Transitioning from outpatient to inpatient only

[Perry Ict]

Does anybody know what is typical for weeks of PTO (if any) for a 7 on 7 off neurohospitalist position?

[Perry Ict]

I'm sure you'll be fine.  As Lordosis mentioned, a key to efficiency in the outpatient setting is knowing how to delegate your work.  That was one thing that I had to learn after training, since as a resident I was used to doing so much tedious work that didn't necessarily require a medical degree. If you have a good proactive office staff, that can be very helpful and save you a lot of annoyances.  On the other hand, there are some nuisances that are hard to avoid - I find denials from insurance sometimes happen no matter how well I document (a simple phone conversation with insurance reiterating exactly what I documented usually gets the approval).

Also, with regard to documentation, I've noticed a lot of physicians using medical scribes. I don't use them, but if you find yourself struggling with tons of notes to write I'd imagine it could be helpful.

[nolamd84]

Yea I haven’t started yet. I’m pretty efficient as a hospitalist so I’m hoping to be as an outpatient doc as well. Smart phrases, auto-dictating, all the things.

[Lordosis]

nolamd84 wrote:

I’m in the same boat. Have been a hospitalist for almost ten years but am really missing all the holidays and weekends. I have gotten good at entertaining myself and having “me” time, but now that the kids are getting older I’m missing too many life events.

I initially resisted outpatient work as I thought I would take a haircut. Recently I found a clinic job for 4.5 days/week that was paying me as much as if not more than my hospitalist job. I’m mostly apprehensive about the clinic flow, but I suppose any job has its pros and cons. I’m going to work on efficiency on the front end as it seems that people do anything from nothing to 3 hours of charting every night depending on their flow and documentation.

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My computer shuts off at 5 and does not turn on again until 7.  Unless I am on call.

If you are charting 3 hours in the evening you are doing something wrong.

Either you have a bad EMR or do not know how to use it.

Maybe you need to be more efficient with patients.  I know docs that will spend a ton of time talking about nonsense with patients.

Use your front office and nurses to the top of their ability.  Filling out forms and making calls is not something that requires a physician.

Learning to type or auto dictate

Getting the chart done right away is much faster then trying to remember the details later that day.

 

[nolamd84]

I’m in the same boat. Have been a hospitalist for almost ten years but am really missing all the holidays and weekends. I have gotten good at entertaining myself and having “me” time, but now that the kids are getting older I’m missing too many life events.

I initially resisted outpatient work as I thought I would take a haircut. Recently I found a clinic job for 4.5 days/week that was paying me as much as if not more than my hospitalist job. I’m mostly apprehensive about the clinic flow, but I suppose any job has its pros and cons. I’m going to work on efficiency on the front end as it seems that people do anything from nothing to 3 hours of charting every night depending on their flow and documentation.

[Perry Ict]

^

May I ask how far that commute would be if you weren't renting a hotel?

I've never had a long commute, so I don't really know my tolerance, but I'm thinking anything over an hour I might have to go with that type of arrangement.

[Radonlake]

In regards to living in 2 places: I moonlight a lot in a nearby town, too far to commute daily. I would say the attractiveness of the job and pay must be awesome to consider living in two places. I found it a lot of hassle by little things and costs, both more than I expected: internet, utilities at two places, garbage disposal. Bed sheets/towels to be washed and hauled back and forth, food, books, laptops need to be hauled back and forth.... I am staying in a suite hotel since renting a place became too much of a hassle - and the job pays for it, but otherwise no way I would do it.

[Drsan1]

One of the neurohospitalists at my hospital was full outpatient before joining and currently rents a place near the hospital but on his week off he lives in another city. They get no PTO but easily switch with each other to get larger stretches off. They are 7on/off with weeknight call covered by the outpatient neurologists. They cover the weekends in total. They have a NP that works with them M-F. They are a 2 person group with only one on at a time. We are a 350 bed hospital.

[Perry Ict]

So, a little follow-up. I've gotten some preliminary interest (just speaking by phone so far), and a couple of the places seem fairly wide open about how I could potentially structure things for myself. The catch is that all of the places I've received interest are at least 45 minutes away, with one of the places closer to 80 minutes (my current commute is 20 minutes), and I am not willing to sell/move from my current house, which is in a very ideal location for me outside of work (near a big city).

With that said, I could conceive of a 45 minute commute. For anything further out, I might consider renting a place near work for my weeks on, but only if it's for a schedule that allows for more flexibility than 7 on 7 off (maybe something that averages out to 7 on, 12 off, or similar), otherwise I'm not sure it would be sustainable for me.

Any thoughts? Has anybody dealt with this sort of situation, potentially living close to work in your weeks on and elsewhere in your time off? Thanks again for the replies.

[HOGMD]

Just a viewpoint from someone considering the switch from hospitalist to outpatient work.

I am in year 4 of an "academic" hospitalist job, but I am essentially 100% clinical with 30% time on teaching services. I have enjoyed it in this phase of my life with no children and wanting to travel/enjoy long periods of time off. However, I can see it becoming not sustainable for me. I do not even have that hard of a schedule in that MOST shifts are not 12 hours. But we do have a share of evening shifts and the occasional overnight. It is the weekend and holiday work really gets to me. I feel like the time I miss from my extended family and friends on weekends is worth much more than having several days off during the week. It gets to the point that it is hard to keep a good social circle because weekends are the time to get together with people. I have the feeling it will only get worse with kids as many of my partners attempt to give away every single weekend shift they have.

And this may be a "grass is greener" thought, but I do miss having long term relationships with patients and really knowing a patient well. Many patients I see really like their PCP or specialist who they consider their primary doctor. And they have much more trust in that physician than they do in me who will be seeing them for maybe 1-2 days. In the system that I work, we have separate admitting shift so I usually do not know patients well the first day I am on. It is the rare patient that I really get to know well and create even the semblance of a relationship with. But, I also know many outpatient docs who would love to get rid of some of their more troublesome patient relationships. Ha ha.

I am not sure what I am going to do yet but I have been in the "exploring" phase for several months and have yet to make the jump.

[Perry Ict]

Thank you everyone for all of the input, including the words of warning and encouragement.  You've all been very helpful.

What's typical for PTO? It sounds like there is a large range, with some places counting the "7 off" as PTO, and other places allowing for an additional month or more.

[q-school]

ticker wrote:

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.

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our neurohospitalist program has evolved several times.  it seems that the non stroke guys would beg the neurohospitalist constantly to see the consults for everything because they were tied up in clinics and meetings.  the frequency of the pages was significant-nonurgent pages would eventually cause such profound sleep deprivation that the job was perceived as intolerable.

regarding bleary eyed comments- i think that bad nights on call do that to everyone.  shopping on weekends and time off-again everyone does that.  to people not on week on/ week off schedules, it sounds like there is a lot of flexibility that other schedules don't naturally have.  no idea whether it is worse or better, but clearly it is different.

having been on call 24/7 in a previous job, i would echo the comment that just carrying the pager eventually becomes burdensome.  it always went off when i was in the shower, taking a swim, etc etc.  it's fine when it's important, not so fine when it was something that could wait or anyone could handle.

to me, the main advantage is no clinic.  no exploding inbasket.  no being at the mercy of a million calls, messages, things to review with no respect to hours.  basically clinic is the opposite of shift work.  you are fully scheduled during your shift, but you have several hours worth of work to prep the clinic and to deal with the detritus of clinic work.

[StateOfMyHead]

I haven't ever done 7 on and 7 off but much prefer inpatient to outpatient. Weekends are fine with me especially in consideration of the premium rate that is factored in. As someone without kids I actually like having an acceptable excuse to avoid some of the less than important, to me, weekend events and can request off for a legit special occasion. In my experience the specialists who are called for consults are generally appreciated and you definitely won't be bored.

[hightower]

Perry Ict wrote:

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?

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For me, I wouldn't be able to tolerate an office based setting.  I'm too much of an introvert to be shuffled from room to room all day.  At the hospital, I can run and hide from people when I need a break.  I also really enjoyed the ability to take time off for travel earlier in my career.  My wife and I traveled a lot those first 6-7 years and it was so easy because I didn't have to worry about finding someone to cover for me. I could take 2-3 weeks off at a time and no one even noticed.  Now that we have a little one, that's not as easy to do so I'm glad I got to do it then.

If you have any interest in travel, that's something to consider while you're young.  It's the best time to do it in my opinion.  I'm sure you can find a job that will let you take 2 weeks off at a time.  I agree with others that you are in high demand.  I know of several hospital systems in my city that would kill for a dedicated neurohospitalist.  So, if I were you, I would negotiate a fair salary AND a flexible schedule with the ability to take time off when you want.  I'm sure they'll find a way to make it work if the alternative is no neurology coverage.  The hospital I used to work for had their neurohospitalist quit (I don't know why, but I suspect burn out).  They were so desperate to get another neurologist on board they actually managed to convince a retired doc to come out of retirement and fill in with a limited schedule.  Everyone was very thankful, but I couldn't help but feel sorry for the guy (although he was an old school academic type that seemed to really love neurology, so I think he enjoyed it).

[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.