A Day in the Life of a Hospital-employed Neurologist
One of the most difficult decisions most fellows and residents face is what type of practice setting to enter after training. Academic? Private practice? Clinic or hospital? For Robert Sterling, Jr., MD, MS—as for many physicians—the choice was impacted by the need to start paying down his loans. “The finances absolutely influenced my decision,” Sterling notes. “Staying with academic would have been very comfortable, because that’s what we experienced as fellows. But it’s not always feasible financially.” With finances as one of his decision points, Sterling focused his attention away from academics and toward clinical practice opportunities.
As it happens, timing was on Sterling’s side. Just as he was finishing his neurophysiology fellowship at the University of Maryland is about when hospitals were starting to get serious about bringing neurologists on board in more numbers. Sterling began his post-training career in 2007 in an employed practice of five neurologists sharing inpatient and outpatient responsibilities for York Hospital in Pennsylvania, part of the WellSpan Health system. Not long after, as the senior neurologists in his group began retiring or moving on, Sterling learned there was a need at the hospital for more help on-site. One thing led to another until he was providing full-time neurology care for WellSpan. Today his titles are Division Chief of Neurology, and Medical Director of WellSpan’s cerebrovascular service line, which includes the newly credentialed comprehensive stroke center. In these roles, he serves as an inpatient consultant covering the entire spectrum of acute neurologic illness—emergency room, routine admission, intensive care unit—as well as telestroke evaluations for three partner hospitals.
Sterling also gives occasional lectures and maintains daily involvement in teaching the medical students, residents, and fellows who rotate through his hospital, which means he gets to take a bite out of the academic apple after all. In an odd way, Sterling almost didn’t need to choose between different career paths, since his post-fellowship work has included elements of private practice, academic roles, clinic leadership, and inpatient and outpatient care, all while employed by the same hospital. In addition, he will soon begin a one-year term as president of the hospital’s medical staff, an elected position that follows two years as vice president. These leadership roles let Sterling step out of his neurology arena to engage with the broader medical and administrative staff.
This variety of work suits Sterling well. “I love it because I have that thriving interaction with other physicians and specialists, and the emergency department,” he says. “This situation is a happy marriage between the academic and the practice components.”
A Career that Allows Growth
Now 13 years out of fellowship, Sterling can see the transformation of both his position and the role of neurohospitalists with some clarity. “In our training, we were heavily focused on the hospital setting, but the idea of a neurohospitalist didn’t really exist,” he notes. “When I joined WellSpan, all of the physicians did double duty. They consulted and they helped out in the hospital.” This model evolved, Sterling says, when they began to realize they needed neurologists in the hospital more than just a couple of hours per day. Now they have three neurologists on board full-time, supported by a nurse practitioner. Services have also expanded to include neurologic care through the stroke center and an epilepsy monitoring system, as well as hardwired EEG monitoring available in the ICUs.
“What I feel happened is the build-it-and-they-will-come phenomenon,” Sterling explains. “The more we were present, the more consults we were able to serve, including a lot of neurologic care that we had been sending elsewhere because we didn’t have the staffing or expertise.”
Now that neurological staffing and expertise have become his responsibility, Sterling has been watching the neurohospitalist model carefully. “It seems like increasing that denominator as health systems get bigger is important. If I had five inpatient neurologists, that would give me flexibility to think about things like, ‘Do I station one of my partners in the emergency department six hours a day? Would that improve how fast or effectively we see patients?’”
Sterling and his team might get to that five-person group eventually but for the moment they’re focused on increasing the quality of life for the neurologists currently on board. For example, with an eye toward work-life balance, they recently got rid of stroke call for the group. By assigning the night call to a contract group, Sterling says they are helping to ward off burnout and increase job satisfaction for the neurology team. Lack of call is also a powerful recruiting tool. “We want to keep neurologists interested in us,” he explains. “I think anyone who comes in and realizes they don’t have night call, they’re excited.” Indeed, having just added a neurologist to the team, Sterling says, “Our new partner, dare I say, is euphoric about not having night call.”
A Typical Day
Sterling is pretty euphoric himself about dropping call from his duties. While he rues the loss of in-house coverage for this service, he’s very happy to regain that part of his life that call used to command. “It’s hard to say how magical it is to turn off your pager at 5 p.m.,” he says. “Even if I’m there physically, it’s the trepidation of that page that’s going to disrupt your family meeting or what you thought was going to be a 30-minute cleanup of your Epic notes. When you’re taking a whole weekend on call, you’re constantly waiting for the beep, the vibration. You’re panicked when you realize your pager isn’t on your hip. Turning off that pager, it’s kind of a Harry Potter magic moment.”
These days, with call off the list for evenings and weekends, Sterling’s work days are predictable in their length, if not in their content. He arrives at the hospital most days by 9, leaving between 5 or 6. The days themselves are a mixture of patient care, electronic reporting, administrative oversight, meetings, and mentoring with the medical trainees. Then, every few days, he will take his rotation in the group as “urgent neurologist”—the point person for stroke alert for all the WellSpan member hospitals, and for any non-vascular neurology question that comes up. This person takes the pager in the morning, switching over to their regular consults for the second half of the day. Sterling explains the urgent neurologist as a “very pager-centric role. You may be paged 30 or 40 times in a half-day period, do five or six tele-consults and just as many phone conversations. This person is pager-on at 7 a.m.”
Advantages and Disadvantages of the Work
One of the aspects Sterling enjoys about being a neurohospitalist is the cooperation shared by everyone at the hospital. Rather than being solely responsible for patient outcomes, he’s part of a team of doctors and staff who are all interacting with the patient. “That makes us very focused on the ‘pay forward’ and how we communicate with our non-neurology peers and how we describe the other doctors to the patients. Because the patients see so many doctors when they’re here, our review is conglomerated. We’re each just a bit piece of this wonderful stew,” he says.
While hospital employment may be a good career choice for team-oriented neurologists, Sterling has seen that it can be the wrong environment for someone craving autonomy. “In private practice, everything starts and stops with you and your partners,” he notes.
Other advantages of the role that have been widely touted by various employers include mobility within the hospital system, paid benefits that include malpractice insurance and continuing education expenses, and even the potential for sabbatical in some cases. And, while high salaries are not as frequently cited, Sterling believes that many of today’s physicians are willing to trade some income potential for the work-life balance that neurohospitalists often enjoy.
One piece of advice Sterling has for those considering hospital employment is to take advantage of leadership opportunities on staff. Not only does this help build skills while giving doctors more of a voice in the hospital, but it helps strengthen the system overall. “We need more residents and fellows to envision themselves in roles that can marry administration and clinical practice in the future,” he says. “If you can envision yourself in a leadership role, that’s where you not only impact your patients, but you can impact all of the patients under your administrative umbrella and how they’re cared for.”
For his part, Sterling is glad he tumbled into the role and he believes the future is strong for others making this choice. “The neurohospitalist is an amazingly sought-after commodity right now,” he says. “As a neurologist, it’s powerful to be in the position of being sought after.”