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Daily census: How many is too many?

November 2010

I am fascinated by the fact that this seemingly simple question–”How many patients should we see in one day?”–has led to such debate and disagreement. Not surprisingly, the lines are usually drawn between the hospitalists doing the work and the administrators who pay for it.

It’s clear that many variables go into trying to come up with the “right” number. Here are factors that I see as increasing our ability to see more patients: more surgical comanagement cases; excellent ancillary services; physician extenders; and non-academic practices.

Factors that make it harder to carry a higher census include greater ICU responsibilities, shorter lengths of stay, doing procedures and seeing more nursing home patients. (I may develop permanent contractures in my right hand from filling out medication reconciliation lists for nursing patients on 32 medications.)

Then there are factors that certainly influence the census equation, but it’s an open question of whether they boost it or bring it down. Those include shift vs. call-based work, a hospital employed vs. a private group model, and a group’s overall subsidy.

On top of that, each physician’s level of experience certainly matters, with greater experience likely bringing more comfort with a higher census. (At the same time, more experience may well mean having a wee bit less of that youthful exuberance you need to make it through the day.)

Here are the standard deviations: First, there is the Nelson Model found on the SHM Web site. He uses an average census of 12–10 daily encounters and approximately two admissions–when trying to determine how many doctors you need to start a program.

This strikes me as low, particularly for a non-academic program. After eight years as a shift-work hospitalist, I’d say that 18 daily encounters for seven days straight is where efficiency ends and trouble begins. I suspect that the number for call-based hospitalists is slightly lower, given that they round on more days than shift workers. Perhaps 16 patients per day is their golden number.

Recently, I saw an ad for a hospitalist position that described the number of patients a potential candidate would see as between “15-25” a day. As a public service to any resident or still-naive hospitalist, let me say that I suspect that this distribution does not fit a bell curve–and that the skew may leave you feeling screwed.

I presume that this potential employer bases these numbers on reasonable market assumptions (maybe I’m being too generous), and I gather that 25 patients per day likely reflects the high side of what any hospitalist is asked to see in one day.

And as an aside, a word to the wise regarding the job interview where you are told that the patient load is capped at 18. What does that mean? When the census is high, do the docs call someone else in to work, or do they offload admissions to another group?

Or does it mean, “We would like you not to see more than 18 patients but, well, there is no other option and we don’t know what else to tell you, other than having this dialogue does not constitute efficient use of time better spend handling your too-large patient load.” Finding ways to cap services, although vital to the success of any program, brings to mind the herding cats analogy in terms of how easily this can be accomplished.

We clearly have no absolutes when it comes to the “right” number of patients we should see each day. But I strongly believe that if you are a hospitalist consistently seeing more than 20 patients a day, you are doing both yourself and our profession a disservice.

I encourage you to look in the mirror and repeat these words, “I see too many patients.” In this market, if you can’t convince others that that is the truth, it may be time to test the employment waters. Just beware of ads that claim your daily load will be somewhere in the “15-25” range.