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Have you transitioned from hospitalist to PCP or fellowship?

Home The Lounge Have you transitioned from hospitalist to PCP or fellowship?

  • Avatar Duckworth 
    Participant
    Status: Physician
    Posts: 21
    Joined: 05/07/2018

    Hi All

    First year (July–>July) of academic hospitalist under the belt and I feel like its not for me.  I worked hard, was able to pull in 220K in 2018 despite only being attending half the year, in 2019 im on target for ~300.  I am a mix, 40% nights, about 1.5 weekends a month, stretches of 2-6 days on service (except when we are with an exclusive teaching service), which is to say its not 7 on 7 off.  Ill have enough cash saved by the end of the year to pay off my ~150K student loan if i wanted to (refinanced 10 year fixed 3.35%).  Maxed 401K, roth, and in a relationship, not married, no house or kids yet.

    I love my group; immediate leadership is great and I am able to explore other interests, such as certain research and teaching.  Loved being OFF when Im OFF…However, it hit me like a brick wall the last few months that I do not like inheriting lists from others who apply variable effort and spending hours away from home making sense of outdated documentation, answering inane pages from nurses or families requesting updates on cross coverage at 3 AM, feeling like specialist H/P and order monkey, and feeling like a cog that can be replaced by midlevel in the eyes of the world.  Even though we are treated with respect, i still feel that way.   I would still dread returning to work to have to make sense of an entire list or put up with pages all night.

    I miss real continuity and long term relationships.  I wish I was seen as more valuable by either the patient or other doctors.  I feel like more and more I get through some annoying shifts just by thinking about the money, which isn’t that great and definitely is a recipe for burnout.  When Im with the patients themselves, I still love medicine, staying on top of journals, following up the cases I admit; acuity here is high and the case mix is great. But the other stuff that takes up 70% of the time drives me nuts.  If I dont like it here, i dont think Id like it anywhere.  I feel like others who like this job are not angered by this the same way I am.

    I actually liked clinic in med school and residency, loved the relationships and the ownership i felt over work ups, screening, the connections built and the fact that I might be able to prevent some of the horrible inpatient pathology before it was too far gone, and also getting to know those patients with advanced disease before they decompensated.  Some of my satisfied days in residency were leaving clinic, and we all know IM residency clinic sucks; but the one thing we had with patients was a decent amount of time.

    I was thinking about transitioning to a PCP set up with possibly an addictions focus (with maybe some additional addiction training in between), seeing my patients in the hospital system if admitted (only M-F, the hospitalist or NP puts in orders/answers pages, I just round and go, with occasionally weekend call); it is not strict RVU based, you get protected time to precept and to work on my separate research projects for the first few years, with an expectation of growing into a certain panel size and acuity by X amount of years (im still learning the details).  I feel like that would give me continuity and real ownership I do not feel currently, a stable schedule that would be better for my personal relationship, even if its less time off.  im ok with less pay (~200) if it comes with seeing less patients.  Im learning more about the details.

    However Im concerned that PCP work will hold some of the the same dissatisfaction once I do it 4 days a week every week.  While the academic portions make it more interesting for me and I could carve out a niche, Im worried I will still feel the horrible pains of administrative burdens, having to refer out things I would otherwise work up and manage due to time pressure, and generally feel like the dumping ground again; Im also worried Im forgetting about how frustrating some of the bread and butter rashes, MSK complaints, sniffles, and staying on top of screening can be while attempting to document it all in clunky EMR with an overlfowing inbox day after day.

    So on other days I seriously consider my initial plan on entering residency, specializing in pulm/cc or cards.  I come from a strong program and was a good resident with research that covers both fields, so with another year of research and connections I have a good chance of matching somewhere Id want.   I didn’t do it right away because I was on the fence and wanted to take time to explore hospital IM to see if Id be happy with it, and Im pretty sure I will not be long term.

    Regardless, my question is if you have switched from hospitalist to PCP or fellowship, i’d love to hear your stories, how you felt before and after about your decision, if expectation matched reality. This is a very personal decision no one else can make, but I’m just curious what your experiences are, especially the cohort of doctors on this forum.

     

     

     

     

    #236774 Reply
    fatlittlepig fatlittlepig 
    Participant
    Status: Physician
    Posts: 1153
    Joined: 01/26/2017

    Hi All

    First year (July–>July) of academic hospitalist under the belt and I feel like its not for me.  I worked hard, was able to pull in 220K in 2018 despite only being attending half the year, in 2019 im on target for ~300.  I am a mix, 40% nights, about 1.5 weekends a month, stretches of 2-6 days on service (except when we are with an exclusive teaching service), which is to say its not 7 on 7 off.  Ill have enough cash saved by the end of the year to pay off my ~150K student loan if i wanted to (refinanced 10 year fixed 3.35%).  Maxed 401K, roth, and in a relationship, not married, no house or kids yet.

    I love my group; immediate leadership is great and I am able to explore other interests, such as certain research and teaching.  Loved being OFF when Im OFF…However, it hit me like a brick wall the last few months that I do not like inheriting lists from others who apply variable effort and spending hours away from home making sense of outdated documentation, answering inane pages from nurses or families requesting updates on cross coverage at 3 AM, feeling like specialist H/P and order monkey, and feeling like a cog that can be replaced by midlevel in the eyes of the world.  Even though we are treated with respect, i still feel that way.   I would still dread returning to work to have to make sense of an entire list or put up with pages all night.

    I miss real continuity and long term relationships.  I wish I was seen as more valuable by either the patient or other doctors.  I feel like more and more I get through some annoying shifts just by thinking about the money, which isn’t that great and definitely is a recipe for burnout.  When Im with the patients themselves, I still love medicine, staying on top of journals, following up the cases I admit; acuity here is high and the case mix is great. But the other stuff that takes up 70% of the time drives me nuts.  If I dont like it here, i dont think Id like it anywhere.  I feel like others who like this job are not angered by this the same way I am.

    I actually liked clinic in med school and residency, loved the relationships and the ownership i felt over work ups, screening, the connections built and the fact that I might be able to prevent some of the horrible inpatient pathology before it was too far gone, and also getting to know those patients with advanced disease before they decompensated.  Some of my satisfied days in residency were leaving clinic, and we all know IM residency clinic sucks; but the one thing we had with patients was a decent amount of time.

    I was thinking about transitioning to a PCP set up with possibly an addictions focus (with maybe some additional addiction training in between), seeing my patients in the hospital system if admitted (only M-F, the hospitalist or NP puts in orders/answers pages, I just round and go, with occasionally weekend call); it is not strict RVU based, you get protected time to precept and to work on my separate research projects for the first few years, with an expectation of growing into a certain panel size and acuity by X amount of years (im still learning the details).  I feel like that would give me continuity and real ownership I do not feel currently, a stable schedule that would be better for my personal relationship, even if its less time off.  im ok with less pay (~200) if it comes with seeing less patients.  Im learning more about the details.

    However Im concerned that PCP work will hold some of the the same dissatisfaction once I do it 4 days a week every week.  While the academic portions make it more interesting for me and I could carve out a niche, Im worried I will still feel the horrible pains of administrative burdens, having to refer out things I would otherwise work up and manage due to time pressure, and generally feel like the dumping ground again; Im also worried Im forgetting about how frustrating some of the bread and butter rashes, MSK complaints, sniffles, and staying on top of screening can be while attempting to document it all in clunky EMR with an overlfowing inbox day after day.

    So on other days I seriously consider my initial plan on entering residency, specializing in pulm/cc or cards.  I come from a strong program and was a good resident with research that covers both fields, so with another year of research and connections I have a good chance of matching somewhere Id want.   I didn’t do it right away because I was on the fence and wanted to take time to explore hospital IM to see if Id be happy with it, and Im pretty sure I will not be long term.

    Regardless, my question is if you have switched from hospitalist to PCP or fellowship, i’d love to hear your stories, how you felt before and after abotu your decision, if expectation matched reality. This is a very personal decision no one else can make, but I’m just curious what your experiences are, especially the cohort of doctors on this forum.

     

     

     

     

    Click to expand…

    OK, so go to the clinic.

    #236814 Reply
    Liked by snowcanyon
    Avatar nephron 
    Participant
    Status: Physician
    Posts: 154
    Joined: 05/09/2019

    I did hospitalist for about 3 years post nephrology fellowship in between jobs and during transition periods.   The last data that I saw suggested some 10% of renal fellows graduating were working as hospitalist.   hospitalists jobs have a lot of benefits, the pay is good, I took a 30% pay cut to go back into a nephrology due to the job market, but I do think lifestyle is better, its nice having to just be able to leave when you finish work rather then staying until the night person takes over your shift.   I agree with it being frustruating if you feel that your colleagues are not providing as good care of pts as you too as there is always that hand-off period.    Anyways, other then pay decrease and loss of autonomy, I don’t think that it is too bad to go back to fellowship, I know a lot that have done it/are doing it, there is a fair amount of burn out as  hospitalists, its ok to do for a couple of years but looking 20-30 years in the future, I think that  a lot of people have difficulty with that.   I think a lot of hospitalists try to get hospital admin jobs which they are well positioned for if they stay as hospitalists.  cutting back on your hours, doing fewer shifts is always possible too, but most programs are so short staffed that you get a lot of pressure to fill in the gaps and be a team player.  It seemed like I was always working in some capacity 3 weekends out of 4 due to weekend coverage and night shifts rolling into the weekends, definitely hard when you have kids/a family.

    #236820 Reply
    Liked by Duckworth
    Avatar Allixi 
    Participant
    Status: Physician
    Posts: 103
    Joined: 03/16/2016

    We have one person in our group who transitioned from hospitalist to a PCP, and several who moved on to fellowships. Grass is always greener, although if you actually enjoyed your time in clinic, then you should give primary care another whirl (we need all the PCPs we can get).

    Sounds like you already have a pretty good lifestyle / position. The other complaints are just part of the job, if not the bread-and-butter itself. Like chest pain for Cardiology, hemodialysis for Nephrology, diabetic foot infections for ID, abd pain for GI. There is no way to get around picking up other people’s pts and going “WTF”, dealing with inane pages/calls, babysitting pts for other specialists, etc.

    #236856 Reply
    Liked by Duckworth
    fatlittlepig fatlittlepig 
    Participant
    Status: Physician
    Posts: 1153
    Joined: 01/26/2017

    Dude is not even done with first year of work and is not happy. Not a good sign.

    i may be off on this one, but you come across as the the type of doctor who thinks he/she is better than everyone else, more thorough and more thoughtful blah blah, those kinds of doctors tend not to be happier and also tend not to be well liked.

    #236858 Reply
    Liked by Tim, Lordosis
    fatlittlepig fatlittlepig 
    Participant
    Status: Physician
    Posts: 1153
    Joined: 01/26/2017

    Part 2, if you start a job fresh out of training and start thinking you are so much better than everyone, man this team I’m inheriting what was that other guy thinking? Man these pages are so below me. I’m just a scut monkey for the specialists blah blah. That attitude definitely won’t get you far as a hospitalist as you are now seeing.

    Instead, when you inherit a team, you can say yeah this guy is doing things a little different, maybe not as thorough as I would be but he’s probably much more efficient and he is probably more skilled than me in certain areas. Yeah I’m being used by the specialists but that’s because they don’t have the skills that I have, like dealing with chest pain or blah blah. Attitude.

    #236862 Reply
    Avatar Duckworth 
    Participant
    Status: Physician
    Posts: 21
    Joined: 05/07/2018
    Splash Refinancing Bonus

    FLP Fair enough. I’m not actually talking so much about medical decision making as in notes not really updated for days, discharge things that aren’t up to date or accurate etc. little things that add up to extra time across a bunch of patients. It’s minor but a thousand cuts. I like and respect my colleagues and learn from them. That stuff is part of the job but it bothers me.

    As for the being used by the specialist I AM being used to write notes on, answer pages for certain post procedure p atients or specialist patients where they drive to boat completely for the one problem they are hospitalized. I’m not saying I’m better than them. They are better than me. It is clearly my role as the hospitalist to be that for them it’s why we exist. Im realizing it doesn’t give me much satisfaction to be in that role. I thought i would view that as easy money and I wouldn’t care but I find it bothers me.

    Just being honest.

    #236869 Reply
    fatlittlepig fatlittlepig 
    Participant
    Status: Physician
    Posts: 1153
    Joined: 01/26/2017

    FLP Fair enough. I’m not actually talking so much about medical decision making as in notes not really updated for days, discharge things that aren’t up to date or accurate etc. little things that add up to extra time across a bunch of patients. It’s minor but a thousand cuts. I like and respect my colleagues and learn from them. That stuff is part of the job but it bothers me.

    As for the being used by the specialist I AM being used to write notes on, answer pages for certain post procedure p atients or specialist patients where they drive to boat completely for the one problem they are hospitalized. I’m not saying I’m better than them. They are better than me. It is clearly my role as the hospitalist to be that for them it’s why we exist. Im realizing it doesn’t give me much satisfaction to be in that role. I thought i would view that as easy money and I wouldn’t care but I find it bothers me.

    Just being honest.

    Click to expand…

    Fair enough. It never bothered me much getting dumped on by specialists who really don’t have any business managing any sort of medical issues. It’s par for the course. The other stuff is par for the course too, everyone copies and pastes notes, sometimes nothing really has changed day to day so the note reflects as such.

    #236873 Reply
    Liked by Duckworth, Zaphod
    Lordosis Lordosis 
    Participant
    Status: Physician
    Posts: 1666
    Joined: 02/11/2019

    When I was a resident we used to manage the ortho post ops medical issues.  Most were much easier then the real medical floor because they were mostly elective hip and knee replacements.  Some fool in admin got the idea that the orthopods should do it themselves.   That did not last long…

     

    OP- you get dumped on in every field.  Just because you are the PCP you still have to deal with poor management from their prior PCP or if they go to urgent care or the ER or your partner sees them.    I cannot tell you how many times I have had to say no to things like “Well my last doc would send in an antibiotic when I called for a sniffle”

    “Never let your sense of morals prevent you from doing what is right.”

    #236885 Reply
    Liked by Duckworth
    Avatar Allixi 
    Participant
    Status: Physician
    Posts: 103
    Joined: 03/16/2016

    For what it’s worth OP, I sympathize with your feelings more than FLP does. My coworkers also do things that bug me, ranging from innocuous (dictation typos/malapropisms) to annoying (nonsensical orders), to kinda egregious (leaving pts on antibiotics long after they’ve ruled out for any kind of infection). That’s not to mention other specialties and the outpatient world – you’d be naive to think these things don’t happen outside the floor beds.

    If you put in more mental effort and can give better reasons/rationale for your decisions, that’s something to be commended and not criticized.

    For me, the thought that I’m probably doing a better job than others, gives me motivation and a sense of purpose, more often than not. If “cleaning up other’s messes” always makes you miserable, then you probably need an attitude adjustment like FLP says, or a different job.

    #236978 Reply
    Liked by Duckworth
    Avatar Duckworth 
    Participant
    Status: Physician
    Posts: 21
    Joined: 05/07/2018

    Thanks. I didn’t mean to come across that I was miserable because my coworkers don’t carry they’re weight or something. Perhaps I highlighted that too much. I think it’s much more embedded in the nature of the game in hospital medicine more so than other specialities since we are supposed to have ownership of the entire picture, that when one np admits with a bear bones h and pand attending staffs (neither of whom will care for patient tomorrow) then a new nf covers and things may happen overnight then someone in on for 2 days on the weekend and copies forward the note w minimal edits maybe by the time it comes to you there feels like a constant game of catch up across a dozen patients to varying degrees every time you come on a service for a stretch. I’m just finding it one source of burnout sensation, it’s not my whole problem. Perhaps immediately grasping the entire salient patient picture is something that comes with time. I appreciate the feedback about attitude, I’ll consider that. But like I said I like my colleagues immensely and where I work, and have very good working relationships ( eg people bounce things off me and I off them all the time, we are friends outside of work etc)

    Anyway if anyone has their own stories to tell about a switch, Curious to hear them

    #236984 Reply
    Liked by q-school
    Avatar trebizond 
    Participant
    Status: Resident
    Posts: 123
    Joined: 12/31/2017

    No stories of a switch, but sympathize. I knew multiple people who did 3-5 years of hospitalists and then became fellows in competitive specialties, i.e. cardiology and hematology-oncology.

    Your complaint is valid. The reality is that what was once a “core” specialty that rarely needed to consult a subspecialist, and then usually for a procedure (dialysis, scope, cath, etc.) is now in the position of consulting on every little thing. Anemia, community acquired pneumonia, AKI, CHF exacerbation, lupus workup, etc. It’s disheartening because the underlying message is that your many hours of training and study don’t cut it and you’re really there just to identify a problem (no better than a midlevel) and then let the “bosses” figure it out. You’re the documentation/order/discharge monkey. Not saying that to be insulting, saying that because that’s what it has become.

    PCP faces many of the same issues as the hospitalist, and in some ways worse. You have the endless screenings, Medicare visits, diabetic stuff, and horrendous prior auths which in many hospital settings are handled by staff. And the inbox is bursting at the seams – uncompensated care.

    I strongly suggest you consider subspecialization. I also think you should consider long and hard about the ICU. Pulm may be a better fit, less consulting others and getting them on board in the ICU, less futile care, more being the specialist for a set of diseases and managing accordingly. ICU the draw has to be saving people from the brink of death, procedures, and being an internist “on roids” (as I put it), but you will get dumped on, you will have specialists dictating “what they want” (surgeons, oncology wanting to give chemo, renal with CCVHD, etc., etc.), you will see lapses in documentation that make it very hard to figure out what happened to the OSH transfer trainwreck, etc.

    Since residency is so inpatient based, your exposure to some of the more outpatient specialties or the outpatient clinics in more inpatient specialties may have been a bit more limited. Not a bad idea if you had limited exposure to some things that pique your interest to request to shadow in clinic briefly and see how things are run.

    #236990 Reply
    Liked by q-school
    Avatar trebizond 
    Participant
    Status: Resident
    Posts: 123
    Joined: 12/31/2017
    Earnest refinancing bonus

    And I will say that it was very disheartening seeing repeated cognitive mistakes, labs ordered and never followed up on, new meds started at discharge without a monitoring plan (started on metolazone, comes back to the ED weeks later with a Na of 110), etc. The pressures for more efficiency in fewer hours are heavy. The virtue of subspecializing is that you narrow your focus and responsibility quite a bit. Even so, many still face high burnout. Would recommend reading a bit about long term satisfaction. Last I checked the specialties have marked discrepancies (>80% of derm happy about their choice, <20% of IM happy about their choice) – there’s a reason for this and no amount of rationalizing can change it because the issues aren’t so much compensation as systemic faults and pressures.

    #236992 Reply
    Liked by q-school, Zaphod
    Avatar Allixi 
    Participant
    Status: Physician
    Posts: 103
    Joined: 03/16/2016

    There’s no law saying you have to consult specialists for everything. I would not consult for AKI, COPD, anemia, hyponatremia, or garden-variety infections unless it’s severe, they’re failing my management or I think they need procedures/outpatient care.

    We can all think like a Cardiologist, Nephrologist, or Pulmonologist, even if we can’t do the procedures.

    #237003 Reply
    Liked by fatlittlepig
    Zaphod Zaphod 
    Participant
    Status: Physician, Small Business Owner
    Posts: 6084
    Joined: 01/12/2016

    This isnt exclusive to hospitalists at all. Its just medicine today and emrs. Every time I get a consult/referral the thing that takes the longest is ofc going over hundreds of notes that dont say anything, or looking for the referral that doesnt exist. I seem to recently be quite peeved reading peoples notes that are for some skin cancer consult and the PE section on skin just says-no rash, wound, erythema as if its negative across the board and then the plan says, consult plastics? Thats super sloppy.

    Im sure I annoy other services as well by only focusing on my area and paying little attention to other spots that arent going to effect what im doing. I agree with FLP that hospitalists, etc…should be taking care of these pts, it makes no medical or efficiency sense to have subspecialists in the OR all day and paying attention to pts with lots of comorbidities. Still have to imagine most pts are low acuity overall.

    #237007 Reply

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