Why the relatively low autonomy in Peds residency?

[MedicineZ0Z]

Have you ever looked at hiring actual hospitalists? It sounds like you're trying to get the local outpatient Pediatricians to do admissions between clinic patients.

I don't think these places have enough Peds volume to warrant hiring a Peds hospitalist. Generally it ends up being a Peds who cover the inpatient or the FM who does it/ adult hospitalist FM who also covers peds.

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[miacomet]

Have you ever looked at hiring actual hospitalists? It sounds like you're trying to get the local outpatient Pediatricians to do admissions between clinic patients.

It's a rural hospital. Do you really think a rural hospital is going to hire NNPs, hospitalists, and have outpatient pediatricians? Have you worked in rural hospital? My guess is not. We have a few hundred deliveries a year and a hundred or so peds admissions. In what universe do you think rural hospitals hire hospitalists? This exemplifies the problem with peds residency today. They can certainly adjust their clinic schedule to admit patients- they could, for example, have each doc take a week of call every six to eight weeks. Their contract clearly states they have to admit peds and be on staff.

 

[Perrotfish]

It's a rural hospital. Do you really think a rural hospital is going to hire NNPs, hospitalists, and have outpatient pediatricians? Have you worked in rural hospital? My guess is not. We have a few hundred deliveries a year and a hundred or so peds admissions. In what universe do you think rural hospitals hire hospitalists? This exemplifies the problem with peds residency today. They can certainly adjust their clinic schedule to admit patients- they could, for example, have each doc take a week of call every six to eight weeks. Their contract clearly states they have to admit peds and be on staff.

I have worked in a small rural hospital, and I can tell you that NRP call is one of the most ulcer inducingly stressful things I have done. Not being able to drive more than 20 minutes away from work for a week at a time, jumping up in the middle of the night to come rushing in for every difficult birth, apologizing to a dozen angry patients after a random ER consult pulls you away from clinic for an two hours, obsessively checking to make sure you never leave your phone uncharged or in another room, and above all knowing that at least a few times a year that its going to be a REAL crisis in a place that has no RT, no experienced NICU nursing, and no idea where to find half of the equipment you need. Every time I handed off the call phone to a new provider it was like feeling a physical weight lift off me.

Pediatric hospitalists are cheap. You can get 24 hours of inpatient pediatrics coverage, half of that in house, for less than it would cost you to get an ED physician to work for 6 hours. If your hospital isn't hiring them it means that they're paying community Pediatricians much less than that, probably around $500/24 hour. Would you do that? Would you expect a high level of service from the type of physician that would agree to that? If you were one of those Pediatricians would you even feel competent covering NRP, knowing that you would only be able to practice the high risk stuff once or twice a year? At least when a hospitalist group covers a rural hospital they are usually also rotating through higher volume centers to keep their skills up. How would someone on Q8 call even maintain the muscle memory to get through a neonatal code?

 

[MedicineZ0Z]

I have worked in a small rural hospital, and I can tell you that NRP call is one of the most ulcer inducingly stressful things I have done. Not being able to drive more than 20 minutes away from work for a week at a time, jumping up in the middle of the night to come rushing in for every difficult birth, apologizing to a dozen angry patients after a random ER consult pulls you away from clinic for an two hours, obsessively checking to make sure you never leave your phone uncharged or in another room, and above all knowing that at least a few times a year that its going to be a REAL crisis in a place that has no RT, no experienced NICU nursing, and no idea where to find half of the equipment you need. Every time I handed off the call phone to a new provider it was like feeling a physical weight lift off me.

Pediatric hospitalists are cheap. You can get 24 hours of inpatient pediatrics coverage, half of that in house, for less than it would cost you to get an ED physician to work for 6 hours. If your hospital isn't hiring them it means that they're paying community Pediatricians much less than that, probably around $500/24 hour. Would you do that? Would you expect a high level of service from the type of physician that would agree to that? If you were one of those Pediatricians would you even feel competent covering NRP, knowing that you would only be able to practice the high risk stuff once or twice a year? At least when a hospitalist group covers a rural hospital they are usually also rotating through higher volume centers to keep their skills up. How would someone on Q8 call even maintain the muscle memory to get through a neonatal code?

I think that's an issue with literally anything that's less common. Or as you pointed out, being somewhere rural where by default it's less common. But there's no real evidence of poor outcomes due to attending incompetence in these places. And the advice that's been given by experienced folks is to visualize steps/go over things every once in a while. But I wouldn't personally know.

Anyway, the solution is either a Peds hospitalist or getting a well rounded FM who is covering the full inpatient scope. Not sure what other options there are lol.

 

[Perrotfish]

Anyway, the solution is either a Peds hospitalist or getting a well rounded FM who is covering the full inpatient scope. Not sure what other options there are lol.

Best solution is a hospitalist group coving multiple sites, so that the guys at the super rural hospital also get their time in the high delivery volume hospitals, or even coving NICU

Second best solution is a Q2 hospitalist. With no clinic that's bearable, and with a lot of drills and education that might crest the bare minimum number of cases necessary for a provider to stay competent.

 

[miacomet]

I have worked in a small rural hospital, and I can tell you that NRP call is one of the most ulcer inducingly stressful things I have done. Not being able to drive more than 20 minutes away from work for a week at a time, jumping up in the middle of the night to come rushing in for every difficult birth, apologizing to a dozen angry patients after a random ER consult pulls you away from clinic for an two hours, obsessively checking to make sure you never leave your phone uncharged or in another room, and above all knowing that at least a few times a year that its going to be a REAL crisis in a place that has no RT, no experienced NICU nursing, and no idea where to find half of the equipment you need. Every time I handed off the call phone to a new provider it was like feeling a physical weight lift off me.

Pediatric hospitalists are cheap. You can get 24 hours of inpatient pediatrics coverage, half of that in house, for less than it would cost you to get an ED physician to work for 6 hours. If your hospital isn't hiring them it means that they're paying community Pediatricians much less than that, probably around $500/24 hour. Would you do that? Would you expect a high level of service from the type of physician that would agree to that? If you were one of those Pediatricians would you even feel competent covering NRP, knowing that you would only be able to practice the high risk stuff once or twice a year? At least when a hospitalist group covers a rural hospital they are usually also rotating through higher volume centers to keep their skills up. How would someone on Q8 call even maintain the muscle memory to get through a neonatal code?

For 100 admissions a year? Plus NNP coverage? Dream on. I doubt your hospital was really rural- do you really think in a rural area there are enough pediatricians to actually find a peds hospitalist? Insane.

I'm sure it's stressful. Sorry. That's what medicine is. Rural FP does it. Peds can, too. This is a group of 8 docs; they can have one person dedicated to this every 8 weeks. That's not unreasonable. The surgeons manage it. So does OB. Why is peds so snowflakey?

 

[DO2015CA]

For 100 admissions a year? Plus NNP coverage? Dream on. I doubt your hospital was really rural- do you really think in a rural area there are enough pediatricians to actually find a peds hospitalist? Insane.

I'm sure it's stressful. Sorry. That's what medicine is. Rural FP does it. Peds can, too. This is a group of 8 docs; they can have one person dedicated to this every 8 weeks. That's not unreasonable. The surgeons manage it. So does OB. Why is peds so snowflakey?

it’s not that they can’t, it’s that they won’t. Snowflakey isn’t the word dummie, it’s lazy.

 

[miacomet]

it’s not that they can’t, it’s that they won’t. Snowflakey isn’t the word dummie, it’s lazy.

True, lazy. Their complaint was that they wouldn't be home with their kids EVERY evening. Insane.

 

[Perrotfish]

For 100 admissions a year? Plus NNP coverage? Dream on. I doubt your hospital was really rural- do you really think in a rural area there are enough pediatricians to actually find a peds hospitalist? Insane.

I'm sure it's stressful. Sorry. That's what medicine is. Rural FP does it. Peds can, too. This is a group of 8 docs; they can have one person dedicated to this every 8 weeks. That's not unreasonable. The surgeons manage it. So does OB. Why is peds so snowflakey?

My hospital was a 400 delivery per year 100-200 admission per year hospital 3 hours from the nearest tertiary care center. Rural. If your area can support 8 separate Pediatricians its nowhere near as rural than the area I was working.

The surgeons deal with the call schedule because they need the hospital. They need privileges or they can't bill for their procedures. Ditto OB. Pediatrics can make their clinics work without any such affiliation. The hospital needs them, they don't need the hospital. Which means the hospital needs to pay a competitive salary to recruit a hospitalist pediatrician. I strongly suspect the group could recruit two pediatric hospitalists if the hospital paid enough.

And, again, even if these guys wanted to do this job, you don't really want them doing it. Dividing up NRP responsibilities among 8 people who didn't focus on it during their training, who aren't in house, and don't really want to do it now is a recipe for seriously injured babies. Would you want the FP from your local clinic covering traumas and strokes in the ER once a month? Would you want him to try to do it from his clinic, in between patients? If not, why would you want a Pediatrician doing that for neonatal emergencies?

Finally no, its not plus NNP coverage. Community Pediatrician + in house NNP is one model. Pediatric hospitalist working alone is another. Either/or, not both.

 

[Perrotfish]

True, lazy. Their complaint was that they wouldn't be home with their kids EVERY evening. Insane.

Aren't you ER? What is your current schedule?

 

[miacomet]

Aren't you ER? What is your current schedule?

Yes. Lots of nights and weekends. All the rest of our consultants take call. I'm not sure why they feel they can't. They picked a rural job, they signed a contract to cover inpatient and neonates, and now they refuse to. This is a desirable area- if they don't do it, they will lose their insurance contract (50% of their income) and hospital privileges and their patients when the hospital easily replaces them. So they actually need the hospital; the hospital doesn't need them- they realize that now and will either step up or go out of business. They thought the hospital needed them, but they were so wrong. Usually I'm pro doc, but they are out of control. They will fall in line, I'm pretty sure.

NNPs seem to have no interest in working outside tertiary care facilities. I can't imagine we'd ever recruit enough to cover all the deliveries. It's just pathetic to me that pediatricians have surrendered a job to midlevels. Why don't they surrender their outpatient well child stuff to midlevels, too?

I'm amazed that your hospital could support a hospitalist for 100-200 admits a year. Ours have varied between 50-100, although it would be hard to say now since they've refused to admit for so long. It just doesn't seem worth it to hire a hospitalist when community pediatricians can easily admit one patient a week. Or two.

 

[Perrotfish]

Yes. Lots of nights and weekends. All the rest of our consultants take call. I'm not sure why they feel they can't. They picked a rural job, they signed a contract to cover inpatient and neonates, and now they refuse to. This is a desirable area- if they don't do it, they will lose their insurance contract (50% of their income) and hospital privileges and their patients when the hospital easily replaces them. So they actually need the hospital; the hospital doesn't need them- they realize that now and will either step up or go out of business. They thought the hospital needed them, but they were so wrong. Usually I'm pro doc, but they are out of control. They will fall in line, I'm pretty sure.

NNPs seem to have no interest in working outside tertiary care facilities. I can't imagine we'd ever recruit enough to cover all the deliveries. It's just pathetic to me that pediatricians have surrendered a job to midlevels. Why don't they surrender their outpatient well child stuff to midlevels, too?

I'm amazed that your hospital could support a hospitalist for 100-200 admits a year. Ours have varied between 50-100, although it would be hard to say now since they've refused to admit for so long. It just doesn't seem worth it to hire a hospitalist when community pediatricians can easily admit one patient a week. Or two.

So my hospital was traditional practice: clinic docs did Q3 inpatient call. It was also military: people put up with it because there was not an alternative, its just not something people do voluntarily. There are lots of people willing to work hospitalist/ER with nights and weekends, and lost of people willing to work clinic for 20 days out of 28, but its either or. Very few people want to work 20/28 days plus nights and weekends for the long term

There were rural civilian hospitals both in the area where I worked in the military and near my current civilian job, and none of them can find civilian pediatricians to replace the old guys who made the traditional model work. Some are transitioning to hospitalist groups, others to pseudo hospitalist arrangements (4 docs in a group each doing 1 week dedicated hospitalist and 3 weeks clinic), and some just keep raising the pay for their old outpatient guys to get them to hold on a little longer. Whatever they're doing it amounts to the same thing: paying more for more coverage. You are right it is a dead loss from a financial perspective to hire pediatric hospitalists for these little hospitals. There is a reason that critical access hospitals usually require state grants to stay open. They need to do a lot of things that operate at a loss and this is one of them.

I am curious what hospital could be described as both rural and desirable. Rich person ski country? Park City Utah, or similar? If that's true you might be correct about the group attached to your hospital, but your hospital is a unicorn. Most rural hospitals are fighting tooth and nail to keep any doc who is willing to stay, in any specialty.

Finally we haven't surrendered this job to the mid-levels. Lots of us do NRP call and inpatient. We just don't do clinic at the same. Just like an ER doctors and adult hospitalists I cover nights, weekends, holidays, admissions, calls, and codes. And then I hand the phone off to someone else and get time off. There are lots of pediatric hospitalists out there, if you want to hire them.

 

[miacomet]

So my hospital was traditional practice: clinic docs did Q3 inpatient call. It was also military: people put up with it because there was not an alternative, its just not something people do voluntarily. There are lots of people willing to work hospitalist/ER with nights and weekends, and lost of people willing to work clinic for 20 days out of 28, but its either or. Very few people want to work 20/28 days plus nights and weekends for the long term

There were rural civilian hospitals both in the area where I worked in the military and near my current civilian job, and none of them can find civilian pediatricians to replace the old guys who made the traditional model work. Some are transitioning to hospitalist groups, others to pseudo hospitalist arrangements (4 docs in a group each doing 1 week dedicated hospitalist and 3 weeks clinic), and some just keep raising the pay for their old outpatient guys to get them to hold on a little longer. Whatever they're doing it amounts to the same thing: paying more for more coverage. You are right it is a dead loss from a financial perspective to hire pediatric hospitalists for these little hospitals. There is a reason that critical access hospitals usually require state grants to stay open. They need to do a lot of things that operate at a loss and this is one of them.

I am curious what hospital could be described as both rural and desirable. Rich person ski country? Park City Utah, or similar? If that's true you might be correct about the group attached to your hospital, but your hospital is a unicorn. Most rural hospitals are fighting tooth and nail to keep any doc who is willing to stay, in any specialty.

Finally we haven't surrendered this job to the mid-levels. Lots of us do NRP call and inpatient. We just don't do clinic at the same. Just like an ER doctors and adult hospitalists I cover nights, weekends, holidays, admissions, calls, and codes. And then I hand the phone off to someone else and get time off. There are lots of pediatric hospitalists out there, if you want to hire them.

I just don't see how it's worth it to hire a pediatric hospitalist. FPs do admits here for their patients, pediatric and adult. Why is it so uniquely hard for peds?

 

[Perrotfish]

I just don't see how it's worth it to hire a pediatric hospitalist. FPs do admits here for their patients, pediatric and adult. Why is it so uniquely hard for peds?

I think the FPs in your hospital are less typical than you think they are. Not a lot of outpatient physicians these days are doing admissions in between clinic patients, regardless of specialty. Like pediatricians FPs who want to do inpatient mostly just do that, they don't try and do clinic on the same day.

Some of the rural civilian hospitals around me still have a traditional pediatric clinic and call model, though they haven't been able to recruit anyone new to it for quite a while. None of them have managed to avoid having adult hospitalists.

 

[miacomet]

I think the FPs in your hospital are less typical than you think they are. Not a lot of outpatient physicians these days are doing admissions in between clinic patients, regardless of specialty. Like pediatricians FPs who want to do inpatient mostly just do that, they don't try and do clinic on the same day.

Some of the rural civilian hospitals around me still have a traditional pediatric clinic and call model, though they haven't been able to recruit anyone new to it for quite a while. None of them have managed to avoid having adult hospitalists.

I agree it's a beast. But there just aren't enough peds admits in many places to support a peds hospitalist. I wish there were more med-peds grads doing this, and I wish in general they would phase out FP and increase med-peds. It's a field that would solve a lot of problems.

 

[PTPoeny]

The few hundred deliveries a year are also a big part of the problem. Not enough to keep anyone actually good at resuscitation and intubation to get back to some of the earlier posts in this thread. Are they recruiting general pediatricians who are comfortable intubating? If so how are they keeping up those skills?

I don't think there are enough sick kids across the country to train every pediatric resident to intubate. And the residents that are interested in practicing rural pediatrics where they are expected to intubate as a general pediatrician are concentrated into some of the smaller residencies in or near rural areas. It isn't the fault of residency that NIPPV and better NRP protocols (not intubating active, well appearing babies born with mec) has drastically reduced the total number of children being intubated each year.

Anesthesia rotations are unlikely to fix the problem either. Not that many tiny neonates are having surgery. As a PICU fellow doing my anesthesia rotation I got a lot of tubes, but the one population they wouldn't let me intubate was the neonates. I found this slightly funny as a resident I had been attending deliveries without an attending.

 

[Perrotfish]

I agree it's a beast. But there just aren't enough peds admits in many places to support a peds hospitalist. I wish there were more med-peds grads doing this, and I wish in general they would phase out FP and increase med-peds. It's a field that would solve a lot of problems.

I don't think med-peds is the solution. Not every pediatric program has the kind of NICU rotation volume that gets people comfortable doing NRP without a neonatologist in house. Usually programs that train with a focus on producing the community pediatricians you need will do 6 months of NICU unopposed by fellows. There is basically no way to do that as a med-peds resident who only has 2 years for the entire pediatric curriculum.

 

[calvnandhobbs68]

They are outpatientologists. It's pretty crazy. They don't seem to practice any actual medicine at all.

lol guess all those outpatient doctors don't "practice any actual medicine at all". Quite the comment there.