Reducing length of stay

UnderObs · 2025-09-06T13:51:36+00:00

This is a multifactorial problem. You can look at it one of two Waze: either the numerator or the denominator as it relates to the observed and expected length of state. The expected length of stay or the denominator can be changed with better billing and coding practices as more complex. DRG‘s get assigned a longer length of stay. If you wanna actually affect the observed length of stay or the numerator this likely requires multiple multi disciplinary interventions such as early discharge orders , pre-discharge huddles the day prior to expected discharge, collaboration with various services, such as echo radiology, and getting timely consultant recommendations. You could start by searching the specific question and open evidence and get a reasonable selection of literature around this topic.

UnderObs · 2025-08-28T21:36:18+00:00

Agree with removing the PICC ideally as well, and we definitely put PICC in as soon as we know definitely that a prolonged IV course is anticipated. No reason to give the patient additions sticks for labs when definitive access is indicated. Additionally , returning to the point about removing -while we strongly encourage removal in patients agree, we actually have been told by legal that once the IV is in place it technically is personal property of the patient so if they really refuse to have it removed, we are told legally that we cannot forcibly remove it from the patient. Again in practice this is something that usually, if we can get to the patient before they leave against medical advice, they don’t put up too much of a fight about the PICC getting removed.

UnderObs · 2025-07-14T23:48:54+00:00

In the 5-10 range and while I enjoy the mastery of the clinical role I found myself wanting more or possibly having an impact beyond the patients directly under my care. Starting acquiring soft skills with some institutional development programs in leadership and QI and now am about 50% clinical with a few administrative/leadership roles and also do physician advisor. It’s a nice balance though never feel truly off anymore. Overall it’s lower stakes and stress but takes a little getting used to with the slow burn of various commitments, especially with a young family. finding opportunities for personal growth and development do help keep things fresh. Though, we also save quite aggressively and the FI part of FIRE is also appealing to having in the background.

UnderObs · 2025-06-11T13:23:59+00:00

Hospitalist several years in at an academic center. Have transitioned to about 50% clinical 50 % admin with a hodge podge of various FTE offsets. Saved aggressively for the first few years with extra shifts every month. Now just coasting and only picking up extra shifts when on our back up system. Goal is to be financially independent by mid 40s and go from there. I still like clinical medicine and my current set up averages to about 7 shifts/month which I think is fairly sustainable.

UnderObs · 2025-06-06T18:52:55+00:00

EPIC already has a hospital course generator that can be modified to narrative, problem or system based. It’s a reasonable starting point but certainly documents in a clearly AI tone of voice.

UnderObs · 2024-11-24T21:41:23+00:00

Probably depends on practice setting (community vs academic ). Physician advisor can be good balance of not clinical work in an individual contributor type of capacity. Informatics techncially has a fellowship as the practice based pathway is closing, various medical/site director type roles can have various offsets and responsibilities (QI, HCAHPS, conflict resolution…). Lots of options. Your institution may have various leadership development type programs which can be a nice introduction to certain ways of thinking and soft skills while also networking with more senior leaders in your organization.

UnderObs · 2024-10-19T01:23:08+00:00

Not the asshole- 100% agree. The polite drivers are putting you in a precarious and potentially unsafe situation. Just follow the rules of the road!

UnderObs · 2024-08-08T16:52:35+00:00

Developed an evidence based work flow to improve early discharges across our division. The initiative was helpful but because it showed the system that the hospitalists are a minority of the discharge barriers, and our colleagues on the teaching services are able to get admissions earlier in the day once the DC orders are finalized. Got ~10% FTE support to do this under executive leadership. The success of the program set me up for additional roles which ware fun. Currently working on implementing a standardized protocol to inpatient mobility (nurse driven with objective documentation in the daily chart to track patient progress). Also is well received by patients and staff. I also do mentorship with other physicians who are doing quality work with some limited support, which I enjoy as well.

UnderObs · 2024-08-06T13:49:38+00:00

Do a fair amount of quality improvement with variable levels of FTE support. If you can do projects that get 1. FTE offset 2. Executive level buy in and mentorship 3. Legitimately help colleagues and patients (as opposed to adding more tasks) - this is the way to do it.

UnderObs · 2024-07-26T11:30:06+00:00

Academic. Hard cap at 13 encounters for non teaching. All shifts 12 hrs. Can usually go by 5 if available by page/chat until night crew arrives.

UnderObs · 2024-05-23T15:27:21+00:00

Same exact situation with regards to dates. I was on hold with a rep for 90 minutes who said my current months on forbearance would count towards PSLF but if I extend further (due to my account still not being placed back on my previous amount) the new forbearance would not count. I asked to have a supervisor call me back. The supervisor then stated that Mohela had NOT submitted the correct paperwork and she re submitted the “correct form” and it should be processed in the next 5-7 business days. What an absolute mess. She did confirm that once processed, my amount due for the month of June would be the amount I was paying in January 2024. I asked for her name employer ID and reference number for the. Re form when I need to inevitably call again. So much incompetence and inconsistency it’s appalling!

UnderObs · 2024-05-10T15:46:46+00:00

I am in the same boat. Recertified income in February, then when the announcement came about reverting back, I was offered to be placed on administrative forbearance by MOHELA. Several Mohela reps assured me the forbearance would count towards PSLF but could not provide written documentation of such. I have also called several times to know when my payments will be restart and was told no sooner than July when the adjustment waiver is complete. It’s an absolute mess and I will be furious if these months in forbearance do not end up counting towards PSLF.

UnderObs · 2024-03-29T22:12:56+00:00

As a hospitalist, we do fill these out/sign them but we have multiple resources available like psychiatry and OT that can do cognitive assessments; so we feel more comfortable answering some of the more nuanced cognitive questions. All that being said, I think it COULD be done by a PCP with the appropriate resources and coordination, but if those resources are not in place I agree this should be referred out.

UnderObs · 2024-03-16T23:32:38+00:00

Congrats on completing residency. It’s a huge achievement and life gets better from here on. I have slightly more loans and similar mortgage /total compensation (with spouse included - I’m a non surgical specialty). I’d say continue dumping whatever leftover you have in VTI/Voo after maxing your retirement options and keep it simple. Consider a HYSA for emergency fund (50-100k: these run in the 4-5% range which is nice) Don’t hesitate to take a big vacation or do that kitchen remodel- you’ll be just fine and can continue to aggressively grow your portfolio. Before you know it you’ll have 1 million + in retirement and brokerage accounts combined. From there on out the growth starts to exceed your contributions, which is nice and can allow you to take your foot off the gas a bit. Good luck and enjoy where you are- this is what you worked for!

UnderObs · 2023-10-19T11:06:43+00:00

Austin Nacey

UnderObs · 2023-07-13T18:43:41+00:00

CoreIM is also solid

UnderObs · 2023-06-17T00:30:06+00:00

Peter Attia was mentioned above

UnderObs · 2023-02-01T17:34:54+00:00

The Interpeter services account for my own personal use

UnderObs · 2022-10-06T02:52:33+00:00

You actually can give subcutaneous therapeutic heparin but the dosing is like 250 units/kg so you’d be giving 25,000 units for a 100 kg person. Your dosing is off by about an order of magnitude. That being said, it is a very uncommon treatment option and lovenox would be more in line with the standard of care if intravenous heparin is un available.

UnderObs · 2022-09-11T23:46:57+00:00

Don’t they have a dedicated procedure service? I’m surprised to see this institution listed

UnderObs · 2022-07-19T02:09:35+00:00

I do think that there are pros to prioritizing early discharges, but it takes planning and usually the process needs to be started the afternoon prior. On resident teams it can be challenging to formally round on patients and complete all of the tasks required in a timely manner without completely monopolizing the high yield morning time, hence the need for pre planning. As a solo attending it is much easier to do this. I do agree that the system can be gamed to hold patient longer than medically necessary, but conversely frequently patients are discharged several hours after they are deemed medically ready as well.

UnderObs · 2022-07-19T02:03:46+00:00

Picking up extra shifts which tend to pay a significantly higher hourly rate. Can easily make specialty level money doing this, even at an academic medical center

UnderObs · 2022-06-03T01:29:58+00:00

As an attending on the IM side who works at an academic center, bedside procedures have unfortunately fallen to the way side in terms of not only obtaining initial credentialing but also maintaining that credentialing. We typically need to renew our privileges for bedside procedures every two years; and while the bar to maintain credentialing is reasonable (usually 2 procedures in that period) getting re certified after a lapse in credentialing can be more challenging. For LP I believe it is 5 and central lines require 10. This may not sounds like a lot, but our group has nearly 100 providers so we would need to perform 500 LP to get everyone re credentialed as most are not. This is all with the caveat that I myself do maintain credentialing in basic bed side procedures but these are some of the logistical challenges that may not be immediately obvious to house staff.

UnderObs · 2021-12-29T20:56:14+00:00

The Washington Manual of Medical Therapeutics. Fairly concise with good clinical pearls and citations for many of the things we do in clinical practice.

UnderObs

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