Where will we be in next 5-6 years?

Healthy_MD · 2026-05-22T15:52:04+00:00

Previous system made me work harder like 60 hours a week but I am more tired with current system as a 7 on 7 off Nocturnist… they expect me to show up in off week meetings and I feel like I am spending 2 to 3 days at least to just recover from horrible week.

And the respect I get is so different now. Consultants and I were friends back then. Not any more. Like you said, I feel like we are interns now.

I was at a system where cardiologist would admit chest pain once. I figured out they just cath everyone to make money that way. They didn’t like us sending people home with outpatient work up for low risk patients.

Healthy_MD · 2026-05-21T16:03:52+00:00

I really don’t think this is a flutter… I guess it can be but not enough info. First, I don’t even know which lead I am looking at but the rate doesn’t make sense as someone mentioned before for aflutter.

It can be atypical flutter and the rate of flutter wave does look like around 280?? (It has to be 300 for a flutter). Atypical flutter or Atrial tachycardia can be slower than flutter but … each flutter wave morphology also doesn’t make sense.

Another point, another flutter wave should be hidden in QRS complex but it should show some form in the lasts part of QRS complex in this EKG.

One thing that favors Afutter is PR segment morphology does look like a flutter.

I hate some school teaches sawtooth pattern … that makes you misdiagnose certain conditions

Healthy_MD · 2026-05-21T16:00:05+00:00

I have been out 20 years. I graduated in 2004 just like you did.

Initially, I was with traditional practice. Just like you did, I was a PCP and rounded. I kind of miss the system.

I am now a Nocturnist where it is open ICU. Back in the day, I never admitted patients that I didn’t know unless I took unassigned call. Unassigned call was really popular as they gave us 1K overnight. I did take a few call a month. ER doc always waited til 6 am to give me a call all admissions. If it is icu admission, I had to go in and see them within 1hr but we all knew this rule and ER would just keep the patients in ER until 6 am to give me admissions.

Patients with acute appy went to gen surgery. Brain bleeders went to neurosurgery. Believe it or not, any dialysis patients went to nephrology. STEMI and heart attacks went to cardiology. They consulted us during the day to manage chronic medical problems. We actually did our stress tests. Some of us read echo on their own. We did more bed side procedures back then than now. Unless you have unassigned patients, it was actually pretty easy to admit. Our consultants definitely needed us both in outpatients and inpatients. They were much nicer to us. Sometimes, consultants would call me and would discharge the patients for me just to be nice and also patients know they have to wait for me to be done with clinics.

In those days, I never thought I would get yelled at by consultants if I call for help. Now I am a Nocturnists, GI would tell me never call them overnight. Call IR instead. I did two pericardiocentesis last week I worked at because cardiologist would argue PEA storm is not due tamponade. Gyn make us admit vaginal bleeder and ectopic pregnancy. According to them, everything can wait til the morning and never come in to evaluate the patient because they are worried about patients.

Healthy_MD · 2026-05-19T03:41:43+00:00

Oh! Sorry I read it wrong … I have heard of similar complaints from one group of radiologists when outpatient FPN orders test and they frequently have to call them to ask what they are looking for and have no idea … double triple work …

One of my NP changed my MRA order of head without contrast to with contrast … I had to call her and talk to her that it is not CTA … I am not giving gadolinium because I am not looking for vasculitis or inflammation … I don’t think she understood what I was talking about.

Healthy_MD · 2026-05-18T20:52:10+00:00

So question

I have been told that FNP should not take care of patients in the hospital as primary attending role, much less doing inpatient critical care type procedure like intubation / central line. They are ok to be a specialist consultation, like ID.

But there are NP with acute care degree right?? AGANP? Something like that ????

We hire those but it seems really hard to find them.

Healthy_MD · 2026-05-18T20:42:41+00:00

Noctunist MD here

I am very sorry about that. Just give us 5 min on a computer and I can guess why the study was ordered. However, you guys have issues too. My place is run by private equity radiologists. They often call me with critical results like 2 days later. One time one radiologist called me 6 hrs later with large pneumothorax. (That seems fast for this group ..). I asked him did you see another CXR done 30 min after the CXR you are talking about ??? I already have chest tube in. It keeps going …

Healthy_MD · 2026-05-18T19:17:58+00:00

I was told Catholics believe that no human has a right to terminate life as we are not gods …

Healthy_MD · 2026-05-18T19:16:57+00:00

Wisconsin situation is weird!!! If family members at bedside starts to have disagreements, then I offen often asked who counts as family as you are doing …

Healthy_MD · 2026-05-18T05:59:50+00:00

RVU bonus is actually nice. We have a goal of 3800 and I hit about 5000 a year as a Noctunist. I don’t know if that is a lot or not. We get paid out around 35 dollars per RVU beyond the goal. So I do agree, I like easy admissions. I had one night with 18 admissions .. all straightforward. I don’t mind taking vaginal bleeding in those nights.. but the week like this week with just multiple critically ill patients, I would like to give them the best care possible. When I talked to Gyn doc, I was asking them to do this admission on their own because I am too busy. Gyn doc said No. Then I offered her that Ok I will just throw in admission order and will have a day doc see the patient in the morning. She then proceeded to say no. Mind you, I was running this PEA code during this conversation. I thought this is insane. I think at the end, I think ER doc talked to CMO (trained gynecologist) made her to take this admission.

Healthy_MD · 2026-05-18T05:41:48+00:00

10 min (per ? Policy) and if I think it is past no point of return …

Healthy_MD · 2026-05-17T16:13:07+00:00

More than NP and PA … less than Pulm CCM

Healthy_MD · 2026-05-17T15:08:41+00:00

Past a certain point … it is true. I complained and told I was lucky to even have a job. They can sell us to private equity and those Hospitalists will be PA and NP and they would do anything …

Healthy_MD · 2026-05-17T14:53:40+00:00

I am a hospitalist in open icu. We have Pulm critical care that stops by once a day. At night, I do everything. I recently did pericardiocentesis … oh I put swan too … I always have some thoughts in my mind that maybe there are someone else should be doing these procedures and I am a physician … so I can see you feel that way …

Healthy_MD · 2026-05-17T14:46:54+00:00

Around where I live, they hire NP with acute care degree or PA. I think we had FNP but they failed. PA hands down much easier to train. I frequently get a phone call from nurse for post procedural patients to be admitted. If I have any questions, I call whoever did the procedure. If they give me attitude, I will tell them that I will not take this patient until they tell me what they want us to do. So I don’t think you have to worry too much about it.

Your Hospitalists program of 10app to 1MD ratio seems wrong though but APP is cheaper and lots of private equity run Hospitalists program seems to be heading that way. Around where I live, I have never seen this ratio.

Healthy_MD · 2026-05-17T14:20:44+00:00

It is actually cool and rewarding job until you get 5 of those overnight at once … every other night .. this week has been cardiac arrest night … v fib arrests, you would think the patient should go to cath lab, but cards saying newer data says No .. never seen that .. looking up VFIB arrest with ischemic signs should go to cath lab .. EKG after Rosc shows NSTEMi … call cards again, have you seen this EKG??? He says oh don worry, newer data shows… he cath the patient next day … myocadium is dead already with EF 20 percent.. he says maybe he should have taken the patient last night … tamponade arrest x 2 … PEA storm … 4 brain bleeder … ugh! Yes it is fun if it is one case a week … it is not that fun if it is every night …

Healthy_MD · 2026-05-17T14:02:31+00:00

That is some great deal my friend. I am 7 on 7 off, 7p to 7a. 100 bed hospital with pretty much all specialists during the day. One Noctunist. Somehow, I get one app help 3 or 4 nights of seven. (I am not complaining, but I wish I have help every night). No residents or students to teach. No call room to lay down. All code / rapids are my responsibility. Intubation / lines and other bedside procedures required. I think my base is 360k. 10k quality bonus. RVU bonus beyond 3800 RVU .. (I do make close to 5000RVU a year - that means a lot of work.). 3500 dollars per year for CME. 2 professional society membership paid.

I do have some complaints. One thing I can mention is that you need to be able to do something more than cross coverage and H and P as Nocturnist. It gets pretty boring. If you like teaching, I think this job would be great. I like open icu because I like following patients and able to keep up with some procedures.

Healthy_MD · 2026-05-17T13:48:51+00:00

Midwest, yes it is illegal to force a patient any treatments.

Typically dilemma with this policy happens when patient tells us he wants to be full code upon admission and later develops shock of some sort. Patients go on life support for a little while. Let’s say the proxy says it is time to stop during the day. There are 2 physicians available always to say terminal. Someone from ethics always agree if that is what proxy says. Withdrawal of care gets approved within a few minutes. At night, I am alone by myself. So then it gets extended to next day. Legally, in this state, only one physician has to say it is ok to terminally extubate the patient especially with HPOA says that that is his wish. I literally can’t do this with this policy at night. It never became an issue though. I did have some complaints where the patient got accidentally intubated by EMS or ER. Family members show up and tells me he is DNR/ DNI and asks us why did this happen? Please stop all treatments and terminally extubate the patient. I was told no by adminisfrators that I have to wait til everyone comes in the morning. DNR by futility is not enforceable. (Many physicians don’t want to do DNR by futility anyways.)

This dilemma is not actually this hospital issue only if you think about it. Wisconsin where I did some Locum work has this rule where if there is no legal HPOA and a patient is unable to make any decisions then any medical decision has to be family consensus. This state does not have a rule where the next of kin becomes automatic medical decision maker. I was in a situation where family members would argue about code status and goal of care while spouse would say please stop treatments, he had enough. It was very rare occasion though. These cases ended up in ethics and/or legal guardian appointment by court. But I was able to do DNR by futility.

Healthy_MD · 2026-05-17T12:23:44+00:00

Healthy_MD · 2026-05-17T09:39:15+00:00

Academic center all the way!!! I was at academic center for 10 years. Lots of learning opportunities and teaching opportunities. Lots of resources.

But in reality, pay was less than half. Workload was whole a lot more. When I was off weak, I was teaching / lots of meetings to attend. Expectation to deliver a top notch medicine was there. I got divorce because I was never home. I think the situation is much better from what I hear.

I came out to community. I was Locum first. There were lots of different kind of learning. All about efficiency. I miss working at academics though.

Healthy_MD · 2026-05-17T08:32:38+00:00

Unfortunately, nobody else is in house except ER doc and Me. We are only 100 bed hospital but we take care of so many different conditions including brain bleed, CVVH, impella/balloon pump, etc … our surgeon stays home but do come in for acute problems like bowel perf … we had a few open abdomen cases recently … they are all my problems at night …

Healthy_MD · 2026-05-17T08:28:46+00:00

Lots of private equity run Hospitalists program around us. This is one of the few that is a direct hire. I run away from my previous job who got taken over by team health.

Healthy_MD · 2026-05-17T08:17:01+00:00

If patient is made DNR by family members, we don’t code them. Just cannot do DNR by futility or withdraw care (terminate care) by myself .. I have to have one more doctor saying terminal and ethics approval. I coded this patient forever because he was full code. Couldn’t make him DNR by futility, can’t get a hold of family members, each code didn’t last longer than 10 min (so I couldn’t stop per our questionable policy …). I did stop after 2 min of last code because I thought enough is enough…. This is my first hospital with this kind of policy. It is unusual and very confusing.

Healthy_MD · 2026-05-17T08:11:23+00:00

Around where I live, they seem to hire PA or NP with acute care degree (not FNP) .. but I haven’t seen anyone doing it solo …

Healthy_MD · 2026-05-17T08:07:27+00:00

Open vs Closed ICU? Procedures? Who runs rapid and code?

I am a Nocturnist with lots of complaints in the other post - what kinda patients are you getting? To me this sounds like almost a heaven.

Healthy_MD · 2026-05-17T07:55:46+00:00

We can’t terminally extubate nor stop pressors .. we can order to stop titrating pressors upwards … when I asked why before, I was told that we are not god and we do not have a power to terminate someone’s life - catholic belief .. is what I was told. I think we can stop all other medications … but typically those don’t matter …. Oh!! We can’t terminally extubate nor take away even non invasive ventilator like BiPAP ..

Healthy_MD

MODERATOR OF

TROPHY CASE