From private practice to hospital medicine

Alfred J. Maher, MD, differs from most hospital physicians in that he didn't begin working as a hospitalist soon after residency. Instead, he was in private practice for 30 years before accepting a job with Sierra Hospitalists, a 20-physician group in Reno, Nevada. Here's why he switched and what he has to say about the day-to-day world of hospital medicine.

Q. Why did you become a hospitalist?

A. My partner, John DeWeerd, and I found that although we were working harder and harder, our incomes were falling and the frustrations of private practice-such as completing countless forms, for free-were increasing. When, in 2004, we were offered a chance to leave most of that behind, work for a salary, and have relatively circumscribed hours, we signed on.

A. No. I'd been doing hospital work, rounding on my own or colleagues' patients, for years, so the transition was easy.

Q. How is your work schedule structured?

A. Our schedule calls for six- or seven day workweeks, from 6 a.m. to 6 p.m., but it varies a lot. We take night call on a rotating basis, so I work from 6 p.m. until 6 a.m. about four nights each month. If I want to take time off, I have to schedule that in advance.

The night-call physicians admit patients from the ED and field questions from the nurses about patients who have already been admitted. When I'm on day shift, after arriving at the hospital I update my rounds list by adding patients who were admitted to my service during the night. I begin rounds in the intensive care units, and then try to see new admissions. Next, I look in on patients who might be discharged that day. Finally, I check on the rest of the patients on my list.

Q. How many patients do you see daily?

A. I used to round on 25 to 32 patients. I now round on roughly 18 patients each day, but I'm responsible for admitting two or three patients from the ED.

Q. What are some of the clinical situations that you deal with during the course of the day?

A. On one "typical" day I saw a 53-year-old woman in the ICU. She acknowledged occasional methamphetamine use, and presented with obtundation, hepatic inflammation, acute renal failure, fever, and coagulopathy. I also admitted two patients from the ED: A 77-year-old with an aneurysm of the descending aorta; and an 83-year-old with a seven-day history of nonproductive cough, fever, headache, myalgias and fatigue.

The patients I saw on rounds included a 33-year-old woman with headache, Chiari malformation, and lots of stress in her life; a 50-year-old man with hypertension and suicidal ideation; and a 58-year-old woman who'd had coronary artery bypass grafting at a major university hospital. Her post-op course had been stormy, and complicated by a sternal wound infection, cardiac dysrhythmias that required placement of an automatic implantable cardioverter/defibrillator-pacemaker, and the development of acute renal failure.

Q. Has becoming a hospitalist freed you from the paperwork you found so onerous when you were in private practice?

A. For the most part, but not entirely. For example, we do very detailed discharge summaries because many of our patients have complex multisystem illnesses, with long stays in the hospital and many consults.

Q. In addition to a steady income and fewer administrative hassles, what do you see as a major benefit of being a hospitalist?

A. Now it's much easier for me to take vacations. When I had an office practice, even a short vacation was difficult to arrange; I always felt the meter was running, by which I mean that office overhead expenses continued while my income dropped to nothing. Vacations back then also meant swapping calls with covering docs. I usually went away exhausted and rapidly became exhausted upon returning because I had to do extra coverage.

Q. What is your advice to physicians who are thinking about becoming hospitalists?

A: The hours are long and the workload is heavy, but it's great to receive a salary and to be able to take vacations without overhead accumulating. I've missed longstanding relationships with patients I'd known for 30 years, although I've stayed in touch with many.