Mid Career Crisis as a Hospitalist

[bronx43]

I mean the entire ER field turned from a gravy train to spoiled milk in 6 months. It can happen very fast. The hospital admins are looking for new ways to save money as this house of cards starts to collapse hospitalists/intensivists will likely be early casualties. Sure you can run to outpatient medicine to be a PCP but depending on your local market you are looking at a year to be properly impaneled before you start to actually have positive income potential. Onc/cards/GI will never have this problem. They own the infusion/echo/ASC and are printing money whether the hospital goes out of business or builds a new tower. They also own the patients that generate hospitals money.

vast majority of cards and onc are employed and own nothing. Maybe 15 years ago they were mainly pp but that’s not the case these days. Onc still makes alot due to chemo/immunotherapy. Cards makes a lot since they generate a ton of RVUs with their consults, clinic and echo interpretations.

But I agree that they aren’t easily replaceable because they own the patients. Also midlevels aren’t going to be reading nucs and echos anytime soon.

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[IM_to_ortho_hopeful]

vast majority of cards and onc are employed and own nothing. Maybe 15 years ago they were mainly pp but that’s not the case these days. Onc still makes alot due to chemo/immunotherapy. Cards makes a lot since they generate a ton of RVUs with their consults, clinic and echo interpretations.

But I agree that they aren’t easily replaceable because they own the patients. Also midlevels aren’t going to be reading nucs and echos anytime soon.

What are your opinions on GI? Still a good career?

 

[bronx43]

What are your opinions on GI? Still a good career?

As long as facility fees aren’t cut (very unlikely to be cut anytime soon), it’s the best specialty in IM.

 

[Señor S]

As long as facility fees aren’t cut (very unlikely to be cut anytime soon), it’s the best specialty in IM.

You think so? For sure salaries are high now and the ability to essentially never be "primary" (either inpatient or outpatient) has its appeal but at the end of the day their income is dependent on a couple of (usually) fairly basic procedures for which some alternatives exist, which others (e.g., surgeons) can do and which even more people (e.g., midlevels) could probably be trained to some basic competency in without too much trouble. I'll give credit to GI as a field; as compared to others (*cough* anesthesia and PCCM) they've thus far resisted the temptation to sell out, but even now I feel like I'm seeing cracks in that dam.

For me the best field out of IM is probably Onc.

 

[collegestud2013]

What are your opinions on GI? Still a good career?

Not everyone likes dealing with poop. And while pay per hour is decent right now, RVUs and reimbursements for C-scopes and EGDs could get cut anytime by CMS to the point doing them is not more profitable than just rounding on patients in the hospital or seeing them in clinic; this has happened multiple times in many procedural specialties in the past. If that happens then GI compensation on a per hour basis will be similar to that of non-procedural IM specialties.

 

[chessknt]

You think so? For sure salaries are high now and the ability to essentially never be "primary" (either inpatient or outpatient) has its appeal but at the end of the day their income is dependent on a couple of (usually) fairly basic procedures for which some alternatives exist, which others (e.g., surgeons) can do and which even more people (e.g., midlevels) could probably be trained to some basic competency in without too much trouble. I'll give credit to GI as a field; as compared to others (*cough* anesthesia and PCCM) they've thus far resisted the temptation to sell out, but even now I feel like I'm seeing cracks in that dam.

For me the best field out of IM is probably Onc.

Oncology income is highly tied to a single point of failure as well (chemo infusion reimbursement). Cardiology is the most resilient in terms of service lines (imaging, stress testing, caths, inpatient/outpatient work, ekgs) and in terms of longevity is the safest income bet by far. On an effort basis nobody can beat oncology's per RVU reimbursement rates though. Billing 2x what all the other IM specialties do per unit is hard to ignore.

 

[collegestud2013]

vast majority of cards and onc are employed and own nothing. Maybe 15 years ago they were mainly pp but that’s not the case these days. Onc still makes alot due to chemo/immunotherapy. Cards makes a lot since they generate a ton of RVUs with their consults, clinic and echo interpretations.

But I agree that they aren’t easily replaceable because they own the patients. Also midlevels aren’t going to be reading nucs and echos anytime soon.

Agreed that most cards and onc are employed these days. Note that onc makes a lot per RVU (close to $90-$100 while it's closer to $40-50 for most other IM specialties). for a non-procedural because of the extra revenue PP heme/onc can generate from "buy and bill" for chemo in additional to the usual E&M. Though many suspect buy and bill will become harder to profit from in the future as insurances tighten down on this practice so would not expect this to be the norm for too long.

Cardiology generates a lot of RVUs because they, on average, work longer hours and see more patients than the typical hospitalist; their hourly pay for general cards (not including interventional or EP) is only slightly higher than hospitalist. Echos aren't really big RVU generators anyways for cardiology with each echo billing only around 1.3-1.5 wRVUs. But I agree that onc and cards are harder than HM since they own the patients.

And both these specialties also require 3 more years of training (so 3 less years of attending income), and the extra money they do make over hospitalist is taxed at over 40% (once accounting for federal, state, local taxes) so the after tax pay difference is much smaller than it looks, and usually only seen at mid-late or later career. Not to mention they're both competitive IM subspecialities with low match rates.

 

[collegestud2013]

I mean the entire ER field turned from a gravy train to spoiled milk in 6 months. It can happen very fast. The hospital admins are looking for new ways to save money as this house of cards starts to collapse hospitalists/intensivists will likely be early casualties. Sure you can run to outpatient medicine to be a PCP but depending on your local market you are looking at a year to be properly impaneled before you start to actually have positive income potential. Onc/cards/GI will never have this problem. They own the infusion/echo/ASC and are printing money whether the hospital goes out of business or builds a new tower. They also own the patients that generate hospitals money.

Do agree that HM long-term outlook isn't that great, for several reasons:
1) HM are easier to replace with midlevels since more of their work is more of the logistics of inpatient care (eg discharge planning, updating families) and a bit less of higher-level decision making that more often is done specialists. Though in most states NPs/PAs still need to be supervised so a MD/DO needs to cosign their notes and orders.
2) They are a shift-based specialty (like EM, ICU, anesthesiology, radiology), which makes them less costly to replace when someone leaves since there is usually no issue with losing patients
3) Most hospitalist programs are subsidized by the hospital since the amount they bring in from just billing E&M doesn't cover all the compensation and overhead costs of running the hospitalist program.
4) any IM and FM trained physician can do HM, and these are 2 of the largest non-competitive specialties out there and pumping a lot of grads each year

Outpatient IM is a decent exit strategy for IM and FM trained physicians if HM job market goes down the drain (though not the only one), especially given the overall shortage of PCPs across the country. And then one would also own the patients which is the main reason outpatient PCPs with a full panel are harder to replace than hospitalists. Though to make it more sustainable, reimbursements would need to go up quite a bit so one doesn't have to see 20+ patients a day just to stay afloat (looks like CMS is slowly moving towards this for example this year by allowing PCPs to bill a little more for complex primary care visits with an add on code).

 

[sloh]

Though many suspect buy and bill will become harder to profit from in the future as insurances tighten down on this practice so would not expect this to be the norm for too long.

Appreciate your posts but do you really think this is going to happen? Cancer strikes fear into most laypeople way more than any other condition.

 

[collegestud2013]

You've been vocal about the benefits of working as a hospitalist, but left this statement up in the air.

Just curious, as a new resident in IM who is considering whether to pursue or not a subspecialty, if the job is automated to the point where one is asking "what do you want me to do?" does that not ring the alarms for the it's eventual evolution.

Won't they just hire NPs or maybe even AI to do the rest?

Doubt AI will have a significant impact in the job market for, any of the patient-facing non-procedural specialties any time soon. AI can assist with some of the medical decision-making or help automate some of the more mundane tasks like writing notes but most patients won't be ready yet to be seen by a robot. Midlevel encroachment is the much bigger threat for these specialties as it already has been.

The imaging-heavy specialties that don't directly see patients like pathology and radiology are most likely to have worsening of their job market due to AI.

 

[collegestud2013]

Appreciate your posts but do you really think this is going to happen? Cancer strikes fear into most laypeople way more than any other condition.

I can see it becoming more common enough that it starts significantly impacting the bottom line for heme/onc practices. Cancer patients may be very sick but that doesn't mean insurance payors will do anything to improve their own bottom line but trying to cut how much they pay for expensive heme/onc drugs. For example, some insurances are already mandating "white bagging" of oncology drugs which basically bypasses the ability for heme/onc practices to profit from buy and bill (How ‘White Bagging’ Affects Patients, Physicians and 340B Funding)

 

[InternistDO]

I mean the entire ER field turned from a gravy train to spoiled milk in 6 months. It can happen very fast. The hospital admins are looking for new ways to save money as this house of cards starts to collapse hospitalists/intensivists will likely be early casualties. Sure you can run to outpatient medicine to be a PCP but depending on your local market you are looking at a year to be properly impaneled before you start to actually have positive income potential. Onc/cards/GI will never have this problem. They own the infusion/echo/ASC and are printing money whether the hospital goes out of business or builds a new tower. They also own the patients that generate hospitals money.

The second that the USPSTF decides that screening colonoscopies should be considered only for positive stool tests or high risk cancer screenings is the second that GI suddenly becomes a middle of the road IM subspecialty.

Regardless, there is so much demand in the outpatient PCP space that you could probably turn 50% of all practicing hospitalists into outpatient docs tomorrow without most of them having to move very far from their current job. It's a completely different environment than EM who are locked into working in the ED and urgent care and have limited fellowship options.

If you like hospital medicine, just do it and if the market ever collapses (which I think is doubtful) then you can re-evaluate and decide if PCP vs nursing home rounding vs fellowship is what you want. It's not like you're signing your soul away to do it forever.

 

[sloh]

I can see it becoming more common enough that it starts significantly impacting the bottom line for heme/onc practices. Cancer patients may be very sick but that doesn't mean insurance payors will do anything to improve their own bottom line but trying to cut how much they pay for expensive heme/onc drugs. For example, some insurances are already mandating "white bagging" of oncology drugs which basically bypasses the ability for heme/onc practices to profit from buy and bill (How ‘White Bagging’ Affects Patients, Physicians and 340B Funding)

Thoughts on this?

State of Play: White Bagging

Over the next few months, we'll be sharing summaries of state action on the Association for Clinical Oncology’s (ASCO) key advocacy priorities. This article examines recent action on white bagging.

society.asco.org

"Since 2021, legislation to address payer-mandated white bagging has been introduced in 32 states. Arkansas and Louisiana became the first states to pass laws prohibiting the use of payer-mandated white bagging policies in 2021. Since then, North Dakota, Tennessee, and Vermont have enacted laws banning payer-mandated white bagging, while Minnesota, Texas, and Virginia have added guardrails around the practice.

In 2023, bills that would address payer-mandated white bagging were introduced in 23 states. Legislation in 10 of these states remains active and will carry over into the 2024 legislative session. ASCO anticipates movement on white bagging legislation in Utah and Wyoming during the states’ next legislative sessions, and the Association has worked with the relevant state societies to submit letters supporting these efforts. ASCO is also monitoring efforts by Washington’s State Pharmacy Quality Assurance Commission to address white bagging via regulations"

 

[bronx43]

You think so? For sure salaries are high now and the ability to essentially never be "primary" (either inpatient or outpatient) has its appeal but at the end of the day their income is dependent on a couple of (usually) fairly basic procedures for which some alternatives exist, which others (e.g., surgeons) can do and which even more people (e.g., midlevels) could probably be trained to some basic competency in without too much trouble. I'll give credit to GI as a field; as compared to others (*cough* anesthesia and PCCM) they've thus far resisted the temptation to sell out, but even now I feel like I'm seeing cracks in that dam.

For me the best field out of IM is probably Onc.

I mean, it's always possible that reimbursement will be cut for scopes. It's also possible that screening guidelines will change depending on the sensitivity and specificity of stool based tests. However, until that happens, I don't see GI losing the crown. Furthermore, the facility fees (often multiple times the payment of the actual procedure) they command means that hospitals will always value them. And facility fees will never be cut, since cutting it would mean the end for most hospital systems.

 

[Splenda88]

As long as facility fees aren’t cut (very unlikely to be cut anytime soon), it’s the best specialty in IM.

I think GI and heme onc is the way to go.

 

[HemeOncHopeful19]

Oncology income is highly tied to a single point of failure as well (chemo infusion reimbursement). Cardiology is the most resilient in terms of service lines (imaging, stress testing, caths, inpatient/outpatient work, ekgs) and in terms of longevity is the safest income bet by far. On an effort basis nobody can beat oncology's per RVU reimbursement rates though. Billing 2x what all the other IM specialties do per unit is hard to ignore.

Because RVUs are really tied to "effort", I'm just gliding through clinic daily lol thank god the rest of you are doing the real hard work

There's literally no way to predict the future except that all of us will probably be worse off together.

 

[The kitchen sink]

You think so? For sure salaries are high now and the ability to essentially never be "primary" (either inpatient or outpatient) has its appeal but at the end of the day their income is dependent on a couple of (usually) fairly basic procedures for which some alternatives exist, which others (e.g., surgeons) can do and which even more people (e.g., midlevels) could probably be trained to some basic competency in without too much trouble. I'll give credit to GI as a field; as compared to others (*cough* anesthesia and PCCM) they've thus far resisted the temptation to sell out, but even now I feel like I'm seeing cracks in that dam.

For me the best field out of IM is probably Onc.

Can you elaborate on the the selling out comparison for anesthesia and pccm?

To the midlevels? Or to something else?

 

[Splenda88]

Do agree that HM long-term outlook isn't that great, for several reasons:
1) HM are easier to replace with midlevels since more of their work is more of the logistics of inpatient care (eg discharge planning, updating families) and a bit less of higher-level decision making that more often is done specialists. Though in most states NPs/PAs still need to be supervised so a MD/DO needs to cosign their notes and orders.
2) They are a shift-based specialty (like EM, ICU, anesthesiology, radiology), which makes them less costly to replace when someone leaves since there is usually no issue with losing patients
3) Most hospitalist progrNO=ams are subsidized by the hospital since the amount they bring in from just billing E&M doesn't cover all the compensation and overhead costs of running the hospitalist program.
4) any IM and FM trained physician can do HM, and these are 2 of the largest non-competitive specialties out there and pumping a lot of grads each year

Outpatient IM is a decent exit strategy for IM and FM trained physicians if HM job market goes down the drain (though not the only one), especially given the overall shortage of PCPs across the country. And then one would also own the patients which is the main reason outpatient PCPs with a full panel are harder to replace than hospitalists. Though to make it more sustainable, reimbursements would need to go up quite a bit so one doesn't have to see 20+ patients a day just to stay afloat (looks like CMS is slowly moving towards this for example this year by allowing PCPs to bill a little more for complex primary care visits with an add on code).

I work with both NP and PA. I dont see NP replacing us anytime soon because length of stay will increase significantly and that cost a lot of money to the hospital. PA is different story but there aren't enough PA out there with 5+ yrs experience to do the job.

As far as we don't generate enough revenue, I see it as the cost of doing business. Without us, the hospital will be in a stand still.

Anyway, I am hoping for the gravy train to last at least another 7-8 years so I don't have to worry about anyone replacing me.

https://www.amnhealthcare.com/siteassets/candidate-blog/physician/merritthawkins_revenuesurvey_2019.pdf

The last number I saw for HM revenue was close to 2.5 mil

 

[FriendlyNeighbor4]

The value added for most hospitalists above a typical NP is low. My prediction for the future of this field is heavy infiltration by midlevels; MDs will exist mostly to cosign their notes/be their scapegoats and to work the limited number of true academic teaching jobs. chessknt is exactly right: pick one of Cards, GI or Onc. Whatever it is that you find intriguing about being a hospitalist can be found in some version in another field that pays better, has better job security and isn't a 24/7 dumping ground. I would never advise anyone to become a hospitalist.

You can't really give this advice to a large number of IM residents who for one reason or another are matched at community programs with/without exposure to in-house fellowship faculty or mentors. You understand that you're basically saying that most IM residents are royally you know what.
They can either roll the dice on the currently "cushy" Hospitalist gig or become PCPs.

A quick read on other specialties available isn't promising. Allergy is as tough, PCCM ditto. You're left with Rheum, Endo and apparently the dreaded corpse of Nephro.

What is a fool to do? Much appreciated.

 

[chessknt]

Because RVUs are really tied to "effort", I'm just gliding through clinic daily lol thank god the rest of you are doing the real hard work

There's literally no way to predict the future except that all of us will probably be worse off together.

Are you arguing oncology deserves 2x reimbursement on an rvu basis because it's objectively harder than all the other specialties? Like your level 5 is 2x harder than a rheum or congenital cardiology level 5? Or any level 5?

 

[Señor S]

You can't really give this advice to a large number of IM residents who for one reason or another are matched at community programs with/without exposure to in-house fellowship faculty or mentors. You understand that you're basically saying that most IM residents are royally you know what.
They can either roll the dice on the currently "cushy" Hospitalist gig or become PCPs.

A quick read on other specialties available isn't promising. Allergy is as tough, PCCM ditto. You're left with Rheum, Endo and apparently the dreaded corpse of Nephro.

What is a fool to do? Much appreciated.

Well, look, being a hospitalist is, objectively, a pretty good job. I'd take my job now over 99.9% of other careers available. And there are things I enjoy about it that I would miss if I were, say, a Cardiologist. It's not all doom and gloom. Making mid-200s doing something interesting (and being a hospitalist, whatever else it is, is interesting) is still a pretty good life outcome, all things considered.

My point is addressed more towards the people who are at better programs who do have the option to do other things. But I'd also say that even people from bottom-barrel places can often get to the mountain top *if* they're persistent. They may not get in on their first application, or their second. They may have to spend years as a hospitalist (the horror) at some academic center grinding out case reports in their free time. They probably won't be matching to MGH or Stanford. But I know a number of these guys and the ones who are persistent, more often than not, make it in the end.

 

[Ubba]

I ran into a guy at a toddler bday party the other day who was a hospitalist and left his inpatient gig for a job essentially doing telehealth PCP type stuff for one of the local prison systems. I barely met the guy so didn't pry too deeply as in to how much his compensation was but sounds like he works from home and telehealth in that particular situation avoids some of the negatives mentioned above. Sounds like he basically gets an hourly wage for doing home-based telehealth on prisoners. I can see the appeal if the compensation is half-way decent. I imagine there's a lot less technical problems because it's an institution and you're paid hourly, not based on encounters and not dealing with a bunch of random people troubleshooting their home internet setups during a tele visit.

That does sound easy, but there comes a point when doing an easy telemedicine job for 100/hr as a doctor (the going rate for places like Teladoc was 35/consult or so a couple years ago, and I doubt the prison system pays any better) just isn't worth the relaxation. Resident-me would have considered that a fantastic life, but time moves on and we have to save/invest for kids' tuitions, retirement, etc.

 

[Señor S]

Can you elaborate on the the selling out comparison for anesthesia and pccm?

To the midlevels? Or to something else?

To midlevels: offloading their work onto midlevels, never drawing a clear distinction between doctor work and midlevel work.

Oncology income is highly tied to a single point of failure as well (chemo infusion reimbursement). Cardiology is the most resilient in terms of service lines (imaging, stress testing, caths, inpatient/outpatient work, ekgs) and in terms of longevity is the safest income bet by far. On an effort basis nobody can beat oncology's per RVU reimbursement rates though. Billing 2x what all the other IM specialties do per unit is hard to ignore.

I'll be very surprised if Oncology reimbursements get cut in any significant way; I think the Oncologists would raise hell if anybody tried and the public would back them. I think they'll always retain control over that field and it's a field that will just keep on growing: better outcomes, patients living longer, more treatment, more follow-ups etc pp.

 

[The kitchen sink]

To midlevels: offloading their work onto midlevels, never drawing a clear distinction between doctor work and midlevel work.


I'll be very surprised if Oncology reimbursements get cut in any significant way; I think the Oncologists would raise hell if anybody tried and the public would back them. I think they'll always retain control over that field and it's a field that will just keep on growing: better outcomes, patients living longer, more treatment, more follow-ups etc pp.

this is a generalization and not applicable to every situation but if you divide pccm into it’s relevant formats then the midlevel usage is by and far utilized in the intensive care unit, reimbursement is dropping with the new cms proprosals, corporate medical groups and the public forgot about the value of critical care so there isn’t much public support. Rates for critical care coverage (per diem and locums) have dropped significantly post-covid, and frankly, why would anyone work for barely more than a hospitalist in certain regions (northeast), be called for every single tiny thing that goes on in the hospital, responsible for rapids, codes, etc, it creates a recipe for midlevel encroachment… yes care suffers but it will take something like covid for the value of critical care to be recognized… otherwise it’s just another form of hospital medicine that is susceptible to the same risks

thats why for pccm folks, general pulm serves as the out, and then you have IP and then to a lesser degree pulm htn, ild etc

For anesthesia, it pays extremely well bc surgery pays but there is a huge supply demand mismatch and crnas fill up that vacuum and make more than hospitalist and other im subspecialties in various localities

 

[laserbeam]

I work with both NP and PA. I dont see NP replacing us anytime soon because length of stay will increase significantly and that cost a lot of money to the hospital. PA is different story but there aren't enough PA out there with 5+ yrs experience to do the job.

As far as we don't generate enough revenue, I see it as the cost of doing business. Without us, the hospital will be in a stand still.

Anyway, I am hoping for the gravy train to last at least another 7-8 years so I don't have to worry about anyone replacing me.

https://www.amnhealthcare.com/siteassets/candidate-blog/physician/merritthawkins_revenuesurvey_2019.pdf

The last number I saw for HM revenue was close to 2.5 mil

Thanks for the link. I suppose the “Internal Medicine” mentioned in the report includes hospital medicine?

 

[CCM-MD]

Thanks for the link. I suppose the “Internal Medicine” mentioned in the report includes hospital medicine?

No it doesn’t, it’s talking about outpatient internal medicine. That 2.5mil is downstream revenue generated by outpatient care (imaging, labs, referrals etc.). Hospital medicine doesn’t bring in any new revenue or patients to the hospital. Professional billing supports at best half of hospitalist salaries depending on the payer mix, the rest is subsidized by the hospital (aka cost of doing business). It's delusional to think you're generating $2.5 mil for the hospital as a hospitalist.

 

[HemeOncHopeful19]

To midlevels: offloading their work onto midlevels, never drawing a clear distinction between doctor work and midlevel work.


I'll be very surprised if Oncology reimbursements get cut in any significant way; I think the Oncologists would raise hell if anybody tried and the public would back them. I think they'll always retain control over that field and it's a field that will just keep on growing: better outcomes, patients living longer, more treatment, more follow-ups etc pp.

Oncology, and all fields, have been cut in significant ways in the past, esp. private practice with the “AWP+6% for thee, 430B for me” system. Nobody is immune to slumps and I would wager almost all fields are doing worse relatively speaking than 15 years ago

 

[sloh]

’ “AWP+6% for thee, 430B for me” system.

Can you expand on this?

 

[HemeOncHopeful19]

Can you expand on this?

Many non-profits have access to substantially reduced drug costs (via 340B programs) compared to private practices under the banner of “we treat indigent patients and need lower cost drugs” meanwhile they still bill the same to insurance (don’t pass on those savings) and build their fancy new cancer centers with floor to ceiling glass windows out in the suburbs where everyone has insurance

 

[TexasMed22]

Many non-profits have access to substantially reduced drug costs (via 340B programs) compared to private practices under the banner of “we treat indigent patients and need lower cost drugs” meanwhile they still bill the same to insurance (don’t pass on those savings) and build their fancy new cancer centers with floor to ceiling glass windows out in the suburbs where everyone has insurance

The oncologist wins in both of these situations though. Either get a 6% cut if you're in PP and make bank, or get heavily subsidized by the hospital since you make them so much money, and make bank

 

[Splenda88]

Thanks for the link. I suppose the “Internal Medicine” mentioned in the report includes hospital medicine?

CCM is right. Our revenue might be due to "the cost of doing business" (the amount of $$$ the hospital save) because we move the meat quicker than NP or the outpatient docs FM/IM with admitting privilege

Interesting artcle.

Turnover rate for hospitalist groups trending downward - The Hospitalist

State of Hospital Medicine

www.the-hospitalist.org

 

[chessknt]

CCM is right. Our revenue might be due to "the cost of doing business" (the amount of $$$ the hospital save) because we move the meat quicker than NP or the outpatient docs FM/IM with admitting privilege

Interesting artcle.

Turnover rate for hospitalist groups trending downward - The Hospitalist

State of Hospital Medicine

www.the-hospitalist.org

What % of revenue do you think is from the hospital doing HM type admits?

Unlike HM, Anesthesia is required for the OR/endo suites to run. The average medicare/uninsured/medicaid HM admit for diabetes/pna/confusion/afib is a money losing prospect for the hospital (look at what happened during Covid financially for them). The confidence that moving these money-losing admits around faster as some kind of value-added proposition is a weak foundation.

 

[Splenda88]

What % of revenue do you think is from the hospital doing HM type admits?

Unlike HM, Anesthesia is required for the OR/endo suites to run. The average medicare/uninsured/medicaid HM admit for diabetes/pna/confusion/afib is a money losing prospect for the hospital (look at what happened during Covid financially for them). The confidence that moving these money-losing admits around faster as some kind of value-added proposition is a weak foundation.

You might be correct. It would be a losing proposition for hospital to go back to have subspecialties and community physicians admit their own patients. This exactly the reason HM has become so popular. I dont think these hospital CEOs are stupid. Maybe they are but I doubt it.

 

[chessknt]

You might be correct. It would be a losing proposition for hospital to go back to have subspecialties and community physicians admit their own patients. This exactly the reason HM has become so popular. I dont think these hospital CEOs are stupid. Maybe they are but I doubt it.

The midlevels man, they can do this. Why do you think cardiology primary has a bunch of midlevels around? The ICU is harder because those patients are very sick and need too much attention to easily offload to unsupervised midlevels.

 

[Splenda88]

The midlevels man, they can do this. Why do you think cardiology primary has a bunch of midlevels around? The ICU is harder because those patients are very sick and need too much attention to easily offload to unsupervised midlevels.

Comparing Hospitalist-Resident to Hospitalist-Midlevel Practitioner Team Performance on Length of Stay and Direct Patient Care Cost

A perception exists that residents are more costly than midlevel providers (MLPs). Since graduate medical education (GME) funding is a key issue for teaching programs, hospitals should conduct cost-benefit analyses when considering staffing models.Our ...

www.ncbi.nlm.nih.gov

Clear example. Today was my first day at work for the week. I took over patient (football player) who was being taken care of by an NP. Patient was admitted for rhabdo 5 days ago with CK 80k+. His serum CK yesterday was 45k. LFTs normal, renal function unrmarkable.

Discharge planning per NP: "Discharge home when CK < 5k.

The individual was RN for 10+ yrs and has been a NP for 9 yrs

Good luck having NPs run hospital medicine service.

 

[chessknt]

Comparing Hospitalist-Resident to Hospitalist-Midlevel Practitioner Team Performance on Length of Stay and Direct Patient Care Cost

A perception exists that residents are more costly than midlevel providers (MLPs). Since graduate medical education (GME) funding is a key issue for teaching programs, hospitals should conduct cost-benefit analyses when considering staffing models.Our ...

www.ncbi.nlm.nih.gov

Clear example. Today was my first day at work for the week. I took over patient (football player) who was being taken care of by an NP. Patient was admitted for rhabdo 5 days ago with CK 80k+. His serum CK yesterday was 45k.

Discharge planning per NP: "Discharge home when CK < 5k"

Good luck having NPs un hospital medicine service.

I mean I can provide examples of mid levels I work adjacent to who discharge post icu patients within 1-2d of transfer to the floor. Anecdotes are irrelevant though--they cost way less (like 1/3 of a hospitalist) and work at nearly the same level outside of academia. I am under no illusions as to what is coming.

 

[Splenda88]

I mean I can provide examples of mid levels I work adjacent to who discharge post icu patients within 1-2d of transfer to the floor. Anecdotes are irrelevant though--they cost way less (like 1/3 of a hospitalist) and work at nearly the same level outside of academia. I am under no illusions as to what is coming.

I provided a specific study along with my anecdote.

It might be coming because admins are looking for way to cut cost everywhere. Physicians are the perfect target since we make a lot of $$$. I am not sure if you have noticed that more NP/PA grads as a percentage are going into specialties than physicians. No specialties are safe except surgical ones and pathology.

 

[chessknt]

I provided a specific study along with my anecdote.

It might be coming because admins are looking for way to cut cost everywhere. I am not sure if you have noticed that more NP/PA grads as a percentage are going into specialties than physicians. No specialties are safe.

Your single center academic setting with residents doesn't generalize to the majority of medicine and it won't matter to the admins anyways who dont let data guide their decisions, only $$.

I am not saying the specialties are safe, but in terms of low hanging fruit, EM/HM are the front lines. CCM is there too albeit a bit more difficult. I am not worried about pulm/endo/ID/nephro midlevels at all, 0 market for it.

 

[Splenda88]

Your single center academic setting with residents doesn't generalize to the majority of medicine and it won't matter to the admins anyways who dont let data guide their decisions, only $$.

I am not saying the specialties are safe, but in terms of low hanging fruit, EM/HM are the front lines. CCM is there too albeit a bit more difficult. I am not worried about pulm/endo/ID/nephro midlevels at all, 0 market for it.

You got me there. There are not even a market for these docs. So I am sure they are safe. Lol

My impression is if we go from low hanging fruit to high Gas > EM > CCM > HM

CCM is below HM because 80%+ of what they do can be done by HM... aka open ICU. Not my words here. Those were the words of one our PCCM attendings.

 

[TexasMed22]

You got me there. There are not even a market for these even for docs. So I am sure they are safe. Lol

My impression is if we go from low hanging fruit to high Gas > EM > CCM > HM

CCM is below HM because 80%+ of what they do can be done by HM... aka open ICU. Not my words here. Those were the words of one our PCCM attendings.

Gas > EM > CCM > HM > Hem/Onc ?

 

[Splenda88]

Gas > EM > CCM > HM > Hem/Onc ?

I don't think Hem/Onc is even in that conversation TBH. No one in their right ming would let NP/PA take care of their cancer.

 

[chessknt]

You got me there. There are not even a market for these even for docs. So I am sure they are safe. Lol

My impression is if we go from low hanging fruit to high Gas > EM > CCM > HM

CCM is below HM because 80%+ of what they do can be done by HM... aka open ICU. Not my words here. Those were the words of one our PCCM attendings.

CRNAs cost just as much as full MDs but are less flexible. The current anesthesia crisis is multifactorial but a large part of it was from PE over-reach and hospital admins misreading their financial position when negotiating with providers.

This is what I meant when I was saying that most of HM is blind to market forces outside of their niche of the world. There are so few PP Hm groups so the vast majority don't understand how contracts/hospital economics/high level C suite admins work so their opinion on their own safety is from a place of ignorance. You definitely aren't going to see any of that in training and if you go in to direct hospital employment and never have to sit across the table and see what value added/subsidies are being discussed how are you ever going to understand how they think?

 

[Splenda88]

CRNAs cost just as much as full MDs but are less flexible. The current anesthesia crisis is multifactorial but a large part of it was from PE over-reach and hospital admins misreading their financial position when negotiating with providers.

This is what I meant when I was saying that most of HM is blind to market forces outside of their niche of the world. There are so few PP Hm groups so the vast majority don't understand how contracts/hospital economics/high level C suite admins work so their opinion on their own safety is from a place of ignorance. You definitely aren't going to see any of that in training and if you go in to direct hospital employment and never have to sit across the table and see what value added/subsidies are being discussed how are you ever going to understand how they think?

Well, you certainly know more than I do. I am waiting for the day when hospitalist are supervising 3 NP like anesthesia.

 

[MD46]

I don't think Hem/Onc is even in that conversation TBH. No one in their right ming would let NP/PA take care of their cancer.

We get constant push back from patients to see the doctor only even if we are alternating chemotherapy visits every 2 weeks with the NP.

I have had to clean up loads of messes caused by NPs.

Mid levels have their perks if utilized correctly but I have yet to meet a patient that says they want their cancer treated by the NP even though they may hold their hand for an hour on followup visits and talk about anything but actual medicine :/

 

[CCM-MD]

You got me there. There are not even a market for these even for docs. So I am sure they are safe. Lol

My impression is if we go from low hanging fruit to high Gas > EM > CCM > HM

CCM is below HM because 80%+ of what they do can be done by HM... aka open ICU. Not my words here. Those were the words of one our PCCM attendings.

Wonder why open ICUs keep disappearing if hospitalists can do my job. Weird trend of hospitals going to 24/7 intensivist coverage when hospitalists can do it for cheaper. Wait a second... maybe thats bs.

My last job was in a large metro community hospital where there was a Sound hospitalist program that switched from 2 nocturnists to nocturnist and midlevel, and slowly transitioned to almost half the daytime rounders being midlevels. The medical director "cosigned" all of the midlevel notes. Consult driven trash care with reflex ICU consults for anyone mildly sick. Forget about ICU work, this hospitalist group barely provided adequate care to anyone remotely complicated. From what I hear many other corporate shops are similar.

Regardless, it really doesn't matter who's the "lowest" hanging fruit, we're all low. If I was a med student right now, I would avoid EM/HM/CC/Gas. If I had to pick without considering my interests, it would be: surgical subspecialty > GI > H/O > Cards > A/I = Pulm = Rheum = Endo > ID > Nephro.

 

[Splenda88]

Wonder why open ICUs keep disappearing if hospitalists can do my job. Weird trend of hospitals going to 24/7 intensivist coverage when hospitalists can do it for cheaper. Wait a second... maybe thats bs.

My last job was in a large metro community hospital where there was a Sound hospitalist program that switched from 2 nocturnists to nocturnist and midlevel, and slowly transitioned to almost half the daytime rounders being midlevels. The medical director "cosigned" all of the midlevel notes. Consult driven trash care with reflex ICU consults for anyone mildly sick. Forget about ICU work, this hospitalist group barely provided adequate care to anyone remotely complicated. From what I hear many other corporate shops are similar.

Regardless, it really doesn't matter who's the "lowest" hanging fruit, we're all low. If I was a med student right now, I would avoid EM/HM/CC/Gas. If I had to pick without considering my interests, it would be: surgical subspecialty > GI > H/O > Cards > A/I = Pulm = Rheum = Endo > ID > Nephro.

I guess we (HM, CCM, GAS) are all doomed. I won't even use EM in that conversation because I think their specialty has already gone under.

I dont know that much about the CCM job market. The CCM docs actually got paid well (500-550k) at my shop to see 13-14 patients on average.

I am not sure why he was ranting about open ICU, and the difficulty to find a CCM job in a big city or nice suburb as opposed to HM. He even said he should have done GI because there is no "overlap" (his word) between GI and HM.

Anyway, I believe these specialties are somewhat "safe" for the next 5 yrs which is what I am counting on. If the proverbial [insert] hit the fan before that, I will get boarded in obesity medicine and open my weight loss clinic.

 

[Señor S]

Oncology, and all fields, have been cut in significant ways in the past, esp. private practice with the “AWP+6% for thee, 430B for me” system. Nobody is immune to slumps and I would wager almost all fields are doing worse relatively speaking than 15 years ago

Has that led to a significant decrease in Onc income though? My impression was that average compensation was still up there with Cards/GI, if not above it? Anyone have data showing the trends over time? Regardless, Onc are still the gatekeepers for the whole cancer world, which gives them enormous leverage; I don't see that ever changing.

Well, you certainly know more than I do. I am waiting for the day when hospitalist are supervising 3 NP like anesthesia.

That arrangement already exists at many places and, anecdotally, I think it's becoming more common.

 

[Señor S]

I don't see hospitalists replacing CCM or any return to open ICU on a large scale: airways, managing vents, placing CVLs/ART lines are things that graduating IM residents are less and less comfortable with as the years go by. The issue I see with CCM is midlevels, especially in the form of "critical care fellowship" trained midlevels that seem to be more and more common. If you can get somebody to do those mechanical tasks and write the notes and call the consults then how many MDs do you really need to sit around "thinking about problems"? Those CCM docs in particular that have midlevels alone in-house overnight are doing their field a massive disservice imo; it's doubly absurd given the movement in academic programs away from letting residents cover the ICU alone. Tele-ICU is another thing. The proliferation of alternate CCM pathways (EM, Anesthesia) is yet another issue. Still a better outlook than hospital medicine though.

 

[CCM-MD]

I don't see hospitalists replacing CCM or any return to open ICU on a large scale: airways, managing vents, placing CVLs/ART lines are things that graduating IM residents are less and less comfortable with as the years go by. The issue I see with CCM is midlevels, especially in the form of "critical care fellowship" trained midlevels that seem to be more and more common. If you can get somebody to do those mechanical tasks and write the notes and call the consults then how many MDs do you really need to sit around "thinking about problems"? Those CCM docs in particular that have midlevels alone in-house overnight are doing their field a massive disservice imo; it's doubly absurd given the movement in academic programs away from letting residents cover the ICU alone. Tele-ICU is another thing. The proliferation of alternate CCM pathways (EM, Anesthesia) is yet another issue. Still a better outlook than hospital medicine though.

It’s like saying horse feces is better than dog feces. At the end of the day it’s feces. (Though I do agree with you.)

Things might still be ok for HM/CC/EM/Gas in 10 years, who knows, but the direction things are going is concerning. If I was a student right now and trying to decide on something that I’m going to do for 30 years, I would try to pick something else.

 

[Splenda88]

I don't see hospitalists replacing CCM or any return to open ICU on a large scale: airways, managing vents, placing CVLs/ART lines are things that graduating IM residents are less and less comfortable with as the years go by. The issue I see with CCM is midlevels, especially in the form of "critical care fellowship" trained midlevels that seem to be more and more common. If you can get somebody to do those mechanical tasks and write the notes and call the consults then how many MDs do you really need to sit around "thinking about problems"? Those CCM docs in particular that have midlevels alone in-house overnight are doing their field a massive disservice imo; it's doubly absurd given the movement in academic programs away from letting residents cover the ICU alone. Tele-ICU is another thing. The proliferation of alternate CCM pathways (EM, Anesthesia) is yet another issue. Still a better outlook than hospital medicine though.

Unfortunately admins always come up with ways to save money.

For instance, our hospitalist group manage about 1/2 of the ICU patients (non vented, only one 1 pressor, DKA etc...). I hate it when I see 2-3 of these patients on my list. Instead of them hiring 2 CCM docs to cover ~30 ICU beds, They toss some of them to our hospitalist group.

I raise my concerns in every monthly meeting like me beating a dead horse. The answer I always got is a closed ICU is not gonna happen.

Will see how these specialties survive admins attack in the next 10 yrs.