Hospitalist groups scramble to find work-life balance by Phyllis Maguire
Published in the August 2011 issue of Today's Hospitalist
Smitha Chadaga, MD, knows a thing or two about making family leave work for hospitalists.
Dr. Chadaga, associate chief of hospital medicine at Denver Health Medical Center in Denver, is currently covering her own position as well as that of the chief of hospital medicine while the chief is out on family leave. She's been given additional time for all those duties, Dr. Chadaga explains, but filling the chief's administrative role as well as doing her own administrative tasks and clinical load can be very time-consuming.
But in her view, turnaround is fair play.
"I'm sure there were some in the group who may have been distraught about having to absorb the shifts that I'd scaled back on."
–Aynna Yee, MD Santa Rosa Memorial Hospital
Dr. Chadaga took family leave last August when her son was born, and her colleagues helped fill in for her.
"I and another physician delivered within two days of each other, and one week later, another physician's wife delivered," Dr. Chadaga recalls. "That month, three of us were out."
In a specialty where so many physicians are in their 30s and where an emphasis on work-life balance is a big draw, family leave is just one of many reasons that hospitalist groups need to be able to provide coverage for one another. Physicians regularly take extended time off to travel to a home country, for example, or to cope with deaths in the family or illness.
And in hospital medicine, there's often an expectation that physicians will want extended periods of time off for less mundane reasons.
"Hospitalists expect programs to extend the flexibility to do something else," explains Kimberly Bell, MD, regional medical director for the Pacific Northwest Region of EmCare Inpatient Services, a national practice management group. "I know hospitalists who travel to China to study acupuncture or take a break to finish an MBA."
But with the supply-demand equation for hospitalists still so lopsided, an extended leave of one or more members leaves many groups scrambling for coverage. Here's a look at how several hospitalists have structured their family leave and how their groups have shared the workload.
No extended unpaid leave
According to Dr. Chadaga, one advantage of working for a large health system is a generous family leave package. While all employees at Denver Health have to take their first week of family leave with paid time off (vacation or sick time), female employees then get between five and seven weeks of short-term disability, depending on their type of delivery.
Women can then round out a three-month family leave by either taking more paid time off or taking that time off unpaid, if they have exhausted their vacation time. Male physicians, Dr. Chadaga points out, typically take between one and four weeks for family leave.
What happens if a doctor wants more time off beyond three months? "We've addressed that as a group," Dr. Chadaga says. For doctors who have banked even more paid time off, that's their prerogative. "But we're not going to give extended unpaid leave unless there is medical need."
Otherwise, she says, "Family leaves would create great unpredictability in workload and coverage. The group can't sustain everyone taking off six months at a time." For doctors who do have medical need, the group allows an unpaid leave of an additional one month.
Pulling extra shifts
For Michele Mohr, MD, a hospitalist in Casper, Wyo., short-term disability to pay for a portion of her maternity leave in 2008 wasn't an option. While both short- and long-term disability are offered at Wyoming Medical Center where Dr. Mohr works, she had opted only for long-term disability at the time.
Instead, Dr. Mohr says, the first month of her three-month leave was covered by deferred paid time off and sick time. She banked the other eight weeks for her leave by pulling additional weeks of shifts during her pregnancy.
"I worked about eight extra weeks in my prenatal period so I would have that time off on maternity leave," Dr. Mohr says. Working what turned out to be an additional week per month was "manageable," she adds, in part because her program director at the time offered to cover her night shifts while she was pregnant.
For Aynna Yee, MD, the director of the hospitalist program at Santa Rosa Memorial Hospital in Santa Rosa, Calif., the bulk of both maternity leaves she's taken since 2007 have been flat-out uncompensated. That's because Dr. Yee is one of 10 physicians who function as a hospitalist group, sharing call and patient care, but who all work as independent contractors.
She—like Dr. Mohr—worked some of her scheduled
time off during her pregnancy to bank some time for her maternity leave. But Dr. Yee points out that one downside of being self-employed is that she and her colleagues "eat what we kill." Put simply, she says, "We have no official requirement for family leave and we are uncompensated for the time we take off."
While colleagues who picked up her shifts during her leave were compensated, Dr. Yee says her decision to return only part-time—even though she'd planned to return full-time—was a source of stress for colleagues.
"My medical director at the time was very supportive because I had worked for several years and had worked well with everybody," says Dr. Yee, who now works three-quarters time. "But I'm sure there were some in the group who may have been distraught about having to absorb the shifts that I'd scaled back on."
Who do you call
Dr. Yee's group was able to recruit another physician around the same time she took leave. And bringing on a nocturnist two years ago not only ensured better continuity of care for day-shift physicians, but has given physicians who might want to take time off some breathing space.
How well a full-time team can absorb additional shifts depends on many factors, including group size and the availability of part-time physicians. EmCare's Dr. Bell, who's also a hospitalist at Auburn Regional Hospital in suburban Seattle, oversees five groups that range in size from only two physicians to 15. To accommodate family leaves in smaller groups, Dr. Bell points out, hospitals sometimes have to spring for locum coverage.
Robert Harrington Jr., MD, chief medical officer for Locum Leaders, a national locum tenens firm based in Alpharetta, Ga., says his firm is now providing locum coverage for a hospitalist group in Hawaii in which two physicians are going out on maternity leave "almost simultaneously."
But he estimates that fewer than 10% of the positions his company covers are related to family leave. "Family leave issues stress programs that are not fully recruited even more," Dr. Harrington says, "but the bulk of what we do is for positions of longer duration."
Hospitalist groups that are lucky enough to be in areas where there's more supply than demand can draw on internal candidates. That's the case for Dr. Bell in Seattle, where full-time hospitalist positions are in short supply.
"We have part-time providers looking for practice opportunities," she says. For many family leaves for which she needs coverage, "the internal pool of candidates will pick up the shifts."
But at community programs that don't have the luxury of physicians looking for extra hours, a little creative thinking is required.
Nathan Ker, DO, a hospitalist with an IPC The Hospitalist Company Inc., practice in Denver, is a case in point.
Until recently, he led Dr. Mohr's program in Wyoming. When she took maternity leave, the group of five hospitalists was whittled down to only four physicians for the months that she was out.
"We had to decide whether to go the route of moonlighters or hire someone to cover some of those gaps," Dr. Ker says. The solution was hiring a nurse practitioner who had worked at the hospital as a neurosurgical NP and had experience rounding on patients.
"She functioned a lot like we do, taking rounds," Dr. Ker explains. "She didn't do admissions, but she would occasionally consult on a particularly easy orthopedic comanagement patient."
When Dr. Mohr's family leave was ending, he notes, the hospitalist group—which previously had been seeing only unassigned patients—signed up its first two primary care physicians, taking over their services. "We picked up enough business to keep our nurse practitioner on," Dr. Ker says.
But he adds that the nurse practitioner couldn't fully replace a physician, so other doctors in the group had to pick up extra shifts and additional patients per shift during Dr. Mohr's family leave. That led the hospitalist group to initiate an RVU incentive "to at least compensate them for the increased work load," Dr. Ker says. "That worked out very well."
Physicians received a certain amount per RVU once they surpassed 12 patient contacts per day, he explains. For that first fiscal year, he adds, the RVU incentive meant that one physician in the group received an additional $30,000 and another received $60,000.
In Charlottesville, Va., Paul Tesoriere, MD, the director of Martha Jefferson Inpatient Services, has helped manage the family leaves of four colleagues. While the group currently has 12 full-time physicians and four midlevels, it wasn't so long ago that the group was smaller. During that time, one scheduled maternity leave coincided with a group member who left unexpectedly.
"We were extremely short-staffed and fairly stressed," Dr. Tesoriere says. "We realized that we needed some sort of a back-up plan for emergencies, vacations and maternity leaves, and it became a priority."
The solution that Dr. Tesoriere negotiated with the administration at Martha Jefferson Hospital was for him, as director, to no longer work a regularly scheduled clinical shift. Instead, he became the group's internal and permanent back-up plan.
"I now cover the 11 other physicians in the group," he says, "and I work about 10 to 12 shifts a month."
Opting for permanent back-up is likewise a strategy used by the hospitalist group at Denver Health Medical Center. While it would seem that a group that includes 28 physicians and 17 FTE midlevels could absorb additional shifts, planning for vacation time and emergencies for so many providers became a major challenge.
"We didn't have a lot of wiggle room," says Dr. Chadaga. Starting this year, the group has hired what it calls "a utility position." "It's an extra person needed to cover everyone's vacation and family leave," she says. "As a result, we're able to better absorb crises and pregnancies."
TeamHealth Hospital Medicine, which has nearly 700 physicians working in more than 100 sites, can draw on what it calls its own "travel team" of physicians. That allows TeamHealth to cover family leave in practices that may not have local part-time physicians looking for more work.
"It's a draw for recruiting, knowing there are resources," says Jasen Gundersen, MD, MBA, chief medical officer of TeamHealth Hospital Medicine. "There's a pool of resources that you can get to for coverage or help."
Dr. Gundersen admits that in his role as chief medical officer, he's no longer managing the details of family leaves. But in his leadership roles at other programs, he's learned that groups that are already growing rapidly should take the opportunity of a family leave to kick recruiting into high gear. They should also have "conservative" expectations of how gung-ho hospitalists returning from a family leave might be.
"If it's their second or third child and they say they're coming back full time, that usually works out," Dr. Gundersen says. But with physicians who plan to take short leaves and then come back "full-time plus," he adds, "that may be more challenging. They often don't come back with the same flexibility."
Program directors should be sure to keep an open dialogue going with family-leave members about their anticipated return and workload and "err on the side of caution in terms of bringing others on," says Dr. Gundersen.
"What you really don't want to do is put pressure on the provider coming back," he explains. "You want them to be able to adjust to his or her new reality of having a family."
Phyllis Maguire is Executive Editor of Today's Hospitalist.
The part-time dilemma
ACCORDING TO AYNNA YEE, MD, she and every woman physician she knows have spent this summer passing around an editorial published in June in the New York Times—and getting annoyed.
Penned by a woman anesthesiologist, the editorial reported 2010 data claiming that nearly 40% of women physicians age 35 to 44 were working part time. The editorialist scolded part-timers for wasting a taxpayer-subsidized education and turning their backs on full-time patient care to spend more time, presumably, with their children.
Neither Dr. Yee nor any of the women physicians she knows agrees with that point of view. But as a hospitalist who began working part-time after the birth of her first child, Dr. Yee says the editorial at least pulled back the curtain on the conflicting priorities that many female physicians face.
"We go into the field to be the best physician we can be, but I also want to raise happy, well-adjusted children," she says. "Unfortunately, there has to be some sacrifice in both those aspects of my life."
For many hospitalists, particularly those in smaller groups, part-time work would be a stretch. That's according to Michele Mohr, MD, a hospitalist at Wyoming Medical Center in Casper, Wyo., who returned to work full time after her family leave in 2008.
Dr. Mohr was at the time one of only a handful of hospitalists covering a growing census. "In such a small group, it's even hard to say, 'I want to work only 8 to 5,' " she points out. "I couldn't do that to the rest of my partners, so I just went back on the 12-hour, seven-on/ seven-off straight shift."
Hospitalist Smitha Chadaga, MD, associate chief of hospital medicine at Denver Health Medical Center, says that some hospitalists within her 28-physician academic group may have dialed back on their hours after a family leave.
"As long as we have a 60-day notice of a change in your FTE status, that's OK," Dr. Chadaga says. "FTE status often changes in an academic center because of the availability of research funding, so it's something we're familiar with."
But according to William Ford Jr., MD, the section chief for the Cogent-HMG hospitalist practice with Philadelphia's Temple University Health System, the flexibility traditionally built into academic practices is evaporating.
"Gone are the days when an academic physician could just see eight patients with residents," Dr. Ford says. "Our academic physicians see those teaching patients, plus five private patients and four surgical comanagement patients. To make the model work, their patient load is getting up there with private practice."
To cover holes in the schedule, Dr. Ford relies on two internal, per-diem and part-time hospitalists who each do eight or nine shifts per month.
And far from heaping scorn on part-timers, Dr. Ford says they're the answer to many of his scheduling problems. Both of the part-timers that he uses—one's a woman hospitalist and one's a man—are primary caregivers for their children, he says.
"I'd much rather hire two part-time doctors than one full-time one," he says. "They're much more beneficial to me in terms of picking up extra shifts."