Hospitalist confused about what to do next

[mdapply]

I am a hospitalist that recently finished residency in 2018.
I am having a bit of a career crisis and I am looking for advice on what to do.
I think hospitalist medicine is okay, but I am worried about long term sustainability as I am already starting to burn out from this. I don't think its job related because I honestly couldnt imagine a much better job than what I have.
I decided on hospitalist because I liked the broad scope of work and I didn't feel strongly about any specific subspecialty, although I could honestly see myself happy doing most IM subspecialties (although I don't think I could handle primary care)

What have other people done? Would it be realistic to get into a fellowship at this point? I didn't do research in residency but have some from medical school. I can get great letters from some residency attendings and my program director. I am a US MD from a mid tier academic university residency program. My top choice would probably be rheum/heme onc.

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[chessknt]

Ask yourself why you are burning out. What is your schedule like (how many shifts, hours, census). What do you find dissatisfying about your job? What is your work environment like? Are people annoying you about documentation, discharge speed etc?

 

[mdapply]

Average of 40 hrs a week. Days. Most weeks 3 x 12 hrs with 4 x 12 hrs every 3rd week. basically a variation of 7 on 7 off without having to do 7 in a row which I like. Although I initially liked having more days off than a 9-5 M-F, I'm finding that the schedule of working weekends,holidays, and 12 hr shifts not very appealing. Having a random Tuesday off doesn't make up for it when I'm missing out on weekend activities with family and friends. And I can only imagine this feeling will be worse with a future family of my own one day. A "round and go" type schedule would probably be a bit better, and I could probably find a job like that. But I don't think that would solve all my problems (see below).

Minimal documentation/discharge pressure and I don't feel overwhelmed with work. I'd consider myself faster and more efficient than most. I just find the job very unrewarding. As I progressed in residency and became comfortable practicing on my own, I realized how little I actually do. Sure there's the occasional exciting line, code, etc. But in reality I'm just reorganizing information on patients with long lists of medical problems that will never get better. I will just tip them from decompensated to compensated until next time. I find some satisfaction in getting some in respiratory distress better or treating sepsis, but in the big picture I question if what I am doing really matters. I do realize this is common in a lot of specialties so I don't expect to be able to fix everything or even the majority of things.

While consultants never talk down to me, I can't help but feel like I'm looked down upon/felt sorry for by the specialists. These things that didn't really bother me in residency, but now they do.

I'm torn between toughing it it out, working several years, saving, then cutting back and doing non clinical work versus making a big change now. Of my residency classmates who went on to fellowship, most honestly told me they were doing it because they didnt want to do hospitalist or primary care, not because they were passionate or interested in the field they were pursing. I always that was crazy but now I'm starting to think that's what I should have done.

 

[lulu09]

I'm doing a gap year now as a hospitalist before fellowship and boy, so much of what you're feeling resonates with me.

But in reality I'm just reorganizing information on patients with long lists of medical problems that will never get better. I will just tip them from decompensated to compensated until next time....but in the big picture I question if what I am doing really matters.

I can't help but feel like I'm looked down upon/felt sorry for by the specialists. These things that didn't really bother me in residency, but now they do.

THIS. So much this.

I'm not doing hospitalist as a career but unfortunately my one year has convinced me that while last year I thought of hospital medicine as a viable career, it is no longer -- for many of the reasons you outlined above.

Many of my hospitalist colleagues genuinely love the positive aspects of hospital medicine and I suppose I could force myself to love it if I didn't have another viable choice, but for now, it's time to leave.

(one of my hospitalist colleagues this year successfully matched in a decently competitive subspecialty after a 3-year hiatus as a hospitalist -- he did additional research with the department on the side when he wasn't working as a hospitalist and got some publications out as well as a research LOR)

 

[mdapply]

@lulu09 I assume you applied at the end of PGY-3 to start 1 year later?

Are you working at an academic center? I'm wondering if I should find an academic position, try to to some research, and apply next year. Kind of kicking myself for not getting publications for fellowship. I looked into research and even met with some potential mentors. But ultimately I was pretty set on hospital medicine.

 

[deleted941485]

@lulu09 I assume you applied at the end of PGY-3 to start 1 year later?

Are you working at an academic center? I'm wondering if I should find an academic position, try to to some research, and apply next year. Kind of kicking myself for not getting publications for fellowship. I looked into research and even met with some potential mentors. But ultimately I was pretty set on hospital medicine.

I remember my intern years. The hospitalist group average age was around 35-40. The older ones either got into admin, did fellowship, or switched to outpatient. It is truly a grind.

 

[lulu09]

@lulu09 I assume you applied at the end of PGY-3 to start 1 year later?

Are you working at an academic center? I'm wondering if I should find an academic position, try to to some research, and apply next year. Kind of kicking myself for not getting publications for fellowship. I looked into research and even met with some potential mentors. But ultimately I was pretty set on hospital medicine.

Yes I work in an academic center. I actually finished up my residency and applied this last fall (still planned, wanted to have a stronger app as I had a lot of research wrapped up during my PGY-3 year). At this rate I think you are also looking at 3 years out like my colleague (you can't really apply this upcoming cycle, so next cycle would come out to be 3 years in hospital medicine). Looking at my colleague's experience this year as long as you can get involved and do well in research and have someone vouch for you (recent LOR from the specialty) you should still be able to get a fellowship spot a couple years out as long as your residency record is solid. I don't know how it is finding research at a community hospital but it's easy to switch jobs in hospital medicine so maybe you can position yourself at an academic center job so you can be closer to research if you're really set for fellowship?

I remember my intern years. The hospitalist group average age was around 35-40. The older ones either got into admin, did fellowship, or switched to outpatient. It is truly a grind.

Yeah I think this is key. To not burn out in hospital medicine you have to be involved in something else other than clinical care like admin, research, or teaching (unless you literally truly don't mind just running through lists all day) -- all of the hospitalists who have been in our group for >3 years are able to obtain contracts that are less than 100% clinical care. I think 70/30 or 60/40 is awesome and sustainable.

 

[cards67]

What's your financial situation look like? I did fellowship because I was interested in the subject matter, not to avoid gen med, but I know many who do. If I weren't interested in my subspecialty I would've stuck with gen med, likely do hospitalist for a few years, save a ton of money, then down shift to part-time, primary care, locums, etc. Fellowship is possible, you can try applying cold-turkey and see what happens otherwise you have to fire up your research. Think hard about what specialty otherwise that could be years of training at 60k/yr to do something you're just as indifferent about.

 

[mdapply]

@cards67
Financial situation is fine. No longer any debt and a decent amount saved. Still living like a resident.

What you mentioned was another big reason I didn't pursue fellowship initially. Big monetary hit for something I wasn't sure I'd like more than hospitalist.

 

[Colorado outliers]

I am a hospitalist that recently finished residency in 2018.
I am having a bit of a career crisis and I am looking for advice on what to do.
I think hospitalist medicine is okay, but I am worried about long term sustainability as I am already starting to burn out from this. I don't think its job related because I honestly couldnt imagine a much better job than what I have.
I decided on hospitalist because I liked the broad scope of work and I didn't feel strongly about any specific subspecialty, although I could honestly see myself happy doing most IM subspecialties (although I don't think I could handle primary care)

What have other people done? Would it be realistic to get into a fellowship at this point? I didn't do research in residency but have some from medical school. I can get great letters from some residency attendings and my program director. I am a US MD from a mid tier academic university residency program. My top choice would probably be rheum/heme onc.

Not the exact same scenario, but I was a 'traditionalist' for four years - saw patients in clinic, admitted them, rounded on them, and did some ICU-level care at a small rural hospital. I enjoyed it but got burned out and went to Pulm-CCM fellowship (I know that sounds like a poor choice, haha). Like you, I had good letters. I had also done some research. Didn't have trouble matching. I'm sure you can match somewhere in rheum or heme onc as FMGs routinely match into those specialties, I think it's very realistic. Matching at 'top' programs would be tricky though without letters from well-known researchers or publications. Would be to your advantage to do research if possible while a hospitalist.

Going to sound like a jerk here, but..I don't see 'hospital medicine' as a real specialty - you basically triage patients, perform floor-level stabilization and consult subspecialists. It's no different than what 'internists' had previously done for years. The difference is that hospitalists have no long-term relationship with their patients and are looked down upon by specialists, leading to low job satisfaction and burnout (for some, not all). I see parallels in physicians who do only critical care and no outpatient work - many also rapidly burn out.

 

[doQuestions2]

Regarding 'sub-specialties looking down on you' isn't it up to the comfort level and education of an internist on when they get subspecialties involved? Like you only consult when you're no longer sure on the treatment plan, what's stopping you from just learning on the job/side and applying that? Also how many of you have tried nocturnist positions? I've heard that can help with the reduced hours/shifts, dealing less with administration and paperwork and the social side of hospital stays.

Asking these as a med student interested in hospitalist medicine.

 

[mdapply]

Regarding 'sub-specialties looking down on you' isn't it up to the comfort level and education of an internist on when they get subspecialties involved? Like you only consult when you're no longer sure on the treatment plan, what's stopping you from just learning on the job/side and applying that? Also how many of you have tried nocturnist positions? I've heard that can help with the reduced hours/shifts, dealing less with administration and paperwork and the social side of hospital stays.

Asking these as a med student interested in hospitalist medicine.

Yes in a way it is up to the internist to decide. This will be heavily dependent on where you practice. Less consulting the more rural you get. A bigger, busy place you may not have time to think, so you just load up on consultants. The culture of the place you work will also dictate how much consulting you do (for example, all chest pain gets a cardiology consult). In terms of learning on the job, lots of the time if not most of the time, you know what to do, but you get that consultant on board because they may provide a procedural service, or for various other reasons (ie medical legal).

The feeling of being looked down upon by specialists is really hard to explain and I didn't really feel it until I went into practice. For example, something about babysitting/copy pasting a note/doing nothing on a GI bleeder while the GI doctor scopes makes you feel like you do nothing. And in many cases you do nothing. And you may have to chase down this consultant to get answers on when/if the patient will be scoped since that consultant doesn't really have any ownership of the patient and doesn't really care when they get discharged. But again this will be heavily dependent on the culture and setting of where you practice. (BTW I have no interest in GI)

In many cases you feel like you exist to cater to the specialist and make that doctor's life easier. Which to an extent is true since that specialist doing the procedure is what makes money, and you exist to handle the BS to make that specialist's life easier so they can do more procedures to make more money. And this money subsidizes your salary because as a hospitalist, you are not an income generator. It's almost like being a nurse, which is exactly how you didn't want to feel because that is why you went to medical school.

Nocturnist definitely has way less to deal with and is a better gig. The problem is you are working at night, which I don't consider a sustainable career long term.

 

[doQuestions2]

Hmm that's a shame, yes the common downside I hear is that it's like being a resident/intern for the rest of your career. Maybe will consider specializing, but from what I've seen most specialists have worse hours, having to do both clinic and see hospital patients with a packed schedule. Or maybe having a 7 on 7 off schedule will help offset some of those complaints of practicing as a hospitalist as long as I have a life outside of medicine, i.e. work to live, not live to work.

 

[rokshana]

Not the exact same scenario, but I was a 'traditionalist' for four years - saw patients in clinic, admitted them, rounded on them, and did some ICU-level care at a small rural hospital. I enjoyed it but got burned out and went to Pulm-CCM fellowship (I know that sounds like a poor choice, haha). Like you, I had good letters. I had also done some research. Didn't have trouble matching. I'm sure you can match somewhere in rheum or heme onc as FMGs routinely match into those specialties, I think it's very realistic. Matching at 'top' programs would be tricky though without letters from well-known researchers or publications. Would be to your advantage to do research if possible while a hospitalist.

Going to sound like a jerk here, but..I don't see 'hospital medicine' as a real specialty - you basically triage patients, perform floor-level stabilization and consult subspecialists. It's no different than what 'internists' had previously done for years. The difference is that hospitalists have no long-term relationship with their patients and are looked down upon by specialists, leading to low job satisfaction and burnout (for some, not all). I see parallels in physicians who do only critical care and no outpatient work - many also rapidly burn out.

Well,the hospitalists has become a necessity since all those traditionalist out there don’t want to admit and round on pts in the hospital ...

 

[Osteoth]

I'm doing a gap year now as a hospitalist before fellowship and boy, so much of what you're feeling resonates with me.





THIS. So much this.

I'm not doing hospitalist as a career but unfortunately my one year has convinced me that while last year I thought of hospital medicine as a viable career, it is no longer -- for many of the reasons you outlined above.

Many of my hospitalist colleagues genuinely love the positive aspects of hospital medicine and I suppose I could force myself to love it if I didn't have another viable choice, but for now, it's time to leave.

(one of my hospitalist colleagues this year successfully matched in a decently competitive subspecialty after a 3-year hiatus as a hospitalist -- he did additional research with the department on the side when he wasn't working as a hospitalist and got some publications out as well as a research LOR)

@lulu09 I assume you applied at the end of PGY-3 to start 1 year later?

Are you working at an academic center? I'm wondering if I should find an academic position, try to to some research, and apply next year. Kind of kicking myself for not getting publications for fellowship. I looked into research and even met with some potential mentors. But ultimately I was pretty set on hospital medicine.

So what is the bare minimum number of publications (if you can break it down by manuscript, abstract, poster that would be even better) to be competitive for a desirable fellowship like GI?

 

[lulu09]

Regarding 'sub-specialties looking down on you' isn't it up to the comfort level and education of an internist on when they get subspecialties involved? Like you only consult when you're no longer sure on the treatment plan, what's stopping you from just learning on the job/side and applying that? Also how many of you have tried nocturnist positions? I've heard that can help with the reduced hours/shifts, dealing less with administration and paperwork and the social side of hospital stays.

Asking these as a med student interested in hospitalist medicine.

I practice in a med center which practices very defensively (any sniff of cardiac problem more than literally HTN or rock solid compensated CHF on lasix 40 mg daily gets a cards consult) -- as a result, the consultants are tired because they run around seeing pointless consults all day. Also, they belittle you for all the pointless consults that are called, even though there are several legit ones each week. I've tried to process the cases more myself instead of calling so many consults but actually had OTHER consultants tell me that I really shouldn't be trying to titrate BB or CCB by myself for Afib and to call cards.

This year I actually do a mixed model as both day and night, and basically yes, I tend to generally favor the nights more. However, you CANNOT be primary coverage (first call). It's fine to do admissions at night and have PAs cover the floor, but when you're covering the floor by yourself it literally is soul-crushing. I did not go through residency just to return to intern year and be called all night about miralax and ambien....

So what is the bare minimum number of publications (if you can break it down by manuscript, abstract, poster that would be even better) to be competitive for a desirable fellowship like GI?

There's no answer to this question. In general, the more competitive the field is (GI, cards, heme/onc, pulm/CCM, rheum) the more scholarly activity is expected across the spectrum. The more competitive the program is (large academic centers, brand-name places) the more research you're expected to have as it almost becomes a filtering mechanism to decide which candidates are the most competitive (even though the majority of fellows won't continue in academic medicine after graduation and a lot only did research to pad their CVs). That being said, people match these fields without any research too, it's just that they generally match in more community-oriented academic or community programs.

To give you some perspective, I matched heme-onc and at the top half of my interviews (all academic) all anyone talked about on the interview was my research. I had a few manuscripts, dozen+ posters/abstracts (which I consider to be above average for the middle-tier of heme-onc fellowship applicants) and was still berated at this place by an interviewer for "not having enough research...."

 

[Osteoth]

I practice in a med center which practices very defensively (any sniff of cardiac problem more than literally HTN or rock solid compensated CHF on lasix 40 mg daily gets a cards consult) -- as a result, the consultants are tired because they run around seeing pointless consults all day. Also, they belittle you for all the pointless consults that are called, even though there are several legit ones each week. I've tried to process the cases more myself instead of calling so many consults but actually had OTHER consultants tell me that I really shouldn't be trying to titrate BB or CCB by myself for Afib and to call cards.

This year I actually do a mixed model as both day and night, and basically yes, I tend to generally favor the nights more. However, you CANNOT be primary coverage (first call). It's fine to do admissions at night and have PAs cover the floor, but when you're covering the floor by yourself it literally is soul-crushing. I did not go through residency just to return to intern year and be called all night about miralax and ambien....



There's no answer to this question. In general, the more competitive the field is (GI, cards, heme/onc, pulm/CCM, rheum) the more scholarly activity is expected across the spectrum. The more competitive the program is (large academic centers, brand-name places) the more research you're expected to have as it almost becomes a filtering mechanism to decide which candidates are the most competitive (even though the majority of fellows won't continue in academic medicine after graduation and a lot only did research to pad their CVs). That being said, people match these fields without any research too, it's just that they generally match in more community-oriented academic or community programs.

To give you some perspective, I matched heme-onc and at the top half of my interviews (all academic) all anyone talked about on the interview was my research. I had a few manuscripts, dozen+ posters/abstracts (which I consider to be above average for the middle-tier of heme-onc fellowship applicants) and was still berated at this place by an interviewer for "not having enough research...."

Oh ok, so a couple of manuscripts plus associated posters, abstracts should get you across the line. Everyone just keeps talking about how competitive fellowships are from IM, so its tough to get perspective sometimes.

 

[alicealicealice]

Not the exact same scenario, but I was a 'traditionalist' for four years - saw patients in clinic, admitted them, rounded on them, and did some ICU-level care at a small rural hospital. I enjoyed it but got burned out and went to Pulm-CCM fellowship (I know that sounds like a poor choice, haha). Like you, I had good letters. I had also done some research. Didn't have trouble matching. I'm sure you can match somewhere in rheum or heme onc as FMGs routinely match into those specialties, I think it's very realistic. Matching at 'top' programs would be tricky though without letters from well-known researchers or publications. Would be to your advantage to do research if possible while a hospitalist.

Going to sound like a jerk here, but..I don't see 'hospital medicine' as a real specialty - you basically triage patients, perform floor-level stabilization and consult subspecialists. It's no different than what 'internists' had previously done for years. The difference is that hospitalists have no long-term relationship with their patients and are looked down upon by specialists, leading to low job satisfaction and burnout (for some, not all). I see parallels in physicians who do only critical care and no outpatient work - many also rapidly burn out.

How did you wind up liking your decision? What is your practice pattern now? Was it worth it and would you do the same thing again?

In a similar situation as op.
Doing academic hospitalist at a major academic center northeast, finishing 1 st year
Sustainable mix of days and nights lots of flexibility and ML opportunities. I’m working a lot to pay off loans. Also teaching service, pocus training, ed work, and procedures I like.

I like general medicine a lot. I love having first crack at a case, making a difficult diagnosis or even just a tricky one remain fun. I like taking ownership and acting as my patients advocate in the hospital and having them see me as their doctor; I am where i buck stops and I take that seriously (though many people don’t and push people out or don’t think beyond specialist recs). I’m good at building inpt relationships. I respect the role of breaking bad news and explaining complicated diagnoses and helping people leave with a chance of success. I know we don’t fix everyone, someone needs to care for the unfixables.

But I wonder about sustainability. It’s hard to do a good job at this job and no one values a good job much besides you and the patient. Specialists respect the good ones and I’ve had many say they’re glad when they see me on the patient. But otherwise I know I’m just a replaceable cog. The system says a first year PA can do my job just as well as I can. And while my ship is great if I ever leave or move I may be forced into a much crappier gig as I’ll never leave a major city. The feeling that I don’t really have a value add or clear skill set bothers me sometime. And not going to lie hospitalist sounds like a dirty word to me because in my head it implies transient clinical relationships, panconsulting, getting through the day, perma-resident, low respect from other doctors and the public. I thought about pcp too; it’s the same thing. Everyone wants a good one, but no one wants to respect pay or train people for it in the same way as a cardiologist. I’m just being the change I want to see but feel like maybe I’m pissing in the wind and I should do Pulm where I can get my inpatient sick fix, inpatient relationships, but also have a longitudinal clinical relationship with patients without being crushed by paperwork and other pcp uncompensated ridiculousness. I love the icu and most Pulm ... it feels like a guilty pleasure to think of working in the icu now...

Then I feel like I’m a cop out and should stick with it cause we need more good gen meds docs...but then I go through all of the above again


Also not thinking I’m amazing just being honest about my struggle. I take pride in my work and I want to feel that I should and it matters. I also don’t like admin crap....

 

[Anicetus]

Oh ok, so a couple of manuscripts plus associated posters, abstracts should get you across the line. Everyone just keeps talking about how competitive fellowships are from IM, so its tough to get perspective sometimes.

If you come from a top IM program, you can get away with only a couple things from a research perspective for GI. If you’re from a mid tier, you’ll need a lot more research. If you’re from low tier you need to make sure you have no one else in the class interested in GI so you can nab an in house spot. Otherwise you need to be a rockstar and have the hand of god him/herself get you placed higher on the ranklist.

 

[Osteoth]

If you come from a top IM program, you can get away with only a couple things from a research perspective for GI. If you’re from a mid tier, you’ll need a lot more research. If you’re from low tier you need to make sure you have no one else in the class interested in GI so you can nab an in house spot. Otherwise you need to be a rockstar and have the hand of god him/herself get you placed higher on the ranklist.

So top tier = top 20
What differentiates mid tier from bottom tier academic?

 

[wjs010]

Where I do residency, hospitalist is a big deal. They don’t just consult every a fib, GI bleed or chest pain. If one loves general medicine, I don’t see what could be so bad about hospitalist.

 

[IMGASMD]

Where I do residency, hospitalist is a big deal. They don’t just consult every a fib, GI bleed or chest pain. If one loves general medicine, I don’t see what could be so bad about hospitalist.

It maybe the culture. It’s probably where you are. I did my residency in the suburbia of nyc. Even my PD encouraged specializing, when he was a general internist.

“Dr. Wjs010, you have full consultation services at your hospital. Why didn’t you ask Dr. cardiology to help you with this afib, which turned out to be Bruguda arrhythmia. You could have asked Dr. cardiology for a consult, then he may asked his colleague, Dr. EP to do a comprehensive cardiology work up, that may have saved Mr. Smiths life.....”

“Dr. IMGASMD, you have cardiologist close to your office, do you not? In fact you have 10 cardiologists within 5 mile radius of where your office is. Did it occur to you, that you can refer Mr. Smith to any of them before you take on this new onset afib by yourself, when in fact it is actually 3rd degree heart block? Do you have the expertise to insert pacemaker?!”

Yes, I am being dramatic, and maybe a little tipsy. But, yes medical-legal and defensive medicine plays a role in what I do, especially when I work in a big hospital or big city when the specialists are literally a stone throw away.

 

[lulu09]

It maybe the culture. It’s probably where you are. I did my residency in the suburbia of nyc. Even my PD encouraged specializing, when he was a general internist.

“Dr. Wjs010, you have full consultation services at your hospital. Why didn’t you ask Dr. cardiology to help you with this afib, which turned out to be Bruguda arrhythmia. You could have asked Dr. cardiology for a consult, then he may asked his colleague, Dr. EP to do a comprehensive cardiology work up, that may have saved Mr. Smiths life.....”

“Dr. IMGASMD, you have cardiologist close to your office, do you not? In fact you have 10 cardiologists within 5 mile radius of where your office is. Did it occur to you, that you can refer Mr. Smith to any of them before you take on this new onset afib by yourself, when in fact it is actually 3rd degree heart block? Do you have the expertise to insert pacemaker?!”

Yes, I am being dramatic, and maybe a little tipsy. But, yes medical-legal and defensive medicine plays a role in what I do, especially when I work in a big hospital or big city when the specialists are literally a stone throw away.

I couldn't have put it better myself. You hit the nail on the head.

I did my residency in a more "rough and tumble" place where the consultants were stretched so thin and also the hospital being kind of dysfunctional that we didn't consult much. Made for great learning. Came out of residency and got culture shock the first few months of this past year with the amount of defensive consults that gets called. I don't agree with it, but I also cannot ignore the culture that I practice in. Even if I don't conform, I still have to meet it halfway.

 

[wjs010]

It maybe the culture. It’s probably where you are. I did my residency in the suburbia of nyc. Even my PD encouraged specializing, when he was a general internist.

“Dr. Wjs010, you have full consultation services at your hospital. Why didn’t you ask Dr. cardiology to help you with this afib, which turned out to be Bruguda arrhythmia. You could have asked Dr. cardiology for a consult, then he may asked his colleague, Dr. EP to do a comprehensive cardiology work up, that may have saved Mr. Smiths life.....”

“Dr. IMGASMD, you have cardiologist close to your office, do you not? In fact you have 10 cardiologists within 5 mile radius of where your office is. Did it occur to you, that you can refer Mr. Smith to any of them before you take on this new onset afib by yourself, when in fact it is actually 3rd degree heart block? Do you have the expertise to insert pacemaker?!”

Yes, I am being dramatic, and maybe a little tipsy. But, yes medical-legal and defensive medicine plays a role in what I do, especially when I work in a big hospital or big city when the specialists are literally a stone throw away.

Yea but as lonf as you were practicing at the standard of care for afib, you’re in the clear right? I mean then why doesn’t the first doc to touch the patient become responsible for what happens?

 

[Anicetus]

So top tier = top 20
What differentiates mid tier from bottom tier academic?

Mid tier numerically is probably 21-70. Low tier is 71-120. The rest is usually either just academic “affiliate” or straight up community program.

A way to tell how competitive a place is is to look at the class profile. If mostly AMG’s with 1-2 bombshell FMGs, likely top or upper mid tier. Mostly AMG’s and a handful of FMG’s/DO’s mid-lower mid tier. If the number of Caribbean grads or DOs goes above 25% you’re getting into the low tier realm.

Yes that was my made up bias approximation.

There’s a lot of variability but there is a general flow to it. Everyone thinks if they aren’t top tier then they are mid tier. But the reality is mid tier is any major academic hospital program with a big name that basically isn’t Harvard level. Low tier Is an academic hospital that has basically no name recognition outside of region. For instance no one from California knows what stony brook is. Likewise no one from the northeast knows what Harbor UCLA or olive view is.

 

[lulu09]

Yea but as lonf as you were practicing at the standard of care for afib, you’re in the clear right? I mean then why doesn’t the first doc to touch the patient become responsible for what happens?

Sure, you are always in the clear if you practice at the standard of care. Am I realistically to lose a lawsuit if I don't call consults but practice at standard of care solo? Most likely not. I am >99% comfortable with my clinical decisions and stand by them. However, if I deviate too much from what is expected of me in the system that I practice in, is my director or the hospital going to advocate for me, the maverick, in the event of a clinical complaint or a lawsuit? Less likely.

One thing I learned this year from being an attending is that although there is this fawning of working in a dream academic place where you diagnose zebra cases with flourish and flair (and teach students and residents) while in residency, once you become an attending you work for a health system and you have a boss and medical directors that you have to report to. If you want to do whatever you want and forget about litigation exposure, practice at the local county hospital or a FQHC. I know for sure I could never stay at this fancy academic center as a hospitalist long term, since everyone is so darned scared of being sued by the well-educated and well-connected patients we serve.

 

[bronx43]

I was a hospitalist before doing fellowship because I thought hospital medicine was not sustainable both from burnout perspective and from career satisfaction.

In terms of how competitive one would be as a hospitalist for a competitive specialty, it basically comes down to this. If you could have matched into a spot straight from residency then doing 1-2 years of fellowship likely won’t hurt you. If you didn’t have a shot at a fellowship spot from residency then doing hospital medicine probably set you back. Research and pubs move the needle very little for the latter unless you somehow worked with a superstar in the field and got a high impact publication which is highly unlikely.

 

[bronx43]

So what is the bare minimum number of publications (if you can break it down by manuscript, abstract, poster that would be even better) to be competitive for a desirable fellowship like GI?

Posters and abstracts mean nothing. For GI, only a true publication in a high or medium impact journal gets you any points. Your med school and residency is probably still the most important. The GI fever is just too great these days. You’re competing with traditional applicants from top to mid tier institutions who all have some form of research.

 

[IMGASMD]

Yea but as lonf as you were practicing at the standard of care for afib, you’re in the clear right? I mean then why doesn’t the first doc to touch the patient become responsible for what happens?

Sometimes the “standard” of care is established by your own community. Like @lulu09 mentioned, when your colleagues consult every single service, but you didn’t. Doesn’t that mean you didn’t follow the standard of care of your own community?

The other considerations which I’ve come to across more recently. I moonlight for a more rural hospital as a overnight nocturnalist. Sometimes over the weekend we only have NPs in house. When I decide to admit or transfer I have to take consideration of their comfort level. So a new onset afib patient that I may be comfortable managing overnight, may give them the chill during the day. As soon as anything that goes sideways, NPs transfer. So I’ve learned just block admissions.....

“Standard” of care does not get established in a vacuum. Everything we do need a context.

since everyone is so darned scared of being sued by the well-educated and well-connected patients we serve.

It cuts both ways, unfortunately. In a rough neighborhood, I worry am I going to be their ticket to get out.....

Sigh, medicine.

 

[wjs010]

Interesting perspectives. Thanks. It sounds more fulfilling to work in a smaller hospital but not completely run by NPs. I rotated at a hospital in med school that had literally 30 beds, and capacity actually averaged 10-15. There was 1 hospitalist and 1 NP. There was only transferring if PCI or other intervention was needed

 

[aafisahar]

Interesting perspectives. Thanks. It sounds more fulfilling to work in a smaller hospital but not completely run by NPs. I rotated at a hospital in med school that had literally 30 beds, and capacity actually averaged 10-15. There was 1 hospitalist and 1 NP. There was only transferring if PCI or other intervention was needed

that's because you never saw the cases that needed cards, GI, surgery, or other specialty service ever get admitted because the admitting hospitalist or ER transferred them out before you ever saw them.

 

[IMGASMD]

that's because you never saw the cases that needed cards, GI, surgery, or other specialty service ever get admitted because the admitting hospitalist or ER transferred them out before you ever saw them.

I was probably on that night....

 

[Osteoth]

Posters and abstracts mean nothing. For GI, only a true publication in a high or medium impact journal gets you any points. Your med school and residency is probably still the most important. The GI fever is just too great these days. You’re competing with traditional applicants from top to mid tier institutions who all have some form of research.

Makes sense. So how many manuscripts do you need to be "competitive". Obviously its hard to say with so many programs, but in your experience what number do people in the trenches try to get to?

 

[bronx43]

Makes sense. So how many manuscripts do you need to be "competitive". Obviously its hard to say with so many programs, but in your experience what number do people in the trenches try to get to?

Impossible to come up with a number. One Nature paper is 100x better than twenty crappy ones in some open access bs journal. But how many GI applicants are first author on a Nature paper? No one or almost no one. If you have 5-10 low to medium impact papers, that’s pretty solid.

 

[lulu09]

"Standard” of care does not get established in a vacuum. Everything we do need a context.

Repeated again for emphasis.

 

[Osteoth]

Impossible to come up with a number. One Nature paper is 100x better than twenty crappy ones in some open access bs journal. But how many GI applicants are first author on a Nature paper? No one or almost no one. If you have 5-10 low to medium impact papers, that’s pretty solid.

Thanks.

 

[doQuestions2]

So then is there any upsides to a general hospitalist career?

 

[IMGASMD]

So then is there any upsides to a general hospitalist career?

Predictable schedule. 5 on/5 off, 7/7. 14/14. Or whatever you choose.

Some places will let you go home if you’re not admitting that day, after you’ve rounded.

You can pick up a side hustle or two if you want. Like a nursing home, when they don’t really mind when you round during the day, if above is true.

Depends where you are, meaning the community or area, people do appreciate a good or two hospitalist who actually care.

It’s easy to “pick up” since you’ve spent a good chunk of your time in IM for inpatient.

Most of hospitalists are employed position, so little overhead or administrative stuff, unless you have to join different committees mandated by your group/hospital.

I think it cannot be overstated that at some point in your life you may not want to be a “owner” or “partner”, and you may “just go to work and do your job.” This is a hard concept for medical students/residents. You’ve trained so hard, spent endless time, energy to do this. To some it will just be a “job” a “means to an end.” Or “life is more than medicine.” Not to say I agree completely, but there are days it’s just tiring and too much, life still goes on with or without your presence.

 

[wjs010]

So then is there any upsides to a general hospitalist career?

About once every 6 months, someone comes along to paint a better picture of it, and the remaining times, everybody else talks about how bad it is. Even though it doesn’t seem that bad.

 

[CatFactorial]

There is always the case of the grass being greener. To the "hypothetical" fellow who, despite the legitimately gratifying ownership of his cancer patients, cannot stand the defensive BS consults he has to see (e.g. vascular surgery consulting to manage a heparin drip, treatment recommendations for a hot but-still-to-be-biopsied nodule on PET/CT that HAS to be lymphoma, whether enoxaparin is 'kay in a dialysis patient, etc.), as well as no cash money, hospitalist seems like a good gig.

But the above points about hospitalists are well-articulated. As a sub specialist there is quite a lot of satisfaction in writing a nuanced consult assessment that isn't easily searchable on uptodate (or so I've been told).

 

[laserbeam]

I think it cannot be overstated that at some point in your life you may not want to be a “owner” or “partner”, and you may “just go to work and do your job.”

THIS, and at some point in your life, you may not want to have patients either, the less the merrier, the shorter encounter the merrier......

 

[bronx43]

THIS, and at some point in your life, you may not want to have patients either, the less the merrier, the shorter encounter the merrier......

Sure. But at what cost? When you can ONLY work for a hospital, they own you. You are a cog in their machine and have little control over your job. When you are a private practice specialist, you call the shots. The patients come for you. The nurses work for you. You control when, where, how you want to work as long as you don't malpractice.

 

[Anicetus]

Sure. But at what cost? When you can ONLY work for a hospital, they own you. You are a cog in their machine and have little control over your job. When you are a private practice specialist, you call the shots. The patients come for you. The nurses work for you. You control when, where, how you want to work as long as you don't malpractice.

This may sound appealing to the person who doesn’t like being a “cog in the machine.” However this is a nightmare to those who just want the job to be solely a job and can take multiple vacations off, not having to rely on a partner or two in your group to help deal with the coverage, not to mention working longer hours. It’s probably more of a personality thing at the end of the day.

 

[bronx43]

This may sound appealing to the person who doesn’t like being a “cog in the machine.” However this is a nightmare to those who just want the job to be solely a job and can take multiple vacations off, not having to rely on a partner or two in your group to help deal with the coverage, not to mention working longer hours. It’s probably more of a personality thing at the end of the day.

As a previous hospitalist, I can tell you that no one (or almost no one) likes being a cog in the machine. Even if you think you do, you'll change your mind the next time a nurse gives you attitude and you can't do anything back for fear of being "written up" or your medical director emails you about expediting discharges twenty times a day.
I honestly don't know many hospitalists who don't want to be a specialist due to love for the career or the "amenities" of being a hospitalist. Most don't go into fellowship due to inability to secure a spot, financial opportunity cost, not wanting to be a trainee, and other life situations. If a specialist skillset and title were handed to them on a silver platter, almost everyone would take it.

 

[Anicetus]

As a previous hospitalist, I can tell you that no one (or almost no one) likes being a cog in the machine. Even if you think you do, you'll change your mind the next time a nurse gives you attitude and you can't do anything back for fear of being "written up" or your medical director emails you about expediting discharges twenty times a day.
I honestly don't know many hospitalists who don't want to be a specialist due to love for the career or the "amenities" of being a hospitalist. Most don't go into fellowship due to inability to secure a spot, financial opportunity cost, not wanting to be a trainee, and other life situations. If a specialist skillset and title were handed to them on a silver platter, almost everyone would take it.

This is actually kind of frightening. So with the “inability to secure a spot” are you referring to all of the people who intended to match GI and cards and failed to do so and are bound by chains to a lifetime of hospitalist medicine? I feel like the hospitalists that I’ve worked with who have a good head on their shoulders are either very good at hiding that they wanted to be a specialist or they just DGAF about work in general and are happier with things outside of their work life, using their job as a means to an end.

 

[bronx43]

This is actually kind of frightening. So with the “inability to secure a spot” are you referring to all of the people who intended to match GI and cards and failed to do so and are bound by chains to a lifetime of hospitalist medicine? I feel like the hospitalists that I’ve worked with who have a good head on their shoulders are either very good at hiding that they wanted to be a specialist or they just DGAF about work in general and are happier with things outside of their work life, using their job as a means to an end.

Yes, they are bound... because what are their other options? Primary care? that's why so many hospitalists want to claw their way into administration, because that's the only reprieve from rounding, admitting, and discharging.

You can be happy with life outside of work as a specialist as well. My hours as an outpatient specialist is far more accomodating to life than it was when I was a hospitalist working half the weekends and some nights.

 

[alicealicealice]

How did you wind up liking your decision? What is your practice pattern now? Was it worth it and would you do the same thing again?

@Colorado outliers
Still wondering what ye has to sayeth

 

[Colorado outliers]

How did you wind up liking your decision? What is your practice pattern now? Was it worth it and would you do the same thing again?

In a similar situation as op.
Doing academic hospitalist at a major academic center northeast, finishing 1 st year
Sustainable mix of days and nights lots of flexibility and ML opportunities. I’m working a lot to pay off loans. Also teaching service, pocus training, ed work, and procedures I like.

I like general medicine a lot. I love having first crack at a case, making a difficult diagnosis or even just a tricky one remain fun. I like taking ownership and acting as my patients advocate in the hospital and having them see me as their doctor; I am where i buck stops and I take that seriously (though many people don’t and push people out or don’t think beyond specialist recs). I’m good at building inpt relationships. I respect the role of breaking bad news and explaining complicated diagnoses and helping people leave with a chance of success. I know we don’t fix everyone, someone needs to care for the unfixables.

But I wonder about sustainability. It’s hard to do a good job at this job and no one values a good job much besides you and the patient. Specialists respect the good ones and I’ve had many say they’re glad when they see me on the patient. But otherwise I know I’m just a replaceable cog. The system says a first year PA can do my job just as well as I can. And while my ship is great if I ever leave or move I may be forced into a much crappier gig as I’ll never leave a major city. The feeling that I don’t really have a value add or clear skill set bothers me sometime. And not going to lie hospitalist sounds like a dirty word to me because in my head it implies transient clinical relationships, panconsulting, getting through the day, perma-resident, low respect from other doctors and the public. I thought about pcp too; it’s the same thing. Everyone wants a good one, but no one wants to respect pay or train people for it in the same way as a cardiologist. I’m just being the change I want to see but feel like maybe I’m pissing in the wind and I should do Pulm where I can get my inpatient sick fix, inpatient relationships, but also have a longitudinal clinical relationship with patients without being crushed by paperwork and other pcp uncompensated ridiculousness. I love the icu and most Pulm ... it feels like a guilty pleasure to think of working in the icu now...

Then I feel like I’m a cop out and should stick with it cause we need more good gen meds docs...but then I go through all of the above again


Also not thinking I’m amazing just being honest about my struggle. I take pride in my work and I want to feel that I should and it matters. I also don’t like admin crap....

Sorry for the late reply. It's great that you take pride in your work and enjoy general medicine, we need more hospitalists (and doctors in general) like you. I enjoyed being a traditionalist, especially the long-term relationships with patients. Like you, I learned quickly not to push people out, because if you're seeing them in clinic, it'll come back to bite you. As I worked in a rural area, I lacked the ability to consult specialists for many patients and had to take care of many subspecialty problems myself - this was stimulating and rewarding. However I would imagine depending where you worked, this would not be feasible. Eventually got burned out taking too much overnight and weekend calls which was also a function of the rural setting. There was a nearby larger town where our patients would sometimes end up if they needed dialysis, cath, etc. The doctors there were often terrible but looked down on me for working at the rural hospital - I also got tired of dealing with them also.

I actually disagree that PCPs are not respected by other doctors (not sure if that's exactly what you meant) - in my experience as a subspecialist, PCPs are treated no differently than the patient's other outpatient physicians and a good one is worth their weight in gold. The impression of the lay public is variable, I think depending on the nature of the patient's issues and the PCP. I would probably have become a PCP if I hadn't specialized.

I'm happy with my current job. I'm an attending at a large referral center (similar to where I trained for IM). I have about 24-28 weeks of service a year (ICU, consults), and 2-3 clinics per week. I work 1 out 5-6 weekends (not overnight thought) and a few nights a month. Was worth it to me (although finances were rough on a fellow salary with young kids) and I like being a subspecialist. Also have some time to do research, although it's more of a hobby than a required part of my job.

If we could somehow go back to a system where internists rounded on their own patients in the hospital (or took turns) and did clinic, I think job satisfaction and patient satisfaction would be much higher...just my 2 cents. That seems unlikely to happen though.

 

[Anicetus]

Yes, they are bound... because what are their other options? Primary care? that's why so many hospitalists want to claw their way into administration, because that's the only reprieve from rounding, admitting, and discharging.

You can be happy with life outside of work as a specialist as well. My hours as an outpatient specialist is far more accomodating to life than it was when I was a hospitalist working half the weekends and some nights.

So where’s the line to reapply in the match to general surgery?

 

[Sushirolls]

Average of 40 hrs a week. Days. Most weeks 3 x 12 hrs with 4 x 12 hrs every 3rd week. basically a variation of 7 on 7 off without having to do 7 in a row which I like. Although I initially liked having more days off than a 9-5 M-F, I'm finding that the schedule of working weekends,holidays, and 12 hr shifts not very appealing. Having a random Tuesday off doesn't make up for it when I'm missing out on weekend activities with family and friends. And I can only imagine this feeling will be worse with a future family of my own one day. A "round and go" type schedule would probably be a bit better, and I could probably find a job like that. But I don't think that would solve all my problems (see below).

Minimal documentation/discharge pressure and I don't feel overwhelmed with work. I'd consider myself faster and more efficient than most. I just find the job very unrewarding. As I progressed in residency and became comfortable practicing on my own, I realized how little I actually do. Sure there's the occasional exciting line, code, etc. But in reality I'm just reorganizing information on patients with long lists of medical problems that will never get better. I will just tip them from decompensated to compensated until next time. I find some satisfaction in getting some in respiratory distress better or treating sepsis, but in the big picture I question if what I am doing really matters. I do realize this is common in a lot of specialties so I don't expect to be able to fix everything or even the majority of things.

While consultants never talk down to me, I can't help but feel like I'm looked down upon/felt sorry for by the specialists. These things that didn't really bother me in residency, but now they do.

I'm torn between toughing it it out, working several years, saving, then cutting back and doing non clinical work versus making a big change now. Of my residency classmates who went on to fellowship, most honestly told me they were doing it because they didnt want to do hospitalist or primary care, not because they were passionate or interested in the field they were pursing. I always that was crazy but now I'm starting to think that's what I should have done.

Here's a niche to consider... The hospitalist who works in the free standing psych hospital. The psychiatrist is likely the primary and you are the consultant. Most of the patients you see will be the obligatory, straight forward consult and a quick sign off. Some will be the usual long med list, long problem list you are accustomed to. But you will be cherished and valued even for something as simple as a UTI or skin rash. When you keep your eyes open and listen to the patients, you will find things that were missed by many other physicians because it is a psychiatric patient the others likely didn't spend the time to fully assess. More severe mental illness with floridly psychotic or manic patients, you will be valued for your efforts to get the consult done - but if you can't, you can't. Furthermore, with psychiatry typically being the primary, you won't have to do discharge summaries! You'll get to wear fun hats like be on the microbial stewardship committee for the hospital, too. Not exactly the CHF, COPD, AKI, DKA grind you are used to and fully capable of but when those things sneak through the doors you will be cherished for helping to spot and transfer out. Or when you speak and say, 'hey, this needs to get done' or this patient needs this test while here (sadly, you'll likely have to spend time coordinating for the test at the outside facility) you will have the satisfaction of knowing you helped a patient who probably wouldn't have gotten that test otherwise. Some of the more severe mental illness have poorer life expectancy, and health outcomes - so your knowledge and personal investment and drive for advocacy really could make the difference in a patient's life. Ex: getting the biopsy on lesion for likely cancer in transient schizophrenic who just showed up in your town from across country.

Its also possible to carve out this set up in a general hospital that has an attached psych unit. My experience has been most of the IM hospitalists loathed setting foot on the psych unit, and if you volunteer in the group to be the designated psych consultant, your IM group will praise you for jumping on the landmine, the psych group will be grateful for quality and consistency.