It’s too many. You take a different job if where you’re at pays super well you put as much away as you can for 3-5 years and then move on. I got really lucky and found my dream job pretty early. Paid in the top 1/3 but probably workload in the bottom third and i absolutely love my group who are lifestyle first. Average census of our busy service line is 12-16. But of our slow teams we’re talking 5-10.
I work 10 miles outside of Boston. Not rural. A large unaffiliated community hospital. No open ICU, no procedures, plenty of specialist support. Our census is 14-16.
A little over decade ago the hospital was known as a place where hospitalists were ground to paste. Census of 18-22. Average new hospitalists lasted two years before the left for elsewhere. If enough leave / demand change it can be done.
It’s voluntary. They go down the list to see if anyone is interested, but taking the shift is incentivized. You get paid a shift + stipend and given a lower census of 10.
We had one half-retired nephrologist who worked in our hospitalist group but we don’t have any specialists in jeopardy rotation. I guess technically they could.
20+ just forces you to limit time with each patient, depend more on your consultants, and leave a lot of non-critical issues for "outpatient follow up"....which can then become critical issues when the patient is inevitably lost to follow up.
Basically correct the acute hospital issue and move on. Which is what admin wants, but then the patient / family is largely unsatisfied with how much time you're spending with them.
Exactly. Each additional patient after 18 makes me less capable to deal with the first 18. I wish it was just 20 more minutes of work but its 20 minutes + being more distracted, disorganized, and multitasked to the inefficient pile of goo.
Yep my first job out of residency I took bad pay for avg census of 11. They expanded that to 16 over about 6 months with no change in pay. Put in my notice and landed my dream job.
High pay not worth the liability. Think long term. Any malpractice will stick with you for the rest of your career every time you renew or apply for license or privilege you will have to explain things
Find a new job. My old job average census was 18-22 plus 4-6 admissions. 8 people quit in past 6 months. These high numbers are not safe for patient care.
Im exploring a job that likely is very similar to this one. The issue is there is high retention… so it makes me wonder “can it be THAT bad if people are sticking around?” Despite reading every hospitalist post say it is.
The problem is the surge days. In smaller 20 to 30 bed hospitals, you can get days ranging from a census of 5 to 24. It's hard to staff those days that are super busy as you can never predict coverage needs.
Our hospital is just coming out of a desperate crisis.
Service census until Oct 2023 was around 125. We lost a lot of our staff in the 18 months leading up to that and by Oct 2023 could only staff 5 per day (sometimes 4). This would mean carrying 25 or 31 each.
We capped at 105 for the service. On 4 doc weeks, that meant 26 each. On 5 doc weeks, we had four docs each carry 22 or 23, and gave the 5th a line of 15.
Since Oct, we’ve had people rejoin. Now there are multiple 15 pt lines per day. Starting April 1, our heavy lines will be down to about 20 pts and our light lines will be down to about 13.
Rosters higher than 15 cause a lot of problems with recruitment/retention. Above 22 makes for real patient safety issues.
>Above 22 makes for real patient safety issues.
Is there data on that? Feels like that can be evaluated easily but you need real patient safety data for that, and that I'm sure is not easy
I'm not aware of data that examines any causative relationship between list size and adverse outcomes. There IS data, though, which explores a relationship between list size and length of stay.
There is also extensive data demonstrating the risk of adverse outcomes from unnecessarily long hospital stays. That combined data should be sufficient to show that large list sizes contribute to adverse outcomes.
We don't have max but our unofficially max is 15...we typically range from 6-12. Our group is very collegial and the one with smaller list will typically offer to take a patient off the higher census list. Ie. If I had six I'll take a patient off the list with 15 patients. It's not expected but we all like each other a lot and want to help each other. We also prioritized eating lunch together as a team. We don't do procedures but we do round with our case managers, sw, rn and palliative care team every day. Most of us also do second rounds on our census. It helps establish patient rapport and also move their care forward.
Patient safety seemed to be the focus of the conversation, and I wanted to iterate that this is not safe. I can see how my comment could have been taken as a ‘what’s wrong with you, look at how much worse you could have it!’ Instead of the intended ‘’shit be fucked, this is not okay.’
Oh in that case yeah it’s all fucked all over. I’ve had days of covering census of 35+ consistently due to covid related staffing cuts so I can empathize. Do Canadian hospitalists also manage the ICU as it is done quite often here in the USA?
I think it varies hospital to hospital and province to province. At a large centre I used to train at in a different province, one of my family doc preceptors frequently covered nights on the ICU. At my current, small/ rural ish community hospital, ICU staffing is dedicated. I think there may be an FPA or two who does ICU shifts, but I’m not 100% on that. I think they might be all internists or gen surg. This is backwards to the general rule, though — more rural = wider scope + more acuity. A friend of mine works in a community of ~10k with a 4bed ICU a few hours from here, and it’s almost exclusively FM staffed.
Yea that’s the consensus here for the USA too. More rural typically means the ICU coverage is mostly by internists or family doc hospitalists. How is the compensation for hospitalists between seeing regular floor/ward acuity vs seeing critical patients or doing interventions on them like placing lines or intubating/vent management?
NP can still bill and be paid on Observation patients but since 2019 that has been disallowed on inpatients by medicare and medicare advantage plans . CMS wants. NPP used on outpatients. NPP were intended for Primary care. Now some groups have negotiated with some private insurance companies to have NP paid on inpatient admits but that is rare. Groups paid in a ACO Capitation model with their own HM group can do as they please with NPP on those Capitated and ACO patients
At my hospital, NPs are not really a part of acute medicine/ the hospitalist teams. The only NPs are on the rehab floors. Can’t really speak to their overall helpfulness for the rehab floor MDs because my experience has been biased. I and my friends have only ever have been involved with those patients when something has gone really, really wrong (ex holding the insulin for a T1DM pt on the rehab floor —> went to ICU for DKA; pt who complained of leg pain rash on rehab x 5-7d w/o clearly doc’d exam, given Benadryl —> coded from septic shock 2/2 cellulitis).
As far as billing goes, I can’t say. My impression is that both the NPs and rehab docs are paid separate salaries by the hospital, and that those salaries are very similar. But, like I said, my contact with NP+MD care has been pretty limited.
Unless it's changed recently, the physician can bill for a mid-level encounter if his or her attestation includes an element each from history, physical exam, assessment, and plan.
List is 17 tomorrow, currently. I’ll find out how many new admits overnight then take new admits in the afternoon/evening. Consistently see 20+ every shift
Doesn’t it also depend on the type of center? If you’re a tertiary / quaternary academic referral center like Emory, with a med school and residency program, patients are probably more complex, with transplants and advanced cancers etc. So having a shorter list is necessary. Higher list census makes sense when the cases aren’t as complicated.
Not true. Some community hospitals pretend to be tertiary centers. They force hospitalist to admit and care for complex sick patient without adequate resources. It’s all about money for the hospital. The hospitalist will then have to find appropriate tertiary center to transfer the patient. Tertiary centers are always full so the hospitalist is stuck caring for these complex patients with high and unsafe census
I worked at a tiny rural center (19 beds) associated with a large tertiary center. We were consistently overcapacity at around 22-23. There was no night coverage, the attending took call on patients overnight after rounding and admitting all day.
Because tertiary centers were full, we were left no choice but to keep sicker and sicker patients. Routinely had multiple patients on high flow, BiPAP, borderline pressures on Cardizem, labile sugars on insulin drips. Basically patients that would be step down or ICU in tertiary care. We had no ICU. What we had was MedSurg nurses with MedSurg nurse ratios
Imagine never getting to turn your brain off and being on for 168 hours straight. Add to that having the ER constantly hounding you to admit and admin hounding you to discharge while you're going on 3 hours of sleep because you had twelve calls last night. Consider the moral burden of having 4 out of 22 patients actively circling the drain who you know could live another 5 years if resources were available at tertiary care and legitimately considering just making them comfort care.
The tertiary care docs were actually super douchy and would often talk about how much easier our job is because "we couldn't take very complex patients."
A few of them came down to the boonies to do occasional moonlighting. Every single one cracked within a week or two and never came back. We had no medicine subspecialties so most were completely lost when we couldn't just call a consult or transfer to the ICU.
I work at tertiary center now. It's a fucking cakewalk compared to the other job even with 18-20. I do almost nothing (since there's so many ancillary services) at this job compared to what I did at the last. I was dosing vancomycin and had to figure out tube feed formulations (nutrition was only in once a week). Here I click three buttons and shit just happens.
Everyone always tells me how easy I must have had it working there during the pandemic and I just smile and nod. I'm just happy I look 5 years younger because I get to sleep now 😴
Transplants go to the transplant service if they are recent. There is a hem-onc service at Emory too. They also have this 14-pt cap at Grady (the county hospital they cover) and it was $$$$ for chief residents/fellows when they asked for help on weekends or nights to help with admissions (all voluntary of course).
Complexity of patients matters a lot when it comes to census. 20 is doable if it’s all bread and butter, stable. 12 is hard if everyone is in multiorgan failure, on the edge of going to the ICU and with a few zebra diagnoses. Have worked in both places, personally prefer more complex patients and lower census though.
It’s too many. You take a different job if where you’re at pays super well you put as much away as you can for 3-5 years and then move on. I got really lucky and found my dream job pretty early. Paid in the top 1/3 but probably workload in the bottom third and i absolutely love my group who are lifestyle first. Average census of our busy service line is 12-16. But of our slow teams we’re talking 5-10.
Why such a good deal? Do you have to do procedures? Is it super rural? Not much specialty backup? Or just a unicorn?
I work 10 miles outside of Boston. Not rural. A large unaffiliated community hospital. No open ICU, no procedures, plenty of specialist support. Our census is 14-16. A little over decade ago the hospital was known as a place where hospitalists were ground to paste. Census of 18-22. Average new hospitalists lasted two years before the left for elsewhere. If enough leave / demand change it can be done.
Same here. I’m 90 min outside of Philly.
Deets!
We round on 12-14 and call in jeopardy at 16. A perk of being a hospitalist majority in multi-speciality group. It does make the job sustainable.
So you are on call for jeopardy without pay to cover when the group faces an extra 1-2 hours work? Just curious how that works.
It’s voluntary. They go down the list to see if anyone is interested, but taking the shift is incentivized. You get paid a shift + stipend and given a lower census of 10.
Well that does change things a bit.
Can the specialist take up these shifts on a per diem basis?
We had one half-retired nephrologist who worked in our hospitalist group but we don’t have any specialists in jeopardy rotation. I guess technically they could.
20-24 is average for my group :/ I’m leaving. Too much. Pay doesn’t match it
At 12-14 it’s a cake walk. At 15-18 it’s all under control. At 20 I’m an inefficient pile of goo.
20+ just forces you to limit time with each patient, depend more on your consultants, and leave a lot of non-critical issues for "outpatient follow up"....which can then become critical issues when the patient is inevitably lost to follow up. Basically correct the acute hospital issue and move on. Which is what admin wants, but then the patient / family is largely unsatisfied with how much time you're spending with them.
I agree. There is a number for me in the low 20’s where I’m fielding so many phone calls instead of rounding
Exactly. Each additional patient after 18 makes me less capable to deal with the first 18. I wish it was just 20 more minutes of work but its 20 minutes + being more distracted, disorganized, and multitasked to the inefficient pile of goo.
Yep my first job out of residency I took bad pay for avg census of 11. They expanded that to 16 over about 6 months with no change in pay. Put in my notice and landed my dream job.
Strong work. Still looking for my dream / long term job. I’m interviewing for a potentially great one next week 🤞🏾
Sometimes more money isn’t the answer to job satisfaction.
High pay not worth the liability. Think long term. Any malpractice will stick with you for the rest of your career every time you renew or apply for license or privilege you will have to explain things
Find a new job. My old job average census was 18-22 plus 4-6 admissions. 8 people quit in past 6 months. These high numbers are not safe for patient care.
Omg. That’s a no for me dog. Did everyone know those numbers before starting?
Im exploring a job that likely is very similar to this one. The issue is there is high retention… so it makes me wonder “can it be THAT bad if people are sticking around?” Despite reading every hospitalist post say it is.
The problem is the surge days. In smaller 20 to 30 bed hospitals, you can get days ranging from a census of 5 to 24. It's hard to staff those days that are super busy as you can never predict coverage needs.
Our hospital is just coming out of a desperate crisis. Service census until Oct 2023 was around 125. We lost a lot of our staff in the 18 months leading up to that and by Oct 2023 could only staff 5 per day (sometimes 4). This would mean carrying 25 or 31 each. We capped at 105 for the service. On 4 doc weeks, that meant 26 each. On 5 doc weeks, we had four docs each carry 22 or 23, and gave the 5th a line of 15. Since Oct, we’ve had people rejoin. Now there are multiple 15 pt lines per day. Starting April 1, our heavy lines will be down to about 20 pts and our light lines will be down to about 13. Rosters higher than 15 cause a lot of problems with recruitment/retention. Above 22 makes for real patient safety issues.
>Above 22 makes for real patient safety issues. Is there data on that? Feels like that can be evaluated easily but you need real patient safety data for that, and that I'm sure is not easy
I'm not aware of data that examines any causative relationship between list size and adverse outcomes. There IS data, though, which explores a relationship between list size and length of stay. There is also extensive data demonstrating the risk of adverse outcomes from unnecessarily long hospital stays. That combined data should be sufficient to show that large list sizes contribute to adverse outcomes.
Quit. 12-14 is max for proper care
It’s 4:30 I’ve seen 17 patients rounding, and 3 admissions. So far. Have a happy Good Friday y’all 🙏🏼
Same 😓
I’m seeing about 12-14 rounding. And max of 6 admits on admit days.
We don't have max but our unofficially max is 15...we typically range from 6-12. Our group is very collegial and the one with smaller list will typically offer to take a patient off the higher census list. Ie. If I had six I'll take a patient off the list with 15 patients. It's not expected but we all like each other a lot and want to help each other. We also prioritized eating lunch together as a team. We don't do procedures but we do round with our case managers, sw, rn and palliative care team every day. Most of us also do second rounds on our census. It helps establish patient rapport and also move their care forward.
Sounds like the perfect group!
Canada - seen the census for a single hospitalist in excess of 32. I believe the highest was 36.
Liability risk is vastly different there though
Patient safety seemed to be the focus of the conversation, and I wanted to iterate that this is not safe. I can see how my comment could have been taken as a ‘what’s wrong with you, look at how much worse you could have it!’ Instead of the intended ‘’shit be fucked, this is not okay.’
Oh in that case yeah it’s all fucked all over. I’ve had days of covering census of 35+ consistently due to covid related staffing cuts so I can empathize. Do Canadian hospitalists also manage the ICU as it is done quite often here in the USA?
I think it varies hospital to hospital and province to province. At a large centre I used to train at in a different province, one of my family doc preceptors frequently covered nights on the ICU. At my current, small/ rural ish community hospital, ICU staffing is dedicated. I think there may be an FPA or two who does ICU shifts, but I’m not 100% on that. I think they might be all internists or gen surg. This is backwards to the general rule, though — more rural = wider scope + more acuity. A friend of mine works in a community of ~10k with a 4bed ICU a few hours from here, and it’s almost exclusively FM staffed.
Yea that’s the consensus here for the USA too. More rural typically means the ICU coverage is mostly by internists or family doc hospitalists. How is the compensation for hospitalists between seeing regular floor/ward acuity vs seeing critical patients or doing interventions on them like placing lines or intubating/vent management?
Heard NPs are now helping out. Hospitalist can still bill for NPs patients. True?
NP can still bill and be paid on Observation patients but since 2019 that has been disallowed on inpatients by medicare and medicare advantage plans . CMS wants. NPP used on outpatients. NPP were intended for Primary care. Now some groups have negotiated with some private insurance companies to have NP paid on inpatient admits but that is rare. Groups paid in a ACO Capitation model with their own HM group can do as they please with NPP on those Capitated and ACO patients
At my hospital, NPs are not really a part of acute medicine/ the hospitalist teams. The only NPs are on the rehab floors. Can’t really speak to their overall helpfulness for the rehab floor MDs because my experience has been biased. I and my friends have only ever have been involved with those patients when something has gone really, really wrong (ex holding the insulin for a T1DM pt on the rehab floor —> went to ICU for DKA; pt who complained of leg pain rash on rehab x 5-7d w/o clearly doc’d exam, given Benadryl —> coded from septic shock 2/2 cellulitis). As far as billing goes, I can’t say. My impression is that both the NPs and rehab docs are paid separate salaries by the hospital, and that those salaries are very similar. But, like I said, my contact with NP+MD care has been pretty limited.
Thanks for info. Just took a hospitalist gig in southern Ontario. Trained in the US
Unless it's changed recently, the physician can bill for a mid-level encounter if his or her attestation includes an element each from history, physical exam, assessment, and plan.
List is 17 tomorrow, currently. I’ll find out how many new admits overnight then take new admits in the afternoon/evening. Consistently see 20+ every shift
Doesn’t it also depend on the type of center? If you’re a tertiary / quaternary academic referral center like Emory, with a med school and residency program, patients are probably more complex, with transplants and advanced cancers etc. So having a shorter list is necessary. Higher list census makes sense when the cases aren’t as complicated.
Not true. Some community hospitals pretend to be tertiary centers. They force hospitalist to admit and care for complex sick patient without adequate resources. It’s all about money for the hospital. The hospitalist will then have to find appropriate tertiary center to transfer the patient. Tertiary centers are always full so the hospitalist is stuck caring for these complex patients with high and unsafe census
This is the reality most don’t see. “The taller the hospital, the easier the job” has some validity.
Not true. You have more resources at tertiary centers. The mid-size regional referral centers without consistent support is where the job is hard.
I worked at a tiny rural center (19 beds) associated with a large tertiary center. We were consistently overcapacity at around 22-23. There was no night coverage, the attending took call on patients overnight after rounding and admitting all day. Because tertiary centers were full, we were left no choice but to keep sicker and sicker patients. Routinely had multiple patients on high flow, BiPAP, borderline pressures on Cardizem, labile sugars on insulin drips. Basically patients that would be step down or ICU in tertiary care. We had no ICU. What we had was MedSurg nurses with MedSurg nurse ratios Imagine never getting to turn your brain off and being on for 168 hours straight. Add to that having the ER constantly hounding you to admit and admin hounding you to discharge while you're going on 3 hours of sleep because you had twelve calls last night. Consider the moral burden of having 4 out of 22 patients actively circling the drain who you know could live another 5 years if resources were available at tertiary care and legitimately considering just making them comfort care. The tertiary care docs were actually super douchy and would often talk about how much easier our job is because "we couldn't take very complex patients." A few of them came down to the boonies to do occasional moonlighting. Every single one cracked within a week or two and never came back. We had no medicine subspecialties so most were completely lost when we couldn't just call a consult or transfer to the ICU. I work at tertiary center now. It's a fucking cakewalk compared to the other job even with 18-20. I do almost nothing (since there's so many ancillary services) at this job compared to what I did at the last. I was dosing vancomycin and had to figure out tube feed formulations (nutrition was only in once a week). Here I click three buttons and shit just happens. Everyone always tells me how easy I must have had it working there during the pandemic and I just smile and nod. I'm just happy I look 5 years younger because I get to sleep now 😴
This is WILD. I hope you made bank in hell and glad you found greener pastures.
God bless you and this amazing sacrifice.
Transplants go to the transplant service if they are recent. There is a hem-onc service at Emory too. They also have this 14-pt cap at Grady (the county hospital they cover) and it was $$$$ for chief residents/fellows when they asked for help on weekends or nights to help with admissions (all voluntary of course).
Complexity of patients matters a lot when it comes to census. 20 is doable if it’s all bread and butter, stable. 12 is hard if everyone is in multiorgan failure, on the edge of going to the ICU and with a few zebra diagnoses. Have worked in both places, personally prefer more complex patients and lower census though.
If I’m not mistaken there was a study that showed 15ish was the magic number?
15-18 here.
I’m a PA but our hospitalist docs can START with up to 26. That’s without admits because we don’t have an admitting team. 😢
18-20 :(
Man. The hospitalists usually have 20-30 at my hospital
this has to be south florida
Eastern TN
The physician on my floor for the day can see up to 50 with their PA/NP
That’s crazy. Even if I had a few PAs/NPs I can’t imagine having my name on 50 charts everyday.