Published in the November 2008 issue of Today’s Hospitalist
After working as a hospitalist for several years with little say in matters of policy or practice, James Leyhane, MD, longed to run his own program.
“There are always so many things that you would do differently,” he says. He quickly discovered, however, what it was like in the director’s hot seat.
In fact, Dr. Leyhane found himself making pivotal decisions about how to run the hospitalist program at Auburn Memorial Hospital in Auburn, N.Y., before he was even offered the job. In his bid to direct the program where he already worked as a front-line hospitalist, Dr. Leyhane says he submitted a budget proposal that he would have to live with for the first year, only to discover that it contained a significant miscalculation. He had assumed that outside doctors would want to moonlight in the more than 100 uncovered shifts covered by that budget, only to discover they weren’t so eager.
“If I had to do it again, I would just put in for another full-time position,” says Dr. Leyhane, who is now six months into the job. “Fortunately, the hospitalists were willing to take the shifts, and the group figured out pretty quickly that if the productivity numbers looked good, then we could hire a fifth doctor.”
Like many in the field, Dr. Leyhane jumped from full-time hospitalist to program director with limited management experience and little time to prepare. In what can be an overwhelming first few months, new directors must set program parameters, decide how to deploy resources, forge working agreements with community physicians, spearhead recruitment and learn how to deflect unmanageable demands.
To get up to speed, new directors have to quickly identify sources of good information and advice. Perhaps most importantly, they also learn the key skill of how to say “no.”
A crash course in communications
For some new directors like Dr. Leyhane, the first priority on the job is solving major coverage snafus. For others, particularly those hired to head start-up programs, the first months can be a crash course in marketing and community relations.
That was the case for Ada Rahn, MD, director of Elmhurst Clinic Hospitalists in Elmhurst, Ill. She had to quickly figure out how to convince a tradition-bound medical community to accept what to some seemed an unwelcome change.
“It was an uphill battle as there were no hospitalists when we started,” says Dr. Rahn, who has now been director for 18 months. “We had to convince the physicians not affiliated with our clinic that we were not trying to take over their patients.”
Other new directors find themselves learning diplomacy, especially if they head up groups that are rebuilding and in transition. That was the case for Vijay Gandla, MD, program director of the Cogent Healthcare hospitalist program at High Point Regional Health System in High Point, N.C.
“My first job was to instill confidence in the medical community that the hospitalist program was devoted to the best quality care,” says Dr. Gandla. (While he has been directing the group now for three months, he started to transition the program more than six months ago.) He got that word out by participating in meetings in and out of the hospital, appraising concerns, and reaffirming the program’s goals and vision.
Where to get help
Where do new directors pick up skills they need? As a director in a national company, Dr. Gandla says that he has an extensive support network, including seasoned advisors and a team of professionals to answer administrative questions.
Other new directors draw on diverse experiences to guide them as managers. Some say hospital committee work prepared them, while others say they learned from past mistakes.
Eric Shouldis, MD, who has directed the hospitalist section at the Charleston Area Medical Center (CAMC) in Charleston, W.Va., for the past five months, says he gained valuable know-how by previously working for a hospitalist program that lacked sufficient backing.
“I learned about the financial aspects of the program there “the revenues that we brought in and the costs “and came to understand that hospitals have to subsidize hospitalist programs,” says Dr. Shouldis.
He is fortunate to have that financial support in his new position, Dr. Shouldis says, and he continues to work closely with hospital administrators, including the chief operating officer. He also turns for advice to a CAMC hospitalist council that includes himself and four elected senior physicians.
New leaders also go far afield for good counsel. Dr. Rahn prepared for her new role by talking to as many far-flung colleagues as possible and attending a seminar on how to manage a hospitalist program.
Dr. Leyhane gets a lot of good advice close to home, meeting every two weeks with his hospital’s medical director and CEO. But some of the best guidance he received came from responses to questions he posted on the Society of Hospital Medicine’s discussion board. Asking about matters as seemingly mundane as scheduling, he heard back from more veteran directors.
“The field is so new that everybody has the mentality of helping each other and sharing information,” says Dr. Leyhane. “We don’t see each other as competitors.”
Just say “no”
New directors say that one of their toughest tasks is defining what their programs can and cannot do, given their staffing and resources.
“Do we care for head fractures and intracranial bleeds? Who gets the postop calls?” Dr. Leyhane says. “The art of it is learning how to say ‘no,’ so you’re not handling too many requests.”
This can be, adds Dr. Shouldis, “a delicate issue,” particularly when part of hospitalists’ value comes from their ability to support subspecialists. “Sometimes I feel like a broken record explaining how important it is to the subspecialists that our program grows so we may continue to absorb the unassigned volume. That will help them with complicated floor issues that interfere with their specialty services.”
Challenging the status quo
Another problem that new leaders face: wading into what may be longstanding problems or bad habits and shaking up the status quo. Directors may have to convince staff to embrace new rules.
Dr. Leyhane notes, for example, that physicians at his hospital worked out a “house doctor” arrangement whereby internists take care of their patients during the day and the hospitalists cover for them at night. But he discovered that the nurses were waiting for the hospitalists to come on duty to unload most of their questions because it was “much easier than sitting on hold with a doctor’s office or getting an answering service.”
“We met with the nursing supervisors and said the goal should be that we are called with emergencies only,” he says. “It was an education.”
In her practice, Dr. Rahn says that she decided to make one doctor on each shift responsible for all patient calls, and to make sure the nurses had the on-call schedule.
“It took a year to get everyone to adapt to this,” she points out. “The nurses were used to seeing the name of an admitting physician and calling that doctor with problems or questions.”
To help resolve the issue, she says, she hired a liaison nurse “just to answer the question, ‘Who is on call today?’ That way, the call is directed to the appropriate physician.”
Finding time to recruit
While they are navigating politics and treating patients, directors say they have little time left to recruit new doctors and do other administrative work. Recruiting, they point out, is a time-consuming and potentially tricky job as directors compete in a tight labor market.
Another challenge for many new directors ” finding the right balance between administrative and clinical duties “remains a challenge.
“I didn’t allow myself enough time to be a director, and so I’ve become a director in my time off,” Dr. Rahn says. “My contract says 30% of my time would be for administrative duties, but that hasn’t worked out.”
Miscalculating the amount of administrative time she’d need has been, she says, “my single major mistake.” She is now proposing to hire another hospitalist, which is a necessary addition to safeguard the 30% time she needs to focus on quality improvement.
One thing that Dr. Leyhane plans to do differently in the next several months is arrange for a full-time administrative assistant. That should put some distance between him and what he says are his “least favorite duties”: the office work that includes paper billing, vacation requests and shift switches.
Tracey Regan is a freelance health care writer based in Hoboken, N.J.