Joshua Ronen, MD - Internist and Hospitalist in San Francisco, California

Eva Sheie (00:03):
The purpose of this podcast is simple. We want you to get to know your doctor before meeting them in person because you're making a life-changing decision, and time is scarce. The more you can learn about who your doctor is before you meet them, the better that first meeting will be. There's no substitute for an in-person appointment, but we hope this comes close. I'm your host, Eva Sheie, and you're listening to Meet the Doctor. Good morning today on Meet the Doctor. I'm so privileged to introduce you to Josh Ronen. He's a board certified internal medicine physician with a really interesting specialty and a unique one that we may have never heard of before. So I'm gonna ask you, Josh, to tell us about your specialty so that I don't screw it up. 

Dr. Ronen (00:52):
No problem at all. Uh, again, Eva, good morning and thanks for having me on the podcast. So I am about two years into my attendingship, practicing medicine, internal medicine independently after residency training. And what I can tell you about hospital medicine, I'm actually fortunate enough to be in the Department of Medicine at U C S F and the current chair of the Department of Medicine at U C S F Medical Center, uh, up in San Francisco, California is, uh, Dr. Bob Walker, and he actually coined the term hospitalist. And the simple explanation is, and this was uh, probably when I was still in diapers when this term originated, is before the style of practice in a hospital involved primary care physicians. So this could be in today's day and age if such a system still existed, it would be internal medicine physicians and family medicine physicians that work, uh, in a clinic. 

Dr. Ronen (01:50):
And they would routinely come in and have rounds in a hospital, rounds being going around every single day and checking in on your patients and writing orders and discharging and that sort of thing. So I think as the system has evolved over time, and I'm by no means doing it justice, or Dr. Bob Walker's, uh, article Justice on, uh, The the New England Journal of Medicine, the system changed to allow primary care physicians to focus their practice in a hospital setting, realizing that the sheer amount of patients that they see on a daily basis may not allow them to dedicate the ample amount of time to their patients that are also in the hospital. And they do have a really close relationship with their patients. So it became a partnership between primary care physicians and hospital medicine physicians. And if we were so fortunate as to work with electronic medical records that bridge the gap between the outpatient and inpatient setting, things like Cerner or the uh, epic electronic medical record, then we could easily see what's going on in the clinic to help manage our patients in the hospital. 

Eva Sheie (03:02):
That was one of the bright spots of EMR was that you could actually access records quickly instead of calling over and getting paper faxed. 

Dr. Ronen (03:09):
Oh my gosh, yes. I feel like, and I don't know if this is completely true, I feel like I was at that stage where there was a transition between paper charts and electronic medical record when I was a medical student, when I started, uh, my clinical clerkships, which are the practical years of medical school in year three and year four. So around 2015 the hospital that I was in was just transitioning from paper charts to to electronic. And that makes everything a lot easier. We do have to sift through a lot of records as primary care physicians or or hospital medicine physicians, but it makes it a lot easier that we can access them. And I think dependent on the hospital system, we're fortunate enough, at least at U C S F to have a patient care assistant who's able to locate records for us and request them from outside hospital. So either way, we're, we're getting them electronically now and they're super helpful to bridge care to the inpatient setting. 

Eva Sheie (04:05):
So will you indulge me on maybe two random, like I'm trying to, I always try to draw a real world example for a patient to understand like the context of a specialty. Cuz this, this stuff is complicated. Is there a TV show where you can think of, I know most doctors don't watch medical TV cuz it's so bad, but is there one you can think of where there's a character on a TV show who has the same job as you? 

Dr. Ronen (04:33):
I think one thing that my friends know about me is as much time as I spend in, in the practice of medicine, I also like to watch medical TV shows. <laugh>.

Eva Sheie (04:41):
You do?

Dr. Ronen (04:41):
Some people are like, why do you do that? I'm like, you know what? I do enjoy a little exercise outside of the hospital and a fun one at that, you know, low stakes, just watching a really provocative medical drama. So I've watched Chicago Med, I've watched House plenty of times. 

Eva Sheie (05:00):
I love House. 

Dr. Ronen (05:01):
I've watched The Good Doctor, I've watched The Resident. All of these things I can easily relate to. So I am fully, fully ready to admit that I'm pretty excited about my fanboy nature for those shows. Um, <laugh>. So I, I easily put myself in their shoes. I feel like while medical dramas may not be entirely realistic about the day-to-day practice of medicine and how certain specialties operate, I think they give the public at least a perspective on what the, what the day-to-day of a, uh, medicine physician like me or a surgeon is like, like a show like The Good Doctor that's, uh, surgery in a hospital as a primary specialty. Something like The Resident is internal medicine or a hospital medicine in a schedule as a specialty in the, in the hospital, the primary specialty. So, 

Eva Sheie (05:54):
So if you were a character on The Good Doctor or The Resident, which one would you be? <laugh>, you need me to remind you? 

Dr. Ronen (06:02):
No, I, there's a, I mean in terms of like easily fitting in, absolutely The Resident.

Eva Sheie (06:09):
You're Dr. Hawkins or your Dr. Pravesh?

Dr. Ronen (06:11):
Now I would fit in the shoes of Dr. Hawkins when I was in training, I would be Dr. Pravesh, but they made it very hip and cool in terms of like, for somebody in in medicine to follow along. I mean, you could easily pick out the things that are not exactly as they are in the real world <laugh> because,

Eva Sheie (06:31):
I think most people could pick those things out. <laugh>

Dr. Ronen (06:34):
Yeah. I guess if you've been in and out of an office or in and out of a hospital, you sort of get an idea of of what's what's real and and what's not. And I think that's, that's a big aspect of mainstream media and these TV shows and how they portray the way that medicine is practiced. That's great. That's awesome. You know, I mean I, I feel great to hear that people can pick those things out easily. So, 

Eva Sheie (06:55):
So my other analogy is that, and I think a lot of women who with kids would be able to pick this one up quickly. The hospitalist came about probably at the same time that pediatricians stopped doing rounds in the hospital too. So when you have a baby, the first person your baby sees as a pediatrician and your, your OB sort of breaks up with you, like, your baby's out, I'm done <laugh>, I'm done with you, you're dead to me. 

Dr. Ronen (07:21):
<laugh>. 

Eva Sheie (07:22):
And here comes the pediatrician and in the, I think just in maybe the last 20 years they stopped coming into the hospital. At least I know they did in mine because when I had my kids I was pretty old and I don't, I don't like it when doctors are younger than me. And I think you're probably younger than me, Dr. Ronen, but I just have a thing about experience and so I look for doctors that are kind of like my dad now. 

Dr. Ronen (07:47):
Yeah. <laugh>. 

Eva Sheie (07:48):
And so that was how I learned what had happened in the hospital here in Austin that all the pediatricians eventually stopped going cuz it just, I don't know, I think it was partly political and probably mostly economic. 

Dr. Ronen (08:03):
You know what I can tell you about that. And I think it, it's very dependent on the state and the hospital system. And the healthcare system is like U C S F has Benioff Children's Hospital and that is a place where they have um, routinely rounding pediatric hospitalists. So this term hospitalist has carried over into pediatric medicine as well. In addition to the other specialties, I have a great friend of mine who is becoming a pediatric intensivist and getting further training as a pediatric cardiovascular intensivist, which is amazing. But the pediatric hospital medicine is strong, at least in this healthcare system. And I feel like it exists elsewhere as well. It may not be a burgeoning field in all states at this moment, dependent on availability of those who are interested to practice it. I feel like just like internal medicine, uh, in in general pediatrics, you will get training on how to take care of pediatric patients in the inpatient setting, which lends itself to, oh, if you would like to choose this as a career route after you graduate instead of going to fellowship, it's an option for you. 

Dr. Ronen (09:11):
So it may not be an option everywhere, but I think that the availability of pediatric hospitalists, not being a pediatrician myself, but having close friends that are, you know, it gives, it gives the opportunity to have pediatricians people, physicians that are specialized in care of patients less than the age of 18 in the hospital because of the nuances of their care. They look at adult medicine, like we look at pediatric medicine when they look at an adult, they're terrified. When we look at kids who are terrified, it was like, we don't know what's going on there at all. <laugh>. I mean we all learn the same things in medical school though, right? About pediatric medicine and internal medicine. But uh, whenever we sit down at the table and have talks about, hey, what happened at work today? It's always very provocative. 

Eva Sheie (09:56):
It is incredible, yeah. How much more there is to know and that super specialization I think is a really positive thing for medicine. Yeah. So let's go back to you. 

Dr. Ronen (10:08):
Sure. 

Eva Sheie (10:09):
You're a hospitalist and you told me also you're a nocturnist, you're gonna have to tell us what that is of course. And then I would love it if you kind of gave us a day in the life. 

Dr. Ronen (10:19):
Sounds great. I am a hospital medicine attending physician at UC San Francisco Medical Center. Right now I am duly appointed as a assistant professor of clinical medicine at the adjoining School of medicine as well. I graduated from residency training in internal medicine at Texas Tech University Health Sciences Center in the Permian Basin in Odessa, Texas. And uh, yeah, that's right, guns up <laugh>. Very proud of that root of myself. 

Eva Sheie (10:48):
They always are. 

Dr. Ronen (10:49):
Yes. 

Eva Sheie (10:49):
They always are. 

Dr. Ronen (10:51):
I'm originally from the Bay Area. I'm from San Jose, California. So for the last 10 years I've been to a lot of places. I went to the Caribbean for my first two years of medical school at Ross University School of Medicine. I followed that up by the, the second two years in which I spent most of my time in Los Angeles but also lived in Miami and Chicago for clinical clerkships in, in the preparation for internal medicine residency training and then moved to Texas. And then I was fortunate enough to find this position and get selected for this physician, the UC San Francisco Medical Center as a nocturnist. And my job as a nocturnist and also as a, what we call in the academic space clinician educator begins with being the primary physician for patients that are already admitted to the hospital. Meaning that if there is an emergency nursing staff get in touch with us primarily to address it. 

Dr. Ronen (11:49):
I also serve to admit patients to the hospital as well. So the emergency department pages me says, "There's this patient here with such and so age, such and so history, and such and so problem, I believe they need admission to the hospital. Could you please come and evaluate them for admission?" So all around the world, this is where hospital medicine's job begins. As a hospital medicine physician or an internal medicine resident on a hospital medicine service, this is what you'll be doing. Uh, you'll be evaluating patients for admission to the hospital and initiating appropriate therapy. And this gets into a little bit of an extended version of the question that you originally asked me, but what an internal medicine physician does a nocturnist though, as you, as you asked me primarily works between the hours of 7:00 PM to 7:00 AM or 9:00 PM to 9:00 AM when you can hear a pin drop in the hospital, hopefully, knock on wood <laugh>, that's what we like to say, although we don't actually say it, but since I'm not in the hospital right now I can say it, we don't like to say it within the walls of the hospital. 

Eva Sheie (12:51):
Yeah. Is that like a thing? You can't just look around and go, oh, it's quiet tonight. 

Dr. Ronen (12:54):
Yeah. 

Eva Sheie (12:54):
Cause you're dooming yourself to a very bad night. 

Dr. Ronen (12:56):
Yes. We cannot say, we cannot say the Q word <laugh> at all. <laugh> if I, I said that as a, as an internal medicine intern in the ER and everybody turns around and looks at me and me like, dude, why did you say that <laugh>? And then the, there's a like a horrible night from that point forward and the next time that I step in the emergency department, all the staff are giving me stink eye, you know, so yeah, so we cross cover and we admit patients and uh, my particular job was for the cross coverage and admission of patients to the hospital medicine service as well as the, uh, cardiovascular disease service. And the latter service actually had a couple of different branches. I would contact patients that have general cardiology type issues such as abnormal heart rhythms or heart failure or having heart attacks actively, or patients that are an end stage heart failure and need advanced interventions that are only available at this hospital in at U C S F where all of the specialists are located, at least in the greater Bay Area. This is a referral center for those types of patients. So as an example, these are the types of patients that I come in contact with. 

Eva Sheie (14:09):
How often do you have to wake up a colleague in the middle of the night and have have them come in or ask them a question? 

Dr. Ronen (14:15):
You know, that's a really great question because on when I'm working on those subspecialty services and I feel like this particular program of a cardiovascular disease hospitalist is nuanced for folks that are interested in practicing more medicine of a cardiovascular variety like general cardiology or heart failure in an academic center like this or maybe not as big of a center, we work directly with a cardiologist at a big center like this. My first call is generally to a cardiology fellow who is an internal medicine trained now after three years, has chosen to pursue as a subspecialty and is doing another three years of cardiology. So internal medicine is three years, cardiology is three years to be a general cardiologist, it takes six years from graduating med school. And if I have a question about E K G or a patient that I'm seeing, I'm concerned that maybe they're decompensating. 

Dr. Ronen (15:08):
All of these things are things that I was trained to identify as an internal medicine physician. Folks I feel like may not be fully up to speed on what an internal medicine physician does or how is, I should say, how a internal medicine physician is trained. We get a heavy, heavy, heavy amount of training in the hospital with hospital medicine and intensive care unit medicine. And that was, I feel like, exemplified during the COVID 19 pandemic. You know, folks were, uh, taken off of, you know, backup services or clinic to support the I C U and even hospital medicine because of the sheer amount of patients that we were seeing. So I often, on the cardiovascular disease services, I have to consult a cardiologist, whether that be the fellow or the attending a physician in cardiology. And they are more than happy to assist. It's a very tiered system. 

Dr. Ronen (15:59):
One that was different than I was accustomed to in um, in residency training where if I had to call up somebody in the middle of the night, it would be an attending physician directly and it'd be a lot more intimidating cuz you're like, I need to make sure that I have everything together before I wake up this guy. And that may be any, any specialist, you know, and we all know in the back of our minds, you know, some specialties. Like they may wake up and be like, okay, okay, what's the problem? It's 3:00 AM But that helps us be prepared and be better. Hopefully when we pick up the phone and call them, 

Eva Sheie (16:29):
You can determine their reaction by their specialty <laugh> willing to be woken up and unwilling. 

Dr. Ronen (16:34):
I feel like all specialties, and I, I don't wanna speak for every specialty, but I feel like we have stereotypes for each other. <laugh> I followed for a long time, uh, Z Dog MD, I loved his humor. 

Eva Sheie (16:46):
Me too. 

Dr. Ronen (16:46):
And the way that he like interwove all the different specialties in medicine. So I feel like that humor, that natural camaraderie between each specialty is there, but you know, everyone identifies that okay, they can do something that I can't, but they're also also nuances of their specialty that are like, oh, you know, why do they do this? Or why do they do that? Or they frequently consult us for this, you know? So that aspect of the relationship in between specialties I think is something that's very special. And medicine is a primary specialty. Medicine is the specialty in the hospital, which will admit you to most hospitals in the United States. So we will be the ones that first contact you and will involve specialists as needed, dependent on your condition. 

Eva Sheie (17:30):
Is it safe to say or to assume that a lot of the people you see are really in trouble? 

Dr. Ronen (17:35):
They could be. And what separates an internal medicine physician, I think from a family medicine physician as far as the training is concerned, and that's dependent on location, is that we spent a lot of our time in the hospital as I alluded to earlier, family medicine. Like I, my, my, one of my first cousins is, is uh, just graduating from family medicine training this year and he works at a university hospital just like I do right now, but there are tons of other specialties there. So that means that his program is unopposed. There is an internal medicine program there and they share privileges inside of the hospital seeing patients in inpatient hospital medicine. But there are family medicine programs that are in more rural areas that get a plethora of experience in the hospital medicine setting, to which point that they don't need extra training after residency to become hospitalists. 

Dr. Ronen (18:23):
So if my cousin wanted to get, uh, training in hospital medicine, he'd have to do a fellowship for one year in hospital medicine in order to be able to practice. But folks that are trained in family medicine as well in rural areas get all this experience in the hospital. They could practice very confidently in the, in hospital medicine without fellowship. And we could both by that extension identify when a patient is critical or their tendency to become critical. That is the beautiful thing about our training is that we're able to identify biomarkers, physical examination signs of decompensation and be like, you know, I don't look like how this patient feels. I don't like how this patient looks. I need to get some ancillary studies, more diagnostic tests and be very aggressive in my management and consideration of subspecialist consultation as well. So I'd say it's 50/50, obviously I hope that patients come into the hospital and they don't ever hit that point of needing to be considered for an intensive care unit, but we need to be able to identify those clinical signs to be able to catch them. 

Dr. Ronen (19:36):
I like to say catch them before they fall because oftentimes patients come into the hospital from what I noticed, you see these patterns that they come into the hospital oftentimes before they decompensate, right before they decompensate, right before they, we term crash. And we need to be able to identify the signs of that so we can cushion the fall. Even if that means they have to spend some time in the I C U. A lot of times that's not possible because we don't have control over the disease process. We can just support them the best we can with the best medical care that is currently available to us. 

Eva Sheie (20:15):
Is there an emotional component to this relationship you have with your patient? People are in trouble or they're about to be in in big trouble, you know, they're in front of you because something is very wrong. How do you build trust with a patient like that when they're also in a, a heightened emotional state or they even the people around them who might have come to the hospital with them? 

Dr. Ronen (20:39):
You know, one of the, um, challenging parts of this job is having to have difficult discussions with patients and families about what's going on. And oftentimes, you know, at night families may be at the bedside with their loved ones or they may be at home and dependent on when they left the bedside to be with their loved one, I may or may not have the opportunity to speak to them on the phone because it's 3:00 AM and their phone may be off or they just don't hear it. Sometimes I do, sometimes they're at the bedside and I like to come in prepared as far as from the hospital medicine standpoint, being the one who's admitting them into the hospital and being responsible for their care overnight and letting them know, okay, from A to Z this is what's going on. I've looked at the data, I've looked at the, what the emergency department has told me, I have maybe also had some time to take a look at your past history as well as far as your clinic records and synthesize it all together with your history and physical examination today. 

Dr. Ronen (21:38):
And using this information, I could reliably more often than not prognosticate whether this is gonna be a routine admission for this patient and they're going to be discharged within two to three days, or it's gonna take some time before we actually settle the problem down. And when it's complex, when the patients are sick, I tend to be very forthright with their families because I don't want any surprises as far as the family coming back and saying, oh, we didn't know this was going to happen. And that's when I feel like we take those very essential skills that we learned as medical students and residents about how to communicate with families. Believe it or not, this is a part of training. Some of it I feel like is ingrained inside of you in terms of being a good communicator. And uh, I start by saying, you know, "Madam, I've had the pleasure of being chosen to take care of your loved one and unfortunately this is what's going on with them and this is the course that I could potentially predict for what's going on with them. 

Dr. Ronen (22:42):
We're doing everything we can to support them and rest assured that if they get worse at any time, we're here to catch them and, and take care of them and amplify the level of care as needed in terms of upgrading them to an ICU U level of care if needed". Or the intermediary between a regular floor and an ICU being a step down unit in most hospitals where we can take care of patients that are sick but they're not sick enough to go to an intensive care unit. So I often have to have those talks with the patients and their families and be very honest. And I think that's something that I've learned is a strength of mine is, uh, being honest and forthright about what's going on because at the end of the day, later on in the hospitalization, the patients and their families value that. 

Eva Sheie (23:30):
Do they ever ask you questions that you feel like you really don't want to answer? Or this feels like a really challenging question and I'm gonna have to think really hard about how I answer this. Does that happen? 

Dr. Ronen (23:43):
I think that is one of the greatest practices as a conversationalist that we can all learn because I feel like in medicine, I mean I've worked now this year, I've worked some during the day as well, rounding and taking care of patients and it does one justice to take a deep breath, maybe internally subconsciously taking a pause before having a response. And what does that lend itself to? I feel like over the course of the day or over the course of the night, we can be pressed for time and I think reflexively, we, we will have an answer to everything and we might be getting paged to see another patient and maybe urgent or non-urgent, but to be able to take a deep breath and gather our response, in terms of they ask a question like, "Hey Doc, could you interpret this result for me?" 

(24:39)
Or "Hey doc, what do you think is happening to my my dad or my mom or my brother or my sister or my grandma or my grandpa?" I find that in that moment, much like when we have to have conversations about end of life care, families will remember the conversation that they had with me and I want to ensure that they know that I was listening to them. And that goes to for any, any physician in the hospital that sees a patient, but we are especially tasked to develop excellent rapport with our patients to make 'em feel like we're treating them as the, as though we were treating our own family members. You know, so to take a pause and before considering answering a question a patient has, I feel like lends itself to a great interpersonal relationship in the hospital where we are showing them that we're confident about what's going on, but also understanding of the circumstances in their life that brought them to the hospital that day. 

Eva Sheie (25:43):
Over these years, I expect that you've seen a lot of this sort of end of life moment with people. And I I wanna ask you if you have advice for anyone who's not at that stage for what we might think about when we do reach that stage. 

Dr. Ronen (26:00):
You know, uh, one of the admittedly scary parts of internal medicine residency training was to be at the bedside when that happens. And the very honest truth is that if you encounter an internal medicine resident or a internal medicine hospitalist or like I mentioned family medicine, trained physicians inside, outside the hospital as primary care based specialties, specialties that take care of patients inside and outside a hospital, we've seen what death looks like and we've undoubtedly had to have end of life conversations with families. This is another thing that I hope the public knows we get extra training on, but I can't really say perfection. It's communication skills that are developed over time. And what I would ask families before they're coming into the hospital, maybe families that are bringing in a more elderly relative, is one of the first things that we will ask in the hospital before I even start asking any questions is something called code status. 

Dr. Ronen (27:10):
And that means if for whatever reason your loved ones heart stops or breathing stops, what do you want healthcare personnel to do? And that involves chest compressions shocking to patients called defibrillation, and also consideration of placing a breathing tube in their lungs and placing them on a life support machine. That's how the air is delivered through the breathing tube. And that's, that's where I start. I will ask them this question and patients in their families are at liberty to answer however they like. I feel like sometimes patients and and, and their families ask me what they think my perspective is on what they should do. And that's really hard. <laugh>, I can't tell them what to do. All I can tell them is if you do have a cardiac arrest at age 80, because of the way that we perform chest compressions to restart the heart, you could break ribs and the amount of pain that you'll be in afterwards could be considerable. 

Dr. Ronen (28:07):
The event of cardiac arrest is very intensive on the whole body. So I tell this to families, that's what I know about the process. I've seen patients go through it, it's an unfortunate part of this job, but it's a, a very realistic one. And you would want me to know what it feels like to go to experience the care of a patient that went through this process so that I could also relate that back to the patient's family. So this is what I would want families to know about what to expect from you when they come in the hospital as far as this question is concerned. And when it comes to end of life care, if you've been thinking about it and you haven't really been sure how to proceed, uh, with your outpatient physician, we can help you have that conversation in the hospital. 

Dr. Ronen (28:49):
I'm not alone in having that conversation in that in the hospital there are hospice specialists, palliative care or pain management specialists that can help me have that conversation. I also work in a community hospital in San Francisco where there are specialized nursing staff that work in palliative care as well that can help me have that conversation. So whether or not families had that idea of their loved one needing comfort care or hospice care or a primarily comfort focused approach to their care before they came to the hospital or not, we are ready and prepared to have that conversation with you and ensure that we take a compassionate approach to that conversation. Because at the end of the day, this is a conversation that we may have every single day and we realize that it's an incredibly moving one to have for your family member. This is somebody else's life and this is a patient on our list who we want to make, feel like they heard me and they're taking good care of my my loved one no matter what. 

Eva Sheie (29:56):
That aspect of being heard that is is so important. And I can see that you're also a thoughtful teacher and a good listener. So it does not surprise me that you have this, uh, professor role and are also teaching other students who are becoming doctors. So maybe go in that direction a little bit and tell us how that layer plays into your everyday work life. What are you doing to to mentor younger doctors on their way up?

Dr. Ronen (30:24):
You know, uh, I gotta say I felt this when I was in residency training that whenever I had a chance to teach or present to learners or fellow residents or even my attending physicians, I really enjoyed that. And when I, when I embrace this role as an attending physician in hospital medicine and additionally as a teacher, I took it very seriously because I'm also coming from the beauty of the beauty of every single trained hospitalist or internal medicine physician is that we come from different backgrounds in terms of training. Everybody gets the same core stuff, but the way that your healthcare system in residency training was structured can be different. And when I, when I transitioned from Texas Tech to U C S F, I went from a community-based university affiliated hospital to a huge tertiary academic center and they have fellows for every specialty in attendings as well. 

Dr. Ronen (31:24):
So that, that the family tree, so to speak, in in, in U C S F is huge. It's humongous. And when it gets to teaching, I have primarily involved myself, although I don't do it regularly. I have worked on the teaching service so that this is hospital medicine rounding with resident physicians who have graduated medical school and are training to be internist themselves during these days. I round with them, I sit down and I teach them, I'm basically their backbone of support. I also give medicine residents, in fact I am today as well, lectures on commonly encountered diagnoses such as syncope or stroke. So I break, I break these things down for them from a hospital medicine standpoint, what do you need to know? I also work as a facilitator in sessions in the training of medical students, taking them through simulations for respiratory and cardiac emergencies as well as clinical reasoning. 

Dr. Ronen (32:30):
One thing that I've been turned onto since stepping into this clinician educator role at U C S F has been the thought process behind, okay, how do physicians figure out what's going on? It's just like I tell 'em all of these things and then they know my diagnosis. How does that work? Do they wave a magic wand? But the thought process behind the diagnosis is something that I've become really fascinated in, and that is by virtue of working with the students and the residents and with my other, you know, fellow clinician educators that are much more experienced than me, I'm in awe of their experience. This experience working with them has been very eye-opening and very exciting. And frankly, during my time off, such as now I take an opportunity to do that, to refresh my brain and remind myself that, hey, I was once there and I can offer them something unique from my perspective. And that is so fulfilling, it warms my heart and I feel like it's going to be a pretty significant part of my professional future. 

Eva Sheie (33:36):
Speaking of time off, two things. Other than it being light outside <laugh>, what are you enjoying about working during the daytime now? 

Dr. Ronen (33:46):
You know, I'm so glad that you asked that this hospitalist is trying to break into the daytime <laugh>. I wanna give a really huge shout out to the staff that I worked with at night at the hospital where I trained in residency though, because I never would've thought at a residency that I would've started as a Nocturnist. But night medicine and day medicine for internal medicine trained physician, a hospitalist, are vastly different. You know, your role at night is to cover patients, advance care overnight, depending on what happens to that patient overnight. Do we need to follow up on blood tests or laboratory studies or see the patient ourselves to make changes to management if needed, if the admitting physician was concerned, respond to emergencies if needed. A daytime physician does, at least at our hospital at U C S F, does not admit patients when they round, we have dedicated admitters at our hospital, in hospital medicine and my day can start as early as 5:30 - 6 in the morning and it can end as late as six to 7:00 PM at night. 

Dr. Ronen (35:03):
And the crazy thing is you'd be like, Hey man, that sounds like 12 hours. How do you do that <laugh>? How do you do that for five to seven days in a row? And it's crazy. Sometimes after a 12 hour shift, I don't exactly feel tired in terms of like even at night or during the day, yes, my mind feels exhausted, but I'm like, I wanna go home. I wanna, you know, cook dinner, I wanna sit down and relax. But the type of care that we provide during the day, that's more like I have a list of 10 patients, I have to analyze their data on a every single day. I have to engage consultants, I have to think of discharge plans and I have to work closely with social workers to ensure that patients are connected when they leave the hospital with nursing services, therapy services ensure that they have their meds when they leave the hospital and they have connections with their outpatient team. 

Dr. Ronen (35:55):
I'm also actively securely messaging their outpatient physicians, letting them know what's going on in the hospital to gain a perspective on, you know what, if there's something that I haven't noticed about my relationship with them so far in the hospital, the patients that the outpatient physicians can contribute, but they can also have a running update from me over the course of their hospitalization being like, "Oh, hey, Dr. Ronen has been in connection with me since Mr. Smith has been admitted to the hospital and I know there's gonna be a discharge summary, but you know what? I really appreciated the fact that he let me know what was going on. And he also asked me, Hey, is there anything that you think that our mutual patient would benefit from before they're discharged?" So in that way I can sort of prep them and optimize them for a transition to the outpatient setting. 

Dr. Ronen (36:46):
Part of the job of a hospitalist is just this, they come from the inpatient, the outpatient setting, being the clinic to the inpatient setting, and then I have to prep them to go back into the outpatient setting. And the transition from inpatient to outpatient care is just as important and watched and magnified under a magnifying glass as the opposite because we want to find ways for patients to safely transition from their homes or the clinic to the hospital and from the hospital back home. I wish that the public knows that we are constantly finding ways to ensure that it's done safely. Hospital medicine during the daytime can be very tasking. People would ask me, "Dr. Ronen, you're typically a night guy. You're wearing all these fancy clothes now in your white coat. You don't typically do that during the day or during the night". I'm like, "That's right. I enjoy dressing up a little bit". But overall, being able to come in and take care of patients during the day, I feel like exercise is a half of hospital medicine that I don't practice at night. And I felt that part of me felt empty. So I wanted to fill that part back up again. 

Eva Sheie (37:59):
Sounds like the biggest difference was really your choice of clothing for  the day.

Dr. Ronen (38:02):
<laugh>, The nursing staff, the nursing staff noticed that. They're like, "Hey, Dr. Ronen outta your scrubs, huh?" I'm like, 

Eva Sheie (38:08):
You clean up good. 

Dr. Ronen (38:08):
You clean up good. I'm like, yeah, I tried to, you know, you know, I mean we have nice, nice scrubs and things, but to be able to come in during the daytime and help people out, take care of patients and go home at night and sleep in your own bed, that's really special. <laugh>. It's the little things. 

Eva Sheie (38:24):
It is. I said I had two questions and the other one was speaking of time off. So you're, you're enjoying daytime work again. 

Dr. Ronen (38:33):
Yeah. 

Eva Sheie (38:33):
What about time off? What do you do to decompress and not think about work? 

Dr. Ronen (38:39):
I am always on my Spotify app. I love music from a very, very young age. I'm into almost everything since I was in medical school. I was turned on to bachata music and I aspire to learn how to dance properly. I probably was a bit on the shyer side when I was a kid about dancing at parties with my parents and birthday parties and stuff like that. But, uh, I definitely was into music since the nineties until now. And I'm Persian by background, so I have a lot of Persian music, I have a lot of Latin music, a lot of reggaeton and a lot of pop music, a lot of hip hop, a lot of rap. I also enjoy listening to music while I work out. And moving to San Francisco, I got myself a Peloton machine, so I have been using that and I've really enjoyed that. 

Dr. Ronen (39:25):
Shout out to my, one of my attending physicians during residency who took me with him to the gym to weight lift every Saturday for three years. He was one of the most incredible role models that I had as a physician and also as a human outside of the hospital. He took, he took care of me as almost like a grandpa when I was there away from home. My parents told him, make sure to take care of our son. So exercise, I think I've gotten into the culinary arts. I'm really big into celebrity chefs, uh, one of them being like Gordon Ramsey and I love to cook. And lately since I have embraced the freedom of being an attending physician, I've got to travel quite a bit with my family to Mexico. I've been all around. Um, I feel like the journey of medical school took me to a lot of places, but I've been to Cancun, to Mexican Riviera, I've been to Miami, Florida, I've been to Vegas. 

Dr. Ronen (40:25):
I love to just get out and have a good time. I feel like a lot of us, after a 12 hour day, even during our days off, you'll be like, don't you just wanna sit at home and do nothing? The answer to that is yes, <laugh>, <laugh>. So I equally appreciate doing that too because imagine you're sleeping and you wake up in the middle of the night and you wake up through this beeping sound and then when you wake up you realize it's not my pager. I'm actually not at work. I don't have to go and respond to anything right now. And then you can just fall back asleep comfortably, and it's so good. 

Eva Sheie (40:58):
What a great feeling. Yeah. 

Dr. Ronen (41:00):
<laugh>, You get so sensitized to the sounds associated with work that it takes time to desensitize yourself. And I think that's one of the most important things of the days off is try and be as far away from your job as possible. That could be you're sitting in the park next door just staring into space or taking a vacation and going far away. 

Eva Sheie (41:23):
I think anyone with a job that requires focus and intensity could relate to that. 

Dr. Ronen (41:28):
Oh yeah, sure. Absolutely. I mean, I love to let it out. You know, I'm a huge Golden State Warriors fan as well, and I go to games. I was a huge Sharks fan when I was in high school. I go to games and I like to let out. I like to yell. And it's incredible to be able to have those interests still. It's really important, Eva, you know, it's, it's like we need to have outside of this job to keep us balanced. And that was especially important during Covid when hours were just off the charts. You know, we'd, we'd be working in the hospital for so long, we wouldn't know what a life outside the hospital looks like, you know? So for that balance, the wellness, uh, mental health, you know, I'm very blessed to have the support of family and friends and as I'm sure you know, all my colleagues do to be able to do this job. You know, I have close friends that are pediatricians, psychiatrists, surgeons, all of them equally need this opportunity for respite. And, uh, it's quite special to be able to have the time to do that and use it, so. 

Eva Sheie (42:33):
Agree. Final question. 

Dr. Ronen (42:36):
Yeah. 

Eva Sheie (42:37):
What would you like listeners to take away from listening to this podcast today? 

Dr. Ronen (42:42):
You know, it's been quite special to have the, had the opportunity to do this today. And when listeners if, if they ever need to come into the hospital for care, I think one thing that's different from me and other physicians that may come on this podcast is that they may see those physicians inside and outside a hospital. So they will have the tools to choose them or choose one that best fits them. I wanted to come on the podcast today for listeners to get to know me, to get to know the field of hospital medicine, internal medicine. They may not necessarily get to choose me per se, because it just depends on who's working in the hospital that night or that day. But I hope this gives them a little bit of insight into my background and not just my medical background, but the fact that I'm a human being too. And I feel like that aspect of being a human being, the human part of medicine, allows us to have a better relationship with our patients. And that what allows, that's what allows me to do my job the best. So whenever you need to come into a hospital, please come and see us. We're ready to take care of you and ensure that you're well and ready to go home. 

Eva Sheie (43:53):
If someone's listening today and they want to find out more about you, where would you point them? 

Dr. Ronen (43:59):
I would point them toward the U C S F Health website. You can actually just Google U C S F Health and then Joshua Ronen. That will actually give a nice, it'll, it'll take it to my physician splash page, and that will give them a nice background about what I do, some of which I've described today, both clinical and nonclinical work in terms of my background training and board certification and academic appointments, that sort of thing. I will give them, um, a great summary of, of what I do and some of which I've captured in the podcast today. 

Eva Sheie (44:30):
And we'll put that link in the show notes for you. Thank you so much Dr. Ronen. It is so nice getting to know you. 

Speaker 3 (44:37):
Likewise. Thank you. 

Eva Sheie (44:41):
If you are considering making an appointment or are on your way to meet this doctor, be sure to let them know you heard them on the Meet the Doctor podcast. Check the show notes for links, including the doctor's website and Instagram to learn more. Are you a doctor or do you know a doctor who'd like to be on the Meet the Doctor podcast? Book your free recording session at Meet the Doctor podcast.com. Meet the Doctor is Made with Love in Austin, Texas and is a production of The Axis, t h e a x i s.io.