How would you describe what you do?
I’d just say we take care of adult patients that are sick enough to be in the hospital, and that ranges from one-night stays to some element of critical care.
What all does your work entail?
Basically, it involves, at this point, shift work – where we’ll work several days in a row for the sake of continuity in managing people’s illnesses while they’re in the hospital. Most patients are in, on average, three to four days, that we take care of them.
One part is managing people with medical illnesses that we manage by ourselves or with specialists consulting on our patients, and then maybe the more desirable part of our work is doing consults for surgeons. So while surgeons, be it orthopedic, or general surgeons, or plastic surgeons, or ENT etc manage the surgical aspects of care, we manage the people’s chronic and acute medical problems.
What does a typical workweek look like for you?
We actually are on a rotation of nineteen days on and nine off. Formerly, we did fourteen on and seven off. In the nineteen on/nine off, there are fourteen days where we manage a census of in-patients, admits, and consults.. Then there are five days of night coverage at the end to round out the nineteen, we cover five 12-hour night shifts, and then have a weekend, the intermittent week and the following weekend off, to make nine days off. But the customary hospital schedule is turning into a seven days on/seven days off, or ten days on/ten days off kind of thing, so that it’s becoming more in vogue for you to have about the same amount of work days as you do days off.
How did you get started in this career?
Hospital medicine is simply internal medicine residency applied over a career. Internal medicine residency is 6 1/2 days a week of managing hospitalized patients and a half a day of clinic, and so all we’ve done is trim out the half day of clinic and manage hospitalized patients. This is actually, to me, the simplest and purest adaptation for a career from what residency is.
What do you like about what you do?
I’ll answer that 180 degrees to the opposite. I really don’t like clinic. I like the fact that there no appointments, people are sick and you can make a difference hopefully. And I don’t have to worry with the staffing and the major overhead concerns of the clinic practice.
What do you dislike about this job?
I have no control over the time that people come in. So you may have a day like today, where you go in at 9:00 or 10:00, and you run for three or four hours, and then at 1:00, 2:00, you’re kind of done, sitting around twiddling your thumbs and then you get busy again at 4:30 or 5:00, after you’ve had some down time in the middle of the day. That’s also common with emergency medicine. Parts of your shift are hopelessly slow and then all of a sudden, somebody pulls back the curtain and you’re overwhelmed.
And basically, we have a deal where you take what gets put on your plate during your assigned shift. So on the slow days at the end of your shift, you’re done. On a very different day, you may stay several hours after your shift. So that’s one of the dislikes, the lack of predictability. On the other hand, as long as people are sick and needing to be in the hospital, it’s interesting enough to stay. You’re just done when the job is done.
How do you make money/or how are you compensated in this career?
Hospitalists in general are paid two ways. One, are employees and have a guaranteed salary and benefits package, and then the others are fee for service. So you show up, take care of what’s there, and you bill and live off the collections, minus overhead. And then there are a few people that have kind of blended that, and this is us, where you have a guaranteed base, not a whole lot, but then you have a productivity type bonus structure, so that if you see hardly anyone, up to whatever the agreed amount of patients is, then you make the guaranteed minimum. But if you see more than that, then you share in the profits or the collections for the patients above the minimum amount. We have a guaranteed amount of money that we’re going to make every year, and then we have productivity model and it’s a month-to-month thing, so for the month of September, if we see X number of patients and X is below the hard deck, then we make a guaranteed amount of money, and if X is above the agreed upon number, then we’ll get paid on the productivity.
How much money do you make as a hospitalist?
The guaranteed is about $250,000 and the productivity above and beyond that is variable depending on numbers, but in this job, I’ve made as little as $180,000 and as much as $450,000. It just depends on volume. When you’re making $450,000, you hate your job.
You’re basically working like a pack mule so, there’s a happy medium somewhere between $275,000 and $325,000, where we feel like we’re making a good living and we’re doing a reasonable amount of work, where you can really take care of people. All those years where we’re making north of $400,000, we’re so busy the quality suffers.
How much money do you make starting out as a hospitalist?
I think you can expect to come out of residency and sign a contract around $200,000. It’ll be better in competitive markets and a little less in academic markets that are saturated. As a general rule, you should anticipate or hope for, and not settle for anything that doesn’t have a 2 in front of it.
Would you say there are any perks associated with your job?
Sure. The flexibility of making our own schedule is a real perk, even though it’s pretty inflexible after we set it up. We can set it up – with partners, I own the company. I get the pride and feel of ownership there, so that’s kind of a perk.
What education or skills are needed to become a Hospitalist?
For internal medicine, it’s four years in college, four years in medical school and a minimum three year residency. As far as skills, it’s mostly a cognitive profession. It’s not very procedural, so while we do some minor procedures, the skill set is mostly cognitive.
We’re mainly thinking, planning, managing cases, working through diagnostic dilemmas, but not scopes and scalpels and that sort of stuff.
What would you say is most challenging about what you do?
For us, it is how sick the patients are. The days are gone where you can put someone in the hospital just because they have something minor wrong. So by the time now that anybody qualifies for admission, they tend to be very sick, so managing a multiplicity of disease and very sick patients is a big challenge,
What would you say is most rewarding about you do?
Watching people get better, absolutely. Watching a plan come together – making a diagnosis, putting the treatment plan together, and watching somebody get well.
What advice would you offer someone considering this career?
To do dentistry instead. (laughs)
Within the whole field of medicine, don’t pick your specialty based on the hours, the procedures, or the reimbursement. Pick it based on what you think you can dedicate a lot of time to, because nobody in this profession that does it well, does it a little bit.
How much time off do you get or take?
Basically, we have 12 weeks off a year right now. But that’s 12 weeks, and not weekends on the other weeks. That’s 12 seven to nine day runs, but you don’t get 12 weeks vacation plus all the weekends and holidays and everything else like a normal job. So all the days just kind of run together and the calendar day doesn’t really matter. If I employ you right now, you’re going to work all but 84 days of the year.
And arguably, you get 104 days off if you just take weekends, and then if you take holidays, that’s probably another 14 more, and if you take two weeks of vacation, that’s 10 more, and you get to 140-150 pretty quick. We work all but 84.
In a small group, trading out a call for a day or two is very, very difficult, so I pretty much say “If it’s important to you for me to be at the wedding, then call and ask me what day I’m off.” If it doesn’t matter, then just tell me what the day is and I’ll tell if you if I’ll be there or not.
With some of the practice guys, it’s work four days a week, and they might complain about not having much vacation time, and how nice it must be to have nine days off at a time. I always ask them when the last time they pulled 19 straight days was and tell them I’m going to do that 16 times this year.
What is a common misconception people have about what you do?
That you make a ton of money right out of the gate. Truth is, they start low on the pay scale with a lot of student debt. That’s probably one. Another is that we’re supposed to get it right all the time. A lot of things are, in my profession at least, are very much trial and error. There’s some diagnostic dilemmas that baffle us and I think people maybe don’t understand sometimes that we have to work through that.
And then maybe a misconception that a doctor is a doctor is a doctor, whereas I know very little about the surgical subspecialties and some of the things like cosmetic surgery and ophthalmology. Hopefully, when it comes to diabetes, heart failure and internal medicine, I know a whole lot, where the eye doctor doesn’t have any idea. So I think the idea is that “because you all went to med school, you all have the same fund of knowledge” and certainly you learn how to be a doctor in residency, not in med school, and your fund of knowledge is dependent on your residency and experience, not on the anatomy course you took in your first year of med school.
What are you goals and dreams for the future in this career?
I have a couple. One is to grow my practice to be big and successful, and respected. Another is to have a management or administrative arm of the practice in the career so it’s not all bedside. And then, I’d like to be one of those guys who plays his whole career for one team, so I can start and finish in the same place, and that’s really uncommon. About 50% of the physicians in this specialty switch their place of practice in the first four years.
And I think that’s because for the last ten years, this career has been kind of sexy and so the offers are bigger and better in other places. So if you’re willing to move, you can change your pay scale. And the other thing is that people change because they start in small groups and the demand of call in a small group is very taxing, and so there is a significant allure of a bigger group, which more shared calls.
What else would you like people to know about what you do?
Specific to the profession, it is the fastest growing specialty in medicine ever. The next closest is emergency medicine, which was kind of championed in the ‘70s, and we’re really at a clip of 400% faster than emergency medicine grew. There’s somewhere between 25,000-30,000 hospitalists in a specialty that’s 10 years old and that takes several years to train somebody. So it’s really, really kind of a rocketship past the moon as far as the growth of this particular sector.
I don’t know where the demand curve is going to plateau, but the supply is being met by a whole lot of people who would normally specialize, but because the money and the lifestyle are fairly attractive, instead of doing a GI fellowship,or rheumatology, or cardiology, if you have the opportunity to get out after three years and become a hospitalist and have a decent lifestyle and decent salary and good opportunities to grow in the field. So, I have a feeling that the rush to this specialty is probably over. We’re starting to hear that in some of the big cities, a really desirable job is hard to find. That’s new in the last couple of years. There’s a few markets that are very desirable – jobs in very desirable locations are starting to be full. But for the most part, there is still lots of need.