Working at Kaiser as an Internal Medicine Hospitalist

So many of you have sent me emails asking for this post. Here it is, words of wisdom from Kaiser IM hospitalists...

I have a few friends who are IM hospitalists at Kaiser. This is what they had to say...

What is a hospitalist?
A hospitalist is the primary care physician who focuses on inpatient care. I chose to become a hospitalist because I grew weary of the day to day mad-house of ambulatory (clinic) work. Hospitalized patients tend to be "more interesting", and I feel more 'productive' (like I'm really helping sick people feel better) working in the hospital. Also, the business aspect is less cumbersome. I don't have to deal with managing people, a clinic, a business, etc. Also, since the hospital is open 24/7, the hours tend to be more flexible, and shift-like...which has it's perks.

Does a hospitalist have a patient panel? Do they see their patients once they are discharged? If not, what about continuity of care?
No (thankfully) I don't have a patient panel. I am apart of a group of docs that take turns admitting 'someone elses patients' and caring for them in the hospital. And even in that regard, I only manage their case for the time I'm physically in house, then the person I sign out to takes over. Just like all the other professionals in the hospital.

I do not see patients in the clinic...not even after they are discharged. They go back to their primary doctor. Continuity of care? Well, that's becoming evermore non-existent as it becomes more difficult to convince young adults to give up their lives and become the "small town doc" that's available for his/her patients whenever they need him/her. Just look at OB. Chances are, the doctor that cares for you for 10 months of pregnancy won't be the one who delivers the baby (unless it's surgical, and unless they happen to be on call that day). Medical students and residents are seeking a better lifestyle for themselves. I guess we're finally coming to realization as a group that medicine isn't worth your happiness and sanity. That it's hardly admirable to subject yourself to abuse (by CMS, by DHS, by joint commissions, by society, by medicine) and be absent in the lives of your loved ones. Maybe when doctors were respected, autonomous, and paid well...but now, not as much. When this happens, when docs start seeing themselves as employees with jobs, continuity of care sounds like crazy talk. Think how crazy it would sound if we suggested that nurses (or anyone else on the 'healthcare TEAM') were made to "feel guilty" about going home at night, or chastised for lack of their continued presence in the health management of a stranger/patient. Everyone has a job these days...which is what government created, and physicians (at least the professional societies) have allowed to happen.

Do you miss the clinic?
I do sometimes. Ideally, I think I'd like to have a very small panel of patients, and manage both their inpatient and outpatient health situations. But, at Kaiser, we have panels in the thousands, and you just cannot be available for thousands of patients...and still be true to yourself. Most places it's easier to simply choose, outpatient or inpatient.

Does it require additional training to be a hospitalist?

Do you take care of ICU patients?
I do, at least initially. We have 'intensivists' who take over the ICU patients shortly after they are admitted to the unit. And we pick them back up once they are d/c from the unit. This is good because the last thing you want to deal with while rounding on your patients, and getting hits from the ED (doing initial H&Ps), is a patient in the unit who's trying very hard to die that day.

What is it like at Kaiser, specifically?
Kaiser has it's pluses and minuses, of course.
The minuses first. Kaiser has lots of rules and protocols. Imagine someone telling you how to do everything. How to manage every problem. What paper to write on. As physicians, since they make you a "partner" you have no advocacy. It's like you sign away your ability to unionize, or otherwise advocate because you're vested. But, practically, you're an employee. Your chief gets orders from their boss, and usually s/he will agree to give their docs that 'one more task to complete', 'that one more piece of paper to fill out.' This is how chiefs get their jobs, keep their jobs, and get promoted. Not by saying 'no, I think my docs have enough paperwork to fill out...I think they jump thru enough hoops...why not hire another clerk to do that paperwork.' Can you imagine saying "no" to your boss...even if it's to benefit the people who work under you? And because of this hierarchy (which is necessary), and the lack of advocacy for the physicians within the group (which is not a morale boosting situation), lots of us are less than enthusiastic about our jobs. It's not about the physician-patient relationship, not to the doctor/employee. It's more akin to working at the DMV and with people who come to you for help. And that is unfortunate.

The hours can be very long, and there is no additional compensation for staying late - and with the amount of paperwork required, most docs stay late. Many docs 'volunteer' lots of their time...and that's just wrong, I think, since the corporation is making record "profits" with our sweat. Without the docs, Kaiser could not exist. The organization should reward those physicians who go the extra mile, stay late, come in early, and wrap things up. This results in better patient care...happier/healthier patients, more members/more money for the organization, and better reputation (=more money). But, the docs won't see these positive results. Any extra effort is simply absorbed into the organization...and this isn't good for morale, or dedication.

Minuses - Lack of advocacy. Too many unnecessary, non-physician tasks (scut), long hours/hard work, and no incentives (therefore waxing/waning motivation), low morale, and feeling like you're being used - all which affect patient care.

Flexibility. Kaiser permits you to work part time with benefits, which is nice. Also, flex-time, swing shifts, and longer/shorter shifts can be created to help individual physicians balance family and career. They have quite a few women in high places, and there is great recognition of the need to offer these things to keep (particularly female) physicians quiet enough to conduct business. The pay is comparable to the outside. As a plus I'll also add the long hours and hard work, since that's not only a bad thing. Afterall, having lots to do validates your job. If you stay long enough I hear the pension is one of the better plans. And hospitalists in general have set hours, no call, and flexible schedules.

Pluses - flexibility, benefits, accommodating of family/personal life without much ado.

Overall, would you recommend working for Kaiser as a hospitalist?
Overall, I would. Not all sites, not all groups have the same internal morale issues. I suggest that a person considering a job with Kaiser find someone in the group to give you the low down. The real deal. This isn't going to happen over email, because no one is going to write/document their discontent with their current employer. Be sure to be persistent with that one doctor that seems nice, and interested, but deflects your questions. Call him/her up and ask to meet. How many times have I seen interviewees, and thought to myself "I wonder what they think this is all about?" "I wonder if they knew the truth about this place, would they still want to come here." Just like residency...not every program is good for everybody. Even the great residencies may be horrible for certain personalities, or people in certain social situations, of a certain gender, ethnicity, etc. (parents, gay, married, Jewish, etc).

Kaiser is a nice place to work...but has very real drawbacks. It won't work for everyone. There are lots of rules, and basically you go to work, follow rules, do whatever 'new' thing they have you do (new sheet of paper to fill out, new box to check, new question to ask, new order form, new protocol to follow...always something else they squeeze into our day with no consideration for time/relevance). It's overwhelming at times, but if you don't think about it too much, aren't too passionate about that particular issue...you'll probably do just fine. Personally, it does get to me every so often, but I enjoy my flex time, and the money is comparable to what I feel I could make on the outside...so the benefits outweigh the drawbacks for me.


MY OWN WOMAN said...

From a doctor's perspective, (and I am not a doctor), I can understand why a physician may like being a hospitalist. My daughter is just starting her role as "physician" and has asked me what I think of the idea of hospitalists.

I told her, to be honest, *I* don't like it. I like the doctor who knows about me, who sees me on a regular basis, who understands my little quirks to be the one who continues to take care for me in the hospital. I don't want to have to explain myself or my symptoms to a new doctor every time I enter the hospital.

My father, a 75 year old man in good health, would be a mean ole grump if "HIS" doctor did not follow up with him in the hospital. Patients, especially the elderly, develop a special trust with their doctor and changing during a stressful time (hospitalization) would be difficult.

Unfortunately, I don't know the clear cut answer. I want my daughter, as I would want any doctor to "have a life," because a happy doctor is more apt to be a better health care provider.

I've just finished reading the book "The E-myth Physician." Very good book which suggests you can have both.

Sorry about the rantings, take what you like, leave the rest. I'll still respect you in the morning.







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