Such thing as a 9-5 outpatient job after residency?

[nitpel05]

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Hi there!

I am applying to pediatric residencies now, but in the process I have discovered I am confused as to how life works after that.

I am working for a private practice doc this month, and told her I was hoping to go into outpatient peds. I am looking for a 9-5 (or even a part time) sort of job with no inpatient responsibilities. My preceptor made it sound as though no one would insure me without a hospital affiliation. She then quizzed me about what I would do if one of my patients had to be admitted. Just send them to an ER?

Can anyone shed some light on this issue for me? I am clueless regarding insurance stuff. And haven't things changed since the rise of hospitalists? Is the only way to have a truly outpatient practice to be around a hospital with hospitalists?? And how does that relationship work?

Would this 9-5 goal be achievable if I were to subspecialize in say, endocrinology, and open a private practice?

Please help!!! Thanks!

 

[Stitch]

This topic definitely comes up fairly often, so be sure to search for other threads.

The short answer is that there's a huge variation of what's available after residency, and a 9-5 job is certainly possible. And you'd not be expected to know about insurance coverage and things like that at this stage of your career, so don't worry too much yet. As you go through residency, be sure to ask these questions to your attendings and be sure to get good outpatient/community experience.

 

[oldbearprofessor]

Would this 9-5 goal be achievable if I were to subspecialize in say, endocrinology, and open a private practice?

Are you willing to take telephone calls and come in rarely for a new Type 1 diabetic who is admitted? If not, then this would be a challenge to arrange until you are a very senior attending and can have others take the calls for you. But, is it so dislikeable to take some telephone night call and a rare trip to see a patient in the hospital? Pediatric endocrinology does a lot of hospital work, mostly daytime, but not always. If anything, private practice, without residents or fellows would involve more call, not less, in endocrinology.

 

[Sweet Tea]

And haven't things changed since the rise of hospitalists? Is the only way to have a truly outpatient practice to be around a hospital with hospitalists?? And how does that relationship work?

Would this 9-5 goal be achievable if I were to subspecialize in say, endocrinology, and open a private practice?

Even with hospitalists, many pediatricians that don't admit to the hospital still take telephone call for their patients and advise them over the phone. Sometimes there's a nurseline buffer, sometimes not. It depends on how the practice is set up to deal with calls. I should say, however, that this type of call tends to be much more relaxed than call where you have to admit the patient to the hospital and then follow them in the hospital.

In our hospitalist service, a private pediatrician will often call the hospitalist attending directly to admit a patient. Say there's a baby with hyperbilirubinemia requiring phototherapy. The private ped will call the hospitalist, give them the story, and then the hospitalist arranges for a bed and when the patient arrives at the hospital they can bypass the ED and go straight to their room where the phototherapy lights will be waiting. After they have completed phototherapy and are discharged, they then follow up with the private pediatrician. Some of these private peds visit the patient (but can't write orders) in the hospital, most don't. At discharge, we send them a copy of the discharge dictation/hospital summary.

I don't see 9-5 hours without any type of call happening in any subspecialty except for maybe developmental.

 

[BigRedBeta]

I don't see 9-5 hours without any type of call happening in any subspecialty except for maybe developmental.

That's the only thing I can come up with that would be completely quiet overnight, every night.

Peds Rheum, the calls are few and far between but there's still a distinct baseline for phone calls (and possibly the rare admission) during the night and that baseline is not absolutely zero.

Adolescent Medicine in an academic center might be possible though too, depending on how the Section was set up. If you had a dedicated eating disorder attending, that might funnel any overnight calls about admissions to them. I've called late evening (10pm) to one of our sports medicine guys about concussion stuff, but if it had been 2am I'd probably have had the family call in the morning. I did, one time, call the ado attending at 4am for a girl with severe menometorhaggia (yeah, I don't know why she decided to come in at 2:30am after multiple weeks of this going on either), to get their OCP regimen. But again, those are pretty rare things, but not entirely zero either.

Another option is to be General Pediatrics faculty at an academic center and not take any inpatient responsibility. We have a number of general pediatricians that do this. It doesn't happen at my program, but I know that at other places these attendings do keep to their own panel of private patients as well for 2 or 3 half days of clinic a week (if that's something you'd want), and then they attend in resident clinics the other parts of the week. I don't know how they handle calls during the night for their private patients though. Then again, maybe not having ANY private patients works out in that regard. A couple of our Gen Peds attendings run specialty clinics for headaches and asthma (1 or 2 half days a week) which residents aren't involved in as a way to gain some continuity of care. This sort of setup may be difficult to get right out of residency though (the lack of inpatient stuff).

 

[oldbearprofessor]

Okay, I'm not criticizing the OP at all here - they asked a fair question and have gotten polite, reasonable answers, but I would like to ask the question "what's so horrible about taking night call as an attending?"

Now, I realize that in-house night call after age 2,000 years, like neonatologists, etc, do, doesn't appeal to many folks, but really, what's wrong with telephone night call with a RARE need to come in at night (or not). This is the type of call taken by a lot of specialists and general pediatricians. If one is covering a small, quiet service, a night on call might mean an occasional call (0-3 per night), on a busy service a few more. Most folks who are taking night call where they are really being called a lot at night only do that once a week or less (yes, there are exceptions).

Now, I've taken "home" call for a couple decades or more in which I've had kids in the house and none of my kids are the worse for it. Kids mostly sleep through calls/pages or rarely if they are woken up go right back to sleep. I've also taken home call on weekends in which I knew that I had to be available to come into the hospital with only a few minutes notice. Again, my kids and I survived going to nearby places only on those days/evenings. Once and only once was I caught on a weekend afternoon by a rare emergency call and had to drag a kid in to the hospital with me. So, my kid came with and survived in the doctors lounge. I wouldn't have gone anywhere with a baby, but by school age I took some chances like that.

I realize this is harder for single parents, etc, but there are emergency solutions for this - It's not uncommon.

So, with 20 years or so as an attending taking attending calls, I understand the desire to do 9-5 but just don't see telephone call in pediatrics as USUALLY being a big deal - and one can avoid practices, etc in which it was a "big deal."

 

[nitpel05]

Thanks for all of the well thought out replies, and I appreciate that no one flat out laughed at my ignorance! 🙂 I really need to do a rotation at a community hospital. I've only been in the academic setting with residents and academic attendings.

Thank you to the person who pointed out I could be at an academic center and just do outpatient stuff, we do have a few of those at the academic center I'm training at now. That would work for general peds at least, not so much for an academic subspecialist. I suppose for some subspecialties there wouldn't be too many consults/inpatients to follow though. For my learning purposes let's assume I want to go into private/group practice though.

I should clarify first that I'm not opposed to taking telephone calls at night!! I guess that qualifies as more than 9-5 so I see where I was unclear about that...but I just meant where I could be home versus in the office. I was just wondering if a parent calls me and his or her kid is in status asthmaticus (or substitute suspected DKA for the endocrinologist scenario, they are covered in hives and throwing up if I'm an allergist, etc, etc) and I send them to the ER and they are admitted, then what? Would I have to meet them at the hospital and be the admitting attending and round on them daily with the residents? Thank you to the person who posted about hospitalists. I believe he or she answered this question. Then it just becomes an issue of sending them to a hospital with hospitalists, or to an academic medical center? Is that correct? Do most community hospitals have hospitalists now?

Then the final issue becomes, does anyone see an issue with my being insured with such an arrangement?? I've also heard this about trying to practice after just an intern year of training, that yeah technically you have your medical license but no one would insure you. Who are these insurers and where can I find their guide on who they will actually insure for what. 🙂

Thanks again for the help!

 

[DrMed2009]

In our hospitalist service, a private pediatrician will often call the hospitalist attending directly to admit a patient. Say there's a baby with hyperbilirubinemia requiring phototherapy. The private ped will call the hospitalist, give them the story, and then the hospitalist arranges for a bed and when the patient arrives at the hospital they can bypass the ED and go straight to their room where the phototherapy lights will be waiting. After they have completed phototherapy and are discharged, they then follow up with the private pediatrician. Some of these private peds visit the patient (but can't write orders) in the hospital, most don't. At discharge, we send them a copy of the discharge dictation/hospital summary.

This is the system we have in Germany. You either work fully in a practice or fulltime in the hospital. I like it a lot. Here the patients also have a free choice of what hospital they want to go to and there are tons around here in the area I live (major city). As a pediatrican in a practice it is nice cause you dont have to drive around (wouldn't be possible anyway - timewise) but we call to check on patients if it something major.
Also I like the hospitalist system a lot. Since there are always the same docs on the ward there is a good continuity in the care of patient. I think that if there are alot of private pediatricians taking care of the patient in the hospital it can cause problems since some doctors treat differently than others and nurses and staff have always different orders on different kids for the same disease cause everyone does it different.