Thoughts on Inpatient Rehab Jobs?

[DRacula]

I am posting this to hear thoughts from anyone who is practicing in a non-academic inpatient rehab facility.

I'm graduating this summer and have been primarily looking for outpatient positions, but I am finding that it is much easier to find inpatient positions. Is that because no body wants to fill them or is it because they are better marketers? When doing rotations, my goal was to find what I ENJOYED doing... I enjoyed being with my patients and I enjoyed my outpatient rotations. But now I'm second-guessing what I know about inpatient since all I've seen up to now is inpatient at my residency which is obviously an academic hospital with residents and attendings.

Any thoughts on what life is like for the non-academic inpatient physician?

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[RUOkie]

IMO,
Primarily inpt rehab = death by boredom and hospital administrator.

 

[SSdoc33]

i would sooner be a bricklayer than work in an inpatient facility, but people do it and people like it.

 

[PMR 4 MSK]

There are so many inpt jobs because no one wants to do it. Many are employed positions meaning no incentives to do well, but lots of pressure from admin to admit. You are on call either for your own pts 24/7 or split call with partners. You typically have 7d/week work.

You'll mostly be doing inpt E&M on Medicare patients, generating about $75/pt per day. You'll still need someone to do your billing, unless you are salaried. And if you have an outpt clinic also, it will be generating bills for you to pay while you are away, without generating income.

You'll get nurses and managers who see you as someone who increases their workload, but not their pay. They will point the finger at you when things go wrong, and take credit for things going well.

You'll have referring physicians who see you as a professional baby-sitter. They'll get mad when you won't admit a febrile CHF patient or a TKA who appears to have thrown a clot to her lungs this morning.

On top of this, you have the pleasure of dealing with one of the most vile creatures in all of existence, the hospital CEO. They will pretend to be your friend. They are all chummy, handshakes and smiles. They'll even smile as they are presenting you with the data of how much money you are costing the hospital in salary, supplies, services that go unpaid, and how they want you to "do a better job" this quarter. And when you need something, "We'll see if we have the budget for it next year."

Other than that, it's a great gig!

 

[fyfanatic]

I know the OP was asking about non-academic rehab facility but why not do inpatient rehab in a hospital where you have residents who basically do a lot of the work? And that way you will have time to do outpatient clinic in the afternoons for example, while the resident takes care of the inpatients for you.

 

[RUOkie]

I know the OP was asking about non-academic rehab facility but why not do inpatient rehab in a hospital where you have residents who basically do a lot of the work? And that way you will have time to do outpatient clinic in the afternoons for example, while the resident takes care of the inpatients for you.

First of all, an attending physician can only bill for what they actually did. The idea that the residents do all the work, and the attending bills for the visit is what got so many academic medical centers in trouble in the mid to late 90's (see CMS v. U. Penn faculty practice plan- or whatever the fraud case was called)

Secondly, most "inpatient" docs also have outpt. clinics. When I used to run a 24 bed rehab unit in a private practice Level 1 trauma center, I had office hours from 10am to 4:30pm. I was at the hospital by 6am and was NEVER home before 7pm. (usually 8-9). I was worked to death. I made good $$, but never had any time to spend it since I was so tired all the time.

Then the CFO of the hospital fired me by telegram on the day of the Level 1 trauma survey because of a dispute over $10K/yr of medical directorship stipend. (I was rehired the next day when the CEO found out what happened)

Hospital administrators are vultures.

 

[bedrock]

There are so many inpt jobs because no one wants to do it. Many are employed positions meaning no incentives to do well, but lots of pressure from admin to admit. You are on call either for your own pts 24/7 or split call with partners. You typically have 7d/week work.

You'll mostly be doing inpt E&M on Medicare patients, generating about $75/pt per day. You'll still need someone to do your billing, unless you are salaried. And if you have an outpt clinic also, it will be generating bills for you to pay while you are away, without generating income.

You'll get nurses and managers who see you as someone who increases their workload, but not their pay. They will point the finger at you when things go wrong, and take credit for things going well.

You'll have referring physicians who see you as a professional baby-sitter. They'll get mad when you won't admit a febrile CHF patient or a TKA who appears to have thrown a clot to her lungs this morning.

On top of this, you have the pleasure of dealing with one of the most vile creatures in all of existence, the hospital CEO. They will pretend to be your friend. They are all chummy, handshakes and smiles. They'll even smile as they are presenting you with the data of how much money you are costing the hospital in salary, supplies, services that go unpaid, and how they want you to "do a better job" this quarter. And when you need something, "We'll see if we have the budget for it next year."

Other than that, it's a great gig!

Nice summary!

 

[Louisville04]

There are so many inpt jobs because no one wants to do it. Many are employed positions meaning no incentives to do well, but lots of pressure from admin to admit. You are on call either for your own pts 24/7 or split call with partners. You typically have 7d/week work.

You'll mostly be doing inpt E&M on Medicare patients, generating about $75/pt per day. You'll still need someone to do your billing, unless you are salaried. And if you have an outpt clinic also, it will be generating bills for you to pay while you are away, without generating income.

You'll get nurses and managers who see you as someone who increases their workload, but not their pay. They will point the finger at you when things go wrong, and take credit for things going well.

You'll have referring physicians who see you as a professional baby-sitter. They'll get mad when you won't admit a febrile CHF patient or a TKA who appears to have thrown a clot to her lungs this morning.

On top of this, you have the pleasure of dealing with one of the most vile creatures in all of existence, the hospital CEO. They will pretend to be your friend. They are all chummy, handshakes and smiles. They'll even smile as they are presenting you with the data of how much money you are costing the hospital in salary, supplies, services that go unpaid, and how they want you to "do a better job" this quarter. And when you need something, "We'll see if we have the budget for it next year."

Other than that, it's a great gig!

I have seen places where hospitals have one floor dedicated to acute rehab. The hospitalist is usually abe to cover for weekends. Some physiatrists don't write notes on weekends.

Acute rehab facilities can also pick and choose who they want to admit (unlike hospitals). Lots of times the decision to accept/deny is based on insurance and expected costs (i.e. requiring TPN, dialysis, etc) and the rehab administrators have a lot of input on that.

When I first started, I thought the CEO of the hospital was a real nice guy

 

[drusso]

Dude, That is the best, most accurate picture of "the real world" I've read in a long time! Kudos!

 

[jsaul]

i have a friend from residency who makes $300,000 plus per year doing inpt rehab. He takes one weekend call per month to round. otherwise the rest of his weekends are free. He does primarily inpt rehab-- he does a little emg and a small outpt clinic as well but his weekday hours are 730-530....He is happy and plenty of time for fun--- he lives in vegas

 

[RUOkie]

i have a friend from residency who makes $300,000 plus per year doing inpt rehab. He takes one weekend call per month to round. otherwise the rest of his weekends are free. He does primarily inpt rehab-- he does a little emg and a small outpt clinic as well but his weekday hours are 730-530....He is happy and plenty of time for fun--- he lives in vegas

I know a guy who does that as well just outside of Houston. He has been at it for 15 yrs and is now bored silly. He pushes paper and babysits for a living. It is a good living though. He is Med director or consultant at 3 rehab units.

The problem is that now, after 15 yrs of this, he no longer has the skills to do anything else. If the government changes the rules (which they are prone to do), He will be SOL.

 

[Louisville04]

i have a friend from residency who makes $300,000 plus per year doing inpt rehab. He takes one weekend call per month to round. otherwise the rest of his weekends are free. He does primarily inpt rehab-- he does a little emg and a small outpt clinic as well but his weekday hours are 730-530....He is happy and plenty of time for fun--- he lives in vegas

I know a guy who does that as well just outside of Houston. He has been at it for 15 yrs and is now bored silly. He pushes paper and babysits for a living. It is a good living though. He is Med director or consultant at 3 rehab units.

The problem is that now, after 15 yrs of this, he no longer has the skills to do anything else. If the government changes the rules (which they are prone to do), He will be SOL.

I think making 300k/year in big cities (Vegas, Houston) is not the norm. I started out in the Chicago area and most of the facilities were closed rehab units (you either work for the facility/hospital or don't get privileges). There was quite a bit of turnover (you work too hard for too little pay),

The government did change the rules for acute rehab (90% rule) where they limited the number of joint replacements that could be admitted. That pushed a lot of physiatrists to subacute units (nursing homes). I did that for a while and hated it. You are like a med student. You write notes that no one reads

 

[DRacula]

This was super helpful! I think I always knew in my heart I wasn't interested in inpatient practice... this just solidified my justifications. Thanks a bunch!

 

[Jumpu]

I currently work as an inpt attending in a pseudo private practice setup with 8 beds (stroke, BI). Other parts of my day are filled by clinic (BI, concussion, msk, emg, spasticity management), day rehab clinic, and hospital consults. In addition to this, I also have residents who keep me on my toes and I get to do some teaching as well.

I *absolutely* love my job! I get best both worlds and although i am on a guarantee salary at the moment, i expect to do well on this current schedule, $200-300 K, in the chicago suburbs. I work from 7:45 to ~5 pm (can be plus/minus 1hr...came home today at 4pm).

 

[SSdoc33]

I currently work as an inpt attending in a pseudo private practice setup with 8 beds (stroke, BI). Other parts of my day are filled by clinic (BI, concussion, msk, emg, spasticity management), day rehab clinic, and hospital consults. In addition to this, I also have residents who keep me on my toes and I get to do some teaching as well.

I *absolutely* love my job! I get best both worlds and although i am on a guarantee salary at the moment, i expect to do well on this current schedule, $200-300 K, in the chicago suburbs. I work from 7:45 to ~5 pm (can be plus/minus 1hr...came home today at 4pm).

big difference between 200 and 300k. and if you dont "know" your salary, it will be 200k. if you love it, i suppose it doesnt matter. how long have you been at this job, if you dont mind me asking?

 

[Jumpu]

big difference between 200 and 300k. and if you dont "know" your salary, it will be 200k. if you love it, i suppose it doesnt matter. how long have you been at this job, if you dont mind me asking?

There are several reasons for my nebulous answer:

1. There are residents who know me who frequent this forum and it's seems rather gauche to discuss it in front of them.

2. Right now I'm on a guarantee salary (graduated in july) and I can only estimate at this point because:

-Still building my outpt practice
-depends on how much coverage I provide to my partners, by choice
-depends on how much I wish to take on, certainly there are those in my group who are well above $500k

Secondly I know the difference between the two numbers is 100k, but in actuality, my life would not change tremendously, (my savings might). Still drive a nice car, still live in a nice house and can provide nice things to my family.

I just want another prospective provided on this forum. I find the world on sdn often skewed toward one prospective. Let me say once more, I *love* my job. Not a thing like brick laying.

 

[jsaul]

There are several reasons for my nebulous answer:

1. There are residents who know me who frequent this forum and it's seems rather gauche to discuss it in front of them.

2. Right now I'm on a guarantee salary (graduated in july) and I can only estimate at this point because:

-Still building my outpt practice
-depends on how much coverage I provide to my partners, by choice
-depends on how much I wish to take on, certainly there are those in my group who are well above $500k

Secondly I know the difference between the two numbers is 100k, but in actuality, my life would not change tremendously, (my savings might). Still drive a nice car, still live in a nice house and can provide nice things to my family.

I just want another prospective provided on this forum. I find the world on sdn often skewed toward one prospective. Let me say once more, I *love* my job. Not a thing like brick laying.

thanks for your response. As I said earlier in this thread people can make a real good living doing primarily inpt rehab.

 

[LiveToday]

Tigermom, I really like what your work entails, especially regarding the various aspects of PM&R you are practicing, including MSK, EMG. I think that I would love to do some inpatient as well as outpatient MSK, EMG, possibly U/S, as I enjoy all of them, but feel a bit ambivalent when I hear from some people that it is extremely difficult to maintain/improve your skillset if one has a 'broad' practice as opposed to the much narrow practice, such as doing solely inpatient versus outpatient. Are you fellowship trained? Was it difficult to look for a job of similar description in terms of region / availability? It sounds like you are in a multi-PM&R group, is it private or academic?

 

[Jumpu]

Tigermom, I really like what your work entails, especially regarding the various aspects of PM&R you are practicing, including MSK, EMG. I think that I would love to do some inpatient as well as outpatient MSK, EMG, possibly U/S, as I enjoy all of them, but feel a bit ambivalent when I hear from some people that it is extremely difficult to maintain/improve your skillset if one has a 'broad' practice as opposed to the much narrow practice, such as doing solely inpatient versus outpatient. Are you fellowship trained? Was it difficult to look for a job of similar description in terms of region / availability? It sounds like you are in a multi-PM&R group, is it private or academic?

Interestingly I was asked by one of my partners yesterday who is focused in peds rehab what my specialty interest was. I told her I had a broad practice and right now was interested in keeping it that way. That could change in the future, who knows?

I am not fellowship trained, so I am constantly learning on the job. Which makes for an interesting day, I am always surprised and challenged by my patients. And again, it's what keeping me engaged and excited about my work.

I'll be honest, when I was job hunting initially, I thought I would only do outpt msk, emg with consults, sharing call for inpt stuff. At the behest of multiple msk outpt mentors in my residency, they said to look at inpt as well, as a means of financing my interests in developing my outpt practice. I'm happy that I did, because I enjoy inpt now more than I did in residency with the reduced number of beds I have. Since inpt is financially lucrative, I get to spend more time in clinic with pts, 60 min for new evals, 30 min followup. My pts appreciate the time and attn I give them, and I feel I have done a thorough job. Later I may whittle the time down, as I become more efficient and confident.

When I job hunted with the broad things I was willing to do, I found there were more opportunities available.

I am in a group of PM&R docs, it is private I guess, but we have residents, and I am one the teaching attendings there. I do some minor research projects as well, which are being held up a little while I study for oral boards now.

 

[PhysiatristDoc]

This is a good thread for new grads. I wish I had some of this advice a few years ago.

Inpatient billings are based on E&M, but you can help your patients if you do joint injections, and sometimes EMG if the insurance allows, and this increases billings a little. Mandatory overhead for a purely inpatient practice is your malpractice insurance, and your billing company or biller's salary - this comes to about 10-20% in your first year. Your medical/dental/disability is above this, you can look into getting COBRA from residency initially.

Outpatient practices often have overhead as high as 50% or beyond because of rent, assistants, reception, charts, EMR, equipment, consumables.... and the above mentioned malpractice insurance. This is why it is sometimes helpful to have some inpatient work in a purely PM&R practice. The inpatient and hospital consult follow ups also feed the practice.

If you don't like inpatient and you can move anywhere, look for ortho or neurosurgery groups to join because they will feed you all the outpatient cases you can wish for (and also some that you didn't wish for, but hopefully it will balance out). Surgeons generally are happy to leave the non surgical stuff to someone else. Most of the people I know who took jobs like this are very happy. Make sure to have a clause in your contract that allows you to see your actual performance so you can negotiate down the road. Most neuro and ortho surgeons make double to triple what PM&R makes so they tend not to be stingy with PM&R docs.

I also know of many people who work in large PM&R practices, partnership models where the docs become real owners on paper are usually better than RVU models where one or two guys own the place and pay you for performance based on some secret recipe of herbs and spices. The PM&R only practices need referrals so are usually linked to inpatient work.

To sum it up, if I could not go out on my own, I would only join a surgeons group, or a true partnership PM&R group. I would not dwell too much on the outpatient only vs mix of in and outpatient work because if the group is well run and there is enough work, you can always transition to outpatient only down the road when you are productive enough for the group to hire out your inpatient work.

 

[LiveToday]

Thank you all for sharing your thoughts/input. As PhysiatristDoc mentioned, our residents also don't get a whole lot of advice about private sector from the mostly academic attendings in our program, and it's great to hear different perspectives from the currently practicing docs.

In our program and certainly within my class as well, the concensus of desirable future practice appears to be either mix inpt/outpt or outpt after fellowship, with almost none of the residents looking for solely inpatient, but many of us sometimes get apprehensive when we start thinking about the actual (potential?) jobs that exist out there.

 

[Xardas]

sorry to necro t he thhread but thought i'd weigh in as someone who has been practicing for a while.

i'm ~7 yrs out from a good residency program. did academics for a few years which included inpt, outpt, emg, a little botox, teaching.

i got real burned out on teaching and the wild swing in resident quality; i was at a well ranked PMR program as well but going from great residents to mediocre residents who couldn't carry their weight was a problem, as well as the very low pay from the institution.

i'm now a medical director of an inpatient rehab unit in a moderate sized city. my patient load is 15-22. income for me is good. i don't want to say exactly but i am north of $200k.

I'm also an employed doc. They treat me well here at my hospital. I am one of the lucky ones; not all employees ahve good relationships with their COO and CEO, as well as the various managers etc.

i work once every 3-4 weekends and choose whetehr to round on sunday or not when i am on. maybe 1-2 admissions per weekend. i take phone call once a week on the weekdays. i do outpatient some and have been appraoched about ramping up emg, baclofen pump, botox but have not really done that as my unit takes most of my time.

do i enjoy what i do? yes mostly. the changes in healthcare are scary but will affect everyone not just us. i'm good at what i do in inpt rehab as well as most of other aspects of PMR. I don't do injections though, no interest, never really had the desire.

for some ppl inpt rehab is horribly boring and when i was faculty i'd tell my residents that if you think that way too just do the work to the best of your ability and know its not for you. its not for everyone but if you likei t don't be ashamed of it. if you don't like it don't do it, even to 'diversify' yourself. its kind of like me with the injections/spine stuff; i tried telling myself to like it but never did. *shrug*.

Hospital admin's can be difficult to deal with but you have some control over that -- by choosing where you want to work. But you choose also what type of place you work at. Work at a big city, for profit type place like Healthsouth? Good luck, expct to get stuff shoved down your throat. Not all places are like that and I know many MD's taht have good relationships with hosptial admin; I am one of them luckily.

I think a lot of young doctors get caught up in wanting to work in this or that city for whatever reasons. I can tell you you're better off choosing a good job that fits your personality at work and you will be much happier wherever you are living. Don't feel compelled to take a crappy job just because 'I *have* to live in XYZ city'.

As for the future? Who knows. If USA turns into Greece it doesn't matter what field you are in well except maybe if you are an ER doc you have the skills to barter for food etc.

I will probably be in demand because I know that no matter what I have the skills to help the aging population in a variety of ways. There';s more demand because as someone earlier said, there's less ppl wanting to do inpt rehab. All things are cyclical.

Do what you like best and life will reward you. Also realize that life is more than medicine and get a career taht gives you time to enjoy the things you like to do outside of work including family.

The nice thing about PM&R is there is a lot of freedom to do what you want. It may take a while to get yourself in a gig that you can do what you want though.

 

[fozzy40]

Thanks for the update. There is a heavy bias towards outpatient on the boards and in the field in general. Glad to see some proud inpatient docs!