Double-Boarded—Life as a Med-Peds Hospitalist


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SS 141: Double-Boarded—Life as a Med-Peds Hospitalist

Session 141

What inspired Dr. Leslie Gonsette to pursue a combined med-peds residency? Join me to find out what she finds so exhilarating about being a hospitalist in Alaska.

Out of training now for six years, Leslie is a pediatric hospitalist even though she is double boarded in medicine and pediatrics. We’re going to talk all about her journey, what she likes, what she doesn’t like and more. If you want to know more about this specialty, check out medpeds.org.

Listen to this podcast episode with the player above, or keep reading for the highlights and takeaway points.

[01:18] Interest in Internal Medicine

Leslie did a Med-Peds residency, which is a combined internal medicine and pediatric residency. During residency, she fell in love with hospitalist type work for internal medicine. Majority of their training in the hospital is clinic work. And when they do subspecialty things like cardiology and pulmonary, they do either hospital or clinic work.

It was during residency training that she preferred working at a hospital because you have the flexibility to either focus on working in the hospital or just working in a clinic.

A lot of people don’t realize what a hospitalist is. It’s a term where you have a hospital, and you have the emergency room. An adult comes in for whatever illness and gets worked up by the emergency room. If they’re too sick or ill, or they still need more medications, management, or diagnostic workup, they call the hospitalist doctor that’s usually an internal medicine or a family practice doctor.

“A lot of the primary care physicians find it overwhelming that they have to both call the clinic and then go to the hospital when their actual patient goes to the hospital.”Click To Tweet

[06:15] Combined Degrees

A lot of medical students don’t know that there are a lot of combined degrees out there. There are a lot of specialties across the country that offer doubles.

Med-Peds is an example of internal medicine pediatrics. Instead of doing each, which would take six years, if you did it separately, it takes four years.

You alternate every four months between internal medicine and then pediatrics and back and forth. At the school she went to, they had triple boards and other double boards like emergency room and internal medicine. There’s also neurology and internal medicine.

“The positions across the country are fewer and there are not as many people wanting to get into these double and triple boards.”Click To Tweet

It’s a special thing. But you have to really want to be able to do both. In her case, Leslie did both internal medicine and pediatrics and she loves both. Then when she finished, she  realized that her passion in internal medicine was hospital medicine. And her passion in pediatrics was clinic pediatrics. And that she didn’t care as much for inpatient medicine. When she  took care of kids, which is a strange sort of opposite.

[07:47] What Hospitalists Do

“Hospital medicine is usually pretty much across the country, either in shift work or week work.”Click To Tweet

What they typically do is you work weeks at a time which really gives you a nice amount of quality life. Leslie might be on for a week or two, sometimes three in a row. And then she may be off for one, two, or three weeks in a row. This allows her to have a great quality of life.

And living up in Alaska, she’s able to travel and go see family. That’s one of the reasons she  chose not to do clinic work so she can have weeks off and get to do a lot of things.

One of the things that she loves about Med-Ped  is you have that flexibility. You could go to rural America and work in a clinic. You could go to a community hospital. You could do academic settings. You can do anything. You can take care of anyone and everyone, which was the physician mindset that she had when she was growing up.

[10:50] Types of Patients

In the pediatric world, when she does outpatient, Leslie sees a lot of healthy visits. She’s able to spend time with healthy patients and really speak to their parents and help guide them along as they raise their child. This is half of the cases that she takes care of when she works in the outpatient clinic setting.

“When you're taking care of kids, they come in routinely for their health checks.”Click To Tweet

The other types are going to be a lot of sick visits like tonsillitis, strep, ear infections, runny nose, cough – a lot of the typical things that you might see kids come through.

Then you have your more chronic population, which is a smaller percentage, which might be children with developmental abnormalities that you have to manage, genetic abnormalities or ADHD.

In Alaska where Leslie is, they don’t have any clinic type setting where they see adults, which is  her preference. They also work not only in acute care facilities, but they also rotate at the long term acute care facilities and cover at a skilled nursing facility.

They have a bunch of different tiers throughout the community in Alaska. When you’re in an acute care setting, there’s a shift that works in the emergency room that admits patients. Emergency room calls the swing person for a workup. Then the hospitalist brings it over to the daily rounders.

On average, they see a consensus of 15 patients on any given day. Bread and butter stuff would include pancreatitis, alcohol withdrawal, endocarditis, IV drug users, pneumonia, COPD, exacerbations, diabetic complications and wounds.

[13:51] Skilled Nursing Facility

A lot of hospitalists across the nation sometimes do 12-hour shifts. Leslie’s pager is on at 7 and off when she finishes at 9. They have a hospital doc overnight that manages their patients while also admitting in the emergency room. They’d either go home, or they go to a skilled nursing facility.

A skilled nursing facility is focused more on rehab. It has 24/7 nursing care. A physician sees them once a month, or more if they get sick. 

And if they’re still too sick and they need to be in an ongoing hospital type setting. They go to a long term acute care facility which is like a hospital. They don’t have any emergency room or a triage but essentially it functions just like a hospital. They see a physician every day. There’s even high acuity capabilities like an ICU and then they manage them and see them every day.

These types of patients might need to stay in the hospital for weeks or months. They can be anywhere from trach patients after a major stroke or respiratory failure to chronic wounds that will take a long time to heal such as quadriplegic, paraplegic patients. These are wounds they need to manage that don’t just heal overnight.

At the end of the day, you have to put your hat on for many different settings. Leslie is helping out in the inpatient rehab. It’s where people go when they’re still too weak to go home and they need about three hours of therapy.

“Internal Medicine can cover across probably all of the continuum of care, anywhere from a clinic setting to a hospital.”Click To Tweet

Internal medicine also covers all the various facilities outside of a hospital like inpatient rehab, skilled nursing facility, and long term acute care facility. It’s really interesting that it never really allows you to get bored.

[16:29] Taking Calls

Leslie is part of a group of contractors, not employees. So they get to set the schedule in their group. When you first come in as a non-partner, you have to work about seven-night shifts.

Leslie says she can put a little Do Not Disturb and that night person they call a “nocturnal” will take or cover calls.

The one area that they would have to answer a call all the time is the inpatient rehab or the long term acute care facility. But the nurses are very good at calling them only when necessary. And then the night duties will depend across the country.

When they started to have a lot more coverage in their group, some of them wanted to sign up for working nights. On average, they’re required to do two nights per quarter. But you can just give them away and not sign up for your two nights and just pay the night person or somebody else to moonlight that out. It basically means you pay them to work for your night shifts.

Leslie says this is a really good way to keep your quality of life and to feel like you’re not in residency again. Because she admits this is something that she has grown very tired of over the years.

In line with this, Leslie encourages fresh new grads to ask themselves whether they want to work at night because that means extra pay.

“Ask what the night coverage is because it really can be very dependent where you go even within the same city.”Click To Tweet

[19:53] Life Outside of the Hospital

One of the reasons why she chose to be a hospitalist is the weeks on and off because it gives her the rest she needs.

What she likes about her lifestyle is you really get to know the patient population, the people you’re caring for over the span of two to three weeks. 

“In the hospitalist medicine world, you have the flexibility of being the boss of your schedules.”Click To Tweet

What Leslie doesn’t like in a clinic setting is you only have 15 minutes with each patient otherwise everybody downstream is now late because they’re waiting for you. But these patients may have complex and multiple problems and you would realistically need 30 mins to an hour to really look into them.

You have this ticking clock, you have the pressure, that you have to hurry up and go, go go. So Leslie didn’t like how she was not in charge of her time. 

Whereas in the hospital, that’s very different. When she sees someone, they’re stable. The medications are working so you might not have to spend that much time. But if someone really goes down, they really need to work up. You need to sit with family. You need to spend an hour then that’s what they get.

[23:39] The Training Path

In the Med-Peds residency that she did over the span of four years overall, she spent two years in both. You can argue that you had one year of less exposure to seeing adults and one year or less of seeing children.

“What the typical residency program would lay out is you start off in one or the other.”Click To Tweet

For example, Leslie started off doing pediatrics for four months. And then she would switch and do four months of Internal Medicine, then she would switch back over to peds.

Her first year was peds heavy, in her second year would be the opposite, because she then would start back in internal medicine and back and forth, back and forth. And when you are an internal medicine resident, you are completely integrated, just like all the other internal medicine residents. When you’re an internal medicine resident, they didn’t look at you as separate. And it’s the same thing when you’re in your pediatrics rotation.

At the end of the fourth year, you have to take your boards and what they found over the years was that you should really focus on doing one. They encouraged you would it take one at a time. And Leslie ended up doing her pediatric one first.

[26:38] The Pros and Cons of a Combined Degree

“When people find out your Med-Peds for some reason, they feel like you're smarter or you're better rounded because you really are like two physicians combined in one.”Click To Tweet

Whether you’re smarter or not, Med-Peds certainly had to study a lot more. They had to pass two boards. But this makes you more well-rounded being able to put different hats on. It’s the diversity that really stood out from the regular internal medicine or pediatric resident.

Moreover, even if you’re a Med-Peds, you may opt to practice just either of the specialty and not both. In fact, Leslie says this is what ends up happening. Because doing both would mean doing two full-time jobs and it can eventually get exhausting. 

But it’s really rare to get a combined residency. You would probably have to then do two fellowships if you wanted to do gastroenterology and adults and then do pediatrics. And Leslie doesn’t think there are as many combined fellowships if you end up specializing. A big majority of people who sub specialize end up having to pick one. 

At Tulane, they had a combined infectious disease fellowship, and both internal medicine and pediatric infectious diseases, but that was an extra year. You’re already doing four years. And then on top of that, you’d probably have to do three.

It’s a lot of extra time that you start to spend if you want to do both. And then that’s probably four boards now that you have to sit on. So it starts to be a lot of studying, a lot of time, and a lot of cost. 

At the end of the day, people start to really find out what they like towards the end of the four years. But at least, you have four years to really think about what you like although it doesn’t really take that long to figure it out.

[31:16] What She Wished She Knew Before Going into the Specialty

Leslie advises students to ask the alumni involved in the medical school about the specialty they want to get into and start talking to an actual specialist.

“If you want to do surgery or hospital medicine, start getting an idea about what that life looks like.”Click To Tweet

Leslie went into medicine thinking maybe surgery because when she was in residency, she was absolutely in love with surgery and she was very strong at it. She loved being in the O.R. But she realized after shadowing that they were in the hospital all the time.

Lifestyle was very, very important to her. So really going into your connections through your medical school and talking to alumni are very important. 

A lot of things are shifting to shift work for example. She didn’t know this and internal medicine, a hospitalist was something that she sort of learned in residency. But it’s also shifting to involve other specialties such as surgery, and OB/GYN. 

In their hospital, they now have hospitalists that are surgical hospitalists, and they have OP hospitalists. They only focus in the hospital and they don’t really have clinics,. They might rotate on and off.

What that means is that a lot of people who don’t want to do surgery because they’re never going to be home, well, they’re doing shift work now. They can now have some time off. And the same thing goes with OB.

So be able to talk to alums that are working now and ask what their typical life looks like now. What does it look like with trying to accommodate a little bit more of a family lifestyle or making sure that you’re not beat down and working hard? And even talking to for example, if you want to be a radiologist, what does that look like? Now that you know AI is around? What is that doing to your job? Are you doing a lot more remote working from home?

All this will help you determine whether you really want to get into a certain field. Hence, shadowing would really help you a lot as well as fourth year electives.

[34:20] Some Tips When You’re on Your Fourth Year

A lot of people think that their fourth year electives need to be at the specialty that you want to go into.

One of the things that Leslie would highly recommend medical students is not much focused on doing all of her specialties during her fourth year in, say, pediatrics because they want to do pediatrics.

“Your fourth year should be into specialties that you find intriguing.”Click To Tweet

It’s important to diversify your fourth year and not just focus on the specialty that you originally want. 

Leslie did her first elective and in Med-Peds at Tulane, and that’s what really got her foot in the door. And she loved it. It ended up being her first choice and she was able to match.

Her advice to medical students is to focus on connecting through a lot of people in the specialty that you’re interested in, or many specialties that you might be interested in. Try to get a balanced or a feel of what their life and work life looks like. Then have fun with your fourth year and picking an elective, maybe at the site that you would want to work at. 

[36:19] Most and Least Liked Things

The most intriguing part is definitely being probably her own boss when she’s in charge of her schedule. She loves the flexibility and being able to spend as much time with a patient as she needs to. 

The other thing is she loves the complexity of it. She loves being able to take care of very very complex medical issues. She loves being able to have an impact right away at something that she can take care of and see results.

And then also loves how quickly she can really make things happen. She can get an X-ray right now or she can get a CT scan right now or you know what this person needs to have surgery.

“You're able to take care of someone really quickly.”Click To Tweet

She loves the pathology that you see. And that’s definitely the one thing that drives her to be a hospitalist. She’s been doing it for almost nine years and it’s never really gotten old for her.

On the flip side, the least thing she likes is when she loses that follow up. She might be off for a week or two, she comes back, and she doesn’t really know, whatever happened to that patient. Or she just admitted someone and she doesn’t really know how that ended up. You’d have to look back at your 15 patients to figure that out.

Secondly, you don’t really see them again. You have a great rapport with a person, and they love you. And when they want to have a follow up at a clinic, you can’t because you only work in the hospital.

[39:05] Major Changes Coming Into the Field

Nine years ago, there were opportunities where you could work in the clinic and then go to the hospital. But that is becoming less and less especially if the group starts to be employed by hospitals. 

The hospital will basically hire hospitalists and you end up doing shift work, versus being able to keep a practice where you can be an internal medicine doc and then take care of your patient in the hospital.

[40:35] Final Words of Wisdom

If she had to do it all over again, Leslie would love to do it again. She didn’t want to do a fellowship because she really found that she was the doctor that she always had in her mind. She could take care of kids and she can take care of older people.

Her advice to medical students out there is to think about your overall thoughts 10 years out of residency. What does your life look like? Does it look like there’s nothing else you could do?

Think of the overall picture. What do you look like when you’re out of residency when you’re just maybe starting to have a family? Where would you want to work? Do you want to work abroad? Do you want to work in global health? Do you want to stick to the ocean? Do you want to do a fellowship?

Look at your work life balance. Do you want to end up going back to the rural community where your family is? Or are you stepping out of that shell because everything is going to be interesting? What will make you sustain your career and not get burned out? How should you consider fellowship?

Really plugging into your medical school alumni connections is very important. The Alumni Association has a very big impact on the decisions for medical students. She realized what a huge resource this is. And it’s something that she didn’t think back when she was in medical school.

Links:

Meded Media

medpeds.org

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