Makes sense. Don't mean to beat a dead horse but what do you do with this setup when you are on vaca? Say there is an epidural hematoma....even if they can get a hold of you by phone, you are not going to be able to go in and see the patient right?
Exactly. If I get that call at two am, whether I'm in town or not, I,
1-Advise the patient they have signs of an epidural hematoma,
2-Tell them to go to the ER immediately, if they don't have a way to do so, advise them to call 911,
3-Call ahead to the ER, speak to ER physician and tell him patient's name, I suspect a hematoma and that they'll need a stat MRI
4-Write down ER doctors name in EMR immediately from home, write note documenting time and that the ER doctor accepted the patient (which by law he has to anyways, but its still good to document the discussion, name and that you explicitly told him what study is needed in case some other doc gets the patient)
5-Tell them that the patient will need an emergency neurosurgery consult (they know this anyways, but again, document you conveyed this over the phone)
6-Hope the MRI shows nothing
7-Give them my cell phone for any further questions
8-Advise them the patient if admitted would likely need to go to either neurosurgery if MRI is positive, or medicine if its negative and they can't ambulate, or need some other workup or have some other reason for admission.
At this point there's absolutely zero reason for me to go to the hospital. They've go an accepting doctor. The facility has all necessary specialties (neurosurg if surgical, Medicine if some non-surgical nonsense, if all is negative normal and patient's ambulating, they can go home.)
I do chronic pain. If all they have after a negative work up is "chronic" pain, they don't need me seeing them daily in the hospital for something chronic. They can be "chronic" at home. If its anything "acute" or emergent, that's what inpatient hospitalists are for, or those doctors who're on the ER call schedule, of which I'm not.
I spent 10 yrs as an ER physician. I know how the system works. The inpatient physicians have zero use for me as long as I'm available and helpful over the phone. Also, they're required by the law, as ER physicians and physician specialists on the ER call schedule, to treat and stabilize the patient. They cannot demand anyone else come in on an emergent basis that's not on the ER call schedule.
Of course if you want to go in and see your patient, and you have privileges, or you want to see them as a courtesy consult as a positive patient related thing, or you do a lot of inpatient work or are required to, than that's different. But if you set up your practice as outpatient only, then you're
outpatient only.
An analogy would be to that of internists, some of whom do outpatient only and whose admitted patients are taken care of by hospitalists when admitted, versus the old school internists who do both, because they
choose to do both. Doing both is a much harder life and career. Do it if you want, but if you don't want to, it's all in how you set it up.
I've done enough acute, high intensity, emergent inpatient medicine that I've had my fill and have no desire for the long sleepless nights, blown circadian rhythms leading to chronic sleep deprivation and chronic jet-lagged feeling and basic unnecessary misery. I'm very happy with my boring, yet very stable and predictable outpatient life, especially since I've had my fill of the crazy, the chaos and the acute.
In summary, it doesn't matter if I'm 2 miles from the hospital or in Jamaica on vacation, because I'm not going into the hospital either way. Cell phone's are a beautiful thing. In fact, I was just in Jamaica on vacation this week for 6 days, and I'm on day 8 of vacation. I've gotten zero phone calls and only 1 work email that required me doing anything. One final thing: As a back up, there are 3 family medicine docs and 2 fam med PAs in my office, that if push came to shove and I needed them to see a patient for a quick script or something, I could call them and have them work a patient in. But in 3.5 yrs I haven't had to do that. Anyone that needs an Rx is brought in early, pre-my vacations and I don't do any big procedures like stim trials or kypho's right before I leave, to avoid issues like lead remove, or complication's from more significant procedures.
It just works. And it's great. I have Derm hours.
