Published in the July 2009 issue of Today’s Hospitalist
It may be the most vexing question in all of hospital medicine: What’s the right number of patients to see?
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During this year’s Society of Hospital Medicine meeting in Chicago, veteran hospitalist John Nelson, MD, moderated a panel discussion that considered that question. While conventional wisdom holds that 15 patients is the optimal daily census, Dr. Nelson pointed out that the right answer varies from group to group and from physician to physician.
While Dr. Nelson said “the sweet spot” of patient census remains elusive, panel members discussed the many variables that go into determining the right clinical workload, both for groups and individual physicians. Those include scope of practice, group culture, individual physician goals and compensation expectations.
“If you approach a practice and say you want to be paid at the 75th percentile of hospitalist income, that’s a reasonable request,” said Dr. Nelson, who works as a consultant and is director of the hospital medicine program at Overlake Hospital in Bellevue, Wash. “But if you then say that you feel comfortable working with only 12 patients a day, that’s a significant disparity.”
All of the panel members admitted that they didn’t know the answer to the question of what the ideal daily census is. But they shared the staffing and scheduling strategies their groups use to get as close as they can to that ideal.
A complex equation
Panel member David Friar, MD, who is president of Hospitalists of Northwest Michigan in Traverse City, Mich., said he thinks he knows why the question of what’s the right patient load is so ubiquitous: In hospital medicine, it’s probably the easiest metric to track.
“It’s the one metric that people focus on,” Dr. Friar said. “Unfortunately, it’s also dangerously easy to benchmark.”
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It’s dangerous because many different factors ” which are just as important as patient load “go into the productivity equation. Scope of practice is obviously a huge factor. Physicians who don’t provide critical care or run codes can comfortably see more patients.
Patient mix is another factor. Panel member M. A. Williams, MD, who is executive director for business development for Sound Inpatient Physicians, a national hospitalist group, said hospitalists in his Denver group average between 2,000 and 2,500 patient encounters per year. However, one colleague “who works in the same group in the same hospital “annually accounts for about 5,000 patient encounters.
That’s because, Dr. Williams explained, the colleague spends his time exclusively comanaging orthopedic patients and does no call or ICU coverage. “He literally has to walk no more than 100 yards in a day,” he said, “to see every postop knee and hip.”
Then there’s the issue of physician experience. “I have new physicians who have been hospitalists for two months who are uncomfortable at the higher end of daily encounter numbers,” said Joanne Brice, MD, CEO of United Health Alliance, a 47-provider group that covers five facilities, including the 720-bed Christiana Hospital in Newark, Del. “I also have doctors who have been hospitalists for 11 years.”
Another big variable is institutional support. Do you have residents or midlevels, for example, who help you treat patients? Do you take call, and does your program staff a swing or night shift?
And do you have to spend time navigating a new electronic health record or CPOE system? While technology may eventually help you practice more efficiently, getting up to speed on a new system will affect the number of patients you’ll be able to see.
Physicians need to be aware of all the factors that contribute to variability, Dr. Williams pointed out, particularly if they’re being pressured by hospital administrators to see more patients.
“If you’re getting pressure to go up or down on patient census,” he said, “you have to be able to identify what you can adjust or tweak.”
A question of group culture
Panel members also pointed out that what doctors perceive as the right number of patient encounters has a lot to do with group culture, which in turn determines the kind of schedule groups opt for.
The Christiana hospitalist group, Dr. Brice explained, was originally launched by infectious disease physicians in 1996 and evolved along private practice lines.
“We came along before the advent of the popularity of block schedules,” said Dr. Brice. “We have gotten used to working Monday through Friday and expect to work a certain number of weekends.” According to survey standards, she pointed out, hers is a “fairly busy, productive group,” with annual RVUs for full-time equivalent running about 3,700.
“We work an average of 260 days per year,” Dr. Brice said, “and our average number of daily encounters per physician is around 18.”
Physicians in Dr. Williams’ group, on the other hand, work 180 days a year on average, which comes out to 15 shifts per month.
The group, which was founded in 1998, became part of Sound Inpatient Physicians in 2007. The decision to merge, Dr. Williams said, was partially to limit physicians’ number of daily patient encounters and the number of days that doctors work each year and to enable them to focus on improving quality as well as work-life balance. According to Dr. Williams, his average day is 11 hours long, and his patient volume ranges between 12 and 18 patients a day.
Dr. Friar’s group in Michigan opts for still another scheduling model. Like Dr. Brice’s program, it has chosen not to take the block-scheduling route.
“This isn’t a sprint,” Dr. Friar said, “and seven-on/seven- off is one of the mistakes that I think our field has made. We burn ourselves out, then we rush home to spend seven days driving our spouses crazy.”
Working more days a year, he added, “allows us to lower the number of patients that we see each day so we can make it home for dinner without sacrificing our productivity.”
Instead of focusing on what number of patients the group believes its physicians should see, Dr. Friar says that his program stays away from a one-size-fits-all approach, tailoring schedules to how much individual physicians can work. That shifts the focus from patient census to career sustainability.
For one of his colleagues, for instance, 15 patients a day would be too many because the physician spends hours every day in meetings. Likewise for another colleague who stays in the ICU managing vents.
And while one female colleague used to have no problem seeing 15 patients a day, she now wants to cut back and spend more time with her growing family. “If we want to retain her,” said Dr. Friar, “we can’t create a system where we say, ‘Sorry, you have to see 15 patients a day.’ ”
Still other physicians in his group “because of mortgages, private school tuitions or “just bravado”, Dr. Friar said “are always going to want more patient encounters than their colleagues. Those doctors, he added, won’t be happy unless they see 20, not 15, patients a day.
“Our concept is that one full-time provider does not equal one FTE,” Dr. Friar explained. Some days, the group needs 11 providers on-site to equal the work of eight FTEs; on other days, depending on which physicians are working, it may take only six providers to cover eight FTEs. “At least we’re able to accommodate a large variety of provider needs, from doctors who are all at different points of their lives with different goals.”
Keeping an eye on revenue
Regardless of how many patients individual physicians feel comfortable seeing, Dr. Friar urged hospitalists to consider these key questions: How large is the stipend that hospitals are paying for their program, and will hospitals start expecting more revenue from physicians in return?
That stipend, he said, is “the elephant in the room, and the elephant is getting very nervous.” Hospitals are hearing a great deal of talk about health care reform at the same time that their endowments and charitable contributions are dwindling, he pointed out.
That may not necessarily mean that hospitals will start pressuring doctors to churn through more patients. But it does mean, Dr. Friar said, that hospitals should expect hospitalists to maximize their billing and their revenue.
“It’s going to be a really important job over the next few years,” said Dr. Friar, “to keep the elephants calm and happy.”
Phyllis Maguire is Executive Editor of Today’s Hospitalist.
What hospitalists stand to lose when patient census rises
WHILE PHYSICIANS MAY NOT KNOW exactly how many patients a day is the right number to see, Kevin O’Leary, MD, associate chief of hospital medicine at Chicago’s Northwestern University, said that doctors know when they’re seeing too many.
As part of a panel discussion at this year’s Society of Hospital Medicine meeting on the right patient workload for hospitalists, Dr. O’Leary asked audience members to raise their hands if they thought their daily census was uncomfortably high. More than half the audience did so.
That, said Dr. O’Leary, could have serious repercussions for safety and quality. “We know that hospitals, when they reach capacity, are less efficient and their LOS goes up,” said Dr. O’Leary, adding that the same probably holds true for hospitalists. “At some certain threshold, we’re less successful at advancing patients’ plan of care.”
Two time-motion studies done at his institution tracked how hospitalists’ work activities change as patient volume rises. (The study was first done in 2004 with results published in the March/April 2006 issue of the Journal of Hospital Medicine, then repeated in 2008.) Researchers looked at hospitalist activities on both low-volume days, defined as 13 or fewer patient encounters, and on high-volume days, which had 14 encounters or more.
Both studies found that as patient volume goes up, the time that doctors spend in direct patient care doesn’t change substantially, nor does the time they spend on professional development or on personal time. Where doctors do significantly cut corners as census goes up, however, is in what they spend the majority of their time doing: indirect patient care.
That includes such essential activities as documentation, writing orders, and communicating with both nurses and primary care physicians.
While that may hardly be news, Dr. O’Leary asked physicians to consider the implications. For one, when hospitalists spend less time communicating with outpatient physicians and put off writing discharge summaries until they have fewer patients, he said, “that affects the quality and safety of the transition out of the hospital.”
And interestingly, he added, when harried physicians respond to a higher census by spending less time documenting, they are sabotaging their ability to support their billing for those patients. That has a direct impact on hospitals’ case mix index and on revenue.
“More volume may not be better for the bottom line if, because of higher volume, we’re not writing notes that support billing,” Dr. O’Leary said.
While the studies found no difference between low- and high-volume days as far as time spent treating patients, researchers did find that doctors who spent more time communicating with patients received higher ratings on the quality of that communication from their patients. That, Dr. O’Leary said, has a direct effect on patient satisfaction. As the number of high-volume days mounts, he added, the risk of errors or possible adverse events is also affected.
It is unclear, he said, what effect having more high-volume days has on individual physicians’ length-of-stay figures. Doctors under the gun to see too many patients, he noted, may “try to reduce their daily volume by pushing patients out of the hospital.”
That in turn may lead to higher numbers of rehospitalizations. “We don’t know the answer to that,” said Dr. O’Leary, “but there’s a lot of potential for future research.”