Welp, #medtwitter, here we go. for context: I do both bc it gives me more time to work with residents (I'm an APD for our small IM program). while I trained as a general internist-pediatrician 1st, I've been an intensivist for the last 12 years, so consider my bias... 1/ https://twitter.com/DrPhilipVerhoef/status/1353936742085136385

"Why being a hospitalist is 100x harder than being an intensivist." in no particular order. and not to diminish the work of my ICU peeps. this might all be "the grass is always greener on the other side" but as one mentor said to me "Phil, the grass is brown everywhere." 2/

1: documentation. in the US, ICU documentation (for the sake of billing) can literally be 3 lines long: "patient on pressors, might die, spent 45 min." for hospitalists, getting E/M coding right to optimize reimbursement (a disaster for a separate ) is... challenging. 3/

2: ICU treats patients with SYNDROMES (set of associated symptoms/signs) like sepsis, shock, ARDS. we have a few syndrome buckets that we put patients in and then we use the same tools to treat anyone in that bucket: think lung protective ventilation/diuresis for all ARDS. 4/

2 cont'd: Hospitalists treat patients with DIAGNOSES. they figure out what is wrong with the patient, and then choose the right treatment tool. Needless to say, the toolbox is much bigger, and making the actual diagnosis is tougher than just pattern-recognition of syndromes 5/

3: speaking of toolbox: in ICU, I use the same set of 20 drugs over and over, and don't have to learn all the new drugs that people are on as outpatient. once in a while we get a hot new ICU therapy (like AngII) but it's not like that one is hard to understand. 6/

3 cont'd: Hospitalists have to know ALL the new drugs, and their adverse effects, because their patients are on them! I still can't get over how many new therapies there are for diabetes in the last 12 years since i finished residency. so much nuance in treatment! 7/

4: physical exam. ICU peeps: how often does your exam matter? I get the bulk of my data from monitors, vents, and talking to the nurse. It's rare that I hear a murmur on an intubated patient and EVERYONE'S lungs are coarse. my neuro exam is a pupil exam + painful stim. 8/

4 cont'd: but the physical exam for a hospitalist is a BIG DEAL. you're actually tracking lung sounds, heart sounds, swelling, mobility, cognition, symptoms, the wound site, spreading erythema, etc... because you don't have data from a monitor or a vent... 9/

5 dispo. ICU transfers to hospital medicine for dispo and basically never dispos themselves. And dispo is tough. depends on patient/family wishes and dynamics, resources available, health insurance, nature of illness, mental status, physical function, home needs...so complex. 10/

6 priorities/philosophy. Often, ICU care means stabilizing and ruling out things that can kill a patient. Once that's done, the hospitalist has to pick up the pieces... in fact, ICU may never diagnose; they just say "welp, whatever you've got, you don't need us!" 11/

7 staffing. I get spoiled in the ICU. there's so many nurses and RTs around so i can get help whenever i need it. Out on the floor, nurses/RTs carry many more patients and can't simply drop everything when i need them! this is by design, of course, but it's still a challenge. 12/

8 time course. in the ICU, if something isn't working, I know almost immediately and i can shift gears/try something else in real time. In hospital medicine, you have to wait longer... fortunately not as long as in the outpatient world, but it still tests my patience! 13/

9 evidence base. ICU is a mix of some evidence (again, for treating syndromes so not very personalized) and a whole lot of physiology guiding decision making. Hospital medicine has a much larger evidence base to guide decisions. the hospitalist has to know so much more. 14/

10 interacting with patients. Obv, ICU doesn't do this much. It takes time and energy! i def enjoy it, but i also feel more drained after the process, and it can be really challenging when patients are delirious or have dementia 15/

clearly there are unique challenges in the ICU: a much higher mortality rate, the stakes/risks are higher for many interventions, and often, there is little you can do to reverse the course of nature, which can make you feel really really helpless. 16/

And of course there are great elements to working in the ICU, which others have written about. for me, one of my top favorites is the active teamwork (and lack of hierarchy): we all have roles and we all work together in real time. 17/

but on the whole, to me, hospital medicine is not EASIER. It's just DIFFERENT. it's funny, i've met so many trainees who consider ICU (because it can be super exciting) but ultimately realize that hospital medicine provides exactly what they want. 18/

and many intensivists will tell you, they'd be terrified to manage floor patients again, which used to strike me as odd... until I started rounding as a hospitalist. I do really enjoy it... but it's much more challenging for me than just walking in to the ICU. /fin