Need smart person's perspective....Hospitalists vs ER Physician

[Howard7]

Was wondering if we could get some wisdom on this board from past applicants and current residency applicants. If you compare lifestyle, money, vacation, sense of accomplishment etc. What are pros and cons of Hospitalists vs ER physician.

Plus, if you had to compare the two which is a better gig. Thank you to current and previous residency applicants.

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[docB]

It really depend more on what you like. Do you like EM or IM more? The shift work, flexible scheduling and ability to not have a office are similar. The money might be a bit better with EM but even that is really a toss up. Some of the bad parts are the same too. Odd hours, second class status, being a slave to every joint comission and hospital policy that comes along. The difference really comes down to what you want to practice.

 

[elwademd]

It really depend more on what you like. Do you like EM or IM more? The shift work, flexible scheduling and ability to not have a office are similar. The money might be a bit better with EM but even that is really a toss up. Some of the bad parts are the same too. Odd hours, second class status, being a slave to every joint comission and hospital policy that comes along. The difference really comes down to what you want to practice.

agreed, its really more about im versus em.

i'm a hospitalist, almost 2 years out of residency, and bought a house last august... it just so happens one of the doc's in docb's er group was looking in the same neighborhood. he and i have been out of residency about the same length of time... so it would seem to me, at least early on, that the money is similar.

 

[Howard7]

How many patients do you guys see in a typical shift. Also, what are the preceived downsides of each career.

 

[J ROD]

I am curious to see how these two compare as well.....

I will more than likely end up in one of these two....

 

[Rendar5]

How many patients do you guys see in a typical shift. Also, what are the preceived downsides of each career.

ED you're supposedly seeing 2.5 pt's an hour if you work in the community. so that would be 20 in an 8 hr shift and 30 in a 12 hr shift. But honestly they're two completely different types of medicine. EM you deal with the full spectrum of acute, acute on chronic, and occasionally chronic disease in all sexes and all ages, and your main misison is to treat what can be treated, and admit what needs a more extensive work up, extended in-patient treatment, or a variety of processes to be done prior to discharge that require extra time and effort that cannot be done in the ED.

In IM, you deal with dictating the course of treatment, complex diagnostics, determining discharge time, and deal with patients from 18 years on with a complaint that can be treated by you, i.e. not ENT, not surg, not gyn, etc.

 

[dragonfly99]

ER is probably better if you like procedures all right and can deal with some stress/acute illness. It's more protocol driven and you don't do stuff in as much depth.

Hospitalist the hospital wants to use you as much as possible and you tend to get dumped on by other services, like surgeons who want you to admit to IM things like orthopedic stuff, maybe neurosurgical head bleeds, etc. Or so I hear...it will depend on which hospital you end up working in, though. You'll probably deal with more social work issues as a hospitalist...have to figure out how to get people OUT of the hospital rather than just turf them out or in...
ER docs also make more money for less hours, I think.

 

[DSM_302.0]

Interesting thread. Would be interested to see if, years later, anyone else has anything to say *bump*

 

[QofQuimica]

If you're a med student trying to pick a specialty, the best thing is to do rotations in both and see which feels like a better fit for you. There are combined EM/IM programs out there, but most people find that they prefer one of these two specialties over the other. They just tend to attract different kinds of people.

 

[Tri4thlete]

Third year med student here wading through a swamp of information. Anyone in this thread still happy with their choice? Currently debating between hospitalist vs EM. Can't for the life of me decide.

 

[npappasan]

One of my best friends and colleagues is a division president for the largest hospitalist company in the US. He says that hospitalist medicine is the wave of the future and that is where it's at. Median starting salary is like $270K for 12 shifts per month. Not too bad. Hospitalist models are the way practically every hospital is going nowadays. You have to wonder if it will bubble and burst at some point though.

 

[npappasan]

And just to clarify, there are no "hospitalist" training/ residency programs. It is not a specialty, just a job description. Your residency will be in either IM or FP, which is what hospitalist physicians typically are; one or the other. You can train EM and still be a hospitalist theoretically.

 

[J ROD]

I ended up in Psychiatry and completely happy with my choice. However, from what I have seen, it comes down to whether you want to handle "acute" problems and be the gatekeeper of the hospital. Or be the one that manages all the patient's problems and get the out the hospital. Want to be in the front or back?

 

[AdmiralChz]

Third year med student here wading through a swamp of information. Anyone in this thread still happy with their choice? Currently debating between hospitalist vs EM. Can't for the life of me decide.

Really? I don't really see many similarities at all...

ER involves an initial assessment and acute stabilization of a patient (if required) followed by admission vs discharge to follow up. As a hospitalist you take it from there (after stabilization) and work on following up their (often chronic) medical problems. And you get to do the least fun part of intern year everyday, work on discharge planning. Patient getting sicker - kick them up to a higher level of care. 8 to 12 hour ER shifts with the unknown coming through the door vs discrete days with usually the same core patients +/- a couple each day. These two fields are so incredibly different.

Personally I'd rather be raked over hot coals than be a hospitalist, god bless the people willing to put up with that crap everyday. Some more community-based IM programs have a "hospitalist" track and even 6 to 12 month "fellowships" in hospital medicine.

 

[Tri4thlete]

Thanks for the responses! I appreciate the feedback.

Really? I don't really see many similarities at all...

ER involves an initial assessment and acute stabilization of a patient (if required) followed by admission vs discharge to follow up. As a hospitalist you take it from there (after stabilization) and work on following up their (often chronic) medical problems. And you get to do the least fun part of intern year everyday, work on discharge planning. Patient getting sicker - kick them up to a higher level of care. 8 to 12 hour ER shifts with the unknown coming through the door vs discrete days with usually the same core patients +/- a couple each day. These two fields are so incredibly different.

Personally I'd rather be raked over hot coals than be a hospitalist, god bless the people willing to put up with that crap everyday. Some more community-based IM programs have a "hospitalist" track and even 6 to 12 month "fellowships" in hospital medicine.

Haha I get that they are different. I like each job for their own reasons. I guess the main problem is I am the type of person that would really be happy in any specialty. I am currently on my inpatient internal medicine rotation and I'm really enjoying it. I also enjoyed my EM rotation. They each have their own unique perks. I'm having a hard time saying "Hmm could I see myself doing this for 40 years without getting burned out?" and "what is the future like for this specialty?" Getting perspective from people like yall is very helpful!

 

[Siggy]

And just to clarify, there are no "hospitalist" training/ residency programs. It is not a specialty, just a job description. Your residency will be in either IM or FP, which is what hospitalist physicians typically are; one or the other. You can train EM and still be a hospitalist theoretically.

With an unrestricted license to practice medicine, I can, in theory, train in pathology and do neurosurgery. I'm sure there's more IM physicians working in the ED than EM physicians working as hospitalists.

 

[Siggy]

ER involves an initial assessment and acute stabilization of a patient (if required) followed by admission vs discharge to follow up. As a hospitalist you take it from there (after stabilization) and work on following up their (often chronic) medical problems. And you get to do the least fun part of intern year everyday, work on discharge planning. Patient getting sicker - kick them up to a higher level of care. 8 to 12 hour ER shifts with the unknown coming through the door vs discrete days with usually the same core patients +/- a couple each day. These two fields are so incredibly different.

In many hospitals, the IM hospitalist also performs the work of the intensivist (not all hospitals have critical care specialists). As such, the hospitalist is running codes, rapid responses, and performing procedures. The average hospitalist patient is more seriously ill than the average EM patient by virtue by the fact that the ED will filter out the less sick patients. Also, the concept of patient's coming out of the ED being "stable" is questionable when the ED is more concerned with door to admit time than providing adequate medical care.

So, the option is to be a hospitalist and actually get patients better, or be an emergency physician where the question is, "Can this patient be discharged in 2 hours or should I just admit the patient now?"

 

[mvenus929]

And just to clarify, there are no "hospitalist" training/ residency programs. It is not a specialty, just a job description. Your residency will be in either IM or FP, which is what hospitalist physicians typically are; one or the other. You can train EM and still be a hospitalist theoretically.

This is beyond the scope of this discussion, but, that's not strictly true. There are pediatric Hospitalist fellowship programs, mostly intended to dive into the research/leadership/QI stuff that they end up doing on their off service weeks.

 

[Tri4thlete]

So to clarify, you can be EM boarded and then obtain a job as a hospitalist? I thought it was strictly IM, FM docs that could do hospitalist work.

 

[Smurfette]

So to clarify, you can be EM boarded and then obtain a job as a hospitalist? I thought it was strictly IM, FM docs that could do hospitalist work.

Each hospital will determine privileges and their qualifications. They can determine which fields can do what, but also which doctors within a field have the privileges for any given thing. There is no law that you work in the field you are boarded in. If a hospital wants to give someone surgery privileges despite being ER boarded, they can. But it may not work out well...

 

[Danbo1957]

Rarely going to find EM trained doctors on IM wards in acute care hospitals.

 

[Apollyon]

Rarely going to find EM trained doctors on IM wards in acute care hospitals.

Yeah, exactly. The closest I've seen are EM guys that did critical care fellowships, and working as intensivists. I don't even know from nothing about titrating meds.

 

[Arcan57]

Each hospital will determine privileges and their qualifications. They can determine which fields can do what, but also which doctors within a field have the privileges for any given thing. There is no law that you work in the field you are boarded in. If a hospital wants to give someone surgery privileges despite being ER boarded, they can. But it may not work out well...

What could possibly go wrong ? <cuts common bile duct, hepatic vein, and ureter in one jerky motion>

The flow and the work, even the way we arrive at diagnoses is completely different between EM and hospitalists. In general, most of an EM doc's time is going to be spent risk stratifying undifferentiated patients. Also, it most setting you are going to discharge far more people than you admit. The fact is that most physicians train in tertiary/quaternary centers with acuity either stratified by shift (PGY-3 runs resuscitation bay so it seems like they are admitting everyone they see because they are), have significant midlevel support that siphon off the a priori not sick, or use the ED a pseudo direct admit suite for subspecialty transfers. All of these skew the average doc's perspective about what an EM doc actually does. Between artificially high admits rates, the fact that residents as a group make significant mistakes fairly commonly, and mandatory consults for resident "education", it's no wonder EM is viewed as a pass-through service by some. The national admit rate is around 11% and,while it happens, it's uncommon to call specialists in to assist with diagnosis prior to admission in most practice settings. YMMV

 

[TooMuchResearch]

Third year med student here wading through a swamp of information. Anyone in this thread still happy with their choice? Currently debating between hospitalist vs EM. Can't for the life of me decide.

Do you want to be an internal medicine or emergency medicine doctor?

I'm happy with EM (3rd year resident graduating in 6 months). I don't think I would like being a hospitalist, but maybe I would.

I know happy and unhappy hospitalists and emergency docs. Depends on what you like and the job you take.

 

[Perrotfish]

This is beyond the scope of this discussion, but, that's not strictly true. There are pediatric Hospitalist fellowship programs, mostly intended to dive into the research/leadership/QI stuff that they end up doing on their off service weeks.

There are Pediatric Hospitalist fellowship programs, mostly intended to hire Pediatric hospitalists for a third of their free market value.

 

[Perrotfish]

Was wondering if we could get some wisdom on this board from past applicants and current residency applicants. If you compare lifestyle, money, vacation, sense of accomplishment etc. What are pros and cons of Hospitalists vs ER physician.

Plus, if you had to compare the two which is a better gig. Thank you to current and previous residency applicants.

One thing that hasn't been mentioned: IM has a lot more escape valves than ER. IM hospitalist has an endless array of fellowships as well as outpatient clinic available for doctors who realize that 12 hour shifts aren't as compatible with adult life as they thought. ER has the option to work in an urgent care... and a pain management fellowshiop.

 

[CaliforniaAppli]

For me personally , I absolutely abhor ER medicine. I think it is one of worst specialities in terms of satisfaction. It has good hours and pay however. To each their own to those who enjoy it i guess.

Things I hated after my ED rotation during intern year:
1)Frequent rectal exams
2)Never feeling like I was in charge of a patient :seemed like all the other specialties ran the show.
3) never knowing /being involved with what happened to my patients after they were admitted or discharged
4) feels like everyone (patients/other specialties) hates you/looks down on you and judges you for decisions you make.
5) all the patients who come in with benign issues. Felt like a glorified urgent care.
6) frequent rectal exams

Hospitalism does have some similar elements but not to the same degree imo.

 

[ThoracicGuy]

For me personally , I absolutely abhor ER medicine. I think it is one of worst specialities in terms of satisfaction. It has good hours and pay however. To each their own to those who enjoy it i guess.

Things I hated after my ED rotation during intern year:
1)Frequent rectal exams
2)Never feeling like I was in charge of a patient :seemed like all the other specialties ran the show.
3) never knowing /being involved with what happened to my patients after they were admitted or discharged
4) feels like everyone (patients/other specialties) hates you/looks down on you and judges you for decisions you make.
5) all the patients who come in with benign issues. Felt like a glorified urgent care.
6) frequent rectal exams

Hospitalism does have some similar elements but not to the same degree imo.

There's only two reasons not to do a rectal exam.

 

[Siggy]

There's only two reasons not to do a rectal exam.

Patient refusal, rectal exam already documented by the ED?

 

[ThoracicGuy]

Patient refusal, rectal exam already documented by the ED?

1. You don't have a finger.
2. They don't have an anus.

 

[Siggy]

1. You don't have a finger.
2. They don't have an anus.

https://www.ncbi.nlm.nih.gov/pubmed/16394903

 

[racerwad]

One thing that hasn't been mentioned: IM has a lot more escape valves than ER. IM hospitalist has an endless array of fellowships as well as outpatient clinic available for doctors who realize that 12 hour shifts aren't as compatible with adult life as they thought. ER has the option to work in an urgent care... and a pain management fellowshiop.

For the benefit of medical students reading (rather than just being argumentative), there are a number of sub-specialties/fellowships/alternate paths that can get EPs out of the ED.

• EMS
• Ultrasound
• Critical Care
• Palliative Care
• Sports Medicine
• Hyperbarics
• Pediatric EM
• Pain Medicine
• Toxicology
• Wilderness
• Disaster/Austere medicine

ABEM

 

[Siggy]

For the benefit of medical students reading (rather than just being argumentative), there are a number of sub-specialties/fellowships/alternate paths that can get EPs out of the ED.

• EMS
• Ultrasound
• Critical Care
• Palliative Care
• Sports Medicine
• Hyperbarics
• Pediatric EM
• Pain Medicine
• Toxicology
• Wilderness
• Disaster/Austere medicine

ABEM

How many of those offer true paths out of the ED? There aren't very many full time EMS related jobs (well... DC is always hiring). Non-ED ultrasound? Non-ED pediatric EM? Full time disaster or wilderness work?

For the other half, it's almost exactly the opposite of why people go into ED. I simply don't see very many ED physicians wanting to go out and open up a sports medicine clinic.

 

[Rendar5]

How many of those offer true paths out of the ED? There aren't very many full time EMS related jobs (well... DC is always hiring). Non-ED ultrasound? Non-ED pediatric EM? Full time disaster or wilderness work?

For the other half, it's almost exactly the opposite of why people go into ED. I simply don't see very many ED physicians wanting to go out and open up a sports medicine clinic.

Most ED physicians don't want to go into sports medicine in general. I know 2 who did specialize in sports and one just prefers fast track shifts and the other works in a sports medicine clinic. Honestly, the ones that will get you out of the ED full-time are sports, pain, and intensivist medicine in terms of fellowships, and of course you can easily do urgent care (which any broad-based doctor can do). The ones that will get you out of the ED part-time (but still might need to do a couple shifts a month) are toxicology, hyperbarics, and less commonly EMS. The others still leave you in the ED pretty much full-time but with extra academic bent.

 

[Rendar5]

What could possibly go wrong ? <cuts common bile duct, hepatic vein, and ureter in one jerky motion>

The flow and the work, even the way we arrive at diagnoses is completely different between EM and hospitalists. In general, most of an EM doc's time is going to be spent risk stratifying undifferentiated patients. Also, it most setting you are going to discharge far more people than you admit. The fact is that most physicians train in tertiary/quaternary centers with acuity either stratified by shift (PGY-3 runs resuscitation bay so it seems like they are admitting everyone they see because they are), have significant midlevel support that siphon off the a priori not sick, or use the ED a pseudo direct admit suite for subspecialty transfers. All of these skew the average doc's perspective about what an EM doc actually does. Between artificially high admits rates, the fact that residents as a group make significant mistakes fairly commonly, and mandatory consults for resident "education", it's no wonder EM is viewed as a pass-through service by some. The national admit rate is around 11% and,while it happens, it's uncommon to call specialists in to assist with diagnosis prior to admission in most practice settings. YMMV

Well-said. (though I work at a shop with ~38% admission rate, but our average patient is over the age of 80, drops to 5-10% when I work at my free-standing)

 

[Perrotfish]

For the benefit of medical students reading (rather than just being argumentative), there are a number of sub-specialties/fellowships/alternate paths that can get EPs out of the ED.

• EMS
• Ultrasound
• Critical Care
• Palliative Care
• Sports Medicine
• Hyperbarics
• Pediatric EM
• Pain Medicine
• Toxicology
• Wilderness
• Disaster/Austere medicine

ABEM

Wilderness, austere, and disaster medicine are also available to IM/FP/Peds and don't really lead to jobs anyway. I mean I don't doubt there is one guy who got a job off of those fellowships but mostly it seems to land you unpaid positions on committees. They're either hobby degrees or scams, depending on how they're structured.

Non-ortho sports is arguably the most oversaturated field in medicine and is, again, available to IM/Peds/FM. Everyone I know who did this fellowship was able to practice part time at best even coming from the much lower compensated worlds of FM and Peds. I have never seen an ER doctor do it at all.

For an EM doctor EMS, hyperbarics, Ultrasound, and Peds EM are usually skill set expanders. They make you a better doctor but they don't usually change your practice environment, other than being a selling point for a position in academic medicine. Again, I am sure there is at least one guy who is full time hyperbaric medicine, or whatever, but it is not common

That leaves four fellowships that are really ways out of EM: Critical care, pain medicine, palliative care, and toxicology. Tox and palliative involve giant pay cuts, so that really leaves with you with critical care and pain.

So my point was that if you hate hospitalist IM there are a huge array of fellowships leading to a huge variety of practice environments with higher salaries, and for that matter you can move into a number of practice environments very different than hospitalist without even doing a fellowship. With EM you're mostly stuck with EM. Or pain. Or critical care. I should have also mentioned critical care.

 

[Perrotfish]

nvm

 

[Tri4thlete]

Wilderness, austere, and disaster medicine are also available to IM/FP/Peds and don't really lead to jobs anyway. I mean I don't doubt there is one guy who got a job off of those fellowships but mostly it seems to land you unpaid positions on committees. They're either hobby degrees or scams, depending on how they're structured.

Non-ortho sports is arguably the most oversaturated field in medicine and is, again, available to IM/Peds/FM. Everyone I know who did this fellowship was able to practice part time at best even coming from the much lower compensated worlds of FM and Peds. I have never seen an ER doctor do it at all.

For an EM doctor EMS, hyperbarics, Ultrasound, and Peds EM are usually skill set expanders. They make you a better doctor but they don't usually change your practice environment, other than being a selling point for a position in academic medicine. Again, I am sure there is at least one guy who is full time hyperbaric medicine, or whatever, but it is not common

That leaves four fellowships that are really ways out of EM: Critical care, pain medicine, palliative care, and toxicology. Tox and palliative involve giant pay cuts, so that really leaves with you with critical care and pain.

So my point was that if you hate hospitalist IM there are a huge array of fellowships leading to a huge variety of practice environments with higher salaries, and for that matter you can move into a number of practice environments very different than hospitalist without even doing a fellowship. With EM you're mostly stuck with EM. Or pain. Or critical care. I should have also mentioned critical care.

I appreciate the insight and honesty!

 

[npappasan]

This is beyond the scope of this discussion, but, that's not strictly true. There are pediatric Hospitalist fellowship programs, mostly intended to dive into the research/leadership/QI stuff that they end up doing on their off service weeks.

There are hospital based QI "fellowships" for IM and FP also, focused on administrative medicine etc. My response was within the scope of the discussion in that a specific "hospitalist" training program does not exist for someone to be considered for a hospitalist position. No "hospitalist" residency or specific board certification. Sorry if my previous response was vague.

 

[npappasan]

With an unrestricted license to practice medicine, I can, in theory, train in pathology and do neurosurgery. I'm sure there's more IM physicians working in the ED than EM physicians working as hospitalists.

You'd be surprised. I've seen EM guys moonlighting as hospitalists. Your statement is probably correct, hence the "theoretically" in my original post.

 

[mvenus929]

There are hospital based QI "fellowships" for IM and FP also, focused on administrative medicine etc. My response was within the scope of the discussion in that a specific "hospitalist" training program does not exist for someone to be considered for a hospitalist position. No "hospitalist" residency or specific board certification. Sorry if my previous response was vague.

Peds is looking towards board certification in Hospitalist medicine (as a subspecialty to Peds), and it will get harder going forward to get an academic position without the fellowship. My class has four people wanting to do Hospitalist, and two are planning on fellowship. In five years, it may not be such an optional thing anymore.

 

[Trogghunter]

Another thing to keep in mind is how different an academic vs community setting is for both. An ED rotation at a level trauma center is going to be different from the community ER where 95% of patients go for pcp or pain management, the other 5% get admitted.

 

[Perrotfish]

Peds is looking towards board certification in Hospitalist medicine (as a subspecialty to Peds), and it will get harder going forward to get an academic position without the fellowship. My class has four people wanting to do Hospitalist, and two are planning on fellowship. In five years, it may not be such an optional thing anymore.

The ABP can't fill the fellowships they have now. With more than half of pulmonology and ID fellowship positions already unfilled, do you really think a hospitalist fellowship is going to attract enough grads to fill every hospitalist position in the country, and thereby make the fellowship mandatory? Its not like these are terribly attractive jobs in the first place.

People are beginning to realize that Peds fellowships are scams.

 

[mvenus929]

The ABP can't fill the fellowships they have now. With more than half of pulmonology and ID fellowship positions already unfilled, do you really think a hospitalist fellowship is going to attract enough grads to fill every hospitalist position in the country, and thereby make the fellowship mandatory? Its not like these are terribly attractive jobs in the first place.

People are beginning to realize that Peds fellowships are scams.

Oh, I think the Hospitalist fellowship is completely asinine, but it is an official fellowship now. And no, I don't think it will be a requirement for every Hospitalist job, but certainly those at larger hospitals once the fellowship gains momentum.

 

[rokshana]

Oh, I think the Hospitalist fellowship is completely asinine, but it is an official fellowship now. And no, I don't think it will be a requirement for every Hospitalist job, but certainly those at larger hospitals once the fellowship gains momentum.

are they 3 yr fellowships for peds hospitalist? that seems to be a bit extreme...i mean shouldn't a peds residency train you to take care of children inpt?

 

[mvenus929]

are they 3 yr fellowships for peds hospitalist? that seems to be a bit extreme...i mean shouldn't a peds residency train you to take care of children inpt?

It's two years, but yeah. Of all the fellowships, Hospitalist is one that shouldn't exist because you should have more than enough training in residency.

 

[Arcan57]

They are trying to do this for medicine too.

One of my friends was looking for a hospitalist job (after already doing a chief year). The head of the hospitalist program tried to pressure him into doing a hospitalist fellowship saying if he was "serious" about academics he would need it.

My friend politely told him hell no...and then they hired him on for hospitalist job at the attending level with protected time for research.

Considering the difference in pay is greater than >$100k, it's hard to blame the director for trying. Good for your buddy on not falling into that trap.

 

[evilbooyaa]

They are trying to do this for medicine too.

One of my friends was looking for a hospitalist job (after already doing a chief year). The head of the hospitalist program tried to pressure him into doing a hospitalist fellowship saying if he was "serious" about academics he would need it.

My friend politely told him hell no...and then they hired him on for hospitalist job at the attending level with protected time for research.

This sounds like the dumbest thing in the world, both in medicine and pediatrics. Most IM residencies have a majority (or at least 50%) floor months. It's like saying a FM doctor needs a fellowship to run a clinic appropriately.

 

[Gastrapathy]

Hospitalist services lose money. Be wary of any job that provides "value" rather than profit as you will forever be a target of the bean counters.

 

[Psai]

Hospitalist services lose money. Be wary of any job that provides "value" rather than profit as you will forever be a target of the bean counters.

Yeah but when everyone dumps their patients on your service because no one wants to write an H&P, your survival is basically guaranteed.