First Job Offer, Im lost

[Doctor W]

I just started the job hunt and I'm so lost. I'm interested in being a nocturnist, and I have an offer from a midwestern state with the following:

PRACTICE
*7 on 7 off
*5 to 10 Admissions per night
*Lots of specialty support
*1 week PTO, health, CME, etc.
+350K Salary
+10K end of each calendar year automatic retention incentive
+wRVU production
+Quality incentive
+Told that it would be 400K+ per year on average for 25 Weeks
+25,000 Sign-on and relocation
+Can do extra shifts ("earn an extra $50K+/yr or more")
+Procedures optional
*Told 3 total nocturnists every night when asked about Cross coverage

Relatively bad thing is being responsible for Codes/Rapids. Its also an Open ICU but I'm Ok with that generally.

Again, this is the first offer I've even gotten. My first and only job in life has been being a resident. I dont know what QI/RVU entails and how negotiating is supposed to work. I have no idea if I should just take this first offer and quit to prevent any more anxiety.

Can anyone please help?

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[DrMetal]

I just started the job hunt and I'm so lost. I'm interested in being a nocturnist, and I have an offer from a midwestern state with the following:

PRACTICE
*7 on 7 off
*5 to 10 Admissions per night
*Lots of specialty support
*1 week PTO, health, CME, etc.
+350K Salary
+10K end of each calendar year automatic retention incentive
+wRVU production
+Quality incentive
+Told that it would be 400K+ per year on average for 25 Weeks
+25,000 Sign-on and relocation
+Can do extra shifts ("earn an extra $50K+/yr or more")
+Procedures optional
*Told 3 total nocturnists every night when asked about Cross coverage

Relatively bad thing is being responsible for Codes/Rapids. Its also an Open ICU but I'm Ok with that generally.

Again, this is the first offer I've even gotten. My first and only job in life has been being a resident. I dont know what QI/RVU entails and how negotiating is supposed to work. I have no idea if I should just take this first offer and quit to prevent any more anxiety.

Can anyone please help?

If you're good with being a nocturnist and in a mid-western state, then it sounds about right.

Admissions, codes,rapids is a lot. Crosscover too?

10 years ago this would get you a $400-$500K base salary. But in 2022, and with the mid-level invasion, $350K may be the best you can do. Also a little more PTO would be nice, like 2 weeks

It's a decent offer. But why rush, how long do you have to consider it? Get some more offers.

 

[Doctor W]

If you're good with being a nocturnist and in a mid-western state, then it sounds about right.

Admissions, codes,rapids is a lot. Crosscover too?

10 years ago this would get you a $400-$500K base salary. But in 2022, and with the mid-level invasion, $350K may be the best you can do. Also a little more PTO would be nice, like 2 weeks

It's a decent offer. But why rush, how long do you have to consider it? Get some more offers.

My hospital told me to get offers now, as licensing could take "months and months". I was under the impression that we had to find a job before end of the year. Everyone in my class has already signed offers, and Im assuming that I'm behind.

 

[gutonc]

I just started the job hunt and I'm so lost. I'm interested in being a nocturnist, and I have an offer from a midwestern state with the following:

PRACTICE
*7 on 7 off
*5 to 10 Admissions per night
*Lots of specialty support
*1 week PTO, health, CME, etc.
+350K Salary
+10K end of each calendar year automatic retention incentive
+wRVU production
+Quality incentive
+Told that it would be 400K+ per year on average for 25 Weeks
+25,000 Sign-on and relocation
+Can do extra shifts ("earn an extra $50K+/yr or more")
+Procedures optional
*Told 3 total nocturnists every night when asked about Cross coverage

Relatively bad thing is being responsible for Codes/Rapids. Its also an Open ICU but I'm Ok with that generally.

Again, this is the first offer I've even gotten. My first and only job in life has been being a resident. I dont know what QI/RVU entails and how negotiating is supposed to work. I have no idea if I should just take this first offer and quit to prevent any more anxiety.

Can anyone please help?

What are the wRVU production and quality numbers? What's the median for the group?

Doesn't seem too bad. If there are 3 of you and you're splitting admit/cross-cover, could be reasonable workload.

Agree that you should get some other offers in hand. Yes, it can take time to get licensed/credentialed, but you've still got time.

 

[chessknt]

I just started the job hunt and I'm so lost. I'm interested in being a nocturnist, and I have an offer from a midwestern state with the following:

PRACTICE
*7 on 7 off
*5 to 10 Admissions per night
*Lots of specialty support
*1 week PTO, health, CME, etc.
+350K Salary
+10K end of each calendar year automatic retention incentive
+wRVU production
+Quality incentive
+Told that it would be 400K+ per year on average for 25 Weeks
+25,000 Sign-on and relocation
+Can do extra shifts ("earn an extra $50K+/yr or more")
+Procedures optional
*Told 3 total nocturnists every night when asked about Cross coverage

Relatively bad thing is being responsible for Codes/Rapids. Its also an Open ICU but I'm Ok with that generally.

Again, this is the first offer I've even gotten. My first and only job in life has been being a resident. I dont know what QI/RVU entails and how negotiating is supposed to work. I have no idea if I should just take this first offer and quit to prevent any more anxiety.

Can anyone please help?

Open ICU but who does the procedures at night? What if you can't wait for that person or they are encumbered? What is the longest you have ever worked nights during your training?

 

[Doctor W]

Open ICU but who does the procedures at night? What if you can't wait for that person or they are encumbered? What is the longest you have ever worked nights during your training?

I didnt even think to ask. My longest stretch wouldve been 3 wks.

 

[HemeOncHopeful19]

Open ICU with “optional procedures” sounds like a big ass red flag to me but I’m not a hospitalist/nocturnist.

What happens when nobody wants to do the procedure, who is it NOT optional for?

Example (admittedly probably not a big concern for a nocturnist): does it take 3-5 days of pushback to get NeuroRads to do an LP?

 

[chessknt]

Open ICU with “optional procedures” sounds like a big ass red flag to me but I’m not a hospitalist/nocturnist.

What happens when nobody wants to do the procedure, who is it NOT optional for?

Example (admittedly probably not a big concern for a nocturnist): does it take 3-5 days of pushback to get NeuroRads to do an LP?

It would be more critical for an airway or pneumothorax, slightly less for central access in an unstable patient. Lots of subspecialty support but making you the intensivist at night seems contradictory. What if he gets an intubated status asthmaticus gift from the ER with an AutoPEEP in the 20s in shock from increased intrathoracic pressure and pH of 7.0X?

So you did 3 weeks straight and were doing ok? No issues with sleeping or social life? I ask because as someone who signed up for the nocturnist life for about a year because I didnt want to deal with daytime bull**** it was the worst and most poorly thought out decision of my life (at the time). Absolutely destroyed me to finish that year out and was counting the shifts left until I was done. I also encountered an insane level of political bull**** for working by myself at night like consulting the wrong group or not cross covering another group's **** ups because I was not formally consulted on the patient etc.

 

[ReviewOfSystems]

I'm a career nocturnist. I have some comments. I would never do 7 on 7 off as a nocturnist. 7 nights in a row is brutal no matter how much you like nights. Also Open ICU in my experience is horrible if you are not basically an intensivist yourself. Covering for these sick patients that you dont know overnight with no support is difficult, q15mins pages from the nurses on really sick ones, being on the hook for procedures that should have been done overnight (falling back on the "optional procedures clause" in your offer is not going to fly), and talking to families (yes you will have many long, serious conversations at 2am) are all just the tip of the iceberg. That is on top of floor admits, crosscover, and rapids/codes (which you will have to manage after you send them to the ICU). Oh yea, and 5-10 admits actually means 10+ unless its a weekend holiday. Do with all of that as you will. All in all, I still prefer nights (when the job makes sense).

 

[Splenda88]

I would ask for 380-400k and 2 wks PTO.

 

[Splenda88]

Open ICU with “optional procedures” sounds like a big ass red flag to me but I’m not a hospitalist/nocturnist.

What happens when nobody wants to do the procedure, who is it NOT optional for?

Example (admittedly probably not a big concern for a nocturnist): does it take 3-5 days of pushback to get NeuroRads to do an LP?

It's not a big red flag. Usually the ED docs take care of the procedures at night.

 

[Splenda88]

If you're good with being a nocturnist and in a mid-western state, then it sounds about right.

Admissions, codes,rapids is a lot. Crosscover too?

10 years ago this would get you a $400-$500K base salary. But in 2022, and with the mid-level invasion, $350K may be the best you can do. Also a little more PTO would be nice, like 2 weeks

It's a decent offer. But why rush, how long do you have to consider it? Get some more offers.

Are you saying that in 2012 nocturnists were making 400-500k? People who have been working for 20 yrs told me that's the best the market has been.

I had a locum that offered me $210/hr a few weeks ago for a hospitalist position and I told them I want $240/hr.

 

[ReviewOfSystems]

It's not a big red flag. Usually the ED docs take care of the procedures at night.

You have to double check on this. A hospital where I did PRN the ER doctors did not because apparently the intensivists were supposed to come in. And the intensivists denied all responsibility. So it fell in my lap. One of the reasons I stopped working there.

 

[chessknt]

It's not a big red flag. Usually the ED docs take care of the procedures at night.

That system is fine until it isnt. Like if the ER doc is swamped or in the middle or something and someone starts to code and needs an airway

 

[DrMetal]

Are you saying that in 2012 nocturnists were making 400-500k? People who have been working for 20 yrs told me that's the best the market has been.

I had a locum that offered me $210/hr a few weeks ago for a hospitalist position and I told them I want $240/hr.

I can't quote exact numbers, but there's no doubt that hospitalist salaries have come down over the last 10 years, and will likely continue to do so.

The current hospitalist model is not financially sustainable. Paying a physician $250K/year to baby sit patients, while multiple other physicians are consulted, leaving the general hospitalist to do just the admin, family discussions, and case management type work . . . just doesn't make financial/business sense.

Our days are numbered. Take the money and run!

 

[Splenda88]

I can't quote exact numbers, but there's no doubt that hospitalist salaries have come down over the last 10 years, and will likely continue to do so.

The current hospitalist model is not financially sustainable. Paying a physician $250K/year to baby sit patients, while multiple other physicians are consulted, leaving the general hospitalist to do just the admin, family discussions, and case management type work . . . just doesn't make financial/business sense.

Our days are numbered. Take the money and run!

Not happening anytime soon because most NP/PA right out of school are not equipped to take care of some of these complex patients.

I don't know where you work at but I don't see hospital going back having outpatient PCP admitting their own patients to the hospital.

I know physicians to NP/PA ratio will decrease but it will take a good 15+ yrs before administrators catch up.

I am taking my money and run as of now!

 

[DrMetal]

Not happening anytime soon because most NP/PA right out of school are not equip to take care of some of these complex patients.

You're right, mid-levels are not equipped to take on complex patients, and they deliver sub-standard care (studies have shown this).

But here's what's changed over the last 10 years: the company doesn't care. They're willing to take the hit with respect to quality of care. The cost savings from using mid-levels is too great. Patient too complex? Just consult the Cardiologist, the Nephrologist, ID, and everyone else the hospitalist would usually consult.

Outpatient physicians admitting their own? Still happens. About 10-20% of the admissions at my hospital are done by private PCMs who have admitting privileges. Another construct one might imagine, is just making the most relevant sub-specialist admit the patient and be the primary MD. AF w/RVR? Goes to the Cardiologist. GIB? Goes to the GI. consult the NP hospitalist to help with discharge planning.

Our generation is probably fine. But I just don't see the general MD hospitalist career path lasting much longer than 20-30 years.

 

[rokshana]

You're right, mid-levels are not equipped to take on complex patients, and they deliver sub-standard care (studies have shown this).

But here's what's changed over the last 10 years: the company doesn't care. They're willing to take the hit with respect to quality of care. The cost savings from using mid-levels is too great. Patient too complex? Just consult the Cardiologist, the Nephrologist, ID, and everyone else the hospitalist would usually consult.

Outpatient physicians admitting their own? Still happens. About 10-20% of the admissions at my hospital are done by private PCMs who have admitting privileges. Another construct one might imagine, is just making the most relevant sub-specialist admit the patient and be the primary MD. AF w/RVR? Goes to the Cardiologist. GIB? Goes to the GI. consult the NP hospitalist to help with discharge planning.

Our generation is probably fine. But I just don't see the general MD hospitalist career path lasting much longer than 20-30 years.

Lol if you think subspecialists are going to admit to a service they run… and they make enough money for the hospital that the admins won’t push that agenda.

 

[DrMetal]

Lol if you think subspecialists are going to admit to a service they run… and they make enough money for the hospital that the admins won’t push that agenda.

Oh they'll do it if a) they're told to do so and b) if their credentialing/reimbursement is threatened should they fail to comply. We're not in charge any more; we are all but pawn soldiers on this battlefield.

Why "Lol"? See, this is our problem. We don't have the imagination to see the shtstorm coming. Then when it arrives in 15 years, we're all aghast.

 

[rokshana]

Oh they'll do it if a) they're told to do so and b) if their credentialing/reimbursement is threatened should they fail to comply. We're not in charge any more; we are all but pawn soldiers on this battlefield.

Why "Lol"? See, this is our problem. We don't have the imagination to see the shtstorm coming. Then when it arrives in 15 years, we're all aghast.

Nope…for some of us…we would simply stop seeing pts in the hospital…for many, especially non procedural specialties, we make more money seeing clinic pts than hospital pts…now a days , it’s more common not to have Inpt coverage for endocrinology, rheumatology, dermatology, etc…make them have an admitting service…there will simply be no presence.

Tell orthopedics or interventional cardiology they have to admit to their own service…they will go to the competing hospital and take their money with them. Or they go to another town that is chomping at the bit to become the cardiology or orthopedic center for service.
Others like GI…will do their procedures in the clinic and set up at say a surgi center…and not do the procedures in the hospital…and the hospitals don’t get to collect that facility fee…money does make the medical world go round…and admin knows who are the money makers…and look to appease them.

 

[DrMetal]

Nope…for some of us…we would simply stop seeing pts in the hospital…for many, especially non procedural specialties, we make more money seeing clinic pts than hospital pts…now a days , it’s more common not to have Inpt coverage for endocrinology, rheumatology, dermatology, etc…make them have an admitting service…there will simply be no presence.

Tell orthopedics or interventional cardiology they have to admit to their own service…they will go to the competing hospital and take their money with them. Or they go to another town that is chomping at the bit to become the cardiology or orthopedic center for service.
Others like GI…will do their procedures in the clinic and set up at say a surgi center…and not do the procedures in the hospital…and the hospitals don’t get to collect that facility fee…money does make the medical world go round…and admin knows who are the money makers…and look to appease them.

The surgical services as my hospital admit their own, if < 50 yo and absolutely no other comorbidities. You're probably right, they'll just replace us with mid-levels.

 

[dozitgetchahi]

I'm a career nocturnist. I have some comments. I would never do 7 on 7 off as a nocturnist. 7 nights in a row is brutal no matter how much you like nights. Also Open ICU in my experience is horrible if you are not basically an intensivist yourself. Covering for these sick patients that you dont know overnight with no support is difficult, q15mins pages from the nurses on really sick ones, being on the hook for procedures that should have been done overnight (falling back on the "optional procedures clause" in your offer is not going to fly), and talking to families (yes you will have many long, serious conversations at 2am) are all just the tip of the iceberg. That is on top of floor admits, crosscover, and rapids/codes (which you will have to manage after you send them to the ICU). Oh yea, and 5-10 admits actually means 10+ unless its a weekend holiday. Do with all of that as you will. All in all, I still prefer nights (when the job makes sense).

Yeah, open ICUs suck.

Part of the problem is that “open ICU” can mean a variety of things:

- A technically “open” ICU where essentially all ICU transfers result in an immediate consult to CCM, who then basically manages the patient themselves with the hospitalist “co-managing”.

- Hospitalist manages most of their patients in the ICU, with CCM sort of intermittently available to consult or do certain types of procedures (intubation, etc) if needed.

- “Wide open” aka there is an ICU, there is no CCM doctor present, and hospitalist basically does everything for their ICU patients. Perhaps ER or someone else intubates, but in some of these situations the hospitalist is expected to do that too. More common in rural or critical access hospitals.

#1 is no big deal. #3 is awful unless somehow you’re really good at managing all ICU related issues and doing the procedures (some cocky fresh IM grads think they are, but they’re probably not). #2 is somewhere in between depending on how things are done (plus, in a pinch they may demand you do procedures and such if ER etc is occupied).

 

[collegestud2013]

Lol if you think subspecialists are going to admit to a service they run… and they make enough money for the hospital that the admins won’t push that agenda.

If the hospital requires it as a condition of having privileges, then they will be required to. For example, at my hospital services like urology, ortho, ENT, gen surg oncology admit themselves if it's a direct admit (eg scheduled post-op, scheduled admission for chemo). They can consult the hospitalist if needed to help with medical management. But if it's coming from the ED the only service that admits frequently themselves in gen surgery; otherwise, the hospitalist service seems to be the default admitting service.

And usually having hospital privileges also usually means required ED call after hours (Unless another group in the same specialty already has ED call covered, or you're excluded for reasons like being >65 years old). Otherwise, they would lose out on a good amount of business by not working in the hospital all.

 

[collegestud2013]

I just started the job hunt and I'm so lost. I'm interested in being a nocturnist, and I have an offer from a midwestern state with the following:

PRACTICE
*7 on 7 off
*5 to 10 Admissions per night
*Lots of specialty support
*1 week PTO, health, CME, etc.
+350K Salary
+10K end of each calendar year automatic retention incentive
+wRVU production
+Quality incentive
+Told that it would be 400K+ per year on average for 25 Weeks
+25,000 Sign-on and relocation
+Can do extra shifts ("earn an extra $50K+/yr or more")
+Procedures optional
*Told 3 total nocturnists every night when asked about Cross coverage

Relatively bad thing is being responsible for Codes/Rapids. Its also an Open ICU but I'm Ok with that generally.

Again, this is the first offer I've even gotten. My first and only job in life has been being a resident. I dont know what QI/RVU entails and how negotiating is supposed to work. I have no idea if I should just take this first offer and quit to prevent any more anxiety.

Can anyone please help?

I would be careful with accepting an open ICU job as nocturnist if you only have IM training (and have not done a pulm/crit fellowship). It's common for hospitals to do open ICU at night and have an IM or FM trained hospitalist cover since they can't find or don't want to pay for a full time intensivist nocturnist; this is especially the case at smaller hospitals that don't have that many ICU beds to justify intensivist coverage at night. Find out if there is an intensivist on call from home at night, or if you're completely responsive for ICU level patients without their assistance. If not, you essentially need to be comfortable with ICU level care (eg intubations, placing central lines, vent management, pressors) without having done a pulm/crit fellowship since there's limited support at night . Some new IM grads may be comfortable if you had solid ICU rotations in residency and took the time to get the most out of them but for many it just increases their medicolegal liability. Also remember if it get's busy (if could very well get to be well over 10 admissions per night on a busy night) there's usually no back up at most hospitals at night so keep that in mind.

Also need to know the specific RVU structure (how much and at what RVU it kicks in). Personally I would expect at least $200 per hour after including RVUs for a full-time position for the job you're describing (nights requiring both admitting and cross coverage, open ICU coverage, possibly requiring procedures, and if it's in the Midwest (especially if it's not in a big city and thus in area that's hard to recruit)). Pay is about $160/hr if just counting the base so would see if the RVU structure brings it to around $200/hr.

Also find out about the amount of staffing to see if it's reasonable for the amount of volume at night (ie how many patients you and the other nocturnists are cross covering and if there is NP/PA support).

 

[rokshana]

If the hospital requires it as a condition of having privileges, then they will be required to. For example, at my hospital services like urology, ortho, ENT, gen surg oncology admit themselves if it's a direct admit (eg scheduled post-op, scheduled admission for chemo). They can consult the hospitalist if needed to help with medical management. But if it's coming from the ED the only service that admits frequently themselves in gen surgery; otherwise, the hospitalist service seems to be the default admitting service.

And usually having hospital privileges also usually means required ED call after hours (Unless another group in the same specialty already has ED call covered, or you're excluded for reasons like being >65 years old). Otherwise, they would lose out on a good amount of business by not working in the hospital all.

and that MAY be true for procedural specialties that need to be performed in the hospital...though typically they will just move over to the hospital that won't make them admit to their service, but admit to hospitalist team and they consult. At one of the community hospitals that i cover (consulting only don't even have admitting privileges there), ortho pts for surgery ar actually admitted to the hospitalist service...because ortho can ask for that and get it.

for non procedural services...endocrine, rheum, derm, so forth...dont really get the bulk of new pts from the hospital setting anymore...wait times (for endocrinology at least) are easily 3-4 months for new pts appts...there are PLENTY of pts to be referred from the output setting...make these services admit to their own service ...they will just let go of inpt services...and won't suffer financially one iota.

 

[Nocturnist]

I just started the job hunt and I'm so lost. I'm interested in being a nocturnist, and I have an offer from a midwestern state with the following:

PRACTICE
*7 on 7 off
*5 to 10 Admissions per night
*Lots of specialty support
*1 week PTO, health, CME, etc.
+350K Salary
+10K end of each calendar year automatic retention incentive
+wRVU production
+Quality incentive
+Told that it would be 400K+ per year on average for 25 Weeks
+25,000 Sign-on and relocation
+Can do extra shifts ("earn an extra $50K+/yr or more")
+Procedures optional
*Told 3 total nocturnists every night when asked about Cross coverage

Relatively bad thing is being responsible for Codes/Rapids. Its also an Open ICU but I'm Ok with that generally.

Again, this is the first offer I've even gotten. My first and only job in life has been being a resident. I dont know what QI/RVU entails and how negotiating is supposed to work. I have no idea if I should just take this first offer and quit to prevent any more anxiety.

Can anyone please help?

Career nocturnist here.

Money wise the offer is average.

$165/hr could be better but definitely not the worst. I used to say nocturnists shouldn't get out of bed for anything less than $150. That's still true, but in the last couple years I'd say that's gotten closer to $175. I'll still work for 160s but it has to be cake.

I agree with some sentiments that 7 on/7 off is not sustainable long term. I've done stretches upto 10-12 nights before but that's the exception in order to have 3-4 weeks off to travel. By night 6-7 you're going to really feel it. The sweet spot is 3-5 in a row.

Also agree with open ICU. Personally that's a line in the sand i won't consider crossing but here in the northeast we don't have an issue staffing units with intensivists. That said some folks right out of residency coming from ICU oriented programs would be quite comfortable with it. Every ICU has different acuities, those in smaller hospitals might be packed with stuff I'm already comfortably managing in my cardiac or step down floors. For example the only things I can't do on my floors are intubations, titratable drips (pressors/nitro/insulin) and amio for VT. I routinely bipap, manage severe withdrawal with phenobarb, start fixed dose levophed, amio drip for afib. Like I said, not a line i would consider crossing but it'd be important to tease out what kind of ICU you'd be dealing with, whether you have remote intensivist support for vent management and who is responsible for procedures. If you're comfortable with lines and like doing them, keep those skills up or you'll lose them in a year. You should never be intubating- no matter how comfortable you are. That should always be anesthesia, icu or ER's job.

Cross coverage and rapid responses aren't red flags, they're a nocturnist's bread and butter. Cross coverage sucks but rapids add a really meaningful and enjoyable dimension to my nights. You can break the death spirals of very sick patients in 30 minutes and really turn them around, plus the critical care time you'll bill can exceed your admissions.

 

[ReviewOfSystems]

Cross coverage and rapid responses aren't red flags, they're a nocturnist's bread and butter. Cross coverage sucks but rapids add a really meaningful and enjoyable dimension to my nights. You can break the death spirals of very sick patients in 30 minutes and really turn them around, plus the critical care time you'll bill can exceed your admissions.

We have different definitions of this word...

 

[Nocturnist]

We have different definitions of this word...

Ha. I look at it like working out: hard to get up off your butt going through all 5 stages of denial when the rapid is paged, can suck during it, but satisfying afterwards when you get the endorphin hit and feel the pump of some real doctoring and 4.5-6.75 rvus.

 

[dozitgetchahi]

and that MAY be true for procedural specialties that need to be performed in the hospital...though typically they will just move over to the hospital that won't make them admit to their service, but admit to hospitalist team and they consult. At one of the community hospitals that i cover (consulting only don't even have admitting privileges there), ortho pts for surgery ar actually admitted to the hospitalist service...because ortho can ask for that and get it.

for non procedural services...endocrine, rheum, derm, so forth...dont really get the bulk of new pts from the hospital setting anymore...wait times (for endocrinology at least) are easily 3-4 months for new pts appts...there are PLENTY of pts to be referred from the output setting...make these services admit to their own service ...they will just let go of inpt services...and won't suffer financially one iota.

Bingo.

In rheumatology, for instance, it has become quite rare for even huge academic hospitals to have a rheumatology admitting service. Last I checked, there’s only two or three in the country that still do this. Outside of the ivory tower, most rheumatologists don’t even go to the hospital - never mind admitting. And we are scarce enough that we can demand outpatient only jobs. I’ve haven’t done any consults in the three jobs I’ve had since fellowship.

 

[collegestud2013]

Bingo.

In rheumatology, for instance, it has become quite rare for even huge academic hospitals to have a rheumatology admitting service. Last I checked, there’s only two or three in the country that still do this. Outside of the ivory tower, most rheumatologists don’t even go to the hospital - never mind admitting. And we are scarce enough that we can demand outpatient only jobs. I’ve haven’t done any consults in the three jobs I’ve had since fellowship.

Maybe for the ones employed by a private practice, but I doubt hospital employed specialists (even in specialties that are primarily outpatient based) will be able to get out of inpatient duties at their respective hospitals. The non-procedural specialists often don't have to admit themselves from the ED at most hospitals (may be they do if it's their own scheduled elective admission), but they will still be expected to be on responsible for ED and inpatient calls for consults even at night. For example, if there's a stat consult on an endocrinology emergency like thyroid storm in in the middle of the night from the ED, they will need to come in and see the patient.

 

[grt398]

and that MAY be true for procedural specialties that need to be performed in the hospital...though typically they will just move over to the hospital that won't make them admit to their service, but admit to hospitalist team and they consult. At one of the community hospitals that i cover (consulting only don't even have admitting privileges there), ortho pts for surgery ar actually admitted to the hospitalist service...because ortho can ask for that and get it.

for non procedural services...endocrine, rheum, derm, so forth...dont really get the bulk of new pts from the hospital setting anymore...wait times (for endocrinology at least) are easily 3-4 months for new pts appts...there are PLENTY of pts to be referred from the output setting...make these services admit to their own service ...they will just let go of inpt services...and won't suffer financially one iota.

I'm in one of the most competitive healthcare markets in the country...and this is very true just FYI for people. There's an 8-12 month wait to see endocrine, rheum, outpatient neurology, no idea for derm. And none of them take hospital consults anymore. Doesn't seem to be affecting their practice at all.

 

[DrMetal]

I'm in one of the most competitive healthcare markets in the country...and this is very true just FYI for people. There's an 8-12 month wait to see endocrine, rheum, outpatient neurology, no idea for derm. And none of them take hospital consults anymore. Doesn't seem to be affecting their practice at all.

The problem with Western medicine nowadays, especially in the outpatient setting, is that we consult for stupid things instead of just doing things ourselves. We (as primary care physicians) have become so scared to act alone and take care of something on the spot.

Going to Endocrine, why? So they can check your labs and titrate your Synthroid? That's dumb, an Internist or FP can do that. Manage insulin? also dumb, should be done by the PCM. Going to Neurology to f/u for your TIA admission, or previous CVA? Why? What's a neurologist going to do but tell you stay on your aspirin and statin, which I can gladly refill for you. Need PT/OT, I got it.
[but we don't do this, hence the 8 month wait to see an endocrine, for an issue that, 30 years ago, would've easily been taken care of by the PCM.]

 

[collegestud2013]

I'm in one of the most competitive healthcare markets in the country...and this is very true just FYI for people. There's an 8-12 month wait to see endocrine, rheum, outpatient neurology, no idea for derm. And none of them take hospital consults anymore. Doesn't seem to be affecting their practice at all.

In most cases a lot of a distribution problem. A lot more physicians want to work in urban areas or coastal areas than rural areas, so the less desirable locations will have worst shortages and the longest wait while the more saturated cities have physicians fighting over patients. Also, some patient demographics are more desirable than others. A lot more want to take a cooperative patient with high-paying commercial insurance or cash, than someone with than an indigent patient with Medicaid or no insurance and tons of underlying social issues (even though the latter patient may medically require the services just as much, if not more, than the first type of patient). If there's an absolute shortage, then there should be an expansion of residency or fellowship spots (though there are always people will want to keep the physician supply in a given specialty artificially low so they can maximize pay and negotiating power).

 

[HemeOncHopeful19]

If there's an absolute shortage, then there should be an expansion of residency or fellowship spots (though there are always people will want to keep the physician supply in a given specialty artificially low so they can maximize pay and negotiating power).

People always allude to this but when I think of the “specialties with long waiting lists” I don’t think of the higher paid specialties.

If you ask me there is not enough of a difference in pay between a new patient and a follow-up to make it worth keeping a bunch of new patient slots open.

I also have a hard time believing there is truly any major metro area in the United States with an 8-12 month waiting period to see a specialist.

 

[MD46]

People always allude to this but when I think of the “specialties with long waiting lists” I don’t think of the higher paid specialties.

If you ask me there is not enough of a difference in pay between a new patient and a follow-up to make it worth keeping a bunch of new patient slots open.

I also have a hard time believing there is truly any major metro area in the United States with an 8-12 month waiting period to see a specialist.

I am in DMV area, for Benign non urgent Hematology its 4-6months wait time for me and most colleagues.

For Oncology, rightly so, we dont have that as cancer patients cant wait that long.

At our hospital, Neuro wait time is 8-10 months, Nephro 4-6 months, Endocrine general: 3-6 months but for immediate immunetherapy related complications they make exceptions, 1-2 months.

So yeh wait times can be that high.

 

[HemeOncHopeful19]

I am in DMV area, for Benign non urgent Hematology its 4-6months wait time for me and most colleagues.

For Oncology, rightly so, we dont have that as cancer patients cant wait that long.

At our hospital, Neuro wait time is 8-10 months, Nephro 4-6 months, Endocrine general: 3-6 months but for immediate immunetherapy related complications they make exceptions, 1-2 months.

So yeh wait times can be that high.

I agree that if you are confined to a single system then perhaps you are stuck with long waiting times but you can’t convince me there is not a single recent Endocrine and Neurology grad in your area that is trying to build up their practice for example and would be happy to see someone sooner.

 

[rokshana]

I agree that if you are confined to a single system then perhaps you are stuck with long waiting times but you can’t convince me there is not a single recent Endocrine and Neurology grad in your area that is trying to build up their practice for example and would be happy to see someone sooner.

The DMV is the DC area, which covers northern Virginia and parts of Maryland…it’s not a single system, it’s a metropolitan area.
And even for the solo practitioner in the DMV, the appts fill up… for endocrine, the typical wait, pretty much anywhere is 2-4 months …usually 4-6 months…there is a reason I stay busy as a Locums endocrine…

 

[gutonc]

I agree that if you are confined to a single system then perhaps you are stuck with long waiting times but you can’t convince me there is not a single recent Endocrine and Neurology grad in your area that is trying to build up their practice for example and would be happy to see someone sooner.

I recently referred a patient of mine to endo after I worked for 3 years on her bone health and thyroid with mixed results. There are literally 2 endo groups here (PNW major metro), one had a 7 month wait (referred in November, appt in June), the other was offering August. Once I called "my people", it became February and March, but I shouldn't have to personally call/text colleagues to get an appointment for my patients.

 

[hotsaws]

Funny because I market myself to PCPs and I tell them I will gladly take their bread and butter rhinitis, asthma, eczema, etc. off their hands so they have one less thing to think about. I'm new in private pracice so my "wait list" is basically how long will it take your patient to drive to my clinic? Please yall don't start managing your own allergic rhinitis. I have a family to support and a mortgage.

 

[aafisahar]

I agree that if you are confined to a single system then perhaps you are stuck with long waiting times but you can’t convince me there is not a single recent Endocrine and Neurology grad in your area that is trying to build up their practice for example and would be happy to see someone sooner.

eh I'm in cardiology so not exactly analogous but when I joined, I basically had a full panel as we had a 3-4 month waiting period to get in unless it was something truly urgent (positive stress, new cardiomyopathy, etc). I have all slots filled with like 80% news and 20% partner and my own follow-ups. I think the days of building a practice slowly are coming to an end as the demand is so high that you basically have a panel on day 1, especially if you are hospital employed. Perhaps in a true private practice, this is different, but I'm not trolling for referrals, they just come to me.

 

[dozitgetchahi]

Maybe for the ones employed by a private practice, but I doubt hospital employed specialists (even in specialties that are primarily outpatient based) will be able to get out of inpatient duties at their respective hospitals. The non-procedural specialists often don't have to admit themselves from the ED at most hospitals (may be they do if it's their own scheduled elective admission), but they will still be expected to be on responsible for ED and inpatient calls for consults even at night. For example, if there's a stat consult on an endocrinology emergency like thyroid storm in in the middle of the night from the ED, they will need to come in and see the patient.

In my town, there are three rheumatologists - two at a large multispecialty private practice and one who works for the local hospital. None of them go to the hospital to round.

My first job as an attending rheumatologist was at a hospital system. It was written into my contract that I wouldn’t be going to the hospital to round.

Probably 75% of the rheumatology jobs I’ve ever interviewed for openly state “no call, no rounding” in the job ads.

Why is this? Several reasons: 1) there aren’t that many rheumatology inpatient consults outside of tertiary care, and the consults that are there are things that generally should be handled by hospitalists (gout flares); 2) rheumatologic emergencies are very rare, and most go straight to tertiary care anyway; 3) since the bulk of rheumatology work is outpatient, running off to the hospital to see one random consult is a waste of everyone’s time and delays care for outpatients waiting in the queue (I can probably see 2-3 outpatients in the time it would take me to see 1 inpatient); 4) most of us rheums dread hospital rounding, and we are scarce enough that we can set the terms for how we want to work.

 

[dozitgetchahi]

People always allude to this but when I think of the “specialties with long waiting lists” I don’t think of the higher paid specialties.

If you ask me there is not enough of a difference in pay between a new patient and a follow-up to make it worth keeping a bunch of new patient slots open.

I also have a hard time believing there is truly any major metro area in the United States with an 8-12 month waiting period to see a specialist.

Major metro areas are oversaturated with doctors, so often there the waiting times will be somewhat lower.

If you head to midsize cities, smaller towns, and especially rural areas, then yes indeed waiting times can be that long. Try to get into psych virtually anywhere in the country, or rheumatology, etc etc. When I started my last job in Alabama, the big rheumatology practice in Birmingham was booked out 10-12 months - and that was in Birmingham. Which is a legit midsize city.

I’ve been booked out 6+ months as a rheumatologist before. I can tell you that when you’re booked out like that, it really is because you’re THAT busy, not because you’re trying to pull some dbag move like “new patients don’t pay that much compared to followups”. For starters…if you’re a PP rheumatologist making money on ancillaries, the vast majority of the ancillaries come in the first 1-2 visits because that’s when you’re doing your workup. What that means is that for a lot of us, new patients are very profitable. So if we’re limiting how many we’re taking, it’s because we are borderline overwhelmed and need to make sure that our followups can get back in to see us when they need to. New rheumatology patients tend to have a lot of monthly followups in the first year or so as we do the workup, start and titrate meds, switch off meds that didn’t work, etc. So we need room for that. It takes a while to stabilize a new rheum pt to the point that were only seeing them every 3-6 months, or annually, or whatever.

 

[CatFactorial]

Funny because I market myself to PCPs and I tell them I will gladly take their bread and butter rhinitis, asthma, eczema, etc. off their hands so they have one less thing to think about. I'm new in private pracice so my "wait list" is basically how long will it take your patient to drive to my clinic? Please yall don't start managing your own allergic rhinitis. I have a family to support and a mortgage.

This is a viewpoint I am trying to get used to. As house staff always was embarrassed to leave for a specialist something I could have taken care of, now I realize the importance of greasing the wheel, so to speak. When our auto transplant patients hit week 4, sayonara back to med onc

 

[MD46]

This is a viewpoint I am trying to get used to. As house staff always was embarrassed to leave for a specialist something I could have taken care of, now I realize the importance of greasing the wheel, so to speak. When our auto transplant patients hit week 4, sayonara back to med onc

I am seeing this more often now, where I trained these autotransplant patients used to be followed by a transplant nurse coordinator now they want referring onc to take over everything from day 100 ‘marrows and vaccines etc

 

[CatFactorial]

I am seeing this more often now, where I trained these autotransplant patients used to be followed by a transplant nurse coordinator now they want referring onc to take over everything from day 100 ‘marrows and vaccines etc

Same. From the med onc perspective how is it perceived to get these autos back after D+30? Assuming that they are tucked in with central line removed, no transfusion requirements or lingering regimen related toxicity, and otherwise straightforward visits for maintenance therapy and the like?

 

[dozitgetchahi]

Funny because I market myself to PCPs and I tell them I will gladly take their bread and butter rhinitis, asthma, eczema, etc. off their hands so they have one less thing to think about. I'm new in private pracice so my "wait list" is basically how long will it take your patient to drive to my clinic? Please yall don't start managing your own allergic rhinitis. I have a family to support and a mortgage.

I do this with gout and osteoporosis. It’s nice to have some simple and straightforward patients mixed in.

(Except OA. PCPs, y’all can keep the OA 😂…I don’t have any magic trick for OA that you guys don’t know about…)

 

[bronx43]

In most cases a lot of a distribution problem. A lot more physicians want to work in urban areas or coastal areas than rural areas, so the less desirable locations will have worst shortages and the longest wait while the more saturated cities have physicians fighting over patients. Also, some patient demographics are more desirable than others. A lot more want to take a cooperative patient with high-paying commercial insurance or cash, than someone with than an indigent patient with Medicaid or no insurance and tons of underlying social issues (even though the latter patient may medically require the services just as much, if not more, than the first type of patient). If there's an absolute shortage, then there should be an expansion of residency or fellowship spots (though there are always people will want to keep the physician supply in a given specialty artificially low so they can maximize pay and negotiating power).

"Shortages" are also the result of the high maintenance and neediness of the American public. In less affluent countries, you go to the doctor, get a diagnosis, receive a medication, then you go home. You get maybe 5 minutes with the doctor. The doctor won't hold your hand, spend 30 minutes discussing every detail you want to know, then jump through 10 hoops to convince you to take a medication with favorable risk versus benefit. They won't entertain the anecdotal concerns you have from reading webmd or the online help group on reddit. If you didn't have a disease, the doctor told you to go home and you do. The doctor doesn't sit there and listen to symptoms of the human condition for 50 minutes then offer no specific therapy.

The fact that seeing 18 patients in this country takes you the whole day (not to mention all the paperwork and unnecessary interfacing with the EMR) is a cosmic joke. If medicine made any sense at all, we would all be seeing 50/day and the shortages would disappear instantly.

 

[MD46]

"Shortages" are also the result of the high maintenance and neediness of the American public. In less affluent countries, you go to the doctor, get a diagnosis, receive a medication, then you go home. You get maybe 5 minutes with the doctor. The doctor won't hold your hand, spend 30 minutes discussing every detail you want to know, then jump through 10 hoops to convince you to take a medication with favorable risk versus benefit. They won't entertain the anecdotal concerns you have from reading webmd or the online help group on reddit. If you didn't have a disease, the doctor told you to go home and you do. The doctor doesn't sit there and listen to symptoms of the human condition for 50 minutes then offer no specific therapy.

The fact that seeing 18 patients in this country takes you the whole day (not to mention all the paperwork and unnecessary interfacing with the EMR) is a cosmic joke. If medicine made any sense at all, we would all be seeing 50/day and the shortages would disappear instantly.

Where I did med school, a typical OPD (out patient day) one could see 100-125 patients from 8-4p

So yeah i agree.

 

[dozitgetchahi]

"Shortages" are also the result of the high maintenance and neediness of the American public. In less affluent countries, you go to the doctor, get a diagnosis, receive a medication, then you go home. You get maybe 5 minutes with the doctor. The doctor won't hold your hand, spend 30 minutes discussing every detail you want to know, then jump through 10 hoops to convince you to take a medication with favorable risk versus benefit. They won't entertain the anecdotal concerns you have from reading webmd or the online help group on reddit. If you didn't have a disease, the doctor told you to go home and you do. The doctor doesn't sit there and listen to symptoms of the human condition for 50 minutes then offer no specific therapy.

The fact that seeing 18 patients in this country takes you the whole day (not to mention all the paperwork and unnecessary interfacing with the EMR) is a cosmic joke. If medicine made any sense at all, we would all be seeing 50/day and the shortages would disappear instantly.

Eh, yes and no.

I know a few rheumatologists who do the whole 30-40 pts/day, “rack em, pack em, crack em” thing. Honestly, their care is pretty abysmal. I would not go to these doctors, and I would not have my family go to these doctors. The countries where doctors see 50-100 patients a day aren’t exactly ones known for quality of care.

I do agree that more needs to be done to restructure how care is delivered for most patients in the US. Perhaps the time you spend with the doctor should be shorter, but there would be nurses and/or other staff who do the bulk of the patient education and handholding. (But then again, perhaps not - I’ve seen how those types of staff handle these tasks, and I haven’t always been impressed.)

The EMR is another matter altogether. Scribes should be much more common, and the bulk of computerized bull**** should either be curtailed or handled by staff other than the physicians. Also, the vast majority of patient concerns, questions, and issues should be handled at visits. The entire phenomenon of “MyChart messages” never should have happened in American medicine. I’m not a DPC or concierge doctor, and my patients should not have 24/7 carte blanche access to me to ask inane and silly questions, or to question lab results that need to wait until the next visit to be reviewed. I know I could see more patients each day if I had less computer-related crap to do.

 

[MD46]

Same. From the med onc perspective how is it perceived to get these autos back after D+30? Assuming that they are tucked in with central line removed, no transfusion requirements or lingering regimen related toxicity, and otherwise straightforward visits for maintenance therapy and the like?

For the most part unless you are doing transplants regularly one doesnt keep up with all the new protocols and required schedules. If they come back D30+ with a plan from the transplanter then its fine.