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Session 7 Whether you are a pre-med or medical student, you have answered the calling to becoming a physician. Soon you will have to start deciding what type of medicine you want to practice. This podcast will tell you the specialists from every field, so you can have the information you need to make the most well-informed decision possible when it comes down to choosing your specialty. Today we hear from Shoshana R. Ungerleider, M.D, an internist practicing hospital medicine at California Pacific Medical Center in San Francisco. CPMC is an academic hospital set in a community setting with several residencies, including internal medicine, where she is on the teaching faculty. She has been practicing medicine for three and a half years and finished her residency in 2013. (2:20) Discovery Moment Shoshana knew she wanted to be a hospitalist midway through internal medical residency while working “night float” shifts (6pm-8am), admitting patients into the hospital overnight as well as doing cross cover. While there were other specialties that she considered, including cardiology and critical care, she knew she could be happy in a hospital setting and ultimately felt like hospital medicine was a good fit for her. There is a variety of patients that a hospitalist cares for, in terms of age, illness, chief complaint and levels of acuity; they may take care of patients who come into the hospital for a routine hip surgery who are otherwise pretty healthy, while on the other end of the spectrum they co-manage ICU patients who are incredibly ill and spend days or weeks in the intensive care unit. (3:51) The Traits That Lead To A Good Hospitalist There are many personalities that can be happy doing hospital work. One must enjoy interacting with patients, which a hospitalist does often. Additionally, maintaining an intellectual curiosity throughout your years in practice, as things are constantly changing as far as how common medical problems are managed. Hospitalists treat for many types of issues so staying up on the literature is very important; in fact, Shoshana finds herself constantly looking up the most recent guidelines. Flexibility and adaptability are also important traits to have as a hospitalist, because the hours and shifts are unstructured. If you love the structure of an 8am-5pm, she says, you are better suited for working in a clinic or outpatient facility, where the hours are standard. Flexibility and adaptability also come into play for the types of conditions a hospitalist sees--one never knows how busy the ER will be at any given day or time, so it’s good to roll with the punches! (6:22) A Typical Day For A Hospitalist (or evening, in Shoshana’s case!) After arriving at the hospital, a quick check-in with colleagues on the previous shift, then the pager almost immediately goes off! As a nighttime doctor, the majority of what she does is admit new patients to the hospital and the majority of those patients come through the emergency room. Sometimes they get direct admissions from specialists or primary care doctors where the patients come directly to the floor or may get a transfer from another hospital, but at least 75-85% come directly from the ER. The majority of her shift is therefore in the ER seeing patients and working with the residents. The residents often go in with the physicians together to see patients, or sometimes the resident goes in and chats with the patient first, does a history and physical and then she will come in later to follow up with more questions. They will do a modified round at night where the residents present the H&P and together they discuss the assessment and plan. On occasion there will be some cross-cover fires to put out on the floor when patients become ill overnight and she needs to read up on the history of the patient to find out what she needs to do in the moment. That can get a little exciting. (8:27) The decision process in choosing an academic hospital over a community hospital that did not have residents As Shoshana completed her residency, she wanted to stay in the area and was searching for a job. She was able to work in the community for the first two years after residency and got a sense of what it meant to be in community hospital medicine. While she enjoyed it, after two years she realized she was missing the educational aspects of working with residents and other trainees. Currently she is working with the residents in the hospital where she trained. Working with residents keeps a hospitalist on their toes, as they often know about the latest in diagnostics and therapeutics. The reality is not everyone can always be on top of everything and Shoshana thrives in that team environment where everyone can learn from one another. As new medicine changes from week to week with regards to the standard of care,it can be really exciting to work in such an academic environment. (10:46) Does a Hospitalist have to take calls? Technically speaking, a hospitalist is always “on call” during a shift. The daytime hospitalists have their panel of patients and when doing their rounds, they make a plan for the day as to whether the patients remain in the hospital or transferred to a different level of care. For a daytime doctor typically there is a timeframe in which they are physically in the hospital and then for those doctors who work at a later swing shift or night shift, they have to physically be in the hospital. But the hospitalists do not have to be on call call when they are not on shift. (12:09) What are the typical shift hours and days for a Hospitalist? For most hospitals, the most interesting thing about hospitalists as a field is that it is fairly young and so many hospital groups figure out what works best for them with scheduling shifts. Often, hospital groups have seven days on, seven days off throughout the year (with the exception of holiday season). Other hospitals may do a three to five day stretch throughout the year, with the exception of holidays. Others do a 3-5 day stretch and then have time off where they can tailor it around their personal schedules. Typically for nighttime doctors, they do anywhere from ten-fifteen nights per month full-time. Getting acclimated with the time change from flipping different shifts can take a toll on the body, so it is beneficial to have days off in-between. (13:50) Residency and becoming a Hospitalist For internal medicine hospitalists, meaning to take care of adult patients, you complete three years of a residency training and you’re fairly well-equipped to go into a hospitalist practice. There are hospitalist fellowships that exist but they are not that common; it is there if you need more hospital based training but for the vast majority of people that become hospitalists you can go straight in after residency into a hospitalist practice. (14:36) Is the big difference between internal medicine physician and a hospitalist the place of practice? The hospitalists are internal medicine doctors but where the distinction lies is the career one could choose right out of conventional medicine residency. You could choose to be in primary care (you’re in an outpatient practice seeing ambulatory patients) or you can become a hospitalist, where you work solely in a hospital. Some physicians do a hybrid of both but it is much more common to choose one or the other. We’re all general internists but some choose to work inside the hospital and some choose to practice in a clinic. (15:25) Is there something that makes an applicant competitive to get into internal medicine residency? Solid grades in your first few years of coursework as a medical student are incredibly important. Because internal medicine is such a broad field, having a really good understanding of physiology, pathophysiology and all that goes into our medical education is incredibly important. A diverse range of clinical experience your ward year as a medical student is important. The more diverse months in a hospital you can do as a medical student are incredibly helpful and informative for internal medicine residency because internists are often the ones interfacing with the specialists, especially the surgical specialists and other internal medicine specialists. The more you can understand how all of those fit together is incredibly helpful. Depending on what your interests are, if you want to be a researcher in addition to clinical medicine, Shoshana says, obtaining a background in research as a medical student can be important. One thing that is different with internal medicine than other fields is that there is a diversity of clinical practices that you can find yourself in after training. Internal medicine acts as a gateway to primary care, to hospital-based medicine and to some specialties such as gastroenterology, hepatology, hematology oncology and endocrinology. There are many specialities you can consider beyond internal medicine training if general medicine isn’t appealing to you. (18:03) Is matching pretty competitive for internal medicine? Yes, it can be. There are several very high-powered academic institutions that are very competitive located all over the country. If you are so inclined to end up in that program, it is highly competitive. That said, there are many different kinds of programs around the country so it just depends on what your goals are for training and what you are interested in--whether it be research or clinical medicine or hybrid of the two or if you are interested in doing another degree on top of medicine. It is helpful to think about these goals going into the application and matching process, as there is a wide range out there. (19:16) Do you see any bias between osteopathic physicians and allopathic physicians when it comes to applying for internal medicine? Shoshana has not encountered this kind of bias before or had a direct experience with that. The residency program is majority MD and there have been some DO’s who have come through the program. From personal experience, the top internal medical residencies typically only look at MD candidates. While she is unsure if this is right or wrong, that is what she has seen in her experience. (20:14) Are there any opportunities as a hospitalist to further sub-specialize? It depends on the place where you practice. For example, in a smaller or rural town, typically you will find only general hospitalists (they take care of general medicine patients and may or may not also take care of ICU-level patients themselves). In larger cities, however, there are opportunities to have a more specialized subset of patients to care for. For example, there may be a team of hospitalists that only take care of complicated G.I. and liver patients so that is their subset of patients that they typically see. Or there may be a team of hospitalists that only cares for bone marrow transplant patients and they work very closely with hematology oncology in caring for those patients. The vast majority of hospitalists practice general hospital medicine and are not sub-specialized but in larger cities or in institutions that have a high volume of specialized patients, there is an opportunity to specialize within your hospitalist practice. (21:58) Is that a fellowship training or is that just the type of patient they are drawn to in seeking out those opportunities? Typically it's not further academic medical training and each hospital or practice has their own culture about how they train the sub-specialty hospital list. Often it's just getting to know the complex G.I. attending and learning the ways that they care for their patients, given that you are the liaison between the patients and their specialists. For example, the specialized oncologists care for patients based on the standards of care that relate to their illness. There is not typically formal training on top of residency but usually you learn within your institution as you go. (23:08) What do the boards look like in internal medicine? The internal medicine board exam is every ten years so most residents complete their three-year internal residency in the month of June, take a few months of that summer studying hard for the exam and take the exam in August or September. They begin their clinical practice and whatever they're going into or they matriculate into a fellowship program if they have decided to specialize. The board exam is a full day, 7 ½ hours! It’s computer multiple choice and after taking the exam it is about six to eight weeks before the written results come back with pass or fail. (24:12) Do you know what the pass rates look like? The pass rates are pretty high, Shoshana says, and this is an exam that most people pass with an approximately 75%--85% pass rate. The actual raw score doesn't really matter in terms of the job you're going to get or what happens down the road, which is much different than the USMLE where your school really matters because you're no longer competing for a spot. Typically they have already been matched with a fellowship or they have a job so the goal is really just trying to pass the exam. (25:05) Knowing what you know now after being in practice for a couple of years, what do you wish you would've known coming into your residency? What Shoshana realizes now is that during her residency you work really hard and spend thousands of hours physically in the hospital. It is really easy, she thinks, to get bogged down by pressure of residency and performing well with taking care of patients. If she could, Shoshana would have told herself on day one of her residency to make sure that she used this time to learn as much as possible and really make the most of every opportunity, even when exhausted. It is a time that a resident will never have again and a teaching environment where you can learn from experts and experiences that you may never have an opportunity to have again. Shoshana advises that the idea of lifelong learning into your clinic practice as a resident is really important because when you finish you may not still be practicing in the academic environment or in a place where there is a specialist you can turn to ask a question. You should constantly be learning and figuring out the ways that you can best access new information in order to take the very best possible care of patients. Physicians need to recognize that in order to be up on the latest information, it takes a lot of work and the clinical practice is very important. (28:00) What do you wish primary care physicians knew about hospitalists to better help you do your job? Shoshana wishes that primary care doctors who have formed a relationship with their panel of patients would recognize that hospitalists do their very best in an incredibly brief encounter with these patients to get to know them and formulate a treatment plan. It can be a challenge to build a rapport quickly with someone literally just walking into the room and meeting them for the first time. If the primary care physicians have patients who have a chronic illness, it is incredibly important for them to inform their patients as much as they can about their medical problems and to discuss prognosis, especially when related to a serious illness. As a hospitalist, Shoshana sees many patients who have a chronic illness where she is the one to break the bad news that things have gotten worse and they may have a poor prognosis. If the primary care doctors could have that conversation with them earlier on, it is very helpful for the patient’s care and for the hospitalist to talk to a patient (and family members) who already have a sense of their medical problems and prognosis. (30:28) What other specialties do you work the most with? A hospitalist works most closely with the Emergency Medicine team and spends the majority of their time in the emergency room. Shoshana also works closely with the Oncologists, as there ar…
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