Published in the March 2013 issue of Today’s Hospitalist
NEW HOSPITALISTS just embarking on their careers usually describe the first couple of years as “exciting.” But in the same breath, most also mention “exhausting” or “challenging.” It’s not uncommon to feel unprepared for the pace, the schedule, the business aspects of practice, and the psychological demands of being the doctor in the hospital “often all alone, sometimes in the middle of the night, with very little safety net.
“There were so many patients and everything had to happen so fast,” Shivali Malhotra, MD, recalls feeling about those first months two years ago as a new hospitalist at Allen Hospital in Waterloo, Iowa. “Looking back at the end of a particularly busy day, I remember thinking to myself, ‘I can’t believe
I saw 28 patients today.’ It was exciting to finish residency and to step out on my own, but the work was much more than I expected.”
And while the siren call of “extracurricular” work “committee slots, quality improvement projects, technology customization assignments, leadership opportunities “draws residents to hospital medicine in the first place, the onslaught of those just adds to the fatigue and sense of being overwhelmed.
All first jobs take adjusting to, and rookies always experience a steep learning curve. But some hospital medicine leaders wonder if the transition from education to employment has to be as hard as it is for many new hospitalists.
“Anecdotal experience says there is a pretty healthy dropout of people in their first couple years of hospital medicine,” says Vineet Chopra, MD, a hospitalist with the University of Michigan Health System and a former member of the early career committee of the Society of Hospital Medicine (SHM). He points out that he’s not talking about the many doctors who take hospitalist jobs in the “gap” year between residency and fellowship, but physicians who initially plan on making hospital medicine a career.
“Because the first few years can be so turbulent,” Dr. Chopra says, “sometimes people who come to hospital medicine with mixed feelings are immediately turned off when they hit the first roadblock.”
On the first day of his first hospitalist job at a hospital in Hot Springs, Ark., Dr. Chopra recalls, he was called to put in several central venous catheters. During his entire residency, by comparison, he had put in only a handful. And while Dr. Chopra had fulfilled the usual critical care rotations in training, he now found himself working in a hospital with limited intensivist support.
But new doctors say that adjusting to the clinical side of hospital medicine is often the easiest part of the transition. A more common complaint is getting up to speed on the scope of hospitalist practice.
“The nuts-and-bolts patient-care piece is similar to what you do as a resident,” says Paul Grant, MD, assistant professor of medicine and a hospitalist at the University of Michigan, and the former chair of SHM’s early career committee.
“What’s new is that you are now responsible for moving the patient safely and efficiently through a hospital stay. ‘Am I following the appropriate core measures that I am being publically reported on? Am I doing anything to reduce the patient’s risk of various in-hospital complications? Am I making the hospital system a better, safer place?’ These are things that you typically don’t think about as a resident.”
The amount and pace of work is also something that many new hospitalists don’t expect and find hard to adjust to. That has no doubt been exacerbated by duty hour restrictions that limit resident workhours.
“There has been a push toward not having residents work toward maximum capacity all the time, even though that may be more reflective of what they will be forced to do later on,” explains Alfred Burger, MD, a hospitalist and associate program director for the internal medicine residency at Beth Israel Medical Center in New York. “We want to maximize their learning opportunities, and a lower workload allows us to do that. The challenge they face, therefore, is going from a relatively predictable experience where there are limits on workload to an experience where there are no limits, but financial incentives to work more.”
Business and generational stressors
Another part of the problem, says Dr. Chopra: Too many hospitalists have little or no training in the business aspects of medicine, starting with how to analyze a contract. “They end up in situations where they may be exploited and overworked, and they don’t know how to turn that around.”
Then there’s the fact that hospitalists in general tend to be young. According to the Today’s Hospitalist 2012 Compensation and Career Survey, the average age of full-time hospitalists who treat adults is 42, while 50.6% of them are younger than 40.
In some hospitals, that demographic reality exacerbates generational conflicts with established physicians, who sometimes treat hospitalists as glorified residents. Having to figure out how to finesse such workplace dynamics can add to the stress of inexperienced physicians.
Says Tommy Bohannon, vice president for recruiting at the Irving, Texas-based national physician recruiting firm Merritt Hawkins, some problems occur when young physicians just coming out of residency don’t comprehend what being a hospitalist in the community entails.
“The nature of the job is that you are the quarterback of the team,” he says. “It isn’t just to walk around the hospital and make sure everybody is tucked in and that nothing is going on. You are coordinating the care of all types of patients across multiple specialties and nursing and therapy.” For new hospitalists who feel overwhelmed, Mr. Bohannon says, “I wonder if some don’t realize that’s the job.”
In general, he says, when recruiters see young hospitalists quit quickly, it is usually “because they don’t have enough support, aren’t making enough money or are being worked too hard.” Insufficient support, Mr. Bohannon explains, can run the gamut from inadequate administrative assistance and lack of subspecialty backup to poor acceptance of the hospitalist program by other community physicians or subpar intra-group collaboration.
Needing more feedback
Halfway through her first year on the job with Metro Hospitalists at St. Luke’s Medical Center in Denver, Elizabeth Harry, MD, credits having good colleagues with easing her transition to professional hospitalist.
“I try to look things up more than when I was a resident because I don’t want to be asking questions all the time,” Dr. Harry says. “I definitely do call colleagues for help, not necessarily asking for a consult but saying I have an educational question.”
For the most part, she adds, “people have been great about that. A few people have been pejorative, but I don’t let it bother me as I am trying to learn to do what’s best for the patient.” It does worry her, however, that now that she is an attending, people might not be giving her critical feedback.
“As a resident, your attending will tell you when you make a mistake,” she says, “But I don’t feel colleagues are as comfortable giving that kind of feedback. When I catch errors here and there, I don’t always bring it to my colleagues’ attention, and I don’t know that anyone is bringing my errors to my attention.”
Dr. Harry, who had a baby during her first few months on the job, also credits her relatively easy transition to the fact that she spent two years of her internal medicine residency at the University of Colorado, Denver, with its unique hospitalist training program.
Residents in that program are required to take several rotations designed to prepare them for the clinical work that hospitalists do: perioperative care, consults, acute care of the elderly, and end-of-life and palliative care.
They are also trained in other key roles that programs expect hospitalists to fill, including quality improvement, leadership, health care policy and the business of medicine.
“One of the things that new hospitalists don’t expect is the amount of responsibility,” says Darlene Tad-y, MD, a hospitalist, assistant professor and associate program for the University of Colorado’s internal medicine residency and hospitalist training program. “This includes things like finishing all the paperwork, getting your discharge summaries done on time, and managing all the calls from consultants and staff. In training, there are a number of buffers to that.”
In the hospitalist training program, she says, one required rotation gives residents “a lot of autonomy so they can experience this,” Dr. Tad-y says. “They get a taste of being in the hot seat, and they always tell us how surprising it is.”
And because a lack of familiarity with the business of medicine contributes to the stress of the first few years, the program teaches future hospitalists how to bill accurately and to understand different types of compensation models.
“If you don’t learn this during residency, you have to devote a lot of your time during your first year to learning it,” says Joseph Sweigart, MD. “You aren’t able to focus on education and quality improvement and patient safety, which you want to do.” Dr. Sweigart started a 100% clinical hospitalist job at the University of Colorado, Denver, last July after finishing the hospitalist training program during his residency there.
“I was terrified my first day,” he says, “but at least I knew how to bill and write good notes.”
Too many options
The nuts-and-bolts of billing and coding is something Dr. Malhotra in Iowa says she spent hours on the Internet trying to teach herself. Figuring out inpatient status vs. observation status was a particular challenge, she recalls.
For Abeezar T. Shipchandler, MD, a second-year hospitalist at Baylor Regional Medical Center at Plano, in suburban Dallas, getting support on business issues is one of the big benefits of being in a group associated with a large organization. His group’s administrative staff and practice administrators run regular meetings on business and practice topics and send coders to share “tips and tricks.”
For hospitalist ThÃ©rÃ¨se Franco, MD, who’s now in her fourth year at Virginia Mason Medical Center in Seattle, everything during her first year there “except the clinical aspects “was new and different. She had trained in a paper-based system in the Northeast, for instance, and now had to learn an electronic system.
“Billing was new, order entry was new and typing notes was new,” Dr. Franco says.
But “the biggest problem was not knowing how to say ‘no.’ ” Drawn to hospital medicine because of “the great variety of ways you can contribute to the field,” Dr. Franco says that she found everything that came her way compelling. But quickly, she found her plate full “”more like Thanksgiving-full than light lunch-full,” and she was “about to burst.”
“I think I had a very hard first year,” she now says. “I had never felt as tired as I did as a first-year hospitalist.” Only after disentangling herself from all the commitments she made, along with becoming more efficient, has Dr. Franco come to love her chosen career.
Finding a good fit
Dr. Shipchandler believes he’s had an easier transition to the working world than many of his colleagues. He chalks that up to his ample experience with being in the hot seat while a resident. Not only was his clinical training at the University of Alabama at Birmingham focused heavily on hospital medicine, but he also had many opportunities there to work both within and outside that community.
“I moonlighted a ton,” he notes. That extensive experience also gave him a very clear idea of what he wanted in a first job: what size group he wanted (eight to 15 physicians), what type of hierarchy among the doctors and nurses (none), and how many hospitals he wanted to cover (just one). Knowing what type of program would be a good fit for him made the jump much easier.
“I was looking for a group that was young and dynamic, and a hospital that felt like a community, even though it was big,” says Dr. Shipchandler. “The job I got has everything I wanted” “with the exception, he notes, of having to work nights and weekends. (See “The seven-on/seven-off dilemma.”)
In an effort to keep new hospitalists from jumping ship, some groups are trying to figure out how to offer more flexible schedules, as well as a timetable for giving new doctors the feedback they need.
At the University of Michigan, new hospitalists shadow more seasoned physicians for several days and carry a lower-than-normal census for their first week. And Dr. Chopra notes that the hospitalist program initiated a faculty development program for young faculty a year and a half ago. That program helps them connect with mentors for research and career development projects. The hospitalists also established book clubs to focus not on medical journals, but on books dealing with fundamental concepts like motivation and leadership.
At the same time, the program tries hard to help new hospitalists be realistic. “Our contracts have clear expectations for education, clinical performance, administrative duties and leadership,” says Dr. Chopra. “It’s very specific, and everyone’s is different.” Otherwise, doctors just starting out end up with no time for teaching or research “areas that drew them to hospital medicine in the first place.
Focus on the clinical
Some of the difficulties that new hospitalists face could be alleviated if only they could ease into their new jobs. The problem for most, however, is that the supply-demand mismatch that makes for a lucrative job market also means that many hospitalists end up joining busy, short-staffed groups.
“It’s not universal, but it’s common that people are thrown into busy practices,” explains Dr. Grant from the University of Michigan. “It doesn’t give you a slow phase-in. People say, ‘I want to do all these quality improvement and safety projects, but I’m full-time clinical and on my days off I’m decompressing. But that’s when I am supposed to be doing the extra work to find a niche or do an administrative role.'”
He offers the same advice he got from his first hospital medicine boss: Spend the first few months or even a year focusing on clinical work and getting to know how to navigate a new health system.
“Patient care is job No. 1,” Dr. Grant says. “And as the year goes on, you will see where you have extra time and where you don’t and you will see opportunities. You need to be aware of burnout.”
Deborah Gesensway is a freelance writer who covers U.S. health care from Toronto.
Tips for an easier first job experience
- Try to choose a bigger group or a place where you have a friend, a colleague or some other support system. Merritt Hawkins recruiter Tommy Bohannon recommends that young hospitalists try to “gravitate toward a larger group” where “there are three or four other hospitalists in the house at a time” “and where you’ll have reasonable access to a diverse selection of available specialists. “You are probably not well-advised to take your first job out of training in a small hospital with three hospitalists and when you are on, the other two are off fishing somewhere.”
- Resist taking on too many nonpatient care responsibilities right off the bat. “It’s important to say ‘yes’ ” when asked to serve on hospital committees and projects, says University of Michigan hospitalist Paul Grant, MD, who is now in his seventh year on the job. “But learning to say ‘no’ is important too.” Because disentangling yourself from commitments can be tricky, he adds, “the better advice is not to overextend yourself from the beginning.
- On the other hand, don’t take too long to get involved in things other than patient care. “You need to think about sustainability from the very beginning, and this includes getting involved in things other than seeing patients so there is more to keep you engaged and happy in your career when you hit your stride as a clinician,” says Darlene Tad-y, MD, at the University of Colorado, Denver. “I think most people struggle with when is the right time to add things to your plate.”
- Take some interest during residency in learning about the business side of medicine. The attempt to “shield residents from the reality of billing, charge capture and appropriate documentation” is done with “the best of intentions,” says Joseph Sweigart, MD, a new hospitalist at the University of Colorado, Denver. “But the unintended consequence is that if you don’t learn those during residency, you have to devote a lot of your time during your first year to that learning.”
CONVENTIONAL WISDOM HOLDS that hospitalist groups won’t be able to recruit newly minted physicians unless they offer seven-on/seven-off schedules. While older physicians may balk at missing every other weekend with a growing family, experts say that physicians right out of training insist on having that amount of downtime. Unless you offer seven-on/seven-off, the thinking goes, you won’t get young physicians interested in even interviewing.
But some young physicians are quickly coming to the same conclusion as their (slightly) older colleagues. Hospitalist Thérèse Franco, MD, who’s in her fourth year at Seattle’s Virginia Mason Medical Center, now has no problem handling the pace and demands of her job. But the one downside she sees as a hospitalist is the seven-on/seven-off schedule, which she just doesn’t consider sustainable over the long term.
“The idea of working every other weekend until I’m 70 is unappealing,” says Dr. Franco, an opinion seconded by many hospitalists. A schedule that may have attracted doctors initially can end up boding ill for longevity in the field.
Abeezar T. Shipchandler, MD, a second-year hospitalist at Baylor Regional Medical Center at Plano, in suburban Dallas, echoes that sentiment. He says that working weekends and nights is “the toughest part” of his job, particularly now that he and his wife are soon starting a family.
“From a financial standpoint, it’s great,” Dr. Shipchandler says. “It’s extraordinarily lucrative, but I don’t think I can do it my whole life.” Trying to balance his schedule with that of his wife, who is an attorney, is tough because there is no overlap between their nights and weekends.
Ironically, the lure of seven-on/seven-off can become a new hospitalist’s “biggest enemy,” says Vineet Chopra, MD, a hospitalist with the University of Michigan Health System in Ann Arbor and a former member of the Society of Hospital Medicine’s early career committee.
“Unfortunately, the draw of our profession has become the seeming luxury of week-on/week-off and the salaries,” he says. “What people don’t see beyond those two areas are the degree of difficulty associated with them and the challenge. They can be dazzled by the idea of all this time off, but then become disillusioned and want to jump ship.”