What I Wish I Knew Before Becoming a Hospitalist

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Finishing residency and beginning a career in hospital medicine is an exhilarating time of autonomy, unlike any time during residency. Now you can finally flex independent clinical skills. However, it can be scary knowing that you’re the attending physician, the quarterback of a multidisciplinary team. Now that we have several years of work experience in different areas of the country, there are some concepts we wish we knew before starting our first job as a hospitalist. These concepts can be organized into four key topics with the mnemonic of TEAM: team dynamics, education, administrative tasks, and growth mindset. 

Team dynamics 

As a hospitalist, you’ll be coordinating patient care with nurses, consultants, care managers, and families. If a nurse is familiar with you and can put a name to your face, it can dramatically improve efficiency and coordination of care. When you start a new job as a hospitalist, we highly recommend introducing yourself to all charge nurses, unit directors, and bedside nurses. This will open the door for streamlined communication.

During rounds, ensure each bedside nurse is updated on the plan for the day either by rounding with them or updating them immediately after finishing. This will enable the nurse to help enact the plan and reiterate it to the patient if needed. It also saves you and the nurse time by limiting questions that come up later in the day.

One unique aspect after completing training is that you may have the opportunity to collaborate with advanced practice practitioners (APPs), such as nurse practitioners or physician assistants. One common misunderstanding is that APPs are similar to residents, which can be misleading. Depending on the model at your hospital, APPs may practice independently (with a supervising physician available when needed) or they may work with a physician more directly.

In the hospitalist setting, an APP may round on several patients alone and bill independently. Depending on the acuity of the patient and/or your comfort level, you may opt to see the patient also and bill for your services. APPs can enhance patient care and efficiency in a team-based setting, and it’s not uncommon to learn tips and tricks on patient care from them.

Starting as a hospitalist, you’ll quickly realize how much you don’t know. Medicine is an ever-changing landscape, and you are not expected to know it all or to know every piece of new evidence. Thankfully, medicine is a team sport. Hospitalists ask each other and consultants for feedback and advice constantly. Your reputation as a collegial teammate, willing to help others, will facilitate this process, and others will be more willing to help you in return. We cannot overstate that one of the keys to the success of being a hospitalist is communication and collaboration. 

Education 

Defining your career is perhaps the most difficult aspect of the job. Deciding to pursue a career in hospital medicine is only the beginning of your career trajectory, given the myriad of options available within this specialty. You can choose to pursue a career in academic hospital medicine, which lends itself to teaching, research, and scholarship, or you can opt for a career in the community setting, which may involve more time providing direct patient care.

Hospitalists inherently make excellent candidates for advanced degrees, such as a master’s in public health or business administration, which have wide applicability within hospital medicine. Given that hospitalists are intricately involved in hospital operations, leadership opportunities are abundant via committee work, quality improvement projects, and specific roles, such as unit director.

Developing the skills and behaviors of an effective leader early in your career via leadership coaching or a specified curriculum (locally and/or through SHM’s Leadership Academy) sets the stage for promotions and new opportunities within the hospital and, if applicable, the academic institution.

In the academic setting, it’s even more important to understand the promotion process. With some variance between institutions, hospitalists can advance from instructor to assistant professor, then to associate professor, and finally to professor, through dedication to teaching, service, and scholarship.

Hospitalists also have an increasing presence in executive-level positions (also known as the C-suite) within hospitals. Hospitalists are systems-level thinkers and problem solvers with a keen understanding of hospital operations. This positions hospitalists for success within the C-suite. Choosing hospital medicine as a specialty opens the door to numerous pathways for a fulfilling career.

Administrative tasks

One aspect that’s frequently foreign to a new hospitalist is the administrative or logistical aspect of being employed. Several compensation models exist in hospital medicine. It can be helpful to know if you’re paid via salary, Relative Value Units (more commonly known as RVUs), or a combination.

Additionally, some shifts, such as nights and weekends, may be worth more than others, which could mean higher pay for those shifts, the need to work fewer shifts, and/or more flexibility in scheduling. Most institutions also offer bonuses for meeting certain metrics, so familiarize yourself with these so you can obtain them. Some hospitalists also choose to work extra shifts, including overtime and moonlighting. Know how that plays into your schedule, your compensation, and your work/life balance, especially if you plan on switching shifts from days to nights.

Also, billing for your work and time can be complicated. There are specifics to observation versus inpatient, critical care time, procedures, and prolonged time that may not be explained during training. Familiarize yourself with billing expectations at your institutions and make sure you have a good understanding of billing when you start as a hospitalist.

In addition to clinical work, there are local, state, and national requirements for maintaining your medical license. At the local level, each hospital and academic institution sets forth policies regarding annual training to remain in good standing and be credentialed to practice. These usually include modules addressing the Health Insurance Portability and Accountability Act (HIPAA), workplace safety, malpractice, and diversity/equity/inclusion, among others.

Each state has different annual continuing medical education (commonly known as CME) requirements with credits obtained via lectures, conferences, workshops, or any approved educational activity. Nationally, the American Board of Internal Medicine (ABIM) requires 100 Maintenance of Certification (MOC) credits every five years to ensure the ongoing process of lifelong learning, self-assessment, and clinical improvement. Additionally, ABIM mandates the 10-year traditional board exam (or, beginning in 2022, the Longitudinal Knowledge Assessment) to maintain board certification. If you are board-certified in pediatrics or family medicine, their respective boards have a similar process, and if your certification is in internal medicine/pediatrics, be sure to look at reciprocity between the two boards.

Growth mindset

Starting as a new hospitalist is exciting but terrifying. Working to understand the logistics of your job, your educational opportunities and requirements, and the team’s dynamics can help make the transition smoother. Knowing that you can grow and change your career over time is exceptionally rewarding, especially if you invest in yourself and your career.

As a hospitalist, you have the luxury of developing your niche over time and tailoring your career accordingly. A tremendous piece of advice that each of us received was to find ‘your people’ and seek mentorship. Identifying good mentors can sometimes be difficult, but it’s one of the most important tasks for your first year on the job. Good mentors can serve as the catalyst for your development, advancement, involvement in projects, and networking. Starting your job with a forward-looking vision and being open to things will help your career flourish. 

We hope that by sharing these concepts we wish we had known before starting our jobs, we’ve helped make your foray into hospital medicine successful and enjoyable. And remember, hospital medicine is all about the TEAM.

Dr. Crecelius is an assistant professor of clinical medicine at Indiana University, Indianapolis.

Dr. Rawal is a clinical assistant professor of medicine at the University of Pittsburgh Medical Center, Pittsburgh.

Dr. Ashford is an assistant professor and program director, department of internal medicine/pediatrics, at the University of Nebraska Medical Center, Omaha, Neb. This article is sponsored by the SHM Physicians in Training Committee, which submits quarterly content to The Hospitalist on topics relevant to trainees and early-career hospitalists.

This article was originally published by The Hospitalist.

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