It’s been a while since I wrote or drew anything. I changed jobs recently. I left a community clinic and joined a hospital-owned primary care practice. When I thought I was going to start, COVID-19 reached the American shore and I found myself wearing scrubs again at the hospital, as a hospitalist.
While this temporary experience at a teaching hospital revived memories of residency, it also reinforced my decision to practice outpatient medicine. Most of those who do not sub-specialize after an internal medicine residency end up working as hospitalists. I took the decision 5 years ago to be an outpatient internal medicine physician. I thought about my decision quite a few times and challenged myself. After all, those who do hospitalist work have every other week off, and earn more on average than their outpatient counterparts. That’s what you hear in residency programs. You also hear that when you are done with your shift, “you are done”, and that there is no paperwork. But more than ever, as this pandemic is winding down, I can’t wait to walk into the job I signed for, at my outpatient clinic.
The internist that does both outpatient and inpatient work is a dying breed, if not already dead. We are in an age when we have to pick one over the other. After hearing all the arguments that favor a hospitalist lifestyle, let me explain why they do not appeal to me after I tasted them first hand for 3 months.
“7 on 7 off” sounds equivalent to “no life for 7 days” then “catch up with life for 7 days”, of which 2 are needed for physical recovery, and 4 for mental recovery. It means not being home every other weekend: important thing to consider if you have a family at home. It can mean being out of tune with your social circle- if you have one. For me, it is a failed marketing strategy. I do reckon it is attractive to many.
The lure of leaving work behind also highlights another reality: these are not your patients. They are just your daily assignments. They did not come to see you. For many doctors, especially the new generation, this allows for even more detachment and ensures a clear partitioning of life at work and outside of work. This bothers me, even when I consider the work I carry home in the outpatient world. I like patient ownership. Call me an old soul.
The hospitalist approach is pathology-driven, and rightfully so. First, you deal with potentially life threatening conditions, and secondly you don’t know your patients. At most, you may develop friendships with some “frequent flyers” and consider them to be hospital mascots. Ideally, you want to hear and know only what’s pertinent. That’s why you may envy the critical care doctors who document with a touch of sorrow that “unfortunately this patient is sedated and intubated and therefore history is limited”, but that actually made their job easier. Much easier than hearing about pain grades, bowel movements, bloating or the family dog.
The days are unpredictable. I saw how this can bring frustration even to the most enthusiastic hospitalist. You don’t want that admission at the end of the day. Some admissions can be qualified as “social”, or “loose”, and they add an unnecessary burden on the census. That’s when you fight with the emergency department for what “they” want to dump on “us”. Yes, “us versus them”, as it is with surgery, and all procedural specialties who can’t write admission orders. Yes, you will do these admissions and then wait for what “they” say, because their spine surgery is worth more than the orders you write to treat a pneumonia. The service is rightfully called the “dumping ground” in the hospitalist sub-culture.
And how can I forget the case management rounds, or the “multidisciplinary rounds”? I would rather work on a prior authorization.
At the end of my 3 months, I am glad I brushed up on inpatient medicine. I also made friends and met remarkable hospitalists. I myself became a master discharge specialist, with decent discharge time estimates. I wore the scrubs well and when I told a few that I am a primary care doctor they said I tricked them. I will return to a job that has its own deterrents, as you may have read about in my previous posts. That’s partly why I am embarking on a new journey, braced with hope.