How the great resignation may affect hospitalists

STEPHEN BEHNKE, MD, MBA, says his big career move last summer—leaving his CEO job in a local Ohio hospitalist group to head up the largest multispecialty group in Lexington, Ky.—had nothing to do with any five-year plan. Instead, the offer just came across his desk.

“I realized my skill sets actually fit what they needed,” says Dr. Behnke of his new role at Lexington Clinic. The fact that he grew up there and his parents still live nearby helped seal the deal. But he also chalks up some of that decision to the fact that he spent more than a year helping steer a hospitalist group through the pandemic.

“You recognize that life is going by very quickly, and the pandemic raised our awareness of our own mortality,” Dr. Behnke points out, noting that he and his former hospitalist colleagues lost a partner to covid. “Many of us are now looking at life through a different lens, reassessing what’s really important in the long run.”

“You recognize that life is going by very quickly.”

~ Stephen Behnke, MD MBA
Lexington Clinic

And while he loved his former job—he joined that group in 2005 and became group leader in 2010— Dr. Behnke admits that treating wave after covid wave felt “restrictive and fatiguing.”

“We couldn’t do the things we were working on before covid,” Dr. Behnke says, citing projects like improving performance, optimizing clinical units and integrating physician-nurse teams. “It was frustrating to put all those on the back burner and stay in this all-hands-on-deck survival mode. There was a sense that we were just in this holding pattern in hospital medicine.”

The “big quit” now roiling so many fields has hit health care hard. Estimates hold that during the pandemic, 12% of health care workers either lost their jobs or were laid off, while another 18% just quit. (Some analyses indicate that many are taking other jobs in health care.) That makes food services the only other U.S. industry with more pandemic-related churn.

In the hospital, the “great resignation” has been particularly devastating in terms of nurses and other clinical staff. And while the same exodus of doctors as nurses hasn’t occurred, there are signs that hospitalists may be among the next wave of clinicians to think about leaving—or at least pare back their presence on the wards.

“Even before covid, more hospitalists were electing to reduce their workload from full to part time, and the pandemic accelerated that,” says John Nelson, MD, a hospitalist in Seattle who consults nationwide with Nelson Flores Hospital Medicine Consultants. “The bigger trend I see now among hospitalists is not wanting to quit, but to dial back to a 0.8 FTE or even a 0.6.”

Amplified hazards
That’s also what Rohit Uppal, MD, MBA, chief clinical officer of TeamHealth Hospitalist Services, says his data show across the country. TeamHealth has more than 4,000 hospitalists in more than 200 programs.

“PRN works well for folks who want to feel out the system and the community before committing.”

~ Ijeoma Carol Nwelue, MD
Baylor Medical Center Ft. Worth

Rather than seeing increased attrition, his company is seeing more “downgrades” where physicians cut back shifts or hours. Doctors who for years reliably picked up extra shifts, saving groups from having to hire, no longer want to. Even some long-time leaders, says Dr. Uppal, are “stepping back from their leadership ambitions.” He worries those trends will only ramp up once covid volumes recede.

“Hospitalists now are exhausted and demoralized,” he says. In addition to numbing waves of disease, doctors are feeling the impact of hospital staff shortages, long patient boarding times in the emergency room, and the inability to interact face-to-face with patients and families, all on top of the personal stresses brought on by the pandemic. Then there’s what Dr. Uppal calls “the misinformation piece.”

“Doctors have had their medical expertise questioned in a way that’s never happened before,” he notes, adding that physicians and staff in two hospitals that TeamHealth serves received death threats from family members of covid patients. While people in every industry are re-evaluating their work lives, he points out, “hospitalists have faced amplified hazards and stressors. It’s reasonable for people to think that other hospitals may not have the same staff shortages or patient populations, and the grass may be greener somewhere else.”

“Record numbers” of potential recruits
That migration may have already started. Jennifer Ashley, MD, hospitalist director for St. Charles Health System in Bend, Ore., notes that even before delta—which overwhelmed her hospitals—some hospitalists in her program had cut back to 0.8 FTE to help themselves recover. Two surges later, fully one-quarter of her hospitalist colleagues have reduced their clinical work from full time.

“Some backed down their hours completely, while others switched some clinical time to administrative, which is less grueling and more flexible,” Dr. Ashley points out. Importantly, a lot of administrative work—utilization review, chairing a committee—can be done remotely from home. “That has a lot of appeal.”

“All the structural problems that were there pre-pandemic have started to resurface.”

~ Suneel Dhand, MD
DocsDox

And two group members left. “Both doctors wanted to be closer to their families,” she explains. “One hadn’t seen his family in a year.”

But Dr. Ashley also reports this flip side: “We’ve been the recipient of this same shifting of doctors that’s going on across the country, and we’re getting fantastic candidates that we otherwise might not have.”

While many of those applicants want to be closer to family, “several want to leave bigger western cities like Portland and Salt Lake City,” she notes. Many potential recruits have children who aren’t yet in school, but many also have previous leadership experience.

While her group currently has 36 doctors, she expects to have 42 by this summer, a testament to not only needing more doctors but also to high inpatient volumes— even without covid—and increased patient acuity. What’s unusual about what she calls “this huge bolus” of applicants: “We’re seeing record numbers,” says Dr. Ashley. In every other recruitment cycle, she’s been able to reach out to each candidate individually. “This cycle, I simply have too many.”

No more extra shifts
Ijeoma Carol Nwelue, MD, hospitalist medical director at Baylor Medical Center Ft. Worth in Ft. Worth, Texas, likewise has a wealth of new potential recruits. Since she took that job in July 2020, Dr. Nwelue says the only hospitalists who have left have migrated to other Baylor hospitals closer to where they live, making it easier to arrange child care. Her own group, which had 13 doctors in 2020, now has 23.

“We’re seeing the usual 182 shifts per year being moved down to 164.”

~ Tom Florence
Merritt Hawkins

Some group members who regularly filled 20 shifts per month during pandemic surges now want to work only 15. To adjust, she hired new physicians PRN, and two of them just came on full time.

“PRN works well for folks who are new to the area and want to feel out the system and the community before committing to a full-time position,” Dr. Nwelue says. While she isn’t actively recruiting—she passes the CVs and queries she receives on to other Baylor facilities—she knows she’ll need more PRN doctors.

That’s because her group, which tried seven-on/seven-off for two months this year, is switching back to a more flexible schedule. Also, two hospitalists who considered transitioning to nights have decided to pass, so her entire team will have to rotate nights once again.

Per diem opportunities
More physicians opting for PRN work may be another trend. Hospitalist Suneel Dhand, MD, has worked per diem since 2017 in hospitals in Massachusetts and New York, averaging between 10 and 18 shifts a month.

With two colleagues, he also started DocsDox, a site where doctors—mainly hospitalists and internists—can find national per diem and moonlighting opportunities without going through a locum agency or third party. Doctors register for free and hospitals pay a nominal fee to connect with physicians directly online, with the two parties then negotiating their own terms.

“In our major markets, we haven’t seen an uptick in the rate of hospitalist attrition—yet.”

~ Rohit Uppal, MD  MBA
TeamHealth Hospitalist Services

Traffic on the site isn’t quite up to where it was pre-pandemic. But it’s picked up dramatically, particularly this year.

“We all just hunkered down when the pandemic hit, sticking with what we knew,” Dr. Dhand says. But with the pandemic’s end possibly in sight, “all the structural problems that were there pre-pandemic have started to resurface.” Those include punishing schedules, higher volumes without more pay, and documentation, billing, and regulatory hassles.

“People want better work-life balance,” says Dr. Dhand, noting that some of his colleagues are cutting back to a 0.5 or 0.7 FTE. Hospitalists signing up with DocsDox are also interested in per diem shifts in urgent care, primary care and nursing homes, which don’t require nights or weekends.

And per diem doctors know they have negotiating power with hospitals. “The market is so mismatched, and there is so much demand, especially in generalist specialties,” he points out. Just like nurses who signed on with traveling staffing companies, per diem physicians can earn more per shift than when they’re employed. “Doctors can set their expectations for hourly rates and pick and choose their shifts. That can work out better for their lifestyle and families.”

Higher pay, more flexibility
As an executive vice president of Merritt Hawkins, a national physician staffing firm based in Irving, Texas, Tom Florence is seeing a lot of physician movement around the country for full-time positions across all specialties.

“We had the highest number of searches in our company’s history in the fourth quarter of 2021,” Mr. Florence says. “And we’ve been around for more than 30 years.” The number of Merritt Hawkins’ prospective physician candidates rose 30%, while search requests for doctors—from hospitals, health systems and private groups— jumped 35% in 2021 over 2020.

“These have been the two hardest years of our career.”

~ Jennifer Ashley, MD
St. Charles Health System

Mr. Florence is finding that it’s even harder to fill outpatient positions than hospitalist ones; doctors now, he says, want to work only shifts—and remote ones in telehealth are particularly appealing. “We’re urging clients to try to shift to those kinds of models because that’s what candidates are asking for,” he says.

Because hospitalist applicants also “have more control,” he advises clients to be more flexible. Sign-on bonuses are inching up to $30,000, and recruits are asking for—and receiving—paid time off in addition to seven-on/ seven-off schedules.

“We’re seeing the usual 182 shifts per year being moved down to 164,” says Mr. Florence. “Cutting-edge clients are trying to make their schedules more appealing.” Salary demands are also rising, up to $350,000—and even that amount probably won’t be enough to successfully recruit a nocturnist.

Dr. Uppal likewise says that TeamHealth had a record recruiting year in 2021. He’s also seeing “a lot of applicants looking to see what is out there—and I assume our clinicians are doing the same.”

As for hospitalists commanding higher salaries and bigger bonuses, “that’s true in challenging recruiting geographies, like in rural hospitals, and it is hard to recruit nocturnists,” he notes. “Right now, in our major markets, we haven’t seen an uptick in the rate of hospitalist attrition—yet.” If (or once) that attrition starts, he adds, “that will drive up rates.”

Promoting retention
In Seattle, Dr. Nelson notes that he is typically called in to consult for groups that face problems or need fixes. Still, he’s hearing more hospital executives in midsized communities, which can have trouble recruiting, say they have reached the point where they need to trim hospitalists’ support.

“I’m worried that any program that has to see 10% more patients or take a 10% pay cut or both is just going to blow up,” Dr. Nelson says. “Reducing support may not actually happen, but that’s the position some executives now are taking initially. I’m hearing a lot more chest-thumping than ever before.”

While TeamHealth’s Dr. Uppal isn’t hearing that from hospital clients, he says conversations with executives now need to strike “a delicate balance.” On the one hand, executives recognize the important of clinician wellness.

“They know that hospitalists are still recovering, so we’re partnering with hospitals to create more supportive conditions and promote retention,” he notes. “On the other hand, hospitals are facing significant financial pressures, and they are focused on throughput and patient experience.” Having fewer nurses and staff also increases the demands being placed on hospitalists.

To help keep the doctors they have, Merritt Hawkins’ Mr. Florence encourages clients to introduce “stay” interviews, a corollary of the exit interviews many organizations hold when clinicians leave, to find out what they like about their jobs and how to enhance those.

“Some doctors don’t speak out on things that bother them, and then they leave,” he points out. “Stay interviews are a way to get in front of that.”

And to help physicians recover going forward, Dr. Nelson hopes that groups will take the time to hold retreats and talk about what came out of the pandemic and what they should keep or discard.

“What did we learn about how the group operates and our jeopardy system, and what do we really need to return to?” he asks. “That also goes for your group’s financial structure and hospital support.”

Stress and appreciation
In Texas, Dr. Nwelue says that—at her group’s request— she did away last month with what she and her colleagues called “weekly huddles,” once-a-week meetings held throughout the pandemic. Those were, she says, a tough commitment of time, but the huddles allowed doctors to vent about difficult patients and daily pressures. Instead, program members will now hold longer monthly staff meetings, with quick huddles scheduled as necessary.

Dr. Nwelue also notes that she and her colleagues appreciated the hospital late last year relocating the hospitalists’ office—with much fanfare—from the basement to a much nicer site in the hospital.

Dr. Ashley in Oregon is likewise looking for ways “to send the message to the team that they are valued, “which will include redoing team rooms. The group at its March meeting also plans to discuss how to build more flexibility and paid time off into the schedule.

But “the reality is that big changes require a lot of financial input, and we see the writing on the wall,” says Dr. Ashley. “Health institutions are completely strapped for cash after these last two years.”

At the same time, “these have been the two hardest years of our career,” she says. “We’ve all had this chronic, indolent stress where ‘I don’t feel happy. What can I do to change things?’ A lot of people think, ‘I’m going to move and try something new, and that might help.’ Hospitalists have very portable jobs.”

Phyllis Maguire is Executive Editor of Today’s Hospitalist.

How sustainable is seven-on/seven-off?

PANDEMIC-FUELED BURNOUT has renewed hospital medicine’s perennial debate: How sustainable is working seven-on/seven-off with 12-hour shifts?

The answer varies across groups. In Bend, Ore., Jennifer Ashley, MD, hospitalist director for St. Charles Health System, says her team every year “universally votes to keep seven-on/seven-off because of its predictability,” she says. “They like to plan out their lives six months in advance.”

But Ijeoma Carol Nwelue, MD, medical director of the hospitalist program at Baylor Medical Center Ft. Worth in Ft. Worth, Texas, says her group for the first time this year had enough doctors to finally activate seven-on/seven-off. After only two months, however, the group is ditching that schedule and switching back to what they had before.

“What many are saying is, ‘I can’t do this. It is so hard every day.’ “

~ John Nelson, MD
Nelson Flores Hospital Medicine Consultants

 

“We decided this is not what we want,” says Dr. Nwelue. “We want flexibility.”

John Nelson, MD, a principal with Nelson Flores Hospital Medicine Consultants, has long advised physicians to consider working more shifts per year, but for fewer hours each shift and seeing fewer patients. That was even before covid brought an outsized census and high mortality.

He understands why more doctors now want to cut their number of shifts. But he doesn’t think that will really solve their problem.

“Most hospitalists already have 15 or more days off a month, so I don’t really think they’re saying, ‘Hey, I need a few more days off,’ ” says Dr. Nelson. “Some may have other interests, but what many are saying is, ‘I can’t do this. It is so hard every day, and it is really difficult to go to work.’ It is just too stressful.”

He puts forward a possible solution that, he freely admits, hasn’t been implemented anywhere as far as he knows and would be a complete non-starter for many: job-sharing with a colleague. Under such an arrangement, two doctors would both cover the same shift 15 days a month. But they’d each have only half their typical census.

Each (and here is the “non-starter” part) would also make only half of a full-time salary. But with twice as much time with the patients they have, doctors might not dread—like they do now—having more admissions or a challenging family meeting. It would be, says Dr. Nelson, a hard solution to implement. “But I think we need to be less busy—and more flexible to spread work out over the course of the day.”

Published in the March/April 2022 issue of Today’s Hospitalist