Talk To Me About Being An Inpatient NP

[FiremedicMike]

I have a few years before I can retire from the FD and go full-time nursing (second career).  I am personally a long-term planner and am looking at a couple of different possibilities of what direction to pursue, one of which would be inpatient medicine.

I am currently an ED RN and enjoy the fast pace, but have little desire to work in the ED as a provider.  

For those experienced in hospitalist work and/or ICU at the provider level, I'd really love to hear your thoughts.  What is a typical day like, do you enjoy it, etc.

[KatieMI, BSN, MSN, RN]

4 hours ago, Tegridy said:

There are some docs where I am that consult for everything (when we are on consult service) and honestly it’s pathetic. IDK where they went to residency but must have been a garbage program. Or they don’t care. 

It is most probably about $$$$, not about knowledge or absence of it. 

Consultant gets paid for his job, in exchange "their" patients are admitted under hospitalist primary so that the said hospitalist gets his check as well. Hospitalist service by itself cannot produce quite as much money as consultants because all insurances "value" them less,  but it usually more than makes up the difference by volume. 

In addition, if every specialist has to write up all H&Ps, daily notes and do all hospitalists' scutwork,  speciality services, which are expensive to keep and support, would be blown up in numbers while bringing the same revenue. It wouldn't be enough to keep just two GI docs (one rounder, one doing procedures) for 400+ bed hospital which takes, say, on average 12 "pure" GI cases daily with same number of discharges and at any moment fills about 8-9% (32- 35) of beds with this type of patients. Only existence of cheap labor force "support" such as residents and APPs makes it possible for just daily functioning with straight specialty responsibilities, with no H&Ps, discharges and all that jazz. 

Not a rocket science, just all-mighty green paper game. 

[Tegridy]

1 hour ago, KatieMI said:

It is most probably about $$$$, not about knowledge or absence of it. 

Consultant gets paid for his job, in exchange "their" patients are admitted under hospitalist primary so that the said hospitalist gets his check as well. Hospitalist service by itself cannot produce quite as much money as consultants because all insurances "value" them less,  but it usually more than makes up the difference by volume. 

In addition, if every specialist has to write up all H&Ps, daily notes and do all hospitalists' scutwork,  speciality services, which are expensive to keep and support, would be blown up in numbers while bringing the same revenue. It wouldn't be enough to keep just two GI docs (one rounder, one doing procedures) for 400+ bed hospital which takes, say, on average 12 "pure" GI cases daily with same number of discharges and at any moment fills about 8-9% (32- 35) of beds with this type of patients. Only existence of cheap labor force "support" such as residents and APPs makes it possible for just daily functioning with straight specialty responsibilities, with no H&Ps, discharges and all that jazz. 

Not a rocket science, just all-mighty green paper game. 

Hospitals get paid by diagnosis code though. For inpatient problems it costs more to bring in more consultants. At least for the hospital, Unless said consultant is needed for a procedure or may circumvent the ordering of a bunch of expensive and low yield tests. Or thirdly for a second opinion on a legit tough case. 
 

by everything I should have been more specific. 
 

- hemorrhoidal bleeding (minor)

-surg for uncomplicated probably doesn’t even need admitted diverticulitis. 
 

-the obvious type 2 NSTEMI

-cap (not kidding here)

- I saw one consult vascular for an incidental 4 cm AAA ? 

I’m not saying to not consult and a lot depends on census levels and patient requests (we had one who wanted pulm for a cough and I just said no)

 

just a few examples.

 

I would add stroke but I believe neuro has to see them for some reason even though usually there is nothing to add (to maintain stroke center status or something similar)

 

 

[Tegridy]

2 hours ago, Numenor said:

Some attendings just don't have confidence in themselves, zero time to think the issue through or are lazy in my experience. I had a few go-getter attendings who refused to consult unless it would involve procedures or in-depth follow-up.

Somewhere in the middle is probably the right place. The worst I see are usually consults for outpatient problems. (Indecentalnobodycareeinthehospital-omas)

[Guest1144461]

56 minutes ago, Tegridy said:

Somewhere in the middle is probably the right place. The worst I see are usually consults for outpatient problems. (Indecentalnobodycareeinthehospital-omas)

Yes consultants will often deflect consults with: this is an outpatient problem LOL. Which is true many times. When I did a neuro rotation we got consults for literally  dementia  work ups all the time…

[Guest1144461]

1 hour ago, Tegridy said:

Hospitals get paid by diagnosis code though. For inpatient problems it costs more to bring in more consultants. At least for the hospital, Unless said consultant is needed for a procedure or may circumvent the ordering of a bunch of expensive and low yield tests. Or thirdly for a second opinion on a legit tough case. 
 

by everything I should have been more specific. 
 

- hemorrhoidal bleeding (minor)

-surg for uncomplicated probably doesn’t even need admitted diverticulitis. 
 

-the obvious type 2 NSTEMI

-cap (not kidding here)

- I saw one consult vascular for an incidental 4 cm AAA ? 

I’m not saying to not consult and a lot depends on census levels and patient requests (we had one who wanted pulm for a cough and I just said no)

 

just a few examples.

 

I would add stroke but I believe neuro has to see them for some reason even though usually there is nothing to add (to maintain stroke center status or something similar)

 

 

Those consults are pretty bad….with diverticulitis I wouldn’t bother with surgery unless it was complicated and greater than 3-4 cm and they have had multiple episodes. For drainage I’d talk IR with anyways…

CAP, inci AAA and demand trop leak…LOL. Were these MDs??

yeah neuro has to see all stroke patients. It’s a compliance thing.

 

[Tegridy]

45 minutes ago, Numenor said:

Those consults are pretty bad….with diverticulitis I wouldn’t bother with surgery unless it was complicated and greater than 3-4 cm and they have had multiple episodes. For drainage I’d talk IR with anyways…

CAP, inci AAA and demand trop leak…LOL. Were these MDs??

yeah neuro has to see all stroke patients. It’s a compliance thing.

 

It was an MD. 
 

at least those on this forum know I throw punches everywhere they are earned 

[Tegridy]

52 minutes ago, Numenor said:

Yes consultants will often deflect consults with: this is an outpatient problem LOL. Which is true many times. When I did a neuro rotation we got consults for literally  dementia  work ups all the time…

Diagnosing specific dementias during an acute illness. Great idea ? 

 

part of it is when the spouse with dementia his/herself wants a workup for dementia inpatient. Just have to have the gall to tell them nah this isn’t the time and places sorry. Esp when they are delirious. ? 
 

 

[JBMmom, MSN, NP]

When I started my hospitalist role I had the opportunity to round with all the specialty groups. Since I was night coverage I asked them what pressing issues might I see overnight that would warrant an appropriate call, and what sort of admission consults are important.

Every single one of them said to please have a SPECIFIC question for them when entering a consult. And I was not, under any circumstances to order neuro consults for a headache, cardiac consults for an asymptomatic mildly elevated troponin, nephrology consults for new AKI in a dehydrate patient making urine, etc.  Everyone is so worried about CYA medicine that they punt everything to the "specialist". It's not the best thing for patients, too many cooks in the kitchen. 

[Tegridy]

20 hours ago, JBMmom said:

When I started my hospitalist role I had the opportunity to round with all the specialty groups. Since I was night coverage I asked them what pressing issues might I see overnight that would warrant an appropriate call, and what sort of admission consults are important.

Every single one of them said to please have a SPECIFIC question for them when entering a consult. And I was not, under any circumstances to order neuro consults for a headache, cardiac consults for an asymptomatic mildly elevated troponin, nephrology consults for new AKI in a dehydrate patient making urine, etc.  Everyone is so worried about CYA medicine that they punt everything to the "specialist". It's not the best thing for patients, too many cooks in the kitchen. 

At night almost  anything less than something that like requires a procedure you can’t perform is weak

[Guest1144461]

4 hours ago, Tegridy said:

At night almost  anything less than something that like requires a procedure you can’t perform is weak

Basically this. I remember we had a senior resident call ID at 2am....bruh. Load em up and wait till morning if you are worried.

[Tegridy]

10 hours ago, Numenor said:

Basically this. I remember we had a senior resident call ID at 2am....bruh. Load em up and wait till morning if you are worried.

No doubt. ID is there to peel off our maybe unneeded abx not to ask what to add at night haha

[JBMmom, MSN, NP]

17 hours ago, Tegridy said:

At night almost  anything less than something that like requires a procedure you can’t perform is weak

After working for a while I understand that now. But as a brand new provider, I wasn't so sure. Like would a rapid afib require cardiology immediately or after I tried lopressor/cardizem, or not at all? Would a stable stroke require neurology consult in real time? I was also going to a teaching hospital from a non-teaching. So just trying to figure out the who is responsible for what took some time.