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Physician Practice Models – The Hospitalist

Pros & Cons of Practicing as a Hospitalist
Stephen Coburn/123RF.com

The Afterlife for the Hospitalist

Finishing your training is “transitioning” to a life vastly different from the one you’re leaving. While the specialty of Hospital Medicine is one of the many choices available to you, the life of a hospitalist, like Hotel California, can be Heaven or it can be Hell. This depends on whether you want to make it your career or whether you’re worried you may have made the biggest mistake of your professional life.

Fret not: nothing is forever. If you’ve landed there as a stepping stone toward what you really want to do in your career, then it’s Purgatory.

Let’s look at the different ways your “afterlife” (the real world) can go on July 1 when the Pearly Gates open for you in a hospitalist position.

Hospitalist—At Your Service.

First of all, what exactly is a hospitalist?

According to the Society of Hospital Medicine,

“hospitalists are physician and non-physician providers who provide medical care for acutely ill patients in a hospital setting. They are generally trained in internal medicine, general pediatrics or family medicine.”

Therefore, a hospitalist (practicing what is called Hospital Medicine) is a physician (sometimes a nurse) who can only practice with a whole hospital wrapped around him or her. Examples include ER physicians, ICU intensivists, anesthesiologists, radiologists, pathologists, and neonatologists. Such professionals supply a service to the hospital that usually requires a medical degree and a completed residency/subspecialty. It is an employed position: you’ll square with the IRS with a W-2 or a 1099.

“Services” can mean something other than providing pathology diagnoses, reading X-Rays, or covering the ER, however. Take the example of an obstetrical hospitalist. If a hospital has a very busy obstetrical service with many obstetricians on staff, it’s a sure bet not every one of them will be able to attend the entire labor until delivery, especially during their regular office hours. A hospitalist can manage the patient’s labor for them, be available for sudden emergencies where every minute counts, make rounds, and/or provide postpartum care. This is a valuable convenience for the private practitioner while it pays well for you as the hospital practitioner. It makes the hospital very attractive for doctors considering where to deliver their patients’ babies. This drives up volume, increases census, and makes more money for the facility. Everyone’s happy.

Gap Coverage

Aside from the hospitalists who provide a service, there’s another role for a hospitalist—filling a gap. Once again, take the example of an OB hospitalist, but for that pregnant woman who arrives crowning and whose delivery is imminent. Now that’s gap coverage. Gap coverage is provided by neonatologists, cardiologists, and other persons for those emergencies requiring immediate presence, and there ain’t no more immediate than being there already. This makes the hospital attractive to patients, due to the extra safety of the life-saving availability of the right person at the right time.

Heaven

Being a hospitalist is very nurturing for the person who only wants to practice medicine. All expenses are provided, including malpractice insurance, along with the other benefits an employee status makes possible. There are no financial surprises, no staff coverage issues, and you get to punch out on schedule to leave the world’s worries for the next guy. You also get to work with a variety of specialists, because the turnover is high when one considers the people that come and go with a position that doesn’t pin a doctor down (like the private practitioner who would lose his or her patient base, office personnel, and call partners when moving on).

Because there are no bureaucratic headaches, a hospitalist position is the perfect retirement job for many reasons, not the least of which it allows part-time employment. With the existence of 24-hour shifts, even full time can seem like part-time when you have three days off every week.

Purgatory

The hospitalist position is also a good steppingstone upon which to start your afterlife. The politics in a hospital are no different than what you will face on the outside, so it’s a more protected position to dodge bullets while you learn the political ropes. It also will allow you, as a temporary hospitalist, to advertise yourself  to the active private practitioner staff so that when it comes time to enter private practice, if that’s the plan, there’s already been a bit of advertising your wares for prospective senior partners in the greener pastures.

Hell

Alternately, because of the high turnover, you will lose the person for whom you like to work by the time you’ve learned habits, preferences, and how you work together. As mentioned before, it’s a good primer for learning medical politics, but lesson number one is that you don’t have anything to offer a hospital more than anyone who can take your place. In other words, you are replaceable. If you don’t get along with a particular nurse, you may very well lose that power struggle.

You’re also at the mercy of what is needed. You have no special protection; you may be that type of hospitalist called the “nocturnist.” If you guessed right, you know that this will mean you’re the one they’ll use for all the night shifts. At best, this is placement used for coverage purposes only, divvied up fairly among your associates; at worst, it’s a ploy to get you to want to be replaced.

Because you’re replaceable, it may happen with no warning or explanations. In the service of a hospital, everyone is replaceable because he or she can be replaced by someone cheaper. This can be a terrible threat under which to work, but you’re not alone. Even the Administrator who can fire you is replaceable: it’s all business.

If you value the doctor-patient relationship, you will enjoy this only briefly—for a few hours. You may like it this way, but it’s going to be “same stuff, different day”…every day. One of the joys of medicine is to relate with your patients, where sympathy matures into empathy. That may be elusive as a hospitalist.

Unlike Hotel California, however, you can check out.

Limbo

None of this may apply to you, of course, if you eventually want a private practice. Also, you may not qualify anyway, because the smaller the hospital, the fewer hospitalist specialists it’ll hire, which may or may not include you. Smaller hospitals may have no hospitalists or may only use anesthesiologists, radiologists, ER physicians, and pathologists.

If you’re uncertain about what you want to do and windows of opportunity are closing fast, being a hospitalist can save your rear when the mortgage is due. Then, whether sitting in Limbo turns into Heaven or Hell is really up to you.

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About Gerard DiLeo, M.D.

Dr. Gerard DiLeo, physician and published women's health author for McGraw-Hill, is now writing full time after a career of over 30 years in private OBGYN practice in the New Orleans area. He has served twice as Chief-of-Staff at a major regional hospital and 5 years in academics as Director of the Division of Pelvic Pain in the Dept. of OBGYN at the University of South Florida College of Medicine. He is an accomplished minimally invasive surgeon, laparoscopist, and an inventor (the catheter-stethoscope--U.S. Patent). He and his family live their post-Katrina life in Florida. He can be reached at drdileo@gmail.com.