SS7 : What is a Hospitalist? An Academic Doc Talks with Us

Session 7

Whether you are a pre-med or medical student, you have answered the calling to becoming a physician. Soon you will have to start deciding what type of medicine you want to practice. This podcast will tell you the specialists from every field, so you can have the information you need to make the most well-informed decision possible when it comes down to choosing your specialty.

Today we hear from Shoshana R. Ungerleider, M.D, an internist practicing hospital medicine at California Pacific Medical Center in San Francisco. CPMC is an academic hospital set in a community setting with several residencies, including internal medicine, where she is on the teaching faculty. She has been practicing medicine for three and a half years and finished her residency in 2013.

(2:20)  Discovery Moment

Shoshana knew she wanted to be a hospitalist midway through internal medical residency while working “night float” shifts (6pm-8am), admitting patients into the hospital overnight as well as doing cross cover. While there were other specialties that she considered, including cardiology and critical care, she knew she could be happy in a hospital setting and ultimately felt like hospital medicine was a good fit for her.

There is a variety of patients that a hospitalist cares for, in terms of age, illness, chief complaint and levels of acuity; they may take care of patients who come into the hospital for a routine hip surgery who are otherwise pretty healthy, while on the other end of the spectrum they co-manage ICU patients who are incredibly ill and spend days or weeks in the intensive care unit.

(3:51) The Traits That Lead To A Good Hospitalist

There are many personalities that can be happy doing hospital work. One must enjoy interacting with patients, which a hospitalist does often. Additionally, maintaining an intellectual curiosity throughout your years in practice, as things are constantly changing as far as how common medical problems are managed. Hospitalists treat for many types of issues so staying up on the literature is very important; in fact, Shoshana finds herself constantly looking up the most recent guidelines.

Flexibility and adaptability are also important traits to have as a hospitalist, because the hours and shifts are unstructured. If you love the structure of an 8am-5pm, she says, you are better suited for working in a clinic or outpatient facility, where the hours are standard. Flexibility and adaptability also come into play for the types of conditions a hospitalist sees–one never knows how busy the ER will be at any given day or time, so it’s good to roll with the punches!

(6:22) A Typical Day For A Hospitalist (or evening, in Shoshana’s case!)

After arriving at the hospital, a quick check-in with colleagues on the previous shift, then the pager almost immediately goes off! As a nighttime doctor, the majority of what she does is admit new patients to the hospital and the majority of those patients come through the emergency room.

Sometimes they get direct admissions from specialists or primary care doctors where the patients come directly to the floor or may get a transfer from another hospital, but at least 75-85% come directly from the ER. The majority of her shift is therefore in the ER seeing patients and working with the residents.

The residents often go in with the physicians together to see patients, or sometimes the resident goes in and chats with the patient first, does a history and physical and then she will come in later to follow up with more questions. They will do a modified round at night  where the residents present the H&P and together  they discuss the assessment and plan. On occasion there will be some cross-cover fires to put out on the floor when patients become ill overnight and she needs to read up on the history of the patient to find out what she needs to do in the moment. That can get a little exciting.

(8:27) The decision process in choosing an academic hospital over a community hospital that did not have residents

As Shoshana completed her residency, she wanted to stay in the area and was searching for a job. She was able to work in the community for the first two years after residency and got a sense of what it meant to be in community hospital medicine. While she enjoyed it, after two years she realized she was missing the educational aspects of working with residents and other trainees. Currently she is working with the residents in the hospital where she trained.

Working with residents keeps a hospitalist on their toes, as they often know about the latest in diagnostics and therapeutics. The reality is not everyone can always be on top of everything and Shoshana thrives in that team environment where everyone can learn from one another. As new medicine changes from week to week with regards to the standard of care,it can be really exciting to work in such an academic environment.

(10:46) Does a Hospitalist have to take calls?

Technically speaking, a hospitalist is always “on call” during a shift. The daytime hospitalists have their panel of patients and when doing their rounds, they make a plan for the day as to whether the patients remain in the hospital or transferred to a different level of care. For a daytime doctor typically there is a timeframe in which they are physically in the hospital and then for those doctors who work at a later swing shift or night shift, they have to physically be in the hospital. But the hospitalists do not have to be on call call when they are not on shift.

(12:09) What are the typical shift hours and days for a Hospitalist?

For most hospitals, the most interesting thing about hospitalists as a field is that it is fairly young and so many hospital groups figure out what works best for them with scheduling shifts. Often, hospital groups have seven days on, seven days off throughout the year (with the exception of holiday season).

Other hospitals may do a three to five day stretch throughout the year, with the exception of holidays. Others do a 3-5 day stretch and then have time off where they can tailor it around their personal schedules. Typically for nighttime doctors, they do anywhere from ten-fifteen nights per month full-time. Getting acclimated with the time change from flipping different shifts can take a toll on the body, so it is beneficial to have days off in-between.

(13:50) Residency and becoming a Hospitalist

For internal medicine hospitalists, meaning to take care of adult patients, you complete three years of a residency training and you’re fairly well-equipped to go into a hospitalist practice. There are hospitalist fellowships that exist but they are not that common; it is there if you need more hospital based training but for the vast majority of people that become hospitalists you can go straight in after residency into a hospitalist practice.

(14:36) Is the big difference between internal medicine physician and a hospitalist the place of practice?

The hospitalists are internal medicine doctors but where the distinction lies is the career one could choose right out of conventional medicine residency. You could choose to be in primary care (you’re in an outpatient practice seeing ambulatory patients) or you can become a hospitalist, where you work solely in a hospital. Some physicians do a hybrid of both but it is much more common to choose one or the other. We’re all general internists but some choose to work inside the hospital and some choose to practice in a clinic.

(15:25) Is there something that makes an applicant competitive to get into internal medicine residency?

Solid grades in your first few years of coursework as a medical student are incredibly important. Because internal medicine is such a broad field, having a really good understanding of physiology, pathophysiology and all that goes into our medical education is incredibly important.

A diverse range of clinical experience your ward year as a medical student is important. The more diverse months in a hospital you can do as a medical student are incredibly helpful and informative for internal medicine residency because internists are often the ones interfacing with the specialists, especially the surgical specialists and other internal medicine specialists. The more you can understand how all of those fit together is incredibly helpful.

Depending on what your interests are, if you want to be a researcher in addition to clinical medicine, Shoshana says, obtaining a background in research as a medical student can be important. One thing that is different with internal medicine than other fields is that there is a diversity of clinical practices that you can find yourself in after training. Internal medicine acts as a gateway to primary care, to hospital-based medicine and to some specialties such as gastroenterology, hepatology, hematology oncology and endocrinology. There are many specialities you can consider beyond internal medicine training if general medicine isn’t appealing to you.

(18:03) Is matching pretty competitive for internal medicine?

Yes, it can be. There are several very high-powered academic institutions that are very competitive located all over the country. If you are so inclined to end up in that program, it is highly competitive. That said, there are many different kinds of programs around the country so it just depends on what your goals are for training and what you are interested in–whether it be research or clinical medicine or hybrid of the two or if you are interested in doing another degree on top of medicine. It is helpful to think about these goals going into the application and matching process, as there is a wide range out there.

(19:16) Do you see any bias between osteopathic physicians and allopathic physicians when it comes to applying for internal medicine?

Shoshana has not encountered this kind of bias before or had a direct experience with that. The residency program is majority MD and there have been some DO’s who have come through the program. From personal experience, the top internal medical residencies typically only look at MD candidates. While she is unsure if this is right or wrong, that is what she has seen in her experience.

(20:14) Are there any opportunities as a hospitalist to further sub-specialize?

It depends on the place where you practice. For example, in a smaller or rural town, typically you will find only general hospitalists (they take care of general medicine patients and may or may not also take care of ICU-level patients themselves). In larger cities, however, there are opportunities to have a more specialized subset of patients to care for.

For example, there may be a team of hospitalists that only take care of complicated G.I. and liver patients so that is their subset of patients that they typically see. Or there may be a team of hospitalists that only cares for bone marrow transplant patients and they work very closely with hematology oncology in caring for those patients. The vast majority of hospitalists practice general hospital medicine and are not sub-specialized but in larger cities or in institutions that have a high volume of specialized patients, there is an opportunity to specialize within your hospitalist practice.

(21:58) Is that a fellowship training or is that just the type of patient they are drawn to in seeking out those opportunities?

Typically it's not further academic medical training and each hospital or practice has their own culture about how they train the sub-specialty hospital list. Often it's just getting to know the complex G.I. attending and learning the ways that they care for their patients, given that you are the liaison between the patients and their specialists. For example, the specialized oncologists care for patients based on the standards of care that relate to their illness. There is not typically formal training on top of residency but usually you learn within your institution as you go.

(23:08) What do the boards look like in internal medicine?

The internal medicine board exam is every ten years so most residents complete their three-year internal residency in the month of June, take a few months of that summer studying hard for the exam and take the exam in August or September. They begin their clinical practice and whatever they're going into or they matriculate into a fellowship program if they have decided to specialize.

The board exam is a full day, 7 ½ hours!

It’s computer multiple choice and after taking the exam it is about six to eight weeks before the written results come back with pass or fail.

(24:12) Do you know what the pass rates look like?

The pass rates are pretty high, Shoshana says, and this is an exam that most people pass with an approximately 75%–85% pass rate. The actual raw score doesn't really matter in terms of the job you're going to get or what happens down the road, which is much different than the USMLE where your school really matters because you're no longer competing for a spot. Typically they have already been matched with a fellowship or they have a job so the goal is really just trying to pass the exam.

(25:05) Knowing what you know now after being in practice for a couple of years, what do you wish you would've known coming into your residency?

What Shoshana realizes now is that during her residency you work really hard and spend thousands of hours physically in the hospital. It is really easy, she thinks, to  get bogged down by pressure of residency and performing well with taking care of patients.

If she could, Shoshana would have told herself on day one of her residency to make sure that she used this time to learn as much as possible and really make the most of every opportunity, even when exhausted. It is a time that a resident will never have again and a teaching environment where you can learn from experts and experiences that you may never have an opportunity to have again.

Shoshana advises that the idea of lifelong learning into your clinic practice as a resident is really important because when you finish you may not still be practicing in the academic environment or in a place where there is a specialist you can turn to ask a question. You should constantly be learning and figuring out the ways that you can best access new information in order to take the very best possible care of patients. Physicians need to recognize that in order to be up on the latest information, it takes a lot of work and the clinical practice is very important.

(28:00) What do you wish primary care physicians knew about hospitalists to better help you do your job?

Shoshana wishes that primary care doctors who have formed a relationship with their panel of patients would recognize that hospitalists do their very best in an incredibly brief encounter with these patients to get to know them and formulate a treatment plan. It can be a challenge to build a rapport quickly with someone literally just walking into the room and meeting them for the first time. If the primary care physicians have patients who have a chronic illness, it is incredibly important for them to inform their patients as much as they can about their medical problems and to discuss prognosis, especially when related to a serious illness.

As a hospitalist, Shoshana sees many patients who have a chronic illness where she is the one to break the bad news that things have gotten worse and they may have a poor prognosis. If the primary care doctors could have that conversation with them earlier on, it is very helpful for the patient’s care and for the hospitalist to talk to a patient (and family members) who already have a sense of their medical problems and prognosis.

(30:28) What other specialties do you work the most with?

A hospitalist works most closely with the Emergency Medicine team and spends the majority of their time in the emergency room. Shoshana also works closely with the Oncologists, as there are many patients that interface with their hospital that have cancer. Other top specialists she works with are Cardiologists and ICU.

(31:37) Are there any special opportunities outside of clinical medicine specifically for hospitalist?

Specifically for Hospitalists there are opportunities to work in skilled nursing facilities and post-acute care, as a variation of hospital medicine. With a general internal medicine background there are opportunities in biotechnology.

(32:38) What do you like the most about being a hospitalist?

The feeling of being a “detective” who have patients coming into the hospital with a chief complaint, but not really knowing what's wrong with them until Shoshana can dig in and use diagnostics to figure out what it is that is going on, based on their medical history and what they can use in order to figure it out. She also enjoys the variety of patients who come in and this keeps her on her toes.

(33:30) What do you like the least about being a hospitalist?

Sometimes as a hospitalist you get stuck in the middle a little bit. They are the doctors that often are in-between the patients and their specialists, so if the patient comes in with advanced heart failure, for example, the hospitalist puts a treatment plan in place and then calls the cardiologist to see them and provide recommendations based on what's going on.

Sometimes it's a little tricky to be caught in the middle, while sometimes it's often wonderful that they can work with the specialists on patient care. It can also be a bit of a challenge navigating the needs of the patient, your own needs as a hospitalist and the needs of the specialist.

(34:42) If you had to do it all over again, would you still choose to be a hospitalist?

Shoshana really enjoys her practice as a hospitalist but wishes back in medical school she would have spent more time exploring other fields, such as neurology and anesthesiology, to see if it was a good fit. However, overall she enjoys internal medicine and is very happy as a hospitalist.

(35:46) Do you see any major changes in the hospitalist realm in the future?

As there are potential changes on every front within medicine in the future, Shoshana is not quite sure if whether it is the near future. She can, however, definitely declare that hospital medicine, while a fairly new field, it is here to stay. Hospitalists serve an excellent purpose and one thing she would like to see more of is better communication between primary care doctors and hospitalists.

That is often a challenge, given they sometimes use different electronic records or needing to track them down on the phone in the clinic can be a challenge.  It's incredibly important for continuity of care that primary care doctors and hospitalists are in good communication.

(37:02) Any last words of wisdom for students possibly looking into hospitalist medicine?

The beauty of hospital medicine is that if you were looking for flexibility in your schedule, it is a great field. Every hospital practice is set up differently so if you like the flexibility of working a variety of different times on different days, hospital medicine can be a perfect career!

Links and Other Resources

@ShoshUMD

California Pacific Medical Center

http://www.cpmc.org/

Transcript

Introduction

Dr. Ryan Gray: Specialty Stories Podcast, session number 7.
Whether you’re a premed or a medical student, you've answered the calling to become a physician. Soon you'll have to start deciding what type of medicine you will want to practice. This podcast will tell you the stories of specialists from every field to give you the information you need to make sure you make the most informed decision possible when it comes to choosing your specialty.
Welcome back to the Specialty Stories Podcast. I am your host, Dr. Ryan Gray, a former Air Force flight surgeon now turned professional podcaster I guess. This is the Specialty Stories Podcast. If you are new here I also host The Premed Years which is our longest running podcast now with over 218 podcasts, and the Old Premeds Podcast at 58 episodes, and The MCAT Podcast now around 26 I believe. So go check out all those podcasts. However you're listening to this you can listen the best way through a podcast app on your iOS device, on your Android device. Just search for Med Ed Media and you'll find all of the podcasts that we do here.
This week's episode is a great one speaking to a hospitalist, and the path that it takes to be a hospitalist, and traits and everything else that we talk about here every week on the Specialty Stories Podcast.

Meeting Dr. Ungerleider – Hospitalist

Shoshana Ungerleider: My name is Shoshana Ungerleider and I practice hospital medicine at California Pacific Medical Center in San Francisco.

Dr. Ryan Gray: Is that an academic hospital?

Shoshana Ungerleider: You know it is. We're technically set in a community setting but we actually have several residencies including internal medicine residents there, and I am on the teaching faculty.

Dr. Ryan Gray: Okay and how long have you been practicing?

Shoshana Ungerleider: I've been practicing medicine for just over three and a half years now. I finished residency in 2013.

Dr. Ryan Gray: When did you know you wanted to be a hospitalist?

Shoshana Ungerleider: I think it was midway through internal medicine residency. So sort of the middle of that second year I was doing a bunch of night float months, meaning that you work something like 6:00 PM to 8:00 AM and admitting patients to the hospital overnight as well as doing [Inaudible 00:02:39] which I really loved. So it was basically halfway through that I thought to myself, ‘Gosh I could really be happy in a hospital setting.' There were other specialties that I considered including critical care and cardiology, but ultimately it felt like hospital medicine was a good fit for me.

Dr. Ryan Gray: Why do you think that? Why was it a good fit?

Shoshana Ungerleider: I like the variety of patients that I see. Variety in terms of age, the illness and the chief complaint they're kind of walking through the door with, as well as different levels of acuity. You know we take care of patients who come in the hospital for a routine hip surgery who are otherwise pretty healthy, and then on the other end of the spectrum we co-manage ICU patients who are incredibly ill and spend days or weeks in the intensive care unit before transitioning out. So I really enjoy the variety there.

Traits of a Good Hospitalist

Dr. Ryan Gray: What traits do you think lead to being a good hospitalist?

Shoshana Ungerleider: Good question. Well I think I'll say first that there are many- well at least within my medical group of hospitalists there is lots of different kinds of people. So lots of different personalities I think can be happy doing hospital work. I think that traits would be obviously you enjoy talking with patients, given that as internists that's a lot of what we do. I think you really have to be kind of curious and maintain intellectual curiosity throughout your years in practice because things are constantly changing as far as how we manage common medical problems all the time, and so staying up on the literature is incredibly important. I think I very often find myself looking up. Gosh have the guidelines changed around treating pneumonia? Or what do we do in the case of sepsis? And so no matter where you are in your training, and then beyond, I think it's incredibly important for hospitalists to stay up on the literature. I think that's important actually for all physicians, but specifically for hospitalists given that we treat so many different types of issues. And I also think that given- depending on your work setup, you might be working different hours. So some hospitalists work a swing shift, so it's 3:00 PM to 2:00 AM. For example I work at night so I prefer to work 9:00 PM to 8:00 AM. And so I think a bit of flexibility really is helpful. I think people that love the structure of an 8:00 AM to a 5:00 PM job are much better suited for a clinic or an outpatient practice where you sort of know when you're going to be seeing patients, whereas with hospital medicine the flexibility has to come in because you don't really know how busy the ER is going to be on any given day, so kind of rolling with the punches there, yeah.

A Day in the Life

Dr. Ryan Gray: Describe typical day.

Shoshana Ungerleider: Well for me it's a typical night. So I show up at the hospital at about 9:00 PM or just a little before, and check in with my colleagues who have been on sort of the afternoon or evening shift, and go and grab the admission pager from them. So as a night-time doc the majority of what I do is admit new patients to the hospital, and the majority of those patients come through the emergency room. Sometimes we get direct admissions from specialists or primary care docs where the patient comes directly to the floor, or we get a transfer from another hospital, but I would say probably at least 75% if not 85% of patients just come directly through the emergency room. And so the minute I get there, usually the pager starts going off, and our emergency room physician colleagues are calling to ask us to come and see patients in the ER. So I spend the majority of my night in the emergency department seeing patients and working with the residents. So at my hospital we have two or three residents on every night, and so we work together to see patients and get them admitted to the hospital. We often see them together, or the resident will go in and chat with the patient first, do a history and physical, and then I'll come in later and follow up with more questions, and then we do a modified sort of rounds at night where the residents present the H&P to me and then we talk through the assessment and plan.

Dr. Ryan Gray: Was there- go ahead.

Shoshana Ungerleider: Oh sorry, I was just going to say that on occasion there will be some cross-cover fires to put out up on the floor where patients become ill overnight, and I need to read up on the history of that patient and figure out what to do in the moment, and so sometimes that can get a little exciting.

Dr. Ryan Gray: Was there a decision process for you for choosing an academic hospital versus a strict community hospital that didn't have residents?

Shoshana Ungerleider: When I finished residency I was in the typical search for a job and I was confined to this area, meaning the San Francisco Bay Area, because I knew I wanted to stay here. And it just so happened that I found a job working in the community for the first two years after I finished residency. It was a bit of a commute for me and I got a sense of sort of what it means to be in community hospital medicine, and I really enjoyed it, and I loved the group I was working with, but I really found myself after two years missing the educational aspects of working with residents and other trainees and so decided to come back to the institution where I trained and it felt like I was coming home. It was really wonderful and now for the last year I've been back working with the residents in the hospital where I trained. So I think that working with residents keeps me on my toes. They often know about sort of the latest in diagnostics and therapeutics, and so we really learn from each other which I always thought was like a weird thing to say. Once you're an attending you're supposed to know all these things and really be up on everything, and the reality is you can't be always up on everything, and so to me I thrive in a team environment where again, we can learn from each other and I really think that's for me the beauty of medicine as a career. Continuing to kind of push yourself to always be learning more, recognizing that as I said medicine changes from week to week as to sort of what the standard of care is and new information that comes out. So I find it really exciting and I love working in an academic environment.

Hospitalists Taking Call

Dr. Ryan Gray: Do you have to take call as a hospitalist?

Shoshana Ungerleider: Well technically speaking we're kind of on call. I mean so when- for the daytime hospitalists, they have a panel of patients that they round on, and check in on, and make a plan for the day whether it's staying in the hospital, being transferred to a different level of care, or being discharged home. And so for the daytime docs it's usually the timeframe in which they're physically in the hospital is pretty well laid out. And then for those of us that work a later swing shift or a night shift, we obviously have to physically be in the hospital. So in that sense we're sort of- when we're working we are ‘on call.' That said, when our shift is over and we've handed off our patients to the next team coming in, we turn the pager off. I don't get calls in the middle of the day while I'm asleep. That's the work of my daytime colleagues. So it's really shift work, and technically speaking we don't have to be on call, we're just working hard when we're in the hospital.

Dr. Ryan Gray: What do the shifts look like as far as number of times per week or month?

Shoshana Ungerleider: For me I work part time and so it's somewhat different than most hospitalists. What's interesting about hospital medicine as a field is it's fairly young, and so many hospital groups sort of figure out what works best for them as far as typical shifts. So very often you'll find hospitalist groups who have seven on, seven off schedule, where they work seven days and then they get seven days off. And so it's throughout the months of the year except for several weeks of holiday that you get, you're seven on, seven off. Other people do a three to a five day stretch, and then have time off, and so they can tailor it around their own personal schedules with families and such. For me I fill in when the full-time night-time doctors need a break, or have family leave or vacation. So I'm lucky in that I get lots of time off to do other things, but I would say typically for night-time doctors they do anywhere from ten to fifteen nights a month as full-time. And it does actually- it's nice to have several days off during a month when you're working full-time just given that flipping your clock from night to day and day to night can take a bit of a toll.

Residency as a Hospitalist

Dr. Ryan Gray: Yeah. What does residency look like to get to be a hospitalist?

Shoshana Ungerleider: Well for internal medicine hospitalists, meaning taking care of adult patients, you complete three years of a residency training and you're fairly well-equipped to right away go into a hospitalist practice. So there are hospitalist fellowships that exist. They're not so common so if you want more training in hospital based care, it's out there, but I would say for the vast majority of people that become hospitalists you can go straight in after residency into a hospitalist practice.

Dr. Ryan Gray: So really the big difference between an internal medicine physician and a hospitalist is just the place of practice?

Shoshana Ungerleider: Well I would say to be clear, the internal medicine- hospitalists are internal medicine doctors. Sort of the distinction is the career that you could choose straight out of internal medicine residency is primary care, meaning you're in an outpatient practice seeing ambulatory patients, or you can become a hospitalist, as you were saying where you work solely in the hospital. Some people do a hybrid of both, but I would say it's much more common to choose one or the other. So that's right, we're all general internists, but some of us choose to practice in the hospital and some choose to practice in the clinic.

What Makes for Competitive Applicants

Dr. Ryan Gray: Is there something that makes an applicant competitive to get into internal medicine?

Shoshana Ungerleider: Into internal medicine residency?

Dr. Ryan Gray: Yeah.

Shoshana Ungerleider: Gosh, good question. I think that absolutely solid grades in your first few years of coursework as a medical student are incredibly important. I think because internal medicine is such a broad field, having a really good understanding of physiology, pathophysiology, I mean everything that goes into our medical education is incredibly important. I think that absolutely a diverse range of clinical experience during your ward years as a medical student is important. And I honestly- I think that the more diverse months in a hospital that you can do as a medical student are incredibly helping and informative for internal medicine residency because internists are often the ones interfacing with specialists, especially our surgical specialists, and then other internal medicine sub-specialists. The more that you can understand how those all kind of fit together, I think is incredibly helpful. I do think depending on what your interests are. If you want to also be a researcher on top of clinical medicine, I absolutely think that getting a background in research as a medical student can be very important. I think one thing that's a little different with internal medicine than other fields is that there are- there is a diversity of clinical practices that you can eventually find yourself in after training. Meaning that internal medicine is the gateway to- like I said primary care, it's the gateway to hospital-based medicine, it's also the gateway to sub-specialties such as gastroenterology, such as hepatology, hematology oncology, endocrinology. So there are many sub-specialties that you can consider beyond internal medicine training if general medicine isn't appealing to you.

Dr. Ryan Gray: Is matching pretty competitive for internal medicine?

Shoshana Ungerleider: So it can be. I think that there are several very high powered academic institutions that are very, very competitive. Those are located all over the country. I think that there are- so if you are so inclined to end up in that kind of program, it's highly competitive. That said, there are many other different kinds of programs throughout the country. So it just depends on what your goals are for training. I think that there's- depending on what you're interested in, whether it be research, or clinical medicine, or a hybrid of both, or if you're interested in doing another degree on top of medicine, those are helpful to think about in going into the application and matching process. So there's a wide range out there.

Dr. Ryan Gray: Do you see any bias between osteopathic physicians and allopathic physicians when it comes to applying for internal medicine?

Shoshana Ungerleider: You know, good question. I didn't encounter that myself, but I don't- I'm not sure that I necessarily have a clear or direct experience with that. My program was- my residency program was majority MD. There are a few DO's that have come through our program. Anecdotally just from my personal experience, the top internal medicine residencies typically only look at MD candidates. I'm not sure if that's right or wrong, but I would say that's what I have seen in my experience.

Sub-Specializing in Hospital Medicine

Dr. Ryan Gray: Okay. Are there opportunities as a hospitalist to further sub-specialize?

Shoshana Ungerleider: As a hospitalist to further sub-specialize? You know, sometimes. It depends a little bit on the place where you practice. So for example in a more rural setting or a smaller town, typically you will just find general hospitalists meaning they take care of general internal medicine patients, they may or may not also take care of ICU level patients themselves. Typically in bigger cities there are opportunities to have a more specialized subset of patients you care for. For example at our hospital there is a team of hospitalists that only takes care of complicated GI and liver patients. So that's their subset of patients that they typically see. And at UCSF, another hospital in San Francisco, there is a team of hospitalists that only cares for the bone marrow transplant patients. It's their subset and they work very closely with the hematologist oncologists in caring for those patients. So I would say that the vast majority of hospitalists practice general hospital medicine and are not sub-specialized, but in larger cities or in institutions that have a high volume of specialized patients, there is an opportunity to specialize within your hospitalist practice.

Dr. Ryan Gray: And are those specialists- is that a fellowship training or extra training, or is it just that's the type of patient they're drawn to and they seek out those opportunities?

Shoshana Ungerleider: I would say there typically is not further academic medical training. Usually each hospital or each practice has their own culture about how they train the sub-specialty hospitalists. Often it's just getting to know the complex GI attendings, and learning how they- the ways that they care for their patients given that you're sort of the liaison between the patients and their specialist. And for example within the more specialized oncology realm you work closely with those specialty oncologists to care for patients based on sort of the standards of care that relate to their illness. So to more specifically answer your question, there is not typically formal training on top of residency, but you sort of learn within your institution as you go.

Board Exams

Dr. Ryan Gray: Okay. What do the boards look like for internal medicine?

Shoshana Ungerleider: The internal medicine board exam is at this point every ten years. So most people complete their three year internal medicine residency in the month of June, and then spend a few months of that summer studying hard for the exam, and then take the exam that usually August or September, and then start their clinical practice in whatever they're going into or they matriculate into a fellowship program if they decided to specialize. The board exam is taken- at least when I took it three years ago, on a computer and it's multiple choice. It's a full day exam, I think I was there for seven and a half hours, and then you- after taking the exam you have about six or eight weeks I want to say until you get your written results back and they tell you if you passed or failed.

Dr. Ryan Gray: Do you know what the pass rates look like?

Shoshana Ungerleider: Great question. The pass rates are pretty high. I would say that this is an exam that most people do well on, and by well I mean they pass. So your actual raw school doesn't really matter in terms of the job that you're going to get or anything that happens down the road, which is much different than the USMLE type exam where your score really matters because you're no longer competing for a spot. Typically people have already matched for fellowship or they already have a job so you're really just trying to pass the exam. And I would say- I unfortunately don't know the number off the top of my head but I would say it's definitely the majority pass, and I would say it's probably closer to a 75% or 85% pass rate.

What Dr. Ungerleider Wishes She Knew Then

Dr. Ryan Gray: Knowing what you know now after being in practice for a couple years, what do you wish you would have known going into your residency?

Shoshana Ungerleider: Wow there are so many ways to answer that question. I think that- I think that what I realize now is that during residency you work really, really, really hard, you spend so many thousands of hours physically in the hospital, and I think that it's really easy to get bogged down by the pressure of residency, of performing well, of taking good care of patients, getting bogged down by just being really tired which of course we're all human beings and that happens. I think- I think that I would have- if I could tell myself on day one of residency, if I could give myself some advice I would say make sure that you use this time to learn as much as you possibly can. Because it's such an intense environment as I'm describing, I think really making the most of every learning opportunity even when you're tired, even when you're ready to like turn the pager off and go home and go to sleep, I think that it's time that you'll never have again in a teaching environment where you can learn from experts, get experiences that you may never have an opportunity to have again. And I think building the idea of lifelong learning into your clinical practice as a resident is really important because when you finish, you may not still be practicing in an academic environment or a place in which there's a specialist to call and ask a question. Or you really should constantly be learning and figuring out the ways that you can best access new information in order to take the best possible care of patients. So I don't know if that makes sense, but I absolutely think that physicians need to recognize that in order to be up on the latest information, it takes a lot of work. And so including that time into your clinical practice is really important.

Working with Other Physicians

Dr. Ryan Gray: What do you wish non-hospitalists, primary care physicians- I guess as a hospitalist you don't call yourself a primary care physician. So what do you wish primary care physicians knew about hospitalists to better help you do your job?

Shoshana Ungerleider: I wish that primary care doctors who have formed a relationship with their panel of patients, and have maybe known them for a long time, I wish that they would recognize that as a hospitalist we do our very best in an incredibly brief encounter with these patients to get to know them, to formulate a treatment plan with the patient and their family together, and that it's a challenge when you really have to build rapport quickly with someone. You're literally just walking into the room and meeting them for the first time. So I would say to my primary care colleagues, especially patients that you've known a long time who maybe have a chronic illness or several, whether it be a heart failure or cancer, I think it's incredibly important for primary doctors to inform their patients as much as they can about their medical problems, and to discuss prognosis, especially when related to a serious illness. I can tell you that as a hospitalist I see many, many patients with- let's use the example of cancer. People that I see have very advanced cancer, they may not be doing well which is why they end up in a hospital, and I often am the one that has to break the bad news that things have gotten worse, and they're not doing well, and they may have a poor prognosis. And what I really wish is that primary care doctors would also have that conversation with them earlier on further upstream before a crisis ensues such that as a hospitalist I'm walking into the room, I'm talking to a patient or to a family who maybe has a sense of that. It's very, very helpful for their care overall and for me as a hospitalist.

Dr. Ryan Gray: What other specialties do you work the most with?

Shoshana Ungerleider: In my practice I work a lot with the oncologists. We have many patients that interface with our hospital who have cancer. In addition the cardiologists as well as our ICU physicians. So we're lucky in that we have a 24/7 intensive care practice available in the hospital so that we co-manage our sickest patients together. So I would say those three are the top specialists that I tend to work with.

Dr. Ryan Gray: Okay and I'm assuming emergency medicine as well?

Shoshana Ungerleider: Oh of course, of course. Yes I always forget that sort of goes without saying. Absolutely. So I work most closely, out of all of those, most closely with our emergency medicine docs. I spend the majority of my time at work physically in the emergency room.

Opportunities Outside of Clinical Medicine

Dr. Ryan Gray: Okay. Are there any special opportunities outside of clinical medicine specifically for hospitalists?

Shoshana Ungerleider: I think that specifically for hospitalists, there's opportunities to work in skilled nursing facilities, or post-acute care. That's sort of a variation of hospital medicine. I think with your general internal medicine background, there are opportunities in biotechnology, especially here in San Francisco, there's Silicon Valley is full of companies that are interested in getting the expertise from practicing general internists. So there are many jobs out there. I would say that's probably the majority of the outside work that comes to mind for internists.

Best and Worst About Hospital Medicine

Dr. Ryan Gray: What do you like the most about being a hospitalist?

Shoshana Ungerleider: I love feeling like I'm a detective. I really enjoy especially working at night, having patients who are what I call undifferentiated. Meaning I know what they're coming in the hospital with, meaning a chief complaint, but I don't really know what's wrong with them. So I like digging in and using diagnostics to figure out what it is that's going on based on their medical history, and what we can use in order to figure it out. So I enjoy the variety of patients that come in, it keeps me on my toes.

Dr. Ryan Gray: What do you like the least about being a hospitalist?

Shoshana Ungerleider: What do I like the least? Sometimes as a hospitalist you get stuck in the middle a little bit. You know we are the- we're the doctors that often are in between the patients and their specialist. So if a patient comes in with advanced heart failure we admit them to the hospital, we put a treatment plan in place, and then we call their cardiologist or we call a cardiologist to come and see them and give recommendations based on what's going on. And so sometimes it's a little tricky to be caught in the middle. It's often wonderful and it's very helpful to have those specialists weigh in on patient care, but sometimes it's just navigating the needs of the patient, your own needs as a hospitalist, and then the needs of the specialist. And so that can sometimes be a bit of a challenge.

Dr. Ryan Gray: If you had to do it all over again, would you still choose to be a hospitalist?

Shoshana Ungerleider: I think so. I'm really enjoying my practice as a hospitalist. I think going back to your question earlier about medical school, I wish I would have gotten more exposure to other fields. Like for example I find neurology fascinating and wish I would have spent more time as a med student exploring that to see if it was a good fit for me. Additionally anesthesiology is a very exciting field, and I wish that beyond my fourth year elective I would have had more exposure, because I think it potentially could have changed my- the outcome of my ultimate practice. But I would say all in all I love internal medicine and I'm very happy as a hospitalist. So that's my answer.

What the Future of Hospitalists Looks Like

Dr. Ryan Gray: Do you see any major changes in the hospitalist realm in the future?

Shoshana Ungerleider: You know I'm not sure. I think that there potentially are many changes on every front within medicine in the future, whether it's the near future I'm not quite sure. For me as a hospitalist I can't really pinpoint anything specific at this time. I definitely think that hospital medicine, while it's a fairly new field it's here to stay, we serve an excellent purpose. One thing I would love to see more of is better communication between primary care doctors and hospitalists. I think that's often a challenge given we sometimes use different electronic health records, or having to call somebody, track them down on clinic on the phone can be a challenge, but I think it's incredibly important for continuity of care that we're in good communication. Beyond that I'm not sure what's on the horizon.

Words of Wisdom

Dr. Ryan Gray: Any last words of wisdom for students possibly looking into hospitalist medicine?

Shoshana Ungerleider: I think that the beauty of hospital medicine is that if you're looking for flexibility in your schedule, it's a great field. So every hospital practice is set up differently, so when you're looking into a career as a hospitalist, if you want to have weeks off at a time potentially, or only work nights, or work a variety of times on different days, I think that hospital medicine can be a perfect career.

Final Thoughts

Dr. Ryan Gray: Alright again that was Shoshana, thank you very much for sharing your story of being a hospitalist and the path it takes, and hopefully motivating students to look into hospital medicine.

If you liked Shoshana and you want to hear more of her, I'm going to have her back on The Premed Years podcast to talk about one of her other passions, and that's palliative care. So keep an eye out for that podcast. Again that will be on The Premed Years.
I hope you enjoyed this week's podcast. Let me know where you are in your journey. Since this is a newer podcast I'm interested to know who's listening. If you would email me, Ryan@medicalschoolhq.net, and just tell me a little bit about yourself, I would love to hear your story and let me know if there's anything that I can do to help you on your path.

I hope you have a great week and we'll catch you next week hopefully- again I always at the beginning of this podcast, I didn't guarantee a weekly podcast but we're doing well. So I hope to see you next week here at the Specialty Stories Podcast.

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