Is a mixed outpatient/inpatient job possible in IM?

[Konigstiger]

I'm still a student, but one of the things I've realized going through rotations is that I don't want to be doing just outpatient or just inpatient all day every day. I have enjoyed the specialties where you do a couple days of outpatient per week and then a couple days of inpatient or procedures per week. The variety in the work schedule and setting is what I like, I think.

So my question is, is this possible in general IM? I do know of a couple IM doctors who have this sort of job, but they have said that it is going extinct and is relatively rare. I'm curious as to the pros and cons of this setup. Does anyone have any experience with this or knows of jobs like this in internal medicine? Or are they too rare to even be a factor in your job search?

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[AlbinoHawk DO]

You know doctors doing this, and you're asking if it's possible?

 

[collegestud2013]

I'm still a student, but one of the things I've realized going through rotations is that I don't want to be doing just outpatient or just inpatient all day every day. I have enjoyed the specialties where you do a couple days of outpatient per week and then a couple days of inpatient or procedures per week. The variety in the work schedule and setting is what I like, I think.

So my question is, is this possible in general IM? I do know of a couple IM doctors who have this sort of job, but they have said that it is going extinct and is relatively rare. I'm curious as to the pros and cons of this setup. Does anyone have any experience with this or knows of jobs like this in internal medicine? Or are they too rare to even be a factor in your job search?

Some still do, it but it's getting less common in general IM. This may have been the case 30 years ago, but there's a reason most hospitals now hire IM/FM hospitalists to just do inpatient work. From a practical standpoint, it's usually not an efficient set up to have to go back and forth between clinic and the hospital in the same day as travel time would end up hurting your productivity. Also, as general IM you're usually the primary admitting service in the hospital (and less often a consult service) so you'll tend to have more responsibilities for your patients while they're in the hospital and that can make it difficult to balance with outpatient clinic (eg if a patient in the hospital is crashing you can't easily go see them if you're in clinic). Another set up that's more doable is if you're in a large IM group and one person in the group rotates inpatient for an entire week at a time (to cover the group's admitted patient) while having no outpatient clinic that week.

Specialists however will more often go between clinic and inpatient. This largely depends on the specialties, but there's not enough volume in many specialties for a full day of work rounding in the hospital. In the more in-demand and rarer specialties there's just not enough of them either (especially in a community or rural setting) for one person to just do inpatient. Also, at many hospitals, a lot of specialists operate as a consult service and are not the primary admitting service so they will be responsible for less of the patient and not responsible for stuff like discharge planning.

 

[dgdg]

It's going extinct or rare likely because the lifestyle is poor. The modern demands on patient volumes in outpatient clinic and the unpredictability of inpatient practice make it a challenge. If you have no children or they are grown, or you're single, it's doable. Otherwise, I think it's just too time consuming at this point compared to years ago and not much of a financial incentive. I used to do moonlight shifts for a hospitalist group and found predictable shift work to be a nice balance to do both types of practice which I enjoyed. Then the contracts became a problem and unfortunately I stopped inpt work. I miss the inpt work but enjoy primary care IM very much.

 

[NewYorkDoctors]

it might be a necessity in a rural setting due to fewer physician resources. However, it is becoming less common of a practice in the large cities. That being said, there are large internal medicine practice that has several providers who can rotate their schedules such that one person is the "inpatient person for the week" and they all rotate around the inpatient duties. In general, the hospitalists are content doing inpatient work and the GIM are content doing outpatient work. As long as the records get transferred over, then the continuity of care can be acceptable. Before EMR and online records, I can imagine how being there in person would help with the clinical context and knowing what exactly happened. With the advent of EMR and online records (provided the outpatient provider has access to it), it is less of a necessity to follow the patient inpatient and outpatient now.

 

[Konigstiger]

You know doctors doing this, and you're asking if it's possible?

I should've clarified because I meant 'is it still possible.' They have had those jobs for a while now, so there may simply be no more new jobs like that available, or they are so rare that they are not really out there.

 

[AlbinoHawk DO]

I should've clarified because I meant 'is it still possible.' They have had those jobs for a while now, so there may simply be no more new jobs like that available, or they are so rare that they are not really out there.

Don't live in any major city or within about 2 hours from one and you should be able to set up whatever arrangement you want. I know doctors that started within the last 3 years that do clinic all day and see their hospital patients in the morning and after work. I know others that do half clinic days and the rest of the day in the hospital. The craziest I've seen is someone do full time clinic plus fulltime hospitalist at the same time in a clinic 5 minutes from the hospital

 

[NewYorkDoctors]

Don't live in any major city or within about 2 hours from one and you should be able to set up whatever arrangement you want. I know doctors that started within the last 3 years that do clinic all day and see their hospital patients in the morning and after work. I know others that do half clinic days and the rest of the day in the hospital. The craziest I've seen is someone do full time clinic plus fulltime hospitalist at the same time in a clinic 5 minutes from the hospital

well it's all about the proximity. i mean this describes old school resident's clinic!

 

[AlbinoHawk DO]

well it's all about the proximity. i mean this describes old school resident's clinic!

They had to do full time clinic and inpatient at the same time in old residencies? Wow. Makes me grateful I had to only do 1 or 2 half-days of clinic in residency

 

[InternistDO]

My big city job has the option to do a month or so of hospitalist coverage a year, but it is not “traditional practice” where you’re seeing your own patients, just covering the standard inpatient service.

In academics it’s also easier since you don’t really have your own patient panel, I’ve seen more of these jobs.

 

[dozitgetchahi]

As a rheumatologist who is very happy to be 100% outpatient, I want to express to you that this type of split arrangement may not be as cool as it sounds once you’re done with training.

In general, you want as few practice environments as possible to deal with. Having to run off to the hospital to deal with consults, inpatient admissions, etc is no longer so much “fun” when you have a full clinic with all of its associated paperwork, notes, and duties. It starts to feel like more of an irritating distraction than anything else.

That said, there are plenty of IM subspecialties where you can split time between outpatient clinic and inpatient if you want.

 

[gutonc]

As a rheumatologist who is very happy to be 100% outpatient, I want to express to you that this type of split arrangement may not be as cool as it sounds once you’re done with training.

In general, you want as few practice environments as possible to deal with. Having to run off to the hospital to deal with consults, inpatient admissions, etc is no longer so much “fun” when you have a full clinic with all of its associated paperwork, notes, and duties. It starts to feel like more of an irritating distraction than anything else.

That said, there are plenty of IM subspecialties where you can split time between outpatient clinic and inpatient if you want.

As a fellow non-procedural IM sub-specialist, I can tell you that every patient I see in the hospital costs me money and adds stress and anxiety to my life that I don't need.

The hospital I round at is across the street, so about as close as you can get to my clinic. It still takes my 5 minutes to get over there and another 5 to get back. The "commute" in and of itself is time I could spend seeing one f/u clinic patient (~2wRVU), seeing the 3 patients I have to see, on 2 different floors, talking to them, family if they're around, nursing, consulting team, pharmacy, etc typically takes 30 minutes a pop, not counting writing the notes. Best case scenario, I'm getting ~2.5wRVU on average for each of those patients, which is 7.5 wRVU for 90+ minutes of work. If I just "stay home", I can see 6-8 patients in that time period, at average 2 wRVU/patient (which is my own personal average), which is 1/3 to 1/2 of what I get in the inpatient setting for the same time input. Worst case scenario, those 3 inpatients cost me $650 for the same amount of work.

 

[dozitgetchahi]

As a fellow non-procedural IM sub-specialist, I can tell you that every patient I see in the hospital costs me money and adds stress and anxiety to my life that I don't need.

The hospital I round at is across the street, so about as close as you can get to my clinic. It still takes my 5 minutes to get over there and another 5 to get back. The "commute" in and of itself is time I could spend seeing one f/u clinic patient (~2wRVU), seeing the 3 patients I have to see, on 2 different floors, talking to them, family if they're around, nursing, consulting team, pharmacy, etc typically takes 30 minutes a pop, not counting writing the notes. Best case scenario, I'm getting ~2.5wRVU on average for each of those patients, which is 7.5 wRVU for 90+ minutes of work. If I just "stay home", I can see 6-8 patients in that time period, at average 2 wRVU/patient (which is my own personal average), which is 1/3 to 1/2 of what I get in the inpatient setting for the same time input. Worst case scenario, those 3 inpatients cost me $650 for the same amount of work.

Ditto. I mean, one thing that has always aggravated me about hospital work is that it’s just so damn inefficient. Nothing in the hospital is set up for you to be able to see patients quickly or easily. You have to travel to the hospital. You have to walk between rooms finding patients (and if it’s a big hospital this can add a ton of time to the process). There are so many people that want to talk to you about the patients - pharmacists, nurses, family members, radiology staff. Have to do a procedure? If you didn’t bring your own equipment, now you have to waste time finding all that stuff too. A couple of sick hospital patients can monopolize your time, crowding out lots of other patients and issues that need your attention too. It’s not unusual for the hospital to have a different EMR than whatever you’re using in the outpatient setting, which means you waste time while you poke around in the computer trying to figure out how to do things in a system you don’t use very much. And all this for a pittance of compensation while you either slow down seeing your long queue of pending outpatient consults, or go to the hospital in your off hours - ensuring that you won’t be home before 9pm.

It’s just a gigantic pain in the ass, and I don’t want to deal with it. Inpatient consults were by far my least favorite aspect of fellowship, and I swore I’d never deal with it again once I was done with training. I’m happy to have had jobs where I haven’t had to.