How common is it for hospitalists to cover the ICU?
I was looking at some hospitalist positions and a couple of them require ICU coverage -- e.g. managing vent, performing procedures, etc.. This sounds more like critical care rather than internal medicine. Has anyone worked in a hospital like this?
It is quite common to be honest. Simply stated, there are not enough intensivists to cover our ICUs. Most ICU patients can probably be managed by IM - run off the mill septic shock, COPDer who needs a few days on the vent, DKA, etc. I did it for two years. However, I think it is less than ideal. After all, we are internists, not intensivists.
The model is a recipe for disaster. ICU patients often require you to be in the unit for hours at a time. That is not compatible with rounding on patients with mild pancreatitis getting IVF in the wards, doing admissions, discharging patients, rounding with case management, social workers, fielding calls from the nurses, etc.
My personal experience is that you shouldn't count on being able to transfer your patients to a tertiary hospital. Once you admit a patient, you own that patient and no one has to accept a transfer. Further, academic centers are often working at capacity and it can take days for a transfer to take place.
Bear in mind that if you find yourself in an adverse medico legal situation you will be judged compared to the standard of care provided by intensivists. Saying that "you didn't know better because you are not an intensivist" is not going to fly.
Beware of hospitals that entice you to join them by telling you that you will not be required to do procedures. If you are not comfortable with common ICU procedures such as central lines and arterial lines you need to ask very carefully who is responsible for doing the procedures. I guess intubations can be managed by the ER doc or GAS. However, asking your colleagues to place a central line for you on a daily basis will not fly.
And I wouldn't be overconfident about intubating anyone. I had to do it emergently a few times but I wish I didn't have to do it.
IR is pretty much ubiquitous in large hospitals, often seven days a week. They can definitely help you out with common bedside procedures. I wouldn't count on this in a small hospital in a rural setting, particularly during the weekends.
If you have been in the outpatient setting for long, transitioning into hospital medicine is harder than you think. I don't remember the last central line or A-line that I placed, or the last paracentesis. I can probably do it but I have not done one in over a year. The more time I spend out of the hospital the harder it is to be competent as a hospitalist and vice versa.
I remember a primary care physician that joined our hospitalist group after more than 20 years in the office. He had to settle for the job due to a non compete clause that he had. To make the story short, he was let go after roughly five days for gross incompetence. I'm sure he was a great primary care doctor though.
I think that IM needs to be split between hospital medicine tracks and primary care tracks. They really are different specialties.
In summary, I think it can be done but ICU care requires emergency procedures and you should be confident doing them or you should have a procedural team available to you 24/7. If this is not clearly available, I wouldn't take the job. You should be confident to do critical procedures in a timely fashion if you are going to provide critical care.
LPs, paracentesis, and thoracentesis, are also common inpatient procedures although often not emergent (meaning you can punt to IR if available). I wouldn't worry too much about these because you have time to find someone that can help you out if you are unable to do them yourself.
PS: Don't believe for a second that because the hospital is rural all you will see are soft cases. The acuity is going to be there wherever you go. Whether the hospital has the capability to care for those patients is the real question here.
