Published in the May 2015 issue of Today’s Hospitalist
HOSPITALIST Randy Ferrance, MD, loves his job. He loves the medicine, the small hospital where he practices, and his roles as director of the hospitalist and hospice programs and of hospital-based quality.
But “I cannot sustain this lifestyle,” says Dr. Ferrance, who is in his mid-50s and has been in his current position at Riverside Tappahannock Hospital in Tappahannock, Va., for nearly 13 years. While he cannot imagine that any other job will be as rewarding, he is blunt about his future: “I need to do something different.”
Dr. Ferrance shares a seven-on/seven-off schedule with only three other doctors; the group’s one nurse practitioner does not take solo shifts. That means that he pulls almost as many night shifts as days, then comes in on many of his days off for meetings.
And with the last of his three children about to graduate from college, Dr. Ferrance says he finally has some breathing room in terms of how much he needs to earn. Now, he wants to spend more time with his wife and to help her care for his in-laws.
“I want to be more than just a paycheck earner,” he says, adding that his neighbors thought he and his wife were divorced when he was in medical school because he was home so seldom. “I would like to be a participating member of the household.”
With hospital medicine being such a new specialty and with so many hospitalists in their 30s and 40s, it may be easy to overlook the fact that some physicians in their 50s and 60s are trying to figure out how to age well as a practicing hospitalist.
But that is particularly tough because most hospitalist programs “unlike groups in other specialties “don’t make scheduling concessions to senior doctors. While ED groups may exempt physicians from pulling nights after they’ve worked 10 years or allow doctors to work eight- or 10-hour shifts instead of 12, most hospitalist groups don’t even consider, let alone offer, those kinds of options.
That’s unfortunate not only because of the hospitalist shortage, but because senior physicians bring real value in terms of clinical and communication skills and administrative capital. But for many hospitalists who find themselves in Dr. Ferrance’s situation, their sole recourse may be to leave the specialty.
Given the small number of providers in his group, Dr. Ferrance says that schedules and clinical work until now have been divided evenly, “almost to a fault.” He recently proposed to his administration working a reduced schedule, with a commensurate pay cut. He would like to work clinically three days a week and one weekend a month, plus devote another half-day each week to hospice. Plus, his proposal included having five weeks off a year.
Dr. Ferrance isn’t sure if that proposal will fly or if his small group could even absorb the shifts he would stop working. While he hopes he can stay where he is part time, he has looked into other positions in his area, including working with elderly patients or joining academia. While such positions would come with a big pay cut, he is sure the time he would gain away from work would be worth it.
Although his current schedule seems unrelenting, Dr. Ferrance remembers when the job was way worse. “When I first started here, we did 24 hours of call so we had 30-hour days, just like in residency,” says Dr. Ferrance.
“We used to do three weeks on and one week off.”
At Reading Hospital in Reading, Pa., I. Michael Goonewardene, MD, who is in his 50s, also remembers rough times from early in his career “and that was before he worked as a hospitalist. He began in a traditional internal medicine practice and followed patients into the hospital. He remembers holding the pager for his own group ” as well as for family practices that his group admitted for “from 12 noon Friday until 7 a.m. Monday.
“There were times when I slept maybe two hours each night over the weekend,” says Dr. Goonewardene. “Compared to that ridiculous lifestyle, hospital medicine was a breath of fresh air.”
Like the other doctors in his 55-member group, Dr. Goonewardene works 16 12-hour shifts per month, including two or three nights. But over his nine years as a hospitalist, he has found that the job has become more challenging.
“There are so many things that we are now expected to do that we never had to do before,” Dr. Goonewardene says, including documentation intricacies, fielding patient expectations, stewarding limited resources, and improving quality and length of stay. “Those are things that hospitalists even a few years ago did not have to do.”
Then there’s the fact that, as far as Dr. Goonewardene can see, hospital medicine makes no concession to doctors getting older. “There is no sense of, ‘Hey you earned it,’ like my senior partner when I was in private practice who stopped working weekends.”
At Duke Regional Hospital in Durham, N.C., Robert Lineberger, MD, is now in his 20th year as a hospitalist. He finds that some aspects of the job have gotten easier.
He no longer, for instance, has to cover nights alone and handle all the cross coverage and admissions. “Now, we have two physicians covering nights, so the stress level has gone down.”
Physiologically, however, he finds it much harder to recover after working nights. “I am just not as resilient as I was 15 or 20 years ago,” Dr. Lineberger notes. “It doesn’t make physiologic sense to treat a 55-year-old like a 30-year-old.”
The problem with shifts
At age 43 and in his 11th year as a hospitalist, Jason Ham, MD, is very concerned about losing senior physicians from the field. He is also paying close attention to how to successfully maintain his own career. For Dr. Ham, nights aren’t the problem. The problem, he says, is having to work 12 hours at a stretch.
While 12-hour shifts may be the norm in hospital medicine, Dr. Ham points out that it is not in other careers “such as piloting or manufacturing “that likewise rely on shift work. And while he admits that some younger physicians prefer working longer shifts because it allows them to take more days off, he thinks that doctors at any age pay a high price, but that the impact is exacerbated by age.
“A 12-hour shift really takes a toll on your mental acuity and physical abilities, particularly during the last two hours of the shift,” he says. “If I had a choice between a great job with a 12-hour shift or a less than ideal one that was eight hours, I’d go with the eight-hour shift every time.”
While he considers himself to be a hospitalist, Dr. Ham is the director of the adult medical observation unit at the University of Michigan Health System in Ann Arbor. He works plenty of late evenings and weekends as well as some nights, but each shift on that unit is only eight hours.
According to former hospitalist Maria Hoertz, DO, MPH, 12-hour shifts are a real problem for the specialty. The trouble is only compounded when shifts turn out to last 15 or 16 hours once you factor in a commute and the need to wait around for test results.
Another big problem in hospital medicine that she sees: not being able to take blocks of time off if, for instance, a family member becomes ill, a situation that Dr. Hoertz thinks may fall more often on women physicians. As a result, she chose to work locums for many of her years as a hospitalist, turning down assignments when she needed to take more than a week or two off.
Are concessions a good idea?
Dr. Hoertz, who lives in Arizona, also balanced out her stints as a hospitalist “including one year as a nocturnist “with other types of clinical practice, such as working in an ED. And now that she has, at age 60, adopted her two-year-old grandson whom she is raising, the possibility of continuing to work in hospital medicine is, she says, not even feasible.
“If you could find a job as an admitting doc from 8 a.m. to 4 p.m., that could be tolerable,” says Dr. Hoertz. “Otherwise, you won’t find a babysitter for 14 hours a day, even if you work only three days a week.” Instead, she is now doing complex population management, working with NPs and case managers and treating high-risk patients with multiple comorbidities. While she has an office, she often visits patients in their homes, and she works Monday through Friday, 8 to 5.
“I have the option to do call on nights and weekends, but I don’t want to,” she says. She adds that she’s able to take all her experience caring for patients in the hospital “to work to keep patients out of the hospital, if possible. It’s just as challenging, and the pay is comparable.”
As for whether Dr. Hoertz ever came across a hospitalist group that built in scheduling allowances for senior members, the answer is “no.”
“Any time you make something easier for someone else, it makes things four times harder on you,” she says. “By making concessions for older doctors, younger physicians are just making it harder on themselves, and nobody wants that.”
So how do older doctors stay in hospital medicine? They don’t, says Dr. Hoertz. “They change their practice.”
Dr. Goonewardene agrees. He plans to continue as a full-time hospitalist for another decade. Then what? “I think the transition out is going to be: You stop being a hospitalist and start being something else,” he says.
He can see himself transitioning to working clinically with senior patients on weekdays or to a full-time nonclinical job like quality-improvement coordinator. But as for hospital medicine, “there is no mechanism to slowly cut back that I can see.”
But Viviane Alfandary, MD, a hospitalist with John Muir Medical Group in Walnut Creek, Calif., points out that her group does allow physicians to cut back some of their hours. Hospitalists in her practice, for instance, are no longer scheduled for night shifts once they hit age 62 “a target that keeps on being pushed back, having been raised already from first age 55, then 60.
However, Dr. Alfandary, who is 57 and has worked as a hospitalist for 19 years, hasn’t pulled a night shift for more than a year.
“I just refuse to do them anymore, so I trade or give away all my nights,” she says, adding that with so many younger doctors in her group dealing with new mortgages and school tuitions, she has no problem finding takers. “I take a pay cut because of that, but I’d rather not work nights.”
Her hospitalist group, which covers two different hospitals, has more than 50 hospitalists, including 10 doctors working a hybrid urgent care/hospitalist schedule who will transition to full-time hospitalists when positions become available. The group also includes four locums.
Like some other senior physicians in her group, she has cut back from doing 18 shifts a month to working only 15 or 16. She points out that some women physicians who have young children in her group work only 14 shifts a month, while other doctors pull 22.
Dr. Alfandary also says that the seven-on/seven off schedule is starting to wear thin. She tries to break that up by trading one of those blocks a month for her group’s nursing home rotation, treating patients recently discharged from the hospital. A big advantage of that rotation is that it is usually only five shifts in a row.
She also trades away some rounding days for acute rehab shifts in the hospital. Those shifts, which run only eight hours from noon to 8 p.m., entail seeing patients in acute rehab for four hours, then admitting patients in the ED for the rest of the shift.
“Eight hours is much easier than 12, less difficult and less stressful,” Dr. Alfandary says. She also notes that her group has opened up extensivist positions where hospitalists see patients in the group’s new post-discharge clinic in the morning, then visit patients at three nursing homes from 1 p.m.-5 p.m. “another eight-hour shift option.
In addition, the group is considering piloting a program of eight-hour hospitalist shifts. That may end up being one more option that Dr. Alfandary believes is “probably not” available in most hospitalist programs.
“It seems clear that programs will have to cut benefits if they allow doctors to work fewer hours, as they would have to hire more to fill empty shifts,” she points out. Still, she adds, for many senior physicians, a cut in pay or benefits wouldn’t be a hardship.
For Dr. Ham, one possible solution for keeping more physicians in hospital medicine could be a job-sharing scenario.
“Instead of one doctor seeing between 10 and 20 patients, two doctors with a PA or NP would cover a double census,” he says. But the doctors would have staggered shifts.” This might allow one doctor to come in early and finish in time to pick up a school-age kid. The other doc would come in later, but get to exercise and drop off kids in the morning.”
As for how to compensate doctors in such a scenario, “the pay scales might be different,” says Dr. Ham. “But productivity might actually improve if the provider team was able to discharge more patients during the evening.”
The good news at Duke, says Dr. Lineberger, is that the issue of aging is being discussed. That wasn’t the case just a few years ago.
“You’d need to have a certain group size and makeup, and you’d have to be careful not to overburden the new doctors in the group,” he says. “But when it comes to retention and the issue of an aging workforce, it’s something we need to pay attention to as a specialty.”
That might be particularly feasible for groups like his own, which are part of a larger organization. Dr. Lineberger also thinks any eventual seniority benefits would have to be gradual and incremental. “Not necessarily doing no nights,” he explains, “but doing a smaller number than those who have not established themselves as long in the practice.”
According to Dr. Goonewardene, his group in Reading is large enough and forward-thinking enough to eventually create some kind of transitional pathway. But so far, he points out, no one has really pushed for one, including him.
“I think hospital medicine is going to parallel emergency medicine with some way to stay full time and still alter how you work,” he says. “But I don’t think this will really shake out for another 10 years.” That’s when, he adds, the first big wave of hospitalists “who have worked only in hospital medicine and who have now been working for 10 or 15 years “are going to be looking for some options for themselves. “That’s when this will become a personal issue for them.”
Phyllis Maguire is Executive Editor of Today’s Hospitalist.
CAN YOU AGE gracefully in hospital medicine? While she worked as a hospitalist for many years, Arizona-based Maria Hoertz, DO, MPH, doesn’t think doctors can maintain a hospitalist career for decades on end “at least, not if they work seven-on/seven-off with 12-hour shifts.
Instead, Dr. Hoertz advises, physicians should plan on transitioning away from hospital medicine, and they should prepare for that transition by taking on different clinical roles: working in an ED or doing critical care, for instance, or volunteering at a clinic to get some outpatient experience.
“You want items on your CV that will make people confident that you can do other types of practice,” she says. “I wanted to get that experience because I knew I was going to have to change my practice as I got older.”
She also urges younger doctors to pack as much into what she calls “the peak earning years and the peak energy years. When you are making a lot of money, put it away and don’t spend it.”
Robert Lineberger, MD, who practices at Duke Regional Hospital in Durham, N.C., and is in his 20th year as a hospitalist, believes you can make a hospitalist career more sustainable by taking on nonclinical responsibilities.
“Don’t just see patients,” says Dr. Lineberger. “Do other things.” For several years, he devoted half of his time to his hospital’s informatics department.
Now that the electronic record he was working on has been rolled out, he is back to doing 100% clinical. That gives him more days off than when he was dividing his time, and he can spend more time with family.
But Dr. Lineberger says he misses the variety. “It was a way to improve patient care in the long run, but it also gave me a bit of balance,” he says. “I didn’t have to be here at the crack of dawn every day with a list of patients staring at me.”
He also believes that doctors need to protect their own work-life balance by making their life away from the hospital a priority. But that’s not possible, he points out, if groups don’t carve out time “and compensation “for nonclinical activities, and instead expect physicians to keep running back to the hospital to be administrators on their days off.
“Not all groups support that, and they get what they pay for,” Dr. Lineberger says. “A lot of groups undervalue that, which means they have to rely on doctors who do not have a lot left in the tank.”