New to FM - how common are hybrid inpatient/outpatient practice setups?

[PuffBlueCat]

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Hello all - 4th year DO student here, making the 11th hour switch to applying FM instead of psychiatry. One aspect that I was looking forward to about psych is how common it is to "job cobble," and work a mix of say inpatient in the mornings, then outpatient PP/other employment in the afternoons and on my weeks off from inpatient. I understand this setup for FM is less common in general, and harder to find in big cities (which is okay with me, as I plan to practice in a rural setting).

I was wondering: in general, what are the different options for an FM doctor to get a mix of inpatient and outpatient? Is this what "traditional" FM practice is like? How common is this setup in the rural areas around the great lakes (i.e. rural MN, WI, MI)?

I also have an interest in building my own private practice (probably DPC), which I understand would make more sense in a bigger urban/suburban area.

Ideally, I envision myself in a 50/50 or 60/40 inpt/outpt mix initially out of residency, and over the next 10 years or so transitioning to eventually 20/80 or 100% outpatient, along with a mix of nursing homes or potentially hospice. Are all these ideas compatible, or does it sound like I'm trying to do too much? I'd love to hear any and all input, and hopefully get an updated discussion on this topic.

 

[Sardonix]

I understand this setup for FM is less common in general, and harder to find in big cities (which is okay with me, as I plan to practice in a rural setting).

True

How common is this setup in the rural areas around the great lakes (i.e. rural MN, WI, MI)?

Decently easy to find. From what my coresidents have found, it's mostly in smaller towns or critical access hospitals that keep relatively simple COPD, DM, pneumonia, CHF etc. They tend to ship anything requiring a vent, procedure, insulin drips to the bigger houses due to need for specialty input as well as more regular RN support. RNs at smaller facilities certainly try and and can be capable... but the staffing support just is not there to facilitate the high intensity monitoring, changes, or managing when **** goes south.

These facilities also tend to have decent mixes of outpatient/inpatient--either with dedicated rounders for a week (Ex: one person rounds on everyone in the hospital for the week for X number of weeks per year) vs being on hospital call while also seeing patients in clinic. Depending on the setup and numbers, either situation can be chill or stressful AF.

That said, I will point out that in bigger towns/smaller cities (let alone big cities) this kind of mix in the midwest is less and less common. The drag on inboxes and the complexity/intensity of clinic combined with higher numbers of increasingly sick and old admitted patients means you are taking on maximal amount of stress of both environs without the benefits. My hospitalist friends get destroyed while working, but they head home without an inbox. Me and my outpatient friends may take out inbox home, but at least we don't get hammer paged constantly and deal with the intense acuity the hospital does.

I also have an interest in building my own private practice (probably DPC), which I understand would make more sense in a bigger urban/suburban area.

A fine goal, but I would guess that this'll make you chances of inpatient very low. Big hospitals would rather shunt inpatients to their outpatient clinics rather than lose money to you. Likewise, they may simply refuse to credential you due to being competition or because they'd rather not deal with the logistics. I've seen several posts online of private solo practitioners have good gigs in their area for years... only to go down the toilet when the local hospital gets bought out or decides to stop playing nice.

The one DPC advocate I've spoken to who said he could make it work was an assistant faculty at an FM residency who was essentially taking advantage of the FM inpatient service to get his DPC clinic patients taken care of without losing them to the hospital they worked out of. When I asked him to explain how his situation was at all transferrable to anyone who didn't have the ability to openly exploit resident labor he didn't have much to say. Called him a hypocrit and walked out of the evangelist DPC lunch he was hosting (that no one at our program asked for).

Ideally, I envision myself in a 50/50 or 60/40 inpt/outpt mix initially out of residency, and over the next 10 years or so transitioning to eventually 20/80 or 100% outpatient, along with a mix of nursing homes or potentially hospice. Are all these ideas compatible, or does it sound like I'm trying to do too much?

In my experience I would say you are trying to do too much especially if you want to raise a family, not work 80hr work weeks etc. But that depends on what your life goals are. There are indeed some doctors still working full spectrum in small towns holding down the ED, inpatient, OB, and clinic life while also doing NH work or even medical examiner positions. They do NOTHING but work and also tend to have been grandfathered in from an older time or are a product of a system that has no other option. But if that's truly the goal, go for it.

 

[VA Hopeful Dr]

True



Decently easy to find. From what my coresidents have found, it's mostly in smaller towns or critical access hospitals that keep relatively simple COPD, DM, pneumonia, CHF etc. They tend to ship anything requiring a vent, procedure, insulin drips to the bigger houses due to need for specialty input as well as more regular RN support. RNs at smaller facilities certainly try and and can be capable... but the staffing support just is not there to facilitate the high intensity monitoring, changes, or managing when **** goes south.

These facilities also tend to have decent mixes of outpatient/inpatient--either with dedicated rounders for a week (Ex: one person rounds on everyone in the hospital for the week for X number of weeks per year) vs being on hospital call while also seeing patients in clinic. Depending on the setup and numbers, either situation can be chill or stressful AF.

That said, I will point out that in bigger towns/smaller cities (let alone big cities) this kind of mix in the midwest is less and less common. The drag on inboxes and the complexity/intensity of clinic combined with higher numbers of increasingly sick and old admitted patients means you are taking on maximal amount of stress of both environs without the benefits. My hospitalist friends get destroyed while working, but they head home without an inbox. Me and my outpatient friends may take out inbox home, but at least we don't get hammer paged constantly and deal with the intense acuity the hospital does.



A fine goal, but I would guess that this'll make you chances of inpatient very low. Big hospitals would rather shunt inpatients to their outpatient clinics rather than lose money to you. Likewise, they may simply refuse to credential you due to being competition or because they'd rather not deal with the logistics. I've seen several posts online of private solo practitioners have good gigs in their area for years... only to go down the toilet when the local hospital gets bought out or decides to stop playing nice.

The one DPC advocate I've spoken to who said he could make it work was an assistant faculty at an FM residency who was essentially taking advantage of the FM inpatient service to get his DPC clinic patients taken care of without losing them to the hospital they worked out of. When I asked him to explain how his situation was at all transferrable to anyone who didn't have the ability to openly exploit resident labor he didn't have much to say. Called him a hypocrite and walked out of the evangelist DPC lunch he was hosting (that no one at our program asked for).



In my experience I would say you are trying to do too much especially if you want to raise a family, not work 80hr work weeks etc. But that depends on what your life goals are. There are indeed some doctors still working full spectrum in small towns holding down the ED, inpatient, OB, and clinic life while also doing NH work or even medical examiner positions. They do NOTHING but work and also tend to have been grandfathered in from an older time or are a product of a system that has no other option. But if that's truly the goal, go for it.

There were two big peds groups when I was in med school that did similar, except they had someone rounding every single day with the residents.

 

[Sardonix]

There were two big peds groups when I was in med school that did similar, except they had someone rounding every single day with the residents.

Welp, good thing that won't be a thing anymore now that pediatrics requires new grads to have a hospitalist fellowship to do inpatient.

I thank god that ABFM/AAFP don't pull that kind of crap.

 

[PuffBlueCat]

True



Decently easy to find. From what my coresidents have found, it's mostly in smaller towns or critical access hospitals that keep relatively simple COPD, DM, pneumonia, CHF etc. They tend to ship anything requiring a vent, procedure, insulin drips to the bigger houses due to need for specialty input as well as more regular RN support. RNs at smaller facilities certainly try and and can be capable... but the staffing support just is not there to facilitate the high intensity monitoring, changes, or managing when **** goes south.

These facilities also tend to have decent mixes of outpatient/inpatient--either with dedicated rounders for a week (Ex: one person rounds on everyone in the hospital for the week for X number of weeks per year) vs being on hospital call while also seeing patients in clinic. Depending on the setup and numbers, either situation can be chill or stressful AF.

That said, I will point out that in bigger towns/smaller cities (let alone big cities) this kind of mix in the midwest is less and less common. The drag on inboxes and the complexity/intensity of clinic combined with higher numbers of increasingly sick and old admitted patients means you are taking on maximal amount of stress of both environs without the benefits. My hospitalist friends get destroyed while working, but they head home without an inbox. Me and my outpatient friends may take out inbox home, but at least we don't get hammer paged constantly and deal with the intense acuity the hospital does.



A fine goal, but I would guess that this'll make you chances of inpatient very low. Big hospitals would rather shunt inpatients to their outpatient clinics rather than lose money to you. Likewise, they may simply refuse to credential you due to being competition or because they'd rather not deal with the logistics. I've seen several posts online of private solo practitioners have good gigs in their area for years... only to go down the toilet when the local hospital gets bought out or decides to stop playing nice.

The one DPC advocate I've spoken to who said he could make it work was an assistant faculty at an FM residency who was essentially taking advantage of the FM inpatient service to get his DPC clinic patients taken care of without losing them to the hospital they worked out of. When I asked him to explain how his situation was at all transferrable to anyone who didn't have the ability to openly exploit resident labor he didn't have much to say. Called him a hypocrite and walked out of the evangelist DPC lunch he was hosting (that no one at our program asked for).



In my experience I would say you are trying to do too much especially if you want to raise a family, not work 80hr work weeks etc. But that depends on what your life goals are. There are indeed some doctors still working full spectrum in small towns holding down the ED, inpatient, OB, and clinic life while also doing NH work or even medical examiner positions. They do NOTHING but work and also tend to have been grandfathered in from an older time or are a product of a system that has no other option. But if that's truly the goal, go for it.

Thank you for the detailed response - I appreciate you taking the time. Sounds like my suspicions were correct on wanting to do too much. I think I have some good ideas, but it's probably better to wait until I’m in residency to really narrow down my interests. I definitely don’t want to work 80hrs/week lol and it sounds like the DPC idea likely wouldn’t be compatible with an inpatient position, which makes sense. I suppose if I was running my own DPC, I wouldn't want to split my responsibilities, and focus my time on running the business.

 

[InternistDO]

You could easily split your time if you work academics, even in a big city. My hospital is always desperate for FM attendings to staff the FM service, for example.

Geriatrics is another option to do a mix of inpatient (+/- nursing homes or consults) and outpatient.

Doing a DPC or regular private practice while rounding...if you're gonna work 80/hrs a week and not see your kids you might as well have done neurosurgery and make some money in the process.

 

[PuffBlueCat]

I love the idea of academics, however I really don't think I can justify the decreased compensation given the amount of loans I will graduate with, which sucks. I know PSLF exists (for now), but I don't think that'd be the right option for me.

 

[Sardonix]

I love the idea of academics, however I really don't think I can justify the decreased compensation given the amount of loans I will graduate with, which sucks. I know PSLF exists (for now), but I don't think that'd be the right option for me.

Could also use the first couple years as an attending (if not starting your own practice) to work down those loans some. Then once more manageable or even gone, consider transitioning to academic position if skills still allow for doing so.

Likewise remember if you are starting your own practice, you will likely be operating in the red for the first 2-4yrs. You have to plan for that. By comparison an academic position isn't so poorly paid and is much more stable. That said, if the goal is absolutely your own practice, many people have been successful doing so.

 

[PuffBlueCat]

Could also use the first couple years as an attending (if not starting your own practice) to work down those loans some. Then once more manageable or even gone, consider transitioning to academic position if skills still allow for doing so.

Likewise remember if you are starting your own practice, you will likely be operating in the red for the first 2-4yrs. You have to plan for that. By comparison an academic position isn't so poorly paid and is much more stable. That said, if the goal is absolutely your own practice, many people have been successful doing so.

Good points - that is about what I was thinking also. Working in an employed role (probably in an underserved area), and paying off my loans aggressively the first few years. I have to get myself to a better point financially before starting my own practice, or transitioning to academics. I am very wary of the 'golden handcuffs' phenomenon, and I'm afraid I'm at high risk of toughing it out in a less than stellar environment because of the finances lol

We'll see what happens. In general, I have just tried following my interests as best I can, and things have worked out well so far!

 

[InternistDO]

I love the idea of academics, however I really don't think I can justify the decreased compensation given the amount of loans I will graduate with, which sucks. I know PSLF exists (for now), but I don't think that'd be the right option for me.

Depending on your geographic area, academics (assuming you aren't talking about super academic like U Penn or Columbia) may pay fairly close to the local group/PP salaries. Not saying you definitely should do it, but just do some looking around when you're job searching. Often when people say academics pays poorly they mean ivory tower programs. A smaller program, especially in FM, may give you a decent salary while still giving you the flexibility of an academic program (or PSLF access, for example).

I'm an internist but I probably make about the same in my academic practice as I would with a local PP. If I spent all my time in resident clinic instead of doing some other stuff that interests me I'd probably make more.

But it's not for everyone and definitely you'd make the most doing locums or more rural type work if you want to try and get the loans down quickly

 

[PuffBlueCat]

We’re talking around the great lakes (MN, WI, MI), so any position is primarily going to be with a community FM residency program. I always just assumed “academics” just paid terribly across the board, but makes sense to hear there’s more variability than I assumed. Good to know. At this point after graduation, I’m thinking I stay/go more rural, live like a resident and pay off the loans aggressively, and at that point I’ll decide if I make the transition to academics or PP or something.

One aspect of FM I find attractive is the variety/flexibility in work settings/situations!