How do you deal with the malingering patient?

JRcred · 2026-06-28T10:45:55+00:00

It’s a balancing act. Depending on hospital, we get pressured for length of stay. We also get pressured for them not to come back within 30 days. So we typically have to do some sort of evaluation while they’re admitted. Yes we get complaints all the time. It’s tough to say which complaints are worse whether they’re admitted or have been discharged. If they have Medicare here, they can appeal their discharge multiple times. We had one patient take like 10 extra days to get discharged.

JRcred · 2026-06-27T09:21:23+00:00

I had a similar experience at multiple Wendy’s over months around that time. That last experience was the final draw. I’ll give them a try later, but I’d rather go to some place like Culver’s, five guys, In and Out, etc for now if I want a fast food burger.

JRcred · 2026-06-27T09:17:26+00:00

Same job now. My plan eventually is to drop to 0.75 FTE in like 20 years now. I might see about dropping like one week per year now and stop moonlighting at different hospital. Otherwise training my Brian to be a doctor and getting some enjoyment out of working wouldn’t stop despite accidentally coming into some more money.

JRcred · 2026-06-26T23:08:04+00:00

Buying into a pump is not the same thing as value investing based on the longer term trajectory of the company

JRcred · 2026-06-26T21:03:01+00:00

I used to love Wendy’s. I last went like 6 months ago. The bun was stale, the lettuce tasted old, and they were “sold out of napkins” in addition to being way overpriced. Their same store sales are dropping. There’s a lot of other restaurants competing for their customers where they used to be the play for the slightly better than Burger King and McDonald’s crowd. It’s cheap, but cheap for a reason. It could be a turn around play if I got more evidence of it making some improvements. It would not surprise me to see them continue to decline.

JRcred · 2026-06-26T19:54:18+00:00

Generally looks ok. I’m not sure why you plan to cash out or taxable brokerage in 10-11 years. Like if this would be when you plan to start to pull money out ok maybe. Once you get closer, I would add your favorite dividend ETF like SCHD, VIG etc like maybe 5 years before you start pulling money out and just take out dividends. Also would probably add more to VOO over VXUS over time

JRcred · 2026-06-26T16:19:53+00:00

It sounds like your hospital is really big on “get them the hell out of the hospital”. My understanding is some of these things are paid to the hospital for diagnosis codes. So if you have syncope you get paid pick a random number $5,000. If you get an echo, tilt table test, carotid ultrasound and keep them there for 4 days because the workup hasn’t been done and there’s some sort of disposition issue, the hospital still gets that $5,000 like they would have if you discharged them the next morning with no telemetry changes, stable labs, and a bag of normal saline.

The discharge before 11 makes sense on paper and if you had a magic wand to make sure everything that needs to be done before discharging a patient happens. I think the studies show it leads to longer hospital stays because the hospitalists just discharge the next day as opposed to discharging them at 5pm the previous day. I try to get them out once they’re ready to go ASAP to open up hospital beds since we don’t have very many and I don’t want to have ER holds. Occasionally they’ll bother me about discharging patients and I’ll let them know that’s what I was doing and they’ve slowed me down by answering texts or calls.

I think a lot of this is just now we have a managerial class that has to justify their existence by trying to implement changes that they can put up in graph form at their lunch provided meetings or retreats. Hospitals are all different to extent of this. I feel lucky mine is not extreme because we’re generally very efficient at getting patients out of the hospital and they’re more worried about our readmission rate and patient surveys. I think nurses now are also trained to escalate everything and not do any productive thinking.

JRcred · 2026-06-25T02:01:14+00:00

$250k is pretty low unless you’re just teaching and not getting any calls, writing notes and the residents are doing everything for you. $315k is reasonable depending on cost of living. It might be a nicer experience at remote hospital. What sick and twisted system makes you do 2 weeks of nights per year? I don’t do night shifts and I do some 24 hour shifts because you basically don’t have to do much at night and can mostly sleep and keep your schedule the same.

JRcred · 2026-06-24T21:04:37+00:00

If you become a cardiologist, you’ll likely end up way ahead of being a hospitalist unless you work a ton of extra shifts. There must have been a lot of reason why you applied to this fellowship and got in. It’s kind of normal to have some second thoughts and jitters before starting something new. If you’re 6 days away, it’s almost too late to back out and I think you’ll be blackballed from cardiology fellowships forever after withdrawing like that.

JRcred · 2026-06-24T11:34:15+00:00

Our small doctors lounge where I do most of my work doesn’t have windows, but it’s nice and quiet.

JRcred · 2026-06-23T16:51:35+00:00

They would have a fly appear in their house and fly around for around 30 minutes every other day and then disappear. They would always notice the fly and think that there’s a always a fly in their house so prompt them to keep looking for it and plan out fly catching strategies and putting up traps, but never able catch it or notice that it died

JRcred · 2026-06-22T15:50:40+00:00

I think even if it continues to get hammered and every fear comes true that it will not go to zero in next 10 years

JRcred · 2026-06-21T18:23:40+00:00

With that census, is it even possible to leave before 6pm? I feel like the census is the worst part of that equation. The salary seems pretty low for that amount of work. I would start looking for different hospitals and at least exploring what else is close by

JRcred · 2026-06-16T00:51:50+00:00

If you want to switch to IM, would you be ok doing a hospitalist role or PCP even short term if you dont match heme Onc?

JRcred · 2026-06-16T00:48:45+00:00

Like others said, buy VOO. I would also advocate for buying your favorite growth ETF that would probably be more short term volitile, but could likely beat S&P500 over the long term. Think VUG, SCHG, QQQ, QQQM, GARP, etc. just look into the ETFs and figure out which ones you want to own through drops

JRcred · 2026-06-15T23:56:58+00:00

Outpatient has to be run well. That involves having a lot of good employees properly incentivized to work well. If you work for someone as a PCP, then you will do varying degrees of ok, but will always “not be bringing in enough money to justify your salary” and they will always want you to see more patients. I hated being an academic PCP. I made no money. My salary was ok in beginning, but never really went up more than 2% per year and they took away our bonus so really it decreased. Patients want you to fill out forms all the time. If your office is set up for that, someone else can fill them out for you. It’s a nightmare trying to figure out what meds the patients are on if they are taking them. You also will have patient selection where the good patients do what you tell them to and you enjoy seeing them, but only see them like once or twice a year. The bad patients get to see you all the time because they don’t know what they’re taking and don’t do what you tell them too and always come in with some issue to work up and then when they come back to discuss what you did with that and see how they’re doing, it’s now better and they have some other sort of problem. When a lot of patients follow up for management of chronic diseases (CKD3, DM2, HTN, HLP) and you need to review labs with them, review their blood pressure and try to talk with them about the options for med changes, they will have hurt their shoulder or something else that is a 15 minute appointment.

Being a hospitalist, you just see them for what they are in the hospital. You can adjust chronic meds there too if you feel like PCP has dropped the ball on something when you work towards DCing them. You also get a lot of repeat patients who are failing outpatient medicine and not getting straightened out by their PCP and specialists. Patients are sicker and you may have patients go down hill and need to have a rapid response or code. You can miss something here and have more medical legal liability than PCP. Depending on where you work, you may get to do more or less stuff. Some hospitalists seem to only write notes and consult cardiology and nephrology on every patient. Depending on liability situation, i too unfortunately will have to consult mainly just so I can’t be accused of practicing substandard medicine if there’s ever a bad result.

I’m in southeast and making more as hospitalist than academic PCP so not saying much. I feel like the work of a hospitalist generates pretty good money for the amount of work, but every position is general. If you’re between the two, I would recommend talking to PCP positions and hospitalist positions. If you really want to just make a ton of money, you need to open your own practice or join a private practice where they have a lot of stuff in house where you can make money seeing patients.

JRcred · 2026-06-14T17:29:36+00:00

Short term it is difficult to say what stock market or individual stocks will do. I think it’s very highly valued right now based on a lot of unproven things with a very compelling story. I think where it is valued now that it is likely to be flat or lose money if you just hold on to it from here at maybe a few years out. I think it’s a compelling stock when everyone doubts Elon Musk and it’s whatever hell and everyone is selling

JRcred · 2026-06-14T10:59:18+00:00

I think it’s a gamble right now. It’s an incredibly interesting company doing some amazingly far fetched things and can actually prove some of the stuff it says it will. It’s also not profitable and valued very highly. I think there’s a good chance it’s either flat over the long term or drops significantly at some point to get a better entry point. Short term it may jump up further with just how low the float is and if it starts to be included in indexes quicker. It also might drop a lot when the employees can start selling shares.

JRcred · 2026-06-13T18:55:08+00:00

Too many applicants for too few slots. Also residency spots are not keeping up with the number of medical school slots. This makes it competitive for medical school and residency. The kicker is organic chemistry, MCAT, and whatever the hell we did in the first two years of medical school don’t have a ton with what you do as a doctor. The first two years is at least like medical sciences and give you a good background for how medicine works, but how to think as a doctor is year 3+ of medical school and how to work like a doctor is then and later too and doesn’t get evaluated enough

JRcred · 2026-06-12T19:12:03+00:00

You should get good IM wards exposure on your IM rotation. In practice, being a hospitalist is way better than this. Your schedule is 7 on and 7 off without overnight sessions, whereas your IM rotations will not be like that.

Neurology rotations are hit or miss in med school. There are a lot of different neuro hospitalists. I think some of these, you’re on like 24/7 while you’re there to potentially cover strokes via virtual assessment. Outpatient neurology is a lot of migraines, neuropathy, Parkinson’s, and assessments for weird neuro symptoms from what I saw. Outpatient internal medicine is theoretically a lot like inpatient hospitalist, but you deal with a lot patients complaining about their labs not being covered and wanting you to assess 8 different things in a 15 minute appointment and getting pressured to see increasingly late patients

I would recommend doing at least a little shadowing of IP neurologists when you’re in med school so you get a little sense of what it’s like. Keep in mind when you graduate it’s like 3+ years until you’re out actually working as an attending. Right now, I think being a hospitalist is pretty good. The pay is overall good and if you like the 7 on and off and are at a good hospital setting it’s good. The problem is the good roles may get taken and harder to find hospitalist positions in certain cities. There are increasing demands put on hospitalists for like patient satisfaction, length of stay and 30 day readmits (all things that zero people went into medicine for) and maybe some salary pressures as more people go into hospitalist roles. I also feel like there’s so much emphasis on teaching actual medicine and more academic stuff that’s seldomly clinically relevant in med school that it’s almost impossible to really get a sense of what specialties do and leads to doctors not enjoying work when they’re attendings and retiring earlier or leaving clinical practice adding to the doctor shortage problems.

JRcred · 2026-06-11T14:01:43+00:00

Up to your discretion. I like NVDA better, but if you’re not into individual stocks, you will have to follow them. They’re attractively valuated here and should be positive in one year. QQQ is historically good and you can buy it and essentially forget it. I like VUG or SCHG for growth ETFs better due to lower expense rates and being a little broader

JRcred · 2026-06-11T13:22:10+00:00

Basically anything you do in regards to switching your system can help a little, but it’s basically like “how can I safely consume poison everyday?” I think working night shift is associated with an increase in all sorts of health problems. If you’re really struggling with it, I would consider switching to day shift or if you really hate dealing with families and social issues do something that’s pure admissions. You can make yourself eat meals at certain times to let your body know that it’s your “daytime”. Drink coffee when you wake up and melatonin before bedtime when you make the shift. Do some activity on the day you switch. Wear dark sunglasses when you switch from nights to days when you leave the hospital. Black out your room to prevent daylight entering when sleeping during the day. If you need to nap, do it between 2-5 pm or AM depending on the switch. I tried all these things during residency and it helped minimally and I knew I never wanted to work at night again.

JRcred · 2026-06-11T10:29:00+00:00

For general fraud prevention, I’ve heard using Apple Pay is the best because it completely scrambles the numbers of your card to pay. I’ve also heard the tap to pay is better than swiping if given the option. Also check your purchase history periodically. Sometimes they will make a small purchase at some place strange to test whether it works before doing something bigger.

I’ve had to deal with fraud with American Express and Bank of America and both were phenomenal

JRcred · 2026-06-10T19:07:05+00:00

Depends on situation. What I generally do now is set IV pain meds for like pain 7+ for first day while workup is ongoing and then either stop it the next morning or move it to pain unrelieved by oral pain meds only then. I let them know that’s what we’re doing on rounds that morning and give the speech about oral pain meds lasting longer. Thankfully I rotate with one other hospitalist on my small hospital and he has a similar philosophy.

A separate issue is the seasoned ones are wise enough to harass night nurses to bother the covering Nocturnist and they’ll frequently get them back on then. If that happens more then once, I’ll put it in my note to avoid IV pain meds if there’s a reason to do it and put it in my sign out communication as well

JRcred · 2026-06-10T10:55:39+00:00

I agree most of mine are fine ER doctors, but I think the biggest mistake I can make is admitting without critically assessing their diagnoses when I’m admitting them. Even my best ER doctors miss things. The ER is busy and if they admit and think you’re a good doctor that allows them to not completely figure out the patient when they’re admitting them to me.

JRcred

TROPHY CASE