While burnout is a chronic threat, hospitalist groups have come a long way in figuring out what keeps doctors in their jobs by Phyllis Maguire
Published in the April 2010 issue of Today's Hospitalist
As a veteran director of a hospitalist program, Joseph Li, MD, sometimes gets e-mail offers from other hospitals, trying to lure him away to head up another program.
Dr. Li, who works at Bostonís Beth Israel Deaconess Medical Center, is happy in his job, so heís not interested. But instead of deleting those e-mails, he takes an unorthodox approach: He forwards them to the 30-plus hospitalists in his group.
"Fortunately, nobody ever leaves," Dr. Li points out, "but itís my responsibility to share opportunities. If people want to do better for themselves,
"It takes a unique person to do seven-on/ seven off, and recognizing that has a lot to do with keeping our physicians happy."
ĖThea Dalfino, MD St. Peterís Hospital
Iíll be supportive."
In central Florida, Krishan Nagda, MD, CEO of Central Florida Inpatient Medicine, a private hospitalist group with 41 providers, is well aware that his physicians can easily find other jobs in their market. Thatís why "hospitalist groups must keep their physicians engaged and provide them with opportunities to grow, if they want to keep them long-term," says Dr. Nagda. Part of the solution in his group is creating different practice tracks to keep physicians happy in their jobs.
Many hospitalists, Dr. Nagda explains, hit a wall after doing clinical work for several years, when the stress, acuity and repetitiveness of patient care can start to wear them down. While some hospitalists want leadership challenges, Dr. Nagda notes, others have goals related to teaching, mentoring or specific areas of clinical responsibility.
According to the 2009 Todayís Hospitalist Compensation & Career survey, 69.7% of respondents indicated that hospital medicine was their long-term career. Only 10.2% said it was not, leaving a whopping 20.1% of respondents in the "donít know/not sure" category. (See "Hospitalists weigh in on career satisfaction," below.)
That survey found that on a scale of 1 to 10, almost 75% of responding hospitalists ranked their satisfaction with their career as a hospitalist as 8 or better. But even more respondentsó86.7%ó said that burnout was either a significant or very significant factor for the specialty overall, while 68.8% said burnout was a significant or very significant threat for them personally.
While veterans like Dr. Li acknowledge that the field is "not even close" to solving all the issues that cause burnout, hospitalists have at least started to identify factors that contribute to career satisfaction.
Leadership of their own
According to Tosha Wetterneck, MD, a hospitalist with the University of Wisconsin School of Medicine in Madison who does research on career satisfaction and job fit, hospital medicine offers many things that physicians need for a sustainable career.
Heading that list, she points out, is "the type of work schedule that meets your work/life balance and allows you to use the skills you have." Hospitalists are in such demand, she says, that doctors who want to work only two days a week or only with a specific type of patient or niche service are able to do so. Dr. Wetterneck co-authored "U.S. physician satisfaction: A systematic review," which appeared in the November/December 2009 issue of Journal of Hospital Medicine.
But the specialty has some big pitfalls. Many programs that experience rapid growthóand thatís just about all of themóhavenít put the time or thought needed into figuring out "the kind of structures that promote the quality of working life," says Dr. Wetterneck. One big piece that has gone missing for many hospitalists, she notes, is "defined leadership that is their own."
At the very least, that ability to exercise leadership has to include having a voice in the type of patient loads that hospitalists carry and what their workload looks like, says Steven Leitch, MD, director of the hospitalist group for INTEGRIS Physician Services in Oklahoma City, which covers two hospitals.
"Hospitalists have to be part of the discussion about picking up new work," Dr. Leitch says. "They may not always get the answer theyíre looking for, but they should always help frame the solution."
A seat at the table
Some hospitalist groups, including the one at St. Peterís Hospital in Albany, N.Y., have taken the concept of defined hospitalist leadership further. Thea Dalfino, MD, who directs that hospitalist program, says that a couple of years ago, the group reported to a chief medical officer "who was not a hospitalist, but was nonetheless speaking on our behalf." The problem, Dr. Dalfino says, is that the CMO assumed the hospitalists were there to fix every problem, including stepping in for any specialty that wanted to give up its privileges.
"We were underpaid and overworked," Dr. Dalfino says, "and the only thing that kept us here was that we loved the nurses and the hospital."
But a new CMO who had experience with hospitalists at another institution turned that situation around, in part by insisting that the hospitalist group split off from the department of internal medicine and form its own department. With their new seat on the medical executive committee, the hospitalists for the first time had a say in issues that directly affected their practice, like the need to hire more night coverage.
Gaining that seat helped broaden hospitalist leadership throughout the hospital. With medical executive representation, for example, the group for the first time was clued into the hospitalís range of patient safety and quality initiatives, which led to much better collaboration across disciplines.
Dr. Dalfino says that one of her first requests to the members of the group, upon becoming program director in October 2008 was that "everybody has to join a committee." Hospitalists at St. Peterís are now involved in initiatives to prevent falls and DVT, among many others.
She adds that having the ability to individually exercise leadership is one reason that 90% of the physicians in the group define themselves as career hospitalists. It also helps that stipends for leadership and for committee participation are built into each hospitalistís annual incentive pool, which can add several thousand dollars a year to each physicianís annual income.
Viviane Alfandary, MD, a hospitalist with John Muir Medical Group in Walnut Creek, Calif., also pinpoints individual leadership opportunities as a must-have for career sustainability. Sheís one of 15 hospitalists who work at the Walnut Creek campus of John Muir Medical Center. (Another 15 hospitalists in the same multispecialty group work at another John Muir campus.)
Each hospitalist team has three representatives on a cross-campus hospitalist committee, Dr. Alfandary says, that is charged with making major hospitalist-related decisions for the group. Those include how to structure the compensation plan and the cutoff age for doctors doing nights.
The group also rotates different hospitalists through the job of assistant medical director, a role that Dr. Alfandary filled for two years. (That was before her family "told me I was giving it up," she says.) But exercising leadership for greater career satisfaction, Dr. Alfandary points out, isnít necessarily finding something with a formal title.
"If someone in your group is very good at keeping up with the latest literature," Dr. Alfandary says, "let them have 10 minutes at each monthly meeting to update everyone." In Boston, Dr. Liís group has several hospitalists in the group acting as liaison with different primary care and specialty groups.
"I am convinced that over a long career, you need something more than just seeing patients," Dr. Li says. "The work that we do is intense, so allowing you to decrease some of your clinical burden by doing other things is very helpful."
Job sharing and flexible schedules
Being flexible with leadership opportunities is part of what Dr. Wetterneck calls an essential "pop-off valve" for a career in hospital medicine. Another key ingredient: flexible options for job sharing.
In Albany, for example, Dr. Dalfino says that the 17 fulltime equivalents in her group include about 30 physicians, several of whom work a 0.75 or 0.8 FTE schedule. She herself works as an 0.8 FTE, dividing her time between administrative and clinical work.
That flexibility, she points out, is drawing physicians from other specialties to hospital medicine. One former group member who left to do an infectious disease fellowship is coming back to St. Peterís to work as a hospitalist when her fellowship ends this summer.
"She just could not find the lifestyle she was looking for to raise two children in any infectious disease practice," Dr. Dalfino says.
Another major satisfier, she adds, is flexible scheduling options. Only two physicians in her group, for instance, work a seven-on/seven-off schedule.
"Most of the hospitalists request not to be on more than four or, maximum, five days in a row," says Dr. Dalfino, adding that full time at St. Peterís is defined as working eight shifts every two weeks. "I think it takes a unique person to do seven-on/seven off, and recognizing that has a lot to do with keeping our physicians happy."
While such flexibility helps create career sustainability for physicians with young children, Dr. Dalfino notes that those options are essential for older physicians as well. One physician in her group, whoís in her 60s, is working toward giving up some clinical rounds to spend more time implementing the hospitalís electronic medical record.
With 10 full-time physicians and five part-timers covering two hospitals within the INTEGRIS system, Dr. Leitch says his group isnít large enough to easily extend flexible scheduling. As a result, he has lost some recruiting candidates because the group canít currently offer seven-on/ seven-off block scheduling.
But the hospital administration understands that hiring moonlighters while building the program reduces the number of weekends that hospitalists work and helps prevent burnout.
And while the physicians in his group "are going to have to work more days of the year" than those working seven-on/seven-off, says Dr. Leitch, "you try to avoid a high census so theyíre able to be more flexible each day." He also points out that being part of a small hospitalist group in a big hospital gives physicians more leadership options.
Looking for career growth
Respondents to the 2009 Todayís Hospitalist Compensation & Career survey signaled two problem areas. Only 46.6% of respondents said they were highly satisfied with their opportunities for career growth. And only 43.6% were highly satisfied with their opportunities for promotion.
In Florida, Dr. Nagda says that heís seen that frustration among some hospitalists as his group has matured. (Dr. Nagda established the private group in 2000.) While the physicians have always been encouraged to take leadership roles among committees in the nine hospitals and 13 nursing homes where they serve, Dr. Nagda says that over the past two years, the group has begun to institute different career tracks to meet group membersí needs.
Some hospitalists who came to the group from an academic background, for instance, find they miss an educational role. To keep from losing those doctors back to academia, the group is creating an academic track and working with the newly-opened University of Central Florida Medical School, even though the hospitalists arenít part of an academic center.
"Weíre working to create a one-month rotation for students that will involve at least some of our physicians," Dr. Nagda says.
A leadership track toward medical directorship is in place where physicians are exposed to day-to-day operations and billing. And now that the group has contracted with Medicare Advantage plans in central Florida, six hospitalists are devoting themselves to the clinical development of a managed Medicare program.
"Those doctors are going to be responsible for those patients in the hospital and interface with the managed care organization," says Dr. Nagda. The program will integrate patients, primary care physicians, hospitalists, skilled nursing facility attendings and the managed care company to follow patients from ED admission through post-acute discharge.
Providing opportunities for professional growth can make or break a hospitalistís decision to remain in hospital medicine. "It happened to me," Dr. Nagda says. "I started dreading taking that call because itís another patient with the same problem."
The issue of targeting career growth is so important, he adds, that he raises the issue when recruiting new physiciansóoften, before doctors just out of residency have thought about moving beyond clinical care.
"I tell them that theyíll be doing clinical work for the first few years and then can start one of the established tracks or help develop something that interests them," Dr. Nagda says. "Otherwise, the stress is too much."
Phyllis Maguire is Executive Editor of Todayís Hospitalist.
Strategies to prevent burnout
WHILE BURNOUT IS STILL A SERIOUS CHALLENGE, hospitalists say that now they at least recognize factors that can increase job satisfaction and help prevent burnout. Hereís a look at strategies theyíve found that work:
The right number of nights. Night coverage is one of hospital medicineís vulnerable areas, particularly for smaller groups that have to spread that pain among fewer people. Thatís according to Steven Leitch, MD, director of the hospitalist program for INTEGRIS Physicians Services in Oklahoma City, which has 10 full-time hospitalists and five part-timers.
"If itís every fifth or sixth night, youíre going to break and lose them," Dr. Leitch says. "If you get to where every seventh week they do a block of nights with some time off, then they can turn their clock around."
The right director. Dr. Leitch says hospitalists need someone who has their back. "Being their advocate is part of my job, when appropriate, with specialists and administration," he says. "I also need to help hospitalists appreciate administrative and specialty needs."
A good age mix. At Beth Israel Deaconess Medical Center in Boston, hospitalist director Joseph Li, MD, says that it helps to have a range of physician ages in the group, even though in hospital medicine, the age difference between a senior and junior physician may be much smaller than in other specialties. Heís one of his groupís most senior physicians, after all, and heís only 42.
"Having a mix allows people to see how the older folks have been able to move through the system," says Dr. Li. A range of ages also provides more mentorship possibilities.
Collegiality and colleague recognition. Every June, Dr. Liís group holds a dinner to hand out that yearís Hospys, awards that go to the "Teacher of the Year," as voted on by the centerís internal medicine residents, and "Clinician of the Year," who is elected by the nurses.
What can be done on a day-to-day basis to foster collegiality? Dr. Li explains that one of his younger physicians has told him how much she appreciates being able to eat lunch with colleagues and have an office where everyone can congregate and touch base. "That collegiality is critical when things get really busy," the young physician has told him.
Keeping group members on the same page. Another unifying factor within Dr. Liís group is the fact that all referring physicians use one e-mail address to address issues and questions for the hospitalist group. While one hospitalist each shift is assigned to answer those e-mails, everyone in the group can read them. "We try to be as transparent as possible," he says. "People see the issues that come, good and bad."
Decent benefits. "On those really bad days," says Viviane Alfandary, MD, a hospitalist with John Muir Medical Center in Walnut Creek, Calif., "it helps to know that you have benefits."
Room to grow. Finally, Dr. Alfandary points out what should probably be your first burnout-prevention strategy: Find the right job.
"The job youíre hired for today will be completely different in five years," says Dr. Alfandary, whoís been a full-time hospitalist since 1998. "If the job is barely OK now, it wonít be in a few years."
Be sure doctors working in a group youíre considering rate administration as fair, she adds; managementís expectations of the group will only grow. "Career satisfaction used to mean getting the perfect job with the right schedule and right amount of money," Dr. Alfandary says. "Now, it means where you have room to grow and enjoy your colleagues."
Hospitalists weigh in on career satisfaction
THE 2009 TODAY'S HOSPITALIST COMPENSATION & CAREER SURVEY asked hospitalist several questions related to their career satisfaction. Among those questions were the following: