]

But you are not making 300k+ like psych or derm..😛

DPC has potential to 500k+. 400 patients X $150/month. Can't have a mid-level though. Paying that much cash, people want the real doctor. Two DPC practices in my area, one has all the bells and whistles with imaging, labs, vaccines, etc but has an ARNP. Another is larger group with few docs and several ARNPs, as an accessory track to their routine insurance practice.

I wish in the med school years I liked all the subspecialities that make up IM more, and not fallen for psych. I had a complete DPC vision had I done IM. It really is the way to go for primary care.

 

[InvestingDoc]

How stressful is it to work as a hospitalist compared to outpatient clinics? Obviously, every job is different but in general which route would provide a better lifestyle? I am trying to decide between the two specialties. IM is a bit more competitive and I wanted to choose where I end up in residency so am leaning towards more so FM. It seems like hospitalists have a better time taking time off work for vacation because it's all shift work and they're technically not providing long term care for a pt compared to outpatient. However, it seems like a lot of hospitalists I see seem pretty unhappy whereas outpatient docs seem like theyre less stressed. Would love to hear your thoughts to help me decide on my specialty

My attendings have told me that depending on your job, you can just round see patients, and just be in and out of the hospital within a few hours. They go home and write up notes and are technically "on call" until something happens. Is this a common thing and is it actually appealing as it sounds?

Well, I did IM and I've been a hospitalist and I'm currently a PCP.

FM if you want to do outpatient is wonderful, so if you're stuck on outpatient, then FM will give you potentially better outpatient exposure to a more broad variety of patient population (peds).

Hospitalist for me was nice to have the 7 on and 7 off. However, the 7 on were brutal. My shifts were 6am to 6pm and at 6am several times I got paged, my patient is coding in the ICU, needed STAT bedside. We had an open ICU so this really made a big difference.

I saw anywhere from 18 to 33 patients a day as a hospitalist. The money was good for working half the year but I was burning out faster than a cheap firework.

Also, VC money (Team health owned by Blackrock) rolled into town and basically tried to do a competitive takeover. They got the contact from the hospital, the TH docs were paid about $75,000 less a year than I was making and required to sign off on NP patients that were seen with no extra pay. This competition pushed our pay down since they ate up a large pool of patients.

Other local hospitalist groups were bought out and similar things happened.

So for me, I was not willing to be some pencil pushers boy to push around. I put in my resignation and moved on and started up my own clinic.

This is my first year open, I take insurance, and I'll net upwards of $400k this year in my own clinic. The stress is high starting up my own clinic but very rewarding. You HAVE to be okay seeing new patients for fatigue, or turning away 30 year old men who want testosterone or 90 pills of xanax. But, for me this is much more enjoyable than waking up at 6am to code blue and being told what to do by hospital admin or being attempted to be pushed out by VC money.

I'm sure there are good hospitalist groups out there but the future is 3-4 large national groups that will run the hospitals.

I currently work 4.5 days per week and have every weekend and holiday off. Yeah, I put up with a lot of bull**** as a PCP but so did I as a hospitalist. It is not a pissing contest about which is more difficult. I view it as, what kind of lifestyle and control do you want over your future. Hospitalist the only way for control is partnership which is rare, or locums and picking your jobs.

If you start your own PCP you will have almost complete control.

PM me if you have any questions.

 

[chessknt]

Maybe not as much for a hospitalist but outpatient work bills very poorly compared to inpatient and requires a lot of uncompensated effort with phone calls/emr messages. I hated my outpatient clinic in every phase of training and now I don't do any outpatient at all. I found the mountain of outpatient bull**** to be insurmountable compared to the inpatient setting.

Some people like busy stressful days, some don't. Hard to tell which one you really are until you do both.

 

[DoubleBogey]

Hard to tell which one you really are until you do both.

Strongly agree.
Inpatient compensates better and if round and go certainly more RVUs generated with less time.
Outpt has its pitfalls, there is a lot of bull**** paperwork, which I usually schedule office visits to fill out (this way your compensated for you work).
I enjoy having my weekends and holidays as opposed to the typical scheduling of a hospitalist, but some enjoy the 7d off sched

 

[VA Hopeful Dr]

Maybe not as much for a hospitalist but outpatient work bills very poorly compared to inpatient and requires a lot of uncompensated effort with phone calls/emr messages. I hated my outpatient clinic in every phase of training and now I don't do any outpatient at all. I found the mountain of outpatient bull**** to be insurmountable compared to the inpatient setting.

Some people like busy stressful days, some don't. Hard to tell which one you really are until you do both.

Something you have to keep in mind is that outpatient clinic in residency/fellowship is almost nothing like clinic as an attending.

If you're filling out paperwork, you're doing it wrong. I sign things that my MA has already filled out. I bet I actually write more than my name on maybe 1 form/week.

Phone messages are irritating certainly, but that can be managed. My patients are all trained that if they need refills they need an office visit and that I don't prescribe new meds without a visit. That cuts down the workload significantly.

Not trying to say outpatient is better, just to be careful about judging it based on your experience in training.

 

[Cheeni17]

Something you have to keep in mind is that outpatient clinic in residency/fellowship is almost nothing like clinic as an attending.

If you're filling out paperwork, you're doing it wrong. I sign things that my MA has already filled out. I bet I actually write more than my name on maybe 1 form/week.

Phone messages are irritating certainly, but that can be managed. My patients are all trained that if they need refills they need an office visit and that I don't prescribe new meds without a visit. That cuts down the workload significantly.

Not trying to say outpatient is better, just to be careful about judging it based on your experience in training.

No phone percs?

 

[chessknt]

Something you have to keep in mind is that outpatient clinic in residency/fellowship is almost nothing like clinic as an attending.

If you're filling out paperwork, you're doing it wrong. I sign things that my MA has already filled out. I bet I actually write more than my name on maybe 1 form/week.

Phone messages are irritating certainly, but that can be managed. My patients are all trained that if they need refills they need an office visit and that I don't prescribe new meds without a visit. That cuts down the workload significantly.

Not trying to say outpatient is better, just to be careful about judging it based on your experience in training.

Do you schedule a followup to discuss test results? Mildly abnormal labs? What is your followup interval for stable medical problems?

I know pp outpatient jobs in my field that see stable medical conditions where nothing changes every 3 months. Sure that is easy and revenue generating but it also feels stupid and pointless which was another strike against outpatient for me.

 

[VA Hopeful Dr]

Do you schedule a followup to discuss test results? Mildly abnormal labs? What is your followup interval for stable medical problems?

I know pp outpatient jobs in my field that see stable medical conditions where nothing changes every 3 months. Sure that is easy and revenue generating but it also feels stupid and pointless which was another strike against outpatient for me.

In order: no, no, depends on the condition but 6M for everything except hypothyroid (1 year) and diabetes if unstable or on more than 1 po med (3M there).

The nice thing about outpatient is that you can practice how you want. If you want to see all of your stable follow-ups once a year you can do that.

 

[Laradd]

Hospitalist for me was nice to have the 7 on and 7 off. However, the 7 on were brutal. My shifts were 6am to 6pm and at 6am several times I got paged, my patient is coding in the ICU, needed STAT bedside. We had an open ICU so this really made a big difference.

You feel like a closed ICU is much better?

 

[rokshana]

You feel like a closed ICU is much better?

Oh god yes.

 

[Doctor_Strange]

As a M3 I found this whole discussion fascinating (slightly worrisome in some aspects!).

Could someone comment on the challenges of developing the proper business acumen needed to start your own clinic? This to me is so daunting, I feel that I would need to go out and get a MBA or MHA just to understand that aspect of private practice? Or like getting your name out there via magazine ads, social media, etc.? The activation energy seems to be really high to get started...

 

[VA Hopeful Dr]

As a M3 I found this whole discussion fascinating (slightly worrisome in some aspects!).

Could someone comment on the challenges of developing the proper business acumen needed to start your own clinic? This to me is so daunting, I feel that I would need to go out and get a MBA or MHA just to understand that aspect of private practice? Or like getting your name out there via magazine ads, social media, etc.? The activation energy seems to be really high to get started...

Nah, you don't need to go that far (MBA/MHA). A lot of it you can learn on the fly by actually working for a year or so in a practice and seeing how they do things. Heck, even residency can work if you want to learn that type of thing.

You can go even easier by going the DPC route.

 

[DoubleBogey]

Net collections - expenses

There’s your MBA

 

[aafisahar]

As a M3 I found this whole discussion fascinating (slightly worrisome in some aspects!).

Could someone comment on the challenges of developing the proper business acumen needed to start your own clinic? This to me is so daunting, I feel that I would need to go out and get a MBA or MHA just to understand that aspect of private practice? Or like getting your name out there via magazine ads, social media, etc.? The activation energy seems to be really high to get started...

MBA -> pay for connections. The actual coursework is superfluous. You are paying for access to the program's network and alumni base.

MHA -> sell-out to hospital admin. Mostly useless coursework, need the initials to convince the head bean counter that you care more about beans than patients.

 

[bronx43]

As a M3 I found this whole discussion fascinating (slightly worrisome in some aspects!).

Could someone comment on the challenges of developing the proper business acumen needed to start your own clinic? This to me is so daunting, I feel that I would need to go out and get a MBA or MHA just to understand that aspect of private practice? Or like getting your name out there via magazine ads, social media, etc.? The activation energy seems to be really high to get started...

You need a MBA/MHA to start a clinic about as much as Elon Musk needed one to start Paypal...

not at all.

 

[NITRAS]

Well in residency, I barely ordered any venous gases. Where I work now, its a lot harder to get ABGs outside of MICU or a rapid. I also just feel my RTs are just plain lazy. So for a non-ICU doc, I don't get many. There is at least one one study that suggests a pCO2 on a venous gas and pCO2 on ABG are pretty much the same, but lots of smart CCM/PCCM always believe, and I don't feel its been a problem.​

You feel like a closed ICU is much better?

I trained at a smaller place that had an open icu. Now I work at a bigger center with a closed ICU.

The biggest problem with a closed ICU is the icu saying no, and taking care of people that have a big risk of de compensation with floors that have 5 or 6 to pts per nurse.

Usually not a problem, but when our MICU gets full you can have a lot of sick people on the floor.

 

[jdh71]

You feel like a closed ICU is much better?

 

[InvestingDoc]

Maybe not as much for a hospitalist but outpatient work bills very poorly compared to inpatient and requires a lot of uncompensated effort with phone calls/emr messages. I hated my outpatient clinic in every phase of training and now I don't do any outpatient at all. I found the mountain of outpatient bull**** to be insurmountable compared to the inpatient setting.

Some people like busy stressful days, some don't. Hard to tell which one you really are until you do both.

The phone messages and the EMR private messages really can easily become overwhelming and yeah it stinks because you are not compensated for them. However, you can do telemedicine visits and bill for that. So, if a patient is not able to come into the clinic and it is going to take too long to type out, I text them a link to hop on, we do a video chat, I write a note and bill for it as a tele-medicine visit with a 95 modifier. Yeah some insurances don't pay for it but if we are going to have the chat anyway, might as well give it a shot to get compensated. This also may depend on your state rules.

I have my nurses do 99% of the paperwork and then it just goes to me for signature. I probably spend maybe 10 minutes a week on printed paperwork and signatures for patient data. Oh, and if you are filling out certifications for home health, or home PT, you can bill for that too.

When I did inpatient medicine, the daily case management rounds, the weekly or monthly IM meetings, Monthly meetings for the group, then the pressure to have admit orders in within 60 minutes of initial page for admission was in my opinion quite frustrating.

Inpatient medicine to me became all about throughput. The only metrics admins care about is throughput to get more people admitted so they can bill and discharged ASAP so they can fill a hospital bed with someone else and minimize staff burden if the patient lingers in the hospital all day.


Now, I will say that dealing with insurance companies to set up contracts, that by itself is enough to turn many doctors away from primary care.

 

[IMreshopeful]

You feel like a closed ICU is much better?

In which universe is this NOT better