Transitioning from outpatient to inpatient only

[Perry Ict]

Has anybody made a transition from mostly outpatient work to only inpatient? In my case this would be neurology outpatient to (potentially, 7 on 7 off) neurohospitalist, but I'm also curious to hear from people in general medicine or other fields. What was your experience?  Did you enjoy or regret the move?  More often, I seem to hear about people making the change away from hospitalist work, so I'll be interested in hearing about the experience from those who have made this sort of change.

Thanks in advance.

[ticker]

Writing mostly to give you a bump.  I've only ever been inpatient, so I can't speak to the transition.  But, the burnout among neurohospitalists seems quite high.  A local hospital network was replacing >30% of their neurohospitalists every year for several years.  They finally recently went to a 7-on-14-off schedule (with reduced pay) to improve retention.  It's working.

A few thoughts:

- 26 weeks a year off sounds amazing.  But, you only ever get 7 days off (vs 9, if you take a standard 5 day week of vacation bookended by weekends... and this is assuming you don't get additional vacation time as a neurohospitalist).  My experience is that I'm bleary-eyed and worthless after 168 hours of carrying the pager, falling asleep all the time.  I need a day to catch up on sleep, which would leave 6 days off.  And, my last day off is just grocery shopping and otherwise preparing the house for my wife to be a quasi-single parent for a week.  So, that would leave 5 days off.  Never taking more than a 5 day vacation would stink.

- Most hospitalists who work 7-on 7-off hand off a pager and get to sleep at night without threat of interruption.  Many neurohospitalists don't get to do that.  Even if the dumb thing doesn't go off, just having it with you on the nightstand/back of the toilet/ table during dinner stinks.

- You'd be missing every other Christmas, birthday, sporting event, wedding, spring break, etc.  Depending on what stage of life you're in, that can be rough.

I'd just advise that you think about what you want to do with your time off and then think about how the 7-on 7-off schedule would accommodate that.  If you love traveling to Europe and your 6-year-old would cry for a week if you're not there Christmas morning... it may not be the best.

[Perry Ict]

Ticker, thank you for the reply.  I'm single, young-ish (mid/late 30's), no children, so that's part of the draw to such a schedule; I figure if there's any time to try it out and see if the lifestyle fits, it's probably now.  I appreciate the heads up - as you suggest, if I do this, I will have to be careful about how things are structured and how I might utilize those days off.

It sounds like you aren't too keen on the lifestyle.  Do you ever consider giving it up and switching to working in the clinic?

[hightower]

ticker wrote:

– 26 weeks a year off sounds amazing.  But, you only ever get 7 days off (vs 9, if you take a standard 5 day week of vacation bookended by weekends… and this is assuming you don’t get additional vacation time as a neurohospitalist).  My experience is that I’m bleary-eyed and worthless after 168 hours of carrying the pager, falling asleep all the time.  I need a day to catch up on sleep, which would leave 6 days off.  And, my last day off is just grocery shopping and otherwise preparing the house for my wife to be a quasi-single parent for a week.  So, that would leave 5 days off.  Never taking more than a 5 day vacation would stink.

– Most hospitalists who work 7-on 7-off hand off a pager and get to sleep at night without threat of interruption.  Many neurohospitalists don’t get to do that.  Even if the dumb thing doesn’t go off, just having it with you on the nightstand/back of the toilet/ table during dinner stinks.

 

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Beautifully put! You just described my life as a hospitalist perfectly, especially the part about our time off which sounds great on paper, but in practice is not as great as it seems.  There's no work-life balance.  It's always hot or cold.  Like you said, your spouse is basically a single parent the whole week you're "on", then you're off and you're basically useless for 5-6 days because you just want to sleep the first day and hide in a corner, then all you want to do is veg out on the couch or catch up on things you can't do during the "on" weeks.  Usually by day 5 or 6 I'm finally out of my funk and ready to be alive and social again, only to feel the need to prepare for the next week coming up.  I will say that as a hospitalist with plenty of partners to fill shifts, it's not that hard to schedule 2 week vacations, usually by taking off the last week of one month and the first week of the next.  I guess that wouldn't be possible with a 2 neurologist group

The thing about handing off a pager without threat of interruption is somewhat true, but since we're the primary care giver for our patients while admitted, the work feels like it follows you home anyway.  All the problems you leave at the hospital that evening are still waiting for you when you wake up the next day which has a negative impact on sleep for sure. I'm glad I don't have to answer a pager at night though.  THAT would be the nail in the coffin for me.

12 hour days for any profession is just ridiculous.  Especially when you factor in the 45 min drive on both ends.  You really only get an hour to yourself each evening before bed.  Zero family time on those days and zero help around the house.  24 hours of carrying a pager is almost medieval torture.  I can't imagine needing to do that.

[fatlittlepig]

Fatlittlepig has said it before and will say it again
7 on 7 off with mandatory 12 hours in hospital per day sucks.

[ticker]

While I'm not in the hospital system I mentioned, I'm 7-on, 14-off.  I could never transition to 7-on, 7-off;  I've been ruined.  I'm willing to tolerate a lot during my weeks on to have 17 2-week vacations per year.  A few times a year I even trade weeks to have 7on-7off-7on-21off.

The weeks on can be hellish.  Way worse than anything in training.  It's not an old person's game, so I'm sure I won't finish my career in this role.  But, for the time off, freedom to travel, etc. we've decided it's worth it for now.

[Perry Ict]

Good to know.  I appreciate the warnings.  Always better to go in with eyes wide open.

Ticker, with 7 on, 14 off, that sounds like a decent trade off for you. For the others, why are you sticking with hospitalist medicine versus going to a standard mostly-outpatient practice, despite the drawbacks mentioned?

[FIREshrink]

There is a psych group which does 14 on, 14 off, 10 hour days. Light phone call for 7 of those 14 days. I think that'd be better. A few months ago I considered taking that job part time 7 on, 21 off. Glidepath into FIRE. But my current job offered new opportunities and I'm happy I stayed.

For you, single, childless, good time to try.

[nephron]

I like inpatient work better then outpatient work by far, much more satisfying to make interventions and get diagnostic tests back and then see the patient.   The main problem that I had with being a hospitalist was the hours though, I agree with everyone saying 7 on/7 off sounds great in theory until you realize that you are missing 50% of your weekends.   The late nights when you are working are really a drag too, on your family life. With me, it felt more like 3/4 of the weekends as we also had to cover a few night shifts which usually ran on Friday or Saturday night effectively eliminating your whole weekend.  I hope that they are paying you a premium to cover neuro-hospitalist, many of the local community hospitals that I round at no longer have 24/7 neurology coverage.   With all the new stroke interventions they are coming out with, I imagine that its only going to get worse as time=brain.  It was probably easier when you could just document they were outside of the 3.5 hr window.  I'm sure the hospitalists will appreciate having you around.  Most specialities probably would be more efficient with a hospitalist model for the inpatient work  but I don't think that most specialties could pay enough to support a dedicated inpatient person without heavily subsidizing that person from their procedures/outpatient work or from the hospital administration.   I would be curious to know how much they were offering you in your contract if you are willing to share.

 

[Perry Ict]

nephron wrote:

 I would be curious to know how much they were offering you in your contract if you are willing to share.

 

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Thanks again for all the replies.  Nephron, if this question is directed at me, I'm actually just now putting out feelers and replying to some postings for these positions.  I will share if/when I get offers.

[LizOB]

Something else to consider is that if you are inpatient only, you will not have patients who know you and specifically choose to see you. Meaning whoever employs you has little incentive to NOT replace you with anyone who comes along offering to do the job for cheaper (or the hospital changes contracts if you are in an independent group). I'm employed, full spectrum ob-gyn and I do feel like having a panel of patients who know me and choose to see me makes me somewhat fire-proof and gives me leverage

[RogueDadMD]

LizOB wrote:

I’m employed, full spectrum ob-gyn and I do feel like having a panel of patients who know me and choose to see me makes me somewhat fire-proof and gives me leverage

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I'm not well versed in this area, so take my speculation and questions with a grain of salt.

Isn't this partially the purpose of non-competes?  If you leave they try to force you into a situation where patients cannot follow you as you're pushed far away. If you're fired it's because they already have decided they aren't worried enough about losing the patients following you to keep you.

If you're fired, unless you're able to stay in proximity to your original location, you're bound to lose patients who just don't want to travel to the new spot.  If you're no longer part of the same hospital/insurance package, you'll lose more patients that way as well, as they may see other doctors in the same system.

I certainly have met patients who follow their doctors when they leave one hospital but stay in town to work elsewhere, but most of the time a specialist chooses it often seems they are leaving town, and if they stay in town the non compete is potentially a barrier.

Granted as a male I don't have an OB so can't speak to that type of relationship -- my wife is quite fond of her OB and I bet would follow her to another hospital as long as she was still in-network for the insurance.  But if my internist moved 20 miles west and wasn't in network, I would likely find a new primary care doc, even though I like him.  As an ER doc I probably am missing some experiential aspects that would inform this better also...

[FIREshrink]

As a psychiatrist I have patients who live as far as 1500 miles away, and fly to see me every 3 months. That is not because I’m the greatest psychiatrist in the world.

[PNWdoc]

I made the switch from full time outpatient neurology to full time inpatient and I couldn't be happier. The key is to realize there is a shortage of neurohospitalists and you are in demand. Decide what you want and look around, you can likely find it somewhere. The initial neurohospitalist job I took was 7 on/7 off with mandatory 12 hour shifts and I burned out after 2 years. My current job has a lot more flexibility. I have to work a certain number of shifts per quarter and for the majority of them we do not have to stay all 12 hours. I also have the freedom to take longer periods off if I want to take a family vacation or just get away.

I also suggest joining a larger group where you are not the only neurologist on at a time. If it is a small group then you have a lot more nights to cover and you are never getting more than 7 days off in a row. In my current group we have 4 day docs and 1 night doc per shift so we take a lot less night call. We can also cover for each other if someone needs to leave earlier.

Good luck with the switch.

[Allixi]

Are you the primary attending for these pts? Would you be dealing with their medical comorbidities/issues, or would you call medical consults from hospitalists? A significant number of “stroke” pts I’ve seen turn out to have encephalopathy, or an infarct that’s completely incidental.

Who would get called for acute decompensations? As an example, my hospital has an in-house PA team for RRTs and codes.

The biggest difference between clinic and hospitalist practice is not the schedule, but the workflow. I am not limited by the 15-20 minutes of face-to-face time for each pt. I could spend an hour talking to them if I felt like it, come back later in the day, etc. Tests are done the same day and results back within 1-2 days usually. I rarely have to fight insurance on prior authorizations, but I do have to do a lot of peer-to-peer appeals for rehab, (even for stroke pts!) The nature of the work is very different - not sure how much of this applies to your situation though.