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How does your region stack up?
While geography may not be destiny, it can play a role in your career

Keywords: Surveys conducted by Today's Hospitalist offer insight into how geography shapes physician careers


by Edward Doyle



Published in May 2012 issue of Today's Hospitalist

HOW MUCH DOES "where you work" affect your career as a hospitalist? The conventional wisdom holds that local markets have more impact on physicians' careers than the broad geographic regions in which they work. The fact that you work in the Boston metro market, for example, may have more bearing on your career than the fact that you work in the Northeast.

But it turns out that geography may have more influence on work lives than you think. A look at data from surveys conducted by Today's Hospitalist offers some insight into how
"If you want to work harder, your work/life balance goes away. If you want a better workplace, then you have to sacrifice satisfaction."

–Anil Goud, MD
Independent Hospitalists
where you work can shape your career. While geography may not be destiny, hospitalists in geographic regions share common traits that reflect the hours they work, their career satisfaction and more.

A good example can be found in the Northeast, where physicians tend to be paid less than colleagues in other parts of the country.

To anyone who follows physician compensation, that's hardly news. One reason hospitalists in the Northeast are paid less, the thinking goes, is that the region has so many academic centers. Hospitalists may earn less, but they enjoy lots of backup from housestaff and other attendings.

However, it turns out that the pay difference in the Northeast is only the beginning. Hospitalists there also report working fewer total hours and fewer night and weekend shifts than elsewhere. And while their pay may be low, hospitalists in the Northeast give very high marks for work/life balance.

But that's not the only trait they share. Compared to colleagues in other regions, Northeast hospitalists—surprisingly—report the lowest rankings on questions measuring autonomy, career satisfaction and plans to remain in hospital medicine. For hospitalists in the Northeast, it appears that a fabulous work/life balance does not translate into a sense of career fulfillment.

An aberration? While it might be tempting to dismiss those data, survey results from another region reveal a similar paradox. Hospitalists in the Southwest also had extreme scores on work/life balance and professional satisfaction—but they're reversed. While hospitalists in the Southwest region place dead last on work/life balance, they report very high scores for professional satisfaction.

Are those differences due just to geography? To find out, we asked hospitalists from all six regions of the country to tell us about the strengths and weaknesses of their regions. Here's what they had to say.

THE NORTHEAST

TO GET A HANDLE ON WHAT HOSPITALISTS THINK about their careers, we looked at results from several Today's Hospitalist surveys in three categories: work/life balance, professional satisfaction and workplace environment. We then divided responses into six geographic regions.

To assign an overall rating for work/life balance, we looked at answers to five questions: hours worked per month, weekend shifts worked per month, how groups cover nights, amount of paid time off and additional benefits offered. On those questions, the Northeast did so well that it racked up almost twice as many points. The Pacific was the only one that came even close to the Northeast in that category, and its total rating was 17% lower.

The Northeast's commanding lead on work/life balance, however, falls apart when it comes to professional satisfaction. For that category, we asked physicians to rate their clinical autonomy, whether they planned to leave hospital medicine before retirement and how they rated the significance of burnout. In terms of professional satisfaction, the Northeast placed dead last.

What's behind that big rift? Edward Ma, MD, medical director of the hospitalist practice at Brandywine Hospital in Coatesville, Pa., thinks it's due in part to the number of academic centers jammed into his part of the country.

Many of his colleagues in Northeastern teaching hospitals talk about the tradeoffs they face, Dr. Ma notes. "They say, 'My pay's not great, and I have very little say in how my practice is managed. But the lifestyle is great, in part because I have residents covering a substantial amount of the workload during nights and weekends.' "

Greta Boynton, MD, chief of the hospitalist service at Eastern Connecticut Health Network in Manchester, Conn., thinks survey data reflect the fact that many hospitalist programs in the Northeast may be large. She notes that her program is now transitioning from being community-based and nonacademic to a more academic model.

There tends to be a distribution in terms of the work flow in larger groups," says Dr. Boynton. "The work may be more subspecialized with dedicated rounders, admitters and nocturnists."

The good news is that few physicians working day shifts expect to take night call. But working in big teams, she adds, has its own downsides. "We have access to so many subspecialists and super subspecialists," Dr. Boynton says. "But the more chefs in the kitchen, the less important one person driving recommendations and care coordination becomes. A lot of people feel like they are a replaceable cog in a machine."

Doctors in larger groups also may have less say in how their program is managed.

"If you are in a program with six or seven people," Dr. Boynton says, "you can sit down at a roundtable and design your program as a group. When you get into groups with 30 or 50 physicians, that can be impossible."

John Krisa, MD, director of the Cogent HMG hospital medicine program at the 160-bed Albany Memorial Hospital in Albany, N.Y., is quick to point out that not all hospitalists in the Northeast work at big academic centers.

"If you're in a community hospital where you're the go-to person, you're the first line of defense," Dr. Krisa says. "In our hospital, we have as much autonomy as we are qualified for, comfortable with and capable of having. It would be very frustrating to be in an environment where you're not able to practice up to the full level of your training."

But Dr. Krisa suspects there are other factors behind the low satisfaction ratings in the Northeast. In New York state, he points out, patient satisfaction scores tend to be lower than in the rest of the country.

And the presence of so many academic centers in the region may influence hospitalists' view of the specialty. For many hospitalists in the Northeast, Dr. Krisa suggests, the jury is out on whether hospital medicine is the best-possible career.

"Through teaching and fellowship programs, physicians in this region are exposed to other specialties," he says. "They see the opportunities in those specialties, whether those are reimbursement, lifestyle or prestige. That might make physicians consider whether hospital medicine is the best career for them."

THE SOUTHWEST

COMPARE SURVEY RESPONSES FROM THE NORTHEAST with those from the Southwest, and the differences are stark. On measures like hours worked per month and night coverage, hospitalists in the Southwest are doing more of just about everything.

Physicians in the Southwest are stretched in part because there's such a shortage of hospitalists. "In New Mexico, every group I know of is short-staffed," says Kendall Rogers, MD, chief of the division of hospital medicine at the University of New Mexico Health Sciences Center in Albuquerque. "That equates to additional hours for everyone in the group."

And while the Northeast may be flush with large health care systems, that's not the case in the Southwest. "We have one, two, three facility hospital systems," Dr. Rogers says. "We don't have a lot of larger systems."

That may explain why Southwestern hospitalists rank their work/life balance as low. But they had the second highest score for professional satisfaction.

And when asked to rate their workplace environment, Southwest hospitalists reported the highest score. That category looked at how much autonomy hospitalists report in how their group is managed, how much specialty support they have, the number of patient encounters per shift and their pay.

Anil Goud, MD, a founding member of Independent Hospitalists, a 14-physician group in Phoenix, thinks the fact that many groups in the region are small and independently owned explains both the high workplace rankings and the low work/life scores.

"We get all the benefits of being independent, but we also take all the lumps," Dr. Goud says. "No one in our group can say that he or she wants to work only one weekend in three."

He's quick to point out that all that responsibility translates into better pay. (At $241,000, the region's mean pay was higher than any other.) "It's not necessarily that we're getting paid more," says Dr. Goud, "but we're getting paid for managing everything ourselves."

As he sees it, hospitalists need to choose between work/life balance and professional satisfaction. "If you want to work harder, your work/life balance goes away," he says. "If you want a better workplace, then you have to sacrifice satisfaction."

Still, Dr. Goud acknowledges that the region's hospitalists probably need to address work/life issues. "You can't work this way for the rest of your life," he points out. "We're looking at what changes we can make to maintain our independence and still work into old age."

According to Dr. Rogers, he's already seen signs that groups are trying to improve that balance.

Just a few years ago, he could attract hospitalists to his program—sometimes from competing groups— by giving physicians protected time for quality improvement activities. While that gave his group an edge, other programs have caught up.

"Other groups reacted to the fact that their hospitalists were leaving," Dr. Rogers says, "and they're competing by putting more emphasis on nonclinical activities."

THE MOUNTAIN REGION

LIKE THE SOUTHWEST, THE MOUNTAIN REGION scored fairly low on work/life balance, but it placed third in professional satisfaction. In terms of work/life balance, hospitalists reported many hours worked per month, as well as a lot of weekend and night shifts. Kenneth R. Epstein, MD, chief medical officer of Hospitalist Consultants Inc., a national hospitalist management company, has for years worked as a hospitalist in Denver. He says the responses make sense given the rural nature of much of the region.

"If you're part of a larger group," Dr. Epstein says, "you have higher volumes, but you also have more physicians to cover. If you have only one or two doctors working per day at a smaller practice, it means you're working every other weekend."

On the plus side, hospitalists in the Mountain region reported above average levels of clinical autonomy, as well as autonomy in how their groups and hospitals are managed.

Karen Zeller, president of Rocky Mountain Medical Search in Fort Collins, Colo., a recruiting firm, says that those high autonomy scores point to the decentralized nature of health care in the area. "Most of our hospitalists are in community hospitals where they have a say," she says.

One interesting result: While hospitalists gave the Mountain region relatively high scores on professional satisfaction, many indicated that burnout was a significant problem. How can high satisfaction exist where burnout is such a problem?

Dr. Epstein suspects it comes down to staffing levels. "You're the only person and there's no backup," he says, "so you get burned out. In urban areas, you have bigger hospitals and less autonomy, but probably less burnout."

THE PACIFIC

THE TRADEOFF BETWEEN work/life balance and professional satisfaction seen in several regions doesn't exist in all parts of the country. A good example is the Pacific region, which received the second best ratings on work/life balance—and the top score on professional satisfaction.

For work/life balance, the Pacific region received high scores for hours worked per month and night coverage. And in terms of professional satisfaction, Pacific hospitalists gave their region the second highest score on clinical autonomy, behind only the Mountain region.

It's hard to parse out why the Pacific region did so well, in part because the area covers the entire West Coast, from Southern California to the Pacific Northwest, along with Alaska and Hawaii. But one trait that many markets in the region share is a long history with hospitalists. That may be a clue to the high ratings.

"The Pacific region probably has the most mature hospitalist programs," says Daniel C. Cusator, MD, MBA, a former hospitalist who is vice president of the national consulting firm The Camden Group and is based in the company's Los Angeles office. "In California, you have large groups like Kaiser and Sutter, and in Oregon and Washington, you have Catholic Systems and Group Health. They all recognized the value of hospitalists long ago and have mature programs."

Regina Levison, president of Levison Search Associates, a recruiting firm in El Dorado, Calif., agrees that the Pacific region's long history with hospital medicine bodes well for individual physicians.

"Over the years, hospitalist practices in the region have been able to address and remedy many of the problems that have come up within the specialty," Ms. Levison says. The region has also produced many leaders in the field who know what goes into job satisfaction.

"There's an acceptance by the hospitalists to view themselves in a career," she adds. "They're not trying out a job for a couple of years after residency. They're in it for the long term."

There's another factor that may make a difference, at least for physicians in California: State law doesn't allow for-profit health systems and hospitals to directly employ doctors. As a result, most physicians work as independent contractors, something that Dr. Cusator suspects may give hospitalists a different outlook.

"When you're not an employee," he notes, "you have a different mindset, motives and incentives that affect personal satisfaction and how hard you're working."

Pacific Northwest
In the Pacific Northwest, hospitalists' high scores may be explained by altogether different reasons.

Mark Rudolph, MD, who until last month served as chief medical officer for the Northwest Region of Sound Physicians, a national hospitalist organization based in Tacoma, Wash., says that physicians in his area put a big emphasis on work/life balance. As a result, hospitalists tend to value their time off before additional shifts or higher patient loads that would increase their income.

"Working seven-on/seven-off and having paid time off are not out of the ordinary in the Northwest," Dr. Rudolph says. "Those likely contribute to physician satisfaction."

And while hospitalists in some parts of the country are feeling pressure to see more patients, Dr. Rudolph says that daily census in his area is kept manageable. "It's uncommon to see programs with volumes exceeding 20 patient encounters a day," he explains. "The market's maturity and focus on quality create a pressure for programs to maintain reasonable volumes."

As for the high professional satisfaction marks in his region, Dr. Rudolph also points to the nonhierarchical approach taken by many hospital administrators.

"Hospitals welcome the input and participation of hospitalists," says Dr. Rudolph, who is originally from the Northeast. "If our group wants to put together an order set or protocol, the hospitals usually say, 'Fantastic!' I can imagine that in other areas, hospital leadership maintains tighter reins on medical staff innovation."

THE MIDWEST

TO FIND SCORES SOLIDLY IN THE MIDDLE, you need look no farther than the middle of the country. For work/life balance and professional satisfaction, hospitalists in the Midwest ranked their region in the middle of the pack.

However, the region saw above-average ratings on questions like clinical autonomy, autonomy in how the hospital is managed and the significance of burnout. Midwestern hospitalists say that the rural nature of much of the region may explain those scores.

According to David Friar, MD, CEO of the 50-provider Hospitalists of Northern Michigan in Traverse City, "The Midwest is as much a cultural middle ground as a geographical one, and we may have a head start in finding 'balance' just because of where we live." In the Midwest, he adds, "the cost of living is reasonable, people are friendly, and hospital medicine is still a new field and we're building programs that fit the communities we serve."

While Dr. Friar knows he doesn't earn as much as hospitalists in other parts of the country, he sees other benefits. "We see 12 to 15 patients a day, so we have more time to spend with them," he notes. And while he's not the highest paid hospitalist in the country, "I'm still one of the highest paid people in my community—and I have time to stop for lunch or sneak out to see a play at my kids' school. That's a tradeoff I'm willing to make."

Dr. Friar sees the noneconomic benefits of working in the Midwest as an important part of job satisfaction. "We know the role we play is vital to our community, the hospital CEO knows all of us by name, and the C-suite and medical staff look to us as leaders and problem solvers. We're valued not because we carry a huge patient load, but because we're key members of the health care team."

One good example is night coverage. Our data show that Midwest hospitalists work more nights than in any other region, a trend Dr. Friar confirms. But he adds that pulling nights in smaller hospitals is not as onerous as in other markets.

"If 10 patients come in at night, I do 10 admits, but that's rare," he explains. "Our value on nights doesn't lie in our productivity, but in our availability. We do all the night admissions for nearly every service line, which improves the quality of life for the entire medical staff."

And while Midwestern hospitalists may work more nights, they don't work as many weekends as hospitalists in other parts of the country. Many hospitalist groups in the Midwest, Dr. Friar points out, rely on primary care physicians to help cover weekends and holidays—"something they are often willing to do, given their desire to keep up their inpatient skills and the extra money they earn."

Because of their schedules and their desire to avoid working "alone" in the hospital, Dr. Friar explains, they're more likely to want to work weekends, which suits him fine. "We're grateful for the chance to spend more time with our families."

More controlled growth
Brian Bossard, MD, founder of the 20-physician hospitalist program at BryanLGH Medical Center in Lincoln, Neb., suspects that working in the Midwest is unique in other ways. While he's heard that hospitalist programs in regions like the Northeast are quickly inundated with patients, he says that's not usually the case in the Midwest.

"You have more time to staff up," Dr. Bossard says. "I've never really felt like we've been chasing our tail in terms of our staffing model. The pace of growth is more controlled."

That may be due to the independent nature of primary care physicians in the Midwest. "They're a little less likely to turn over their patients," Dr. Bossard explains, "particularly early on in a program's life. You have a more calculated, slower growth process, which allows you to keep up with staffing."

Dr. Bossard also notes that because of the region's intensivist shortage, most ICUs tend to be open. He thinks that leads not only to better continuity of care, but a greater sense of career satisfaction among hospitalists.

And J. Kevin Ahern, MD, chief hospitalist for the Sound Physicians practice at Springfield Regional Medical Center in Springfield, Ohio, suspects that the relatively low number of academic centers in the region translates into more of a level playing field in terms of physician collegiality. "We are not an academic medical center and we do not have teaching programs," Dr. Ahern says, "so we have a good relationship with the specialists. They help us out and we help them out. It is pretty collegial."

That relationship extends to the community-based internists who still admit their own patients. "If their patients are getting into trouble and they're not available," Dr. Ahern explains, "I will go see their patients. We will try to stabilize and help them out."

THE SOUTH

IF THERE IS ONE REGION WHERE HOSPITALISTS COULD USE A LIFT, it's the South. On all three categories—work/life balance, professional satisfaction and workplace environment—hospitalists in the South reported lower scores.

That's not to say that the South did poorly in all categories. On questions like hours worked per month and night coverage, for example, the South did well.

Like in the Southwest, hospitalists in the South work hard; they report the most patient encounters per shift. Brian W. Kendall, MD, medical director of hospitalist services for the Regional Medical Center of Orangeburg and Calhoun Counties in Orangeburg, S.C., makes it clear that he and his colleagues are very happy where they work. But he also says that because many larger groups in the region put a premium on volume, it's not unusual for some hospitalists to clock 20 to 25 patient encounters per shift.

"Volume is the No. 1 issue I'm seeing in the South," Dr. Kendall says. "It seems to be driving physician satisfaction—or a lack thereof—more than anything else."

But can high workloads alone explain the South's rankings on professional satisfaction? Hospitalists in the Southwest, for example, work more hours per month and cover more nights than their Southern colleagues, and they have the highest satisfaction levels of the country.

Survey data show that hospitalists in the South report working a manageable number of hours per month; the region had the second best score in that category. But hospitalists in the South do report working a lot of weekends.

According to Dr. Kendall, it's easier to find moonlighters who prefer to work nights—the reverse of the situation in the Midwest. "A premium is placed on free weekends in the South," he explains. "A lot of physicians, especially older physicians in private practice, want weekends off. Hunting is big down here. College football is big."

It's also not unusual for primary care physicians in the South to ask hospitalists to care for their patients on weekends and then return them Monday morning. Dr. Kendall has heard of hospital administrators and practice leaders signing off on such deals.

The CEO of a hospital last year unilaterally mandated that his hospitalist group provide weekend coverage for a very large local private practice," Dr. Kendall says, adding that such a mandate is "a recipe for dissatisfaction."

"Hospitalists are working hard to enhance the lifestyle of other physicians, whether surgical subspecialists or PCPs who want the weekend off," Dr. Kendall explains. "In this case, it upset those particular hospitalists, resulting in a mass exodus."

Longevity in the specialty
But there are bright spots in the Southern data. For one, hospitalists there rank in the top three regions in terms of pay. And more Southern hospitalists plan to retire as a hospitalist than colleagues in other parts of the country.

That last result is surprising because hospitalists in the South say they're slightly more unlikely to stay in their current job than hospitalists elsewhere. (On average, hospitalists report planning to stay in their current job for about eight more years.)

Dan Fuller, president and cofounder of IN Compass Health Inc., a national hospitalist company based in Alpharetta, Ga., says that he does see hospitalists in the South frequently changing positions. He attributes that to the physician shortage and the tremendous growth of the specialty across the country—factors that he says can lead to program instability and dissatisfaction among a team.

As for the fact that Southern hospitalists report being more likely to retire from the specialty, Mr. Fuller sees that as an indication of the commitment of Southern hospitalists to the specialty.

"They might hit some bumps in the road in terms of satisfaction," Mr. Fuller says, "but they're dedicated to working in hospital medicine for the long haul, and that bodes well for the specialty in the region."

Edward Doyle is Editor of Today's Hospitalist.


Regional rankings

TO LOOK AT DIFFERENCES ACROSS GEOGRAPHIC REGIONS, we used responses from several questions on the 2011 Today's Hospitalist Compensation & Career Survey to rate each region according to work/life balance, professional satisfaction and workplace environment.

That survey, which was conducted in May 2011, collected data from 838 hospitalist respondents. To find out which factors drive hospitalist satisfaction, we also conducted an attitudinal survey earlier this year among 121 hospitalists, with representatives from each region. We asked them to rate job attributes according to the following scale: very important, important, slightly important and not important.

Based on those responses, we assigned a weight to each of those job attributes, reflecting the importance of each. Combining the results of both surveys led to the following regional rankings:




For a full methodology, see the "Regional rankings" box on our home page at
www.todayshospitalist.com.


What really counts? Having a say

When it comes to all the variables that go into career satisfaction, which is the most important to hospitalists? Compensation? Daily census? Shifts per month?

According to a small survey conducted by Today's Hospitalist earlier this year, the answer is none of the above. The biggest single factor contributing to hospitalists' career satisfaction, respondents said, was how much autonomy they have in how their practice is run. Number of patient encounters and compensation placed a close second and third.

The fact that hospitalists identified autonomy in group management as the No. 1 factor in career satisfaction struck more than a few physicians as significant. The hospitalists we spoke to hope that it's a sign that as the specialty matures, physicians are realizing that money is only one item in career happiness.

David Friar, MD, CEO of the 50-provider Hospitalists of Northern Michigan, puts it this way: "This survey gives us permission when we talk with each other to say, 'Money is important, but it ranks No. 3 on the hit list. Let's talk about other things like sustainability, schedules, and how many weekends and nights you work.' "

Edward Ma, MD, medical director of the hospitalist practice at Brandywine Hospital in Coatesville, Pa., says the results reflect conversations he's had with older career hospitalists—physicians who have been in the specialty for 10 or more years—who are looking for more from their professional lives.

"They're saying, 'After 12 years, I feel like I have no ownership of the practice,' " Dr. Ma says. " 'Administrators are still telling me what to do, even though I've been here for so long, trying to build the program. I have no control over how we run our group, and I should be able to function with some authority in my own practice.' "

Hospital roles
While there has been plenty of grumbling by hospitalists, particularly in the early days of the specialty, about a lack of respect from specialists, the physicians we spoke to see a different type of concern about hospitalist autonomy.

Daniel C. Cusator, MD, MBA, a former hospitalist who is vice president of the national consulting firm The Camden Group, says that he has seen examples of why some hospitalists feel like they're functioning with less than full autonomy. Many groups, he says, are still a long way from being recognized by their hospitals as instrumental in cost savings and hospital leadership.

He recently visited a hospitalist program in a rural setting that was originally launched to give community physicians a break from caring for unassigned patients. But the program hasn't grown professionally or taken on more responsibility since.

"If you start a hospitalist program to cover nights and weekends," Dr. Cusator explains, "the whole rationale would be to work the hospitalists hard to give other physicians time off. You can see how that would leave the hospitalists feeling frustrated."

Brian W. Kendall, MD, medical director of hospitalist services for the Regional Medical Center of Orangeburg and Calhoun Counties in Orangeburg, S.C., hears similar stories.

"I'm seeing two big issues that demoralize hospitalists," Dr. Kendall said. "Some are facing such a high volume that they can't practice hospital medicine the way they think is appropriate. Others are being asked to admit or care for patients who really are more appropriate for other services, particularly surgical subservices."

Dr. Kendall says he's also seen some hospitals taking a hard financial line. As budgets tighten, some administrators are wondering why their hospitalist programs aren't able to support themselves.

When hospitalists can't make a profit caring for the unassigned and uninsured patients they've been charged with treating, Dr. Kendall says, administrators push them to make it up in volume.

"These administrators are more likely to view hospitalist value in terms of profit and loss," he explains. "It ends up being a vicious cycle in which hospitalists are being pushed to see more and more patients."

But Dr. Cusator notes that in his travels, he's also seen plenty of hospitalist groups that evolved into having much more autonomy— and are thriving as a result. "My sense is that hospitalists are recognizing their value in clinical integration and reaching important metrics," he says.

Dr. Ma agrees: "Hospitalists are realizing that they are at the forefront of helping hospitals save or recoup millions of dollars that they were previously getting a year ago, but now Medicare is making them earn back through value-based purchasing."


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