Week On, Week Off

One of a soaring number, DO takes to hospital medicine’s fast pace, complexity

“There are more job openings for hospitalists than physicians to fill the positions, so it’s a seller’s market,” DO says.

As a resident in internal medicine at Geisinger Medical Center, Scott L. Girard, DO, relished the intensity and intellectual stimulation of treating hospitalized patients. So like a surging number of other young American physicians, he decided to pursue hospital medicine.

For the past five years, Dr. Girard has been employed as a hospitalist by Danville, Pa.-based Geisinger Health System. Today the site director for Geisinger’s eight-physician hospitalist program at Lewistown (Pa.) Hospital, the 35-year-old general internist appreciates the abundance of career opportunities in this fast-turnover field.

Following is an edited interview with Dr. Girard.

Your field has grown from 2,000 practicing hospitalists in 1998 to more than 30,000 today. Why is hospital medicine growing in importance?

A few trends have converged that increase the demand for physicians who treat only hospitalized patients.

For one thing, because insurance companies have made it harder and harder to get patients into a hospital, those who are admitted tend to be sicker overall than hospitalized patients in decades past and, therefore, require more care. And with the baby boomers beginning to enter their retirement years, the number of seriously ill patients needing hospitalization is increasing. Another contributing factor is the 80-hour a week limit on resident work hours, which has created the need for many additional hospital-based physicians.

So the big hospitals tend more and more to be full of very ill baby-boomer patients, while the residents can see fewer patients. In addition, the pressure on hospitals to measure and improve quality and reduce medical errors has driven up the demand for physicians who develop expertise in hospital systems and the treatment of very sick patients. Hospital medicine doctors fill that niche.

What makes hospital medicine a popular career choice?

Speaking as a general internist, I think many residents are gravitating toward hospital medicine because this is the type of work they are used to. Internal medicine residencies are hospital-based, with only a half-day or so of clinic or outpatient care each week. So it’s very natural for internists to become hospitalists straight out of residency because they are doing essentially the same thing they did as residents.

Because of the demand for hospitalists, the career prospects are excellent. Physicians can be private-practice hospitalists who contract out their services. But like me, many hospitalists are employed by health systems, as well as hospitals and large group practices. Some of the biggest companies in medicine right now are hospital medicine groups. There are more job openings for hospitalists than physicians to fill the positions, so it’s a seller’s market for hospital medicine doctors right now. In addition, general internists can make more as hospitalists than they can in primary care.

I am employed by Geisinger Health System. As many new physicians are finding, being employed has a number of advantages. You don’t have to worry much about medical liability insurance, billing, the change from ICD-9 to ICD-10, or even Medicare. You just have to make sure that you do a good job so you can collect your salary.

But one disadvantage is that as an employee, you aren’t building up a practice that you can later sell. And I make a somewhat lower salary than I would as a hospitalist in private practice because when you own the shop, you would give yourself a bigger piece of the pie. But my job security is a little better, and I don’t have to worry about the overhead. And at Geisinger, there are opportunities to be promoted, do research and get involved in graduate medical education.

The lifestyle of a hospitalist appeals more to young physicians than older physicians with families. I work a 12-hour day, seven days a week, followed by seven days off. That’s sort of the standard, though some schedules are different. Many young physicians like having a long stretch of time off. It is nice for me because I’m married and own a farm, but I don’t have kids. The 84-hour work week is difficult for physicians who have children and want to be home on weekends.

Although long hours are expected, we allow some flexibility in scheduling. One female hospitalist on my team works 14 12-hour days followed by two weeks off. She travels to Europe several times a year. She loves her schedule, but it would not be feasible for most married physicians with kids.

While the 12-hour work days are long, hospitalists work regular hours and their time off is their own. At Lewistown Hospital, hospitalists work from 7 a.m. until 7 p.m., followed by a second shift. They can leave their pagers at the hospital; they are not on call. They don’t have to bring anything home with them. They can have a couple of drinks, go out to dinner, and do whatever else they want to do. I have always appreciated this aspect of hospital medicine.

But while hospital medicine is attractive to a growing number of new physicians, a lot of turnover occurs for several reasons. Many internists become hospitalists right out of residency with the idea of making a good salary for two to four years before entering a subspecialty fellowship program. So these physicians don’t intend to remain hospitalists for very long. Many other physicians leave hospital medicine because of the demands of family life.

In addition, because there are so many job possibilities, salaried hospitalists frequently leave one position for another. As the director of an eight-person hospitalist team, I am trying to hire most of the time. Many of the physicians I interview say, “If you don’t offer me something, the guy down the road will.” There are so many places competing with each other for hospitalists.

Because of the turnover, those who stick with hospital medicine and work for a large employer have many opportunities for advancement. Hospitalists tend to be the quality-assurance leaders at hospitals. And many hospital administrators come from the ranks of hospitalists because they tend to know what’s going on at a facility and what’s needed.

I have been out of residency just five years now and am already the head of a group, but that is not unusual. Hospitalists who have been out of residency for seven years can be the head of a 10- or 20-physician group, as long as they are willing to do the work and have shown a lot of enthusiasm.

What characteristics do hospitalists need to excel?

Beyond the knowledge and skills needed to be decent physicians, hospitalists have to be good communicators and have excellent organizational skills. An impressive work ethic is also essential since our standard schedule is 84 hours a week and we see 20 to 25 patients a day. What’s more, the patients we see are very sick—they’re not coming in for well checkups—so the stress level of the job is high. So hospitalists need to be good at handling pressure. And they have to work with speed and efficiency. The payoff is that we get paid more than most regular internists and only have to work 26 weeks a year.

What do you like most about hospital medicine?

I enjoy all of the day-to-day excitement. I think most of us who stick with it for five to 10 years tend to really like what we’re doing. What appeals to me about hospital medicine is what drew me to internal medicine in the first place. It’s a complex, intellectual type of medicine that forces you to sit down and think and do research to find new and different approaches. In addition, it is very gratifying to be able to help people through their illnesses.

Even though our work day is 12 hours long, I don’t think too many hospitalists find it a rough day. It’s great to be able to come in and see patients and make them better and think about these complex processes. Hospital medicine distills the essence of internal medicine into one great big day.

Why did you become a DO?

I’m from Massachusetts, where there aren’t a lot of DOs; the only DO school in all of New England is in upper Maine. So in college, I hadn’t even heard of osteopathic physicians.

I was a biology and philosophy major at Anna Maria College, a Catholic liberal arts college in Paxton, Mass. I applied to some MD schools but didn’t get many interviews. So I took a little time off to reassess what I was going to do. I decided to go to Rome as an exchange student through a program at the University of Dallas. My friends from Texas turned me on to the idea of osteopathic medical school. They knew about osteopathic medicine because of the school in Fort Worth. So when I got back home, I applied to the Philadelphia College of Osteopathic Medicine and a couple of other DO schools and got admitted into PCOM.

Have you done much osteopathic manipulative treatment on hospitalized patients?

OMT has never been my calling, but a number of DO residents I work with do a fair amount of it. They’ve found that using it in the hospital is gratifying and effective, and patients do appreciate it. I just never developed the ability myself.

You served a residency that is accredited by both the AOA and the Accreditation Council for Graduate Medical Education (ACGME), and you are certified by both the American Board of Internal Medicine (ABIM) and the American Osteopathic Board of Internal Medicine. Do you recommend that other hospitalists serve dually accredited residencies and pursue dual board certification?

Just about every internist is worried right now about what the ACGME is going to do. If approved, the proposal to limit ACGME fellowships to only those who have served ACGME residencies will affect many DOs in AOA-approved internal medicine residency programs. So we all are in limbo right now about what’s going to happen. The AOA is trying to persuade the ACGME to repeal or modify the proposal. Hopefully, everything will work out all right.

But until we know for sure, I’d say that DOs who plan to subspecialize in internal medicine should probably pursue a dually accredited or an ACGME-accredited residency over one that is only AOA-approved. If you serve an ACGME-accredited residency, you can have your training approved by the AOA and take both the American Board of Medical Specialties and AOA board exams.

For recent graduates who know they want to do hospital medicine over the long term, just doing an AOA-approved residency shouldn’t be a big worry. But you may not have as many options when you’re done.

I am dually certified because it expands my future career options, and I plan to maintain both board certifications. When I get recertified by the ABIM in a couple of years during the maintenance of certification process, I’m going to get a focused practice recognition in hospital medicine.

I think hospital medicine may evolve into a separate specialty just as emergency medicine has. The focused practice recognition is the first step.

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