IM / Hospitalist (after residency)

[Ellomate]

I'm almost done my MS-3 and coming closer to making a decision on what I want to do.
I've search extensively on my questions written below, but was either outdated or unsatisfied with the answers.
Hoping for some clarification.

In addition to the work, I value family time > travel > hobbies.
I was initially interested in EM, but I do not want those random 7pm-3am shifts.
I hope to stay along East coast (ranges from Boston to Virginia)
My GF is in corporate insurance, so she needs to be in a city or a suburban 20-30 mins away.

I know IM inpatients are usually 7on 7off. (7a-7p).
However, my experience in my IM clerkship is that most attending leave around 430-5pm.
So my questions are as follow:

1. Although it varies, do most hospitalist usually get off once they finish their work around 430-5pm
2. What time do YOU start the day and end the day?
3. I know my hospital is a teaching hospital (thus residents take over), but how about the coverage in community hospitals or non-academic hospitals (do you have other doctors that watch your back or NP/PA who stays for the remainder of the shift?)
4. One drawback of 7on 7off is working weekends. Are the weekend shifts lighter than weekdays? (do you get out earlier?)
5. Also, doximity 2021 compensation report recently reported 295k salary. That sounds like an overestimation. What are your thoughts? Accurate? Inflation?
6. If I become drawn to outpatient, is it wise to do IM PCP vs FM PCP? Any difference in type of work? Is it as easy to find jobs as IM PCP vs FM PCP?


For me, working 7 straight days is not an issue if the schedule is apprx 830am-430pm (5).
However, if the norm is working 12hr-shifts (80 hour weeks), IM will likely be a deal-breaker.

I know talking about scheudle/lifestyle/compensation can be taboo on these platforms, but I just want to know what I'm signing up for.
I also hope answering these questions can help other med students make the right career decision.
Thank you all for your time.

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[IMGASMD]

I'm almost done my MS-3 and coming closer to making a decision on what I want to do.
I've search extensively on my questions written below, but was either outdated or unsatisfied with the answers.
Hoping for some clarification.

In addition to the work, I value family time > travel > hobbies.
I was initially interested in EM, but I do not want those random 7pm-3am shifts.

I know IM inpatients are usually 7on 7off. (7a-7p).
However, my experience in my IM clerkship is that most attending leave around 430-5pm.
So my questions are as follow:

1. Although it varies, do most hospitalist usually get off once they finish their work around 430-5pm
2. What time do YOU start the day and end the day?
3. I know my hospital is a teaching hospital (thus residents take over), but how about the coverage in community hospitals or non-academic hospitals?
4. One drawback of 7on 7off is working weekends. Are the weekend shifts lighter than weekdays? (do you get out earlier?)
5. Also, doximity 2021 compensation report recently reported 295k salary. That sounds like an overestimation. What are your thoughts? Accurate? Inflation?
6. If I become drawn to outpatient, is it wise to do IM PCP vs FM PCP? Any difference in type of work? Is it as easy to find jobs as IM PCP vs FM PCP?


For me, working 7 straight days is not an issue if the schedule is apprx 830am-430pm (5).
However, if the norm is working 12hr-shifts (80 hour weeks), IM will likely be a deal-breaker.

I know talking about scheudle/lifestyle/compensation can be taboo on these platforms, but I just want to know what I'm signing up for.
I also hope answering these questions can help other med students make the right career decision.
Thank you all for your time.

Two words answer for all your questions.
- It depends.

You can find any sort of arrangement for any kind of schedule, but it depends where you want to be = location.

You can find any pay (some of them higher, some much lower) but it depends how you want to work for it = lifestyle

You can find any job, but it depends where you want to be and how hard you worn for it = money

Pick two, if lucky.

You probably think who is this jerk off. But it really depends on all those three factors, especially for any of the specialities that’s tied to the hospital. (EM, hospitalist Anesthesia). You likely get whatever your market rate, or whatever schedule is set by the hospital. Sure there are still some EM/hospitalist/anesthesia private practices out there, but you’d have to find those yourself.

FM vs IM? That’s another question that I will answer with, it depends. Do you want to be closer to major cities, big suburban areas, smaller cities, rural America? My take would be, IM if you’re more skewed to the cities, IM/FM if the rural area. I think IM will give you better inpatient training and also give you a little better opportunities if you want to specialize. FM if you want to be in the community and wants to see everyone, your breadth should be more, at the expense of your depth. (Generally speaking).

Some of the answers you found, really hasn’t changed drastically in the last few years. Probably just more work for the same pay-ish. You won’t be rich doing medicine, you won’s starve either. Good luck.

 

[DrMetal]

I'm almost done my MS-3 and coming closer to making a decision on what I want to do.

You're an MS3? So you'll be entering the job market sometime in 2027, or 28? Hurry up! By then the NPs will have taken over.

 

[obiwan]

1. Although it varies, do most hospitalist usually get off once they finish their work around 430-5pm
2. What time do YOU start the day and end the day?

I got into the hospital at 7:00 AM this morning with it being my first day on service and left at 5:30 with a few notes left to do but didn't want to stay in the hospital so am finishing them up as I type this reply. Tomorrow will probably be a little bit faster but nothing is guaranteed given s**t can happen at any time and depends on number of new patients I will get tomorrow.

One thing you have to understand is that the attending may be leaving at a certain time on a teaching team because the residents stay behind to handle cross cover etc but that is not necessarily the case when its just you seeing 15-20 patients by yourself

 

[chessknt]

I'm almost done my MS-3 and coming closer to making a decision on what I want to do.
I've search extensively on my questions written below, but was either outdated or unsatisfied with the answers.
Hoping for some clarification.

In addition to the work, I value family time > travel > hobbies.
I was initially interested in EM, but I do not want those random 7pm-3am shifts.
I hope to stay along East coast (ranges from Boston to Virginia)
My GF is in corporate insurance, so she needs to be in a city or a suburban 20-30 mins away.

I know IM inpatients are usually 7on 7off. (7a-7p).
However, my experience in my IM clerkship is that most attending leave around 430-5pm.
So my questions are as follow:

1. Although it varies, do most hospitalist usually get off once they finish their work around 430-5pm
2. What time do YOU start the day and end the day?
3. I know my hospital is a teaching hospital (thus residents take over), but how about the coverage in community hospitals or non-academic hospitals (do you have other doctors that watch your back or NP/PA who stays for the remainder of the shift?)
4. One drawback of 7on 7off is working weekends. Are the weekend shifts lighter than weekdays? (do you get out earlier?)
5. Also, doximity 2021 compensation report recently reported 295k salary. That sounds like an overestimation. What are your thoughts? Accurate? Inflation?
6. If I become drawn to outpatient, is it wise to do IM PCP vs FM PCP? Any difference in type of work? Is it as easy to find jobs as IM PCP vs FM PCP?


For me, working 7 straight days is not an issue if the schedule is apprx 830am-430pm (5).
However, if the norm is working 12hr-shifts (80 hour weeks), IM will likely be a deal-breaker.

I know talking about scheudle/lifestyle/compensation can be taboo on these platforms, but I just want to know what I'm signing up for.
I also hope answering these questions can help other med students make the right career decision.
Thank you all for your time.

The irony is that any answers you receive here will be just as outdated when you finish.

 

[DrMetal]

The irony is that any answers you receive here will be just as outdated when you finish.

Exactly.

The current physician (IM/FP) hospitalist system is not financially sound for any hospital system. We don't do procedures, we don't do surgeries, we take care of the mostly uninsured medicare/medicaid bombs that the hospital loses a lot of money over.

I predict, by 2030, your typical group of 20 physician hospitalists will consist of 15 NPs + 5 MDs. The hospital will save lots of money that way, and the 5 MDs will be "rounding" (really just co-signing) notes on 50 patients per day. The physicians will complain about this, but it'll become the new normal very quickly

 

[CCM-MD]

Exactly.

The current physician (IM/FP) hospitalist system is not financially sound for any hospital system. We don't do procedures, we don't do surgeries, we take care of the mostly uninsured medicare/medicaid bombs that the hospital loses a lot of money over.

I predict, by 2030, your typical group of 20 physician hospitalists will consist of 15 NPs + 5 MDs. The hospital will save lots of money that way, and the 5 MDs will be "rounding" (really just co-signing) notes on 50 patients per day. The physicians will complain about this, but it'll become the new normal very quickly

LOS will decrease due to patients dying, which translates into more $ due to DRG bundled payments.

 

[bronx43]

Exactly.

The current physician (IM/FP) hospitalist system is not financially sound for any hospital system. We don't do procedures, we don't do surgeries, we take care of the mostly uninsured medicare/medicaid bombs that the hospital loses a lot of money over.

I predict, by 2030, your typical group of 20 physician hospitalists will consist of 15 NPs + 5 MDs. The hospital will save lots of money that way, and the 5 MDs will be "rounding" (really just co-signing) notes on 50 patients per day. The physicians will complain about this, but it'll become the new normal very quickly

At some of the outlying hospitals near me, it's already 50/50 midlevels in the hospitalist program. May not take until 2030 to hit the 75/25 ratio.

 

[collegestud2013]

I'm almost done my MS-3 and coming closer to making a decision on what I want to do.
I've search extensively on my questions written below, but was either outdated or unsatisfied with the answers.
Hoping for some clarification.

In addition to the work, I value family time > travel > hobbies.
I was initially interested in EM, but I do not want those random 7pm-3am shifts.
I hope to stay along East coast (ranges from Boston to Virginia)
My GF is in corporate insurance, so she needs to be in a city or a suburban 20-30 mins away.

I know IM inpatients are usually 7on 7off. (7a-7p).
However, my experience in my IM clerkship is that most attending leave around 430-5pm.
So my questions are as follow:

1. Although it varies, do most hospitalist usually get off once they finish their work around 430-5pm
2. What time do YOU start the day and end the day?
3. I know my hospital is a teaching hospital (thus residents take over), but how about the coverage in community hospitals or non-academic hospitals (do you have other doctors that watch your back or NP/PA who stays for the remainder of the shift?)
4. One drawback of 7on 7off is working weekends. Are the weekend shifts lighter than weekdays? (do you get out earlier?)
5. Also, doximity 2021 compensation report recently reported 295k salary. That sounds like an overestimation. What are your thoughts? Accurate? Inflation?
6. If I become drawn to outpatient, is it wise to do IM PCP vs FM PCP? Any difference in type of work? Is it as easy to find jobs as IM PCP vs FM PCP?


For me, working 7 straight days is not an issue if the schedule is apprx 830am-430pm (5).
However, if the norm is working 12hr-shifts (80 hour weeks), IM will likely be a deal-breaker.

I know talking about scheudle/lifestyle/compensation can be taboo on these platforms, but I just want to know what I'm signing up for.
I also hope answering these questions can help other med students make the right career decision.
Thank you all for your time.

1 and 2) the typical 7on-7off schedule involves 12 hr shifts. A typical schedule would technically be be 7am-7pm, though many hospitals informally use a "round and go" model where on rounding shifts, you can leave a bit early if all your patients are tucked in and stable and cross cover pages/calls from home for the rest of your shift (this is often doable if your patient census is reasonable and you work efficiently within your system). You probably won't be able to leave early on admitting or night shifts though.

Note that not every place uses 12 hr shifts. Some will use 10 or 8 hr shifts though these end up being more problematic in getting out on time since you're often squeezing almost as much work of a 12 a shift into a 10 hr shift (or 8-9 hr shift at some places), but will get paid less per shift, and will have to work more days out of the year.

3) In a non-teaching service, you may have PAs/NPs for coverage of some patients depending on the staffing at your particular hospital, but if you do you will likely have to round on many patients on your own. Remember that PAs/NPs cost money to hire and usually go for 40-50% per hour of the attending rate (unlike resident salaries, which are completely funded by CMS) so their pay must be justified by the attendings seeing higher volumes (including PA/NP notes that they cosign and bill for).

4) In general, yes, as less happens in the hospital on weekends. Again, you probably can't leave early on an admitting shift. If working 7 days in a role seems like a lot, some places will do alternate schedules such as 5on/5off, though you still work the same number of weekends.

5) Probably a little underestimating. Median total compensation (including bonuses) for a hospitalist is nowadays in low $300ks (obviously there is a lot of variation depending on geography, patient volume, practice setting, number of shifts worked. Though as with most specialties, you will probably make less than that in academics and at the VA). Also, I would use the MGMA numbers over other sources for the most accurate compensation data (though you have to pay to get access to it) as the other sources tend to be self reported by individual physicians which inherently introduces a lot of bias. Note that doximity uses average compensation. which tend to be skewed and not as representative as median compensation.

6) Pretty easy to find a PCP jobs nowadays since not many people want to do it (historically low pay, lots of paperwork and insurance BS to deal with in the outpatient setting), but the flipside is that that pay is catching up and pretty close to that of hospitalist to get more IM/FM grads to do it and because it's one of the few specialties' where CMS has raised reimbursements recently . In the past few years hospitalist work has paid higher per hour than PCP but the difference is narrowing. And outpatient PCP work is probably the better schedule for someone who wants to work just Mon-Fri.

And as others have said, by the time you finish residency the system a most hospitals can change significantly.

 

[NITRAS]

Exactly.

The current physician (IM/FP) hospitalist system is not financially sound for any hospital system. We don't do procedures, we don't do surgeries, we take care of the mostly uninsured medicare/medicaid bombs that the hospital loses a lot of money over.

I predict, by 2030, your typical group of 20 physician hospitalists will consist of 15 NPs + 5 MDs. The hospital will save lots of money that way, and the 5 MDs will be "rounding" (really just co-signing) notes on 50 patients per day. The physicians will complain about this, but it'll become the new normal very quickly

Billing for 2023 will make billing less favorable doctors actually seeing PA/NP patients. (like you have to say that you spent more time than the NPP dealing with the patient) and that usually isn’t the case.

 

[Splenda88]

Exactly.

The current physician (IM/FP) hospitalist system is not financially sound for any hospital system. We don't do procedures, we don't do surgeries, we take care of the mostly uninsured medicare/medicaid bombs that the hospital loses a lot of money over.

I predict, by 2030, your typical group of 20 physician hospitalists will consist of 15 NPs + 5 MDs. The hospital will save lots of money that way, and the 5 MDs will be "rounding" (really just co-signing) notes on 50 patients per day. The physicians will complain about this, but it'll become the new normal very quickly

What should we do then? Make our $$$ before sh***t hits the fan.

Not sure about your assessment. We order a bunch of expensive test/imaging. Is reimbursement for these MRI/CT we order really that bad?

10 physician specialties that generate the most revenue for hospitals

The average amount of revenue physicians generate for hospitals has jumped significantly in recent years, and a decline in patient volumes and elective procedures due to the COVID-19 pandemic is putting hospitals and physicians in a fragile financial position.

www.beckershospitalreview.com

 

[DrMetal]

What should we do then? Make our $$$ before sh***t hits the fan.

I agree with you that the current system is not sustainable.

Yeah, pretty much. And be flexible with your geography. The day's of a hospitalist being able to walk into any community hospital and get a job are long gone.

 

[Splenda88]

Whatever type of hospitalist gig you want, it's out there. As @DrMetal said: you gotta be geographically flexible i.e you are ok to be 45mins to 1 hr away from a major city.

 

[CCM-MD]

All of medicine in general is going to **** due to midlevels and predatory corporate run physician groups. All fields have their own issues, some more than others but none are immune. Make money now and have the ability to get out.

The current trainees won’t know “what it used to be” and will be fine with the new status quo. The rest of us will be miserable.

 

[bronx43]

What should we do then? Make our $$$ before sh***t hits the fan.

Not sure about your assessment. We order a bunch of expensive test/imaging. Is reimbursement for these MRI/CT we order really that bad?

10 physician specialties that generate the most revenue for hospitals

The average amount of revenue physicians generate for hospitals has jumped significantly in recent years, and a decline in patient volumes and elective procedures due to the COVID-19 pandemic is putting hospitals and physicians in a fragile financial position.

www.beckershospitalreview.com

Reimbursement for imaging and labs are great. And that’s actually another reason why hospitals would want midlevels. The number of tests they order per patient dwarves that ordered by physicians.

 

[Planes2Doc]

I work as a nocturnist, so it's a bit different. I'm 7 on and 14 off. I work 7 to 7, and am there from the beginning to the end of the shift. But once the clock hits 7AM, I set myself to unavailable on Epic and all messages get forwarded to the on-call hospitalist for the rest of the day. I commute for work and don't expect to do anything on these days. When I'm working, I'm working. But once I'm home, I'm a stay-at-home dad. The setup they use at my hospital is fantastic and great for avoiding burnout. I got crapped on in a nocturnist thread here because of that.

Anyway, hospitalist gigs can vary dramatically. Some have open ICU and some have closed. Ours is the latter, and it makes a huge difference. Some have midlevel coverage, which can make a huge difference. We have it, and I can't imaging working somewhere without it. Cross-coverage sucks (except on my own patients that I am admitting during that shift). We are also capped at night, where you won't get blasted if you don't see patients after a certain number. We have RVU bonuses, so I don't mind going above and beyond but will not make myself go crazy. Other things can also make the difference.

When I come in, there are some hospitalists that work a bit slower that are there sometimes till 8 or 9PM. The majority leave earlier. The latest I've seen a hospitalist stay was until 1AM. The latest I've worked was 10:30AM. Lately patients have been getting more complex with far fewer BS admits in between.

When I was looking for jobs, the majority were 7 on 7 off with technically 12 hour shifts, but people leaving earlier around 4PM or so depending on call. We have a swing doctor that starts taking admissions at 2PM, so that helps. I actually spoke to a recruiter about a mostly Monday through Friday position with some weekends. I was told they tend to finish between 2PM to 4Pm each day, but definitely preferred the block scheduling.

 

[FutureInternist]

Am I crazy for thinking that hospital medicine is one of the best lifestyle specialties?

Any outpatient clinic - suppose you work M-F 8-5. Get home around 530 optimistically after wrapping up. Dinner with the wife, chill with the kids, then it's 7. I start my bed time routine about an hour before I want to be asleep, and I take about an hour to get ready, so that gives me, what...

forums.studentdoctor.net

 

[Ganon]

All of medicine in general is going to **** due to midlevels and predatory corporate run physician groups. All fields have their own issues, some more than others but none are immune. Make money now and have the ability to get out.

The current trainees won’t know “what it used to be” and will be fine with the new status quo. The rest of us will be miserable.

My entire career has been fenestrated with these attitudes, which are totally warranted. But every time I encounter it I like to say: It's really easy to point out issues, but takes actual thinking to propose and implement solutions.

If physicians don't take steps to fix these issues, who will? Who do we believe is smarter/knows more about the systems we denounce than physicians themselves?

Because right now the people making moves are nurses, and physicians are taking it lying down. "The rest of us will be miserable" is the end of this post, so my question is what can be done to sidestep that misery?

Most doctors I ask these questions reply by shrugging. I get it, they've made their money, it isn't their problem.

And that's how we arrived here.

 

[IMGASMD]

My entire career has been fenestrated with these attitudes, which are totally warranted. But every time I encounter it I like to say: It's really easy to point out issues, but takes actual thinking to propose and implement solutions.

If physicians don't take steps to fix these issues, who will? Who do we believe is smarter/knows more about the systems we denounce than physicians themselves?

Because right now the people making moves are nurses, and physicians are taking it lying down. "The rest of us will be miserable" is the end of this post, so my question is what can be done to sidestep that misery?

Most doctors I ask these questions reply by shrugging. I get it, they've made their money, it isn't their problem.

And that's how we arrived here.

I don’t think it’s we’ve made enough money…. It’s just that after 4 years of med school, 3 years of residency (+fellowship). People have spent their most of their entire adult life to get here….
Finally becoming an attending, with a family, with a stable income and job. I don’t know how much fight is there left….

 

[CCM-MD]

I’m a member of PPP. I personally avoid working with midlevels if I can help it. When I have to, I avoid giving them independence and try to let them function as my note and order writing bitches. But this is not enough and the reality is that midlevels are going to continue to metastasize throughout medicine. There are just enough physicians that are not just ok with it, but are actively promoting midlevel independence. Below is an example.

Development of a novel hospitalist advanced practice provider

 

[aafisahar]

Reimbursement for imaging and labs are great. And that’s actually another reason why hospitals would want midlevels. The number of tests they order per patient dwarves that ordered by physicians.

That's not how reimbursement works. More labs and imaging doesn't help if the patient is admitted under a DRG. They actually cost thr system money money.

 

[aafisahar]

Billing for 2023 will make billing less favorable doctors actually seeing PA/NP patients. (like you have to say that you spent more time than the NPP dealing with the patient) and that usually isn’t the case.

I think this is a very important thing people are missing here. NPs and PAs take longer to see patients, can't see as many, and their LOS is longer. Most admissions are under a DRG so turn around time is paramount because less days = more profit.

With the new system, if you want MD level reimbursement, the MD has to do most of the work. Sure you can game the system right now, but if you are cosigning 25 notes all with >30 minutes of time spent (because starting in 2023 that's the only modifier that CMS will accept) your ass is grass on any audit. Otherwise, the NP/PA will bill and hospitals already lose money on most hospital admissions, now you're compounding that issue by billing at a lower rate.

If anything, I think the future is rosier now for hospitalists than it has been for the last few years.

 

[DrMetal]

If anything, I think the future is rosier now for hospitalists than it has been for the last few years.

Now stop it with that optimism. That's not allowed here on SDN.