Published in the November 2005 issue of Today’s Hospitalist
Kris McDonough, MD, wasn’t really interested in working as a hospitalist for the rest of his life. He was, however, thrilled to work in inpatient medicine for a year or two before moving on to fellowship training.
That was just fine with the University of Chicago, which offered Dr. McDonough a short-term job as a hospitalist. The inpatient medicine program there needed a doctor fast to fill one of several new positions being created in the wake of resident work hour rules. The program was specifically looking for someone who would fill in for a year or so until it started a hospitalist-scholars program.
With hospital medicine facing a major growth spurt, the notion of a hospitalist program agreeing to bring physicians on board for a year or two might seem to make little sense. In what appears to be an emerging trend in hospital medicine, however, hospitalist services across the country are doing just that by creating short-term jobs for hospitalists.
Many of these jobs, like the one Dr. McDonough took, are in academic hospitals starting and expanding non-teaching hospitalist services to cope with duty-hour regulations. Other short-term hospitalist jobs are being offered by community hospitals that would prefer to hire doctors who want to work as hospitalists for the long-haul. The problem is that they simply can’t find physicians given the large demand for “and short supply of “for hospitalists.
A marriage of convenience
While these temporary jobs may meet the needs of two groups “young physicians who find themselves between training opportunities and growing hospitalist services that are starved for staff “some wonder how the phenomenon will affect hospital medicine. Does the proliferation of short-term jobs tell young doctors and hospitals alike that hospitalists are little more than interchangeable, shift-working super-residents?
“It is something to worry about, but we are stuck,” says Scott Flanders, MD, associate professor of medicine and director of the hospitalist program at the University of Michigan, who has himself hired a number of short-timers to staff his nonresident hospitalist service. “There is such a shortage of bodies compared to the demand. The reason we’re seeing this is because we don’t have a great alternative.”
But it’s worth noting that there are positives for both programs offering short-term jobs and the physicians taking them. Dr. Flanders, for example, says his program has been able to hire enthusiastic, top-notch people who bring a fresh outlook and energy to his well-established hospitalist program.
Brian Schwartz, MD, who is working as a hospitalist at the University of California at San Francisco’s Mt. Zion Hospital in a one-year hospitalist position, echoes that view. He recently finished his internal medicine training at Boston’s Massachusetts General Hospital and started interviewing for a number of hospital medicine jobs. His goal was to find a job for a year or two before he started an infectious disease fellowship.
Dr. Schwartz explains that his residency training had fully prepared him to take care of hospitalized patients, so a hospitalist job was an obvious choice. Besides, he adds, it made no sense to him to build a primary care practice that he would leave just as he was starting to build it up.
When Dr. Schwartz looked at the San Francisco market “his girlfriend is doing a dermatology residency in the Bay Area “he found a plethora of hospitalist jobs. Both short- and long-term positions were available, including a number of night-shift positions where nobody objected to hiring a short-timer.
He says that he took the UCSF job in part because it allows him to continue working in an academic setting, and in part because the position offers good pay and hours.
A good match
The salary of a full-time, temporary hospitalist job similarly convinced Dr. McDonough to apply for a temporary hospitalist job at the University of Chicago. He started in July.
“I love the fact that I am going to be able to get myself out of a little debt” in the year between finishing a residency at Chicago and starting a pulmonary/critical care fellowship at Loyola in July, he says.
As a clinical instructor, Dr. McDonough is earning significantly more this year than he would have earned as a research assistant or chief resident. Those positions, which typically pay $35,000 to $40,000, been the typical job choices of physicians with time to kill between a residency and fellowship.
While the additional income is welcome, Dr. McDonough says that short-term hospitalist jobs fill another important role: They eliminate some of the stress that internal medicine residents face early in their residency.
Generally speaking, residents have to apply for fellowships immediately after they finish their intern year. The problem is that many physicians simply aren’t ready to make a life-changing decision so early in their training.
“Knowing I had options available made it easier to take a year to decide,” Dr. McDonough explains. In addition, being able to spend a year practicing medicine appealed much more than the notion of spending a year doing research.
Before he accepted the short-term hospitalist job at Chicago, Dr. McDonough interviewed for several other hospitalist jobs. Because those hospitals were looking for permanent, long-term hospitalists, he says, he had no choice but to be somewhat less than honest about the fact that he wanted to work only for a year.
“That wasn’t fair to them,” he admits, “but I had to look out for me. And then, when this position opened up “a documented one-year position “it fit perfectly. It gives me the advantage of honing my clinical skills before I go into a demanding fellowship.”
Now that he’s working as a hospitalist, he says he has found the match to be good. “I am doing the same job as I was doing as a resident,” Dr. McDonough explains, “but with a little bit more responsibility and less work hours ” and a lot more money.”
Concerns about quality and costs
While young physicians may welcome short-term hospitalist positions, hospital medicine leaders wonder how they will impact both individual hospitalist services and the specialty as a whole. One major concern relates to the evidence that experienced hospitalists provide higher quality and more cost-efficient care than newcomers.
“If you establish a system that only ever uses people who never get that experience, you are going to reap what you sow,” explains Steven Z. Pantilat, MD, a UCSF hospitalist and current president of the Society of Hospital Medicine. (He notes that the society has not taken a position on the merit of these new positions and that his opinions are his own, not the society’s.)
“If you set up a program that is going to use people for a year who are right out of training and who are going to continually turn over,” Dr. Pantilat says, “then you will have no institutional memory in your program. You are unlikely to see all the benefits that a hospitalist program can bring in terms of quality of care and systems improvement and efficiency.”
Dr. Pantilat says this type of “resident replacement” reminds him of the era before hospitalists. “There were always jobs like that before there were hospitalists,” he explains. “They were house docs. And when you do shift work, by definition, you do your shift and leave and you are not as invested in making the system better.”
“One of the hallmarks of a good hospitalist,” Dr. Pantilat adds, “is that the physician is thinking about quality and populations of patients and how to make the systems better, not just about individual patients.”
The reputation of hospitalists
Another concern has to do with how hospitalists’ colleagues will perceive hospital medicine as a specialty if it hires what are essentially temporary workers.
“There is no question that it is something you can do right out of residency, but that doesn’t mean that you won’t get better over time,” Dr. Pantilat says. He worries that hospitals that create jobs that turn over every year or two risk damaging the credibility of the new field, which has worked hard over the last decade to prove that inpatient medicine is not only good for health care, but sustainable for its practitioners.
Dr. Flanders from the University of Michigan wonders whether hospital medicine’s reputation will take a hit. “It doesn’t help the reputation of our group and the institution, similar to what it means to the profession, if people view hospitalists as a bunch of recent, inexperienced graduates and if people think the profession does not have the rigor of other specialties,” he says. “It is an issue for us.”
But for now, at least, he sees few other options to the workforce shortage plaguing his and other programs.
“I would love nothing more than to have longer-lasting faculty,” Dr. Flanders explains. “But I would turn it right back to myself, that it’s my job to create a position that someone finds attractive.”
The good news is that at Dr. Flanders’ program in Michigan, that shift has already started to occur. One of the eight people he hired for the non-resident service is an experienced hospitalist who had been working at a community hospital and has decided to come to the University of Michigan.
While the physician is not particularly interested in being an academic hospitalist and duties like teaching and doing research, Dr. Flanders says, he does like working in an academic setting and getting involved in quality improvement projects. And in another encouraging sign, one faculty member is now spending half of her time on this non-resident service and half on the resident service.
While few programs are happy to turn over their physicians every few years, Dr. Flanders hypothesizes that if the core of a hospitalist group is long-term and permanent, there may be a place for new hospitalists to come in and work for a year or two.
“There are a decent number of people who want a short-term job,” he explains, “and we need bodies to care for patients. Like every program, we need to grow. We need bodies for the added roles we are being asked to play in the hospital.”
Deborah Gesensway is a freelance writer who reports on U.S. health care from Toronto, Canada.