Drinking (your coffee) alone?

Published in the December 2017 issue of Today’s Hospitalist

GROWING UP WITH RELATIVES who were doctors, Kevin Sowti, MD, readily recalls the allure of becoming one himself: “One, it was taking care of patients,” he says. “Two, it was the close community that physicians represented.”

Now, as hospitalist medical director at Penn Medicine Chester County Hospital in Philadelphia’s western suburbs, Dr. Sowti is working hard to keep that sense of community alive. But sometimes, he says, it feels like a losing battle.

Some collegiality has been lost across across all specialties, he points out, because of too much work and too little time. As for hospitalists, they may be victims of their own success. “We started small, like all groups do, but then we boomed,” he says. “When you have to hire quickly, it’s hard to build a collegial culture that grows organically.”

“The closeness of the medical staff correlates to better communication and patient care.”

~ Kevin Sowti, MD
Penn Medicine Chester County Hospital

At stake, Dr. Sowti adds, is something much more important than just having time in the day to share a coffee with a colleague. “I believe the closeness of the medical staff correlates to better communication and patient care,” he says. “Losing that would be terrible.”

When hospitals started focusing on patient satisfaction several years ago, some of them began to ask their doctors about career satisfaction. Many got some very scary answers. While medical practice has changed profoundly, not enough attention may have been paid to the toll those changes were taking on professional relationships.

“That’s where we really blew it,” says Robert Wachter, MD, chief of the department of medicine at the University of California, San Francisco. “We didn’t think about collegiality as an issue, and we didn’t approach it with any strategy whatsoever.”

That’s now changing. Some administrations have at least figured out that fraying collegiality contributes to the burnout that threatens their bottom line. And even in hospitals where administrators aren’t helping physicians foster stronger relationships, doctors themselves have stepped up to do so.

Generosity and respect
Noemi Doohan, MD, PhD, a family physician who follows her patients into Adventist Health Ukiah Valley, a 50-bed hospital in Ukiah, Calif., and who moonlights as a hospitalist, says collegiality is “being generous with your time and expertise.”

As a rural physician, Dr. Doohan sees that generosity play out every day. “My colleagues who are reaching retirement age are putting it off so they can help younger physicians get established.”

Jerome Siy, MD, heads the hospital medicine department at HealthPartners in Minneapolis-St. Paul. He defines collegiality as “mutual respect” along with social and professional connection. “It’s the quality of your interactions with each other, not just the quantity,” Dr. Siy says, pointing to studies that find that burnout is fueled by both exhaustion and loneliness. “Collegiality contributes to wellness and helps prevent burnout.”

“We didn’t think about collegiality as an issue, and we didn’t approach it with any strategy whatsoever.”

~ Robert Wachter, MD University of California, San Francisco

But practice and regulatory changes have transformed physician relationships in both academic and community centers. Dr. Wachter says his own center is now twice as big as a decade ago.

“We used to have attending rounds every day where the entire team sat down, talked about cases and did some teaching,” he says. “Everybody was there and it was the time you stopped running around and thought and learned.”

Now, it’s much harder to carve out that time, Dr. Wachter explains. That’s partly due to duty hours, and partly to pressures that physicians in community hospitals also face, like having to discharge patients before noon.

EMRs and the “digital water cooler”
Dr. Wachter also notes that the electronic medical record, and the hours doctors spend feeding it, have profoundly affected working relationships.

“There used to be only one copy of the paper chart, and it was at the nurses’ station on the floor,” he says. “So you were in an open, social space with colleagues all doing the same thing.” Now, “we’re not tethered to the nurses’ station, so we have less time to get to know each other and collaborate face-to-face.”

The rise of what Dr. Wachter calls the “new digital water cooler”— social media, which is flush with physician forums—means that people’s connections are no longer so local.

But they’re also not real, he points out. “I’d rather have a friend I can go out for a drink with than a Twitter friend.”

Hospitalist Suneel Dhand, MD, who’s worked in hospitals up and down the East Coast, is co-founder of DocsDox, a company that matches physicians who want to do moonlighting and per diem work with hospitals. As part of that new digital water cooler, he maintains a blog entitled DocThinx.

“It’s the quality of your interactions with each other, not just the quantity.”

~ Jerome Siy, MD HealthPartners

One post this year—”The demise of the physicians’ lounge is symbolic”—was reprinted by KevinMD and shared 14,000 times. Dr. Dhand chalks up that demise, and the loss of collegiality it embodies, in part to doctors now having “much less time” to connect.

But he also faults “the whole cost-cutting environment that takes place in any corporation.” Granted, “the squeeze is on” in health care financing, Dr. Dhand says, but “I think it’s outrageous that doctors’ lounges are considered too much of a perk when you compare it to other professions at the same level. I feel like everything is being stripped away from physicians, and it’s not good.”

Dr. Wachter notes that that may well be happening in hospitals around the country. But “I think the doctors’ lounge goes away for the same reason the hospital library closes: You find it empty,” he says. “It’s the lack of use that leads to it going away.”

Disconnects in hospitalist practice
Of course, the population of doctors in hospitals has changed dramatically: Many primary care doctors no longer visit, while specialists are rushing back to offices and may not choose to linger. And on top of a workload that allows little time for doctors to touch base, Penn Medicine Chester County’s Dr. Sowti points to a factor in hospitalist practice that can chip away at collegiality.

“The standard has become shift-based, mostly week-on/week-off,” he says. “That develops a clock-puncher mentality where you leave for a week and you’re completely disconnected.” While that schedule is part of the “allure of hospital medicine, it’s also a big challenge.”

Another innovation that may hurt collegiality as it gains traction: His hospital moved to unit-based rounding a few years ago. “We used to see each other all over the hospital and be able to catch up,” Dr. Sowti says. “Now on the unit, you may not even see the other doctor you’re working with that week if you’re really busy.”

“We fought very hard to preserve a workspace solely for general medicine. We wanted to promote this sense of community and shared identity.”

~ Michael Janjigian, MD
Bellevue Hospital

In response, Dr. Sowti last year initiated twice-weekly, 30-minute huddles among the hospitalists, ostensibly to discuss readmissions. “But the main reason was just to bring us all together.”

Carol Nwelue, MD, hospitalist medical director for Sparrow Health System in Lansing, Mich., points out that her group this year likewise launched unit-based rounding in one unit. Length of stay in that unit has dropped 20%, while readmissions fell 39%.

Another noticeable change: The level of collegiality between doctors and nurses on that unit has grown. Sources note that while doctors may spend less time now with other physicians, they’re spending much more time—and developing better relationships—with nurses and other clinicians.

“Initially, some nurses said, ‘I hope Drs. X and Y aren’t assigned to the unit because they can be hard to work with,’ ” Dr. Nwelue recalls. “And I said, ‘No, everyone is going to rotate through.’ ” Now, almost a year later, “the nurses have gotten to know and respect the doctors they thought were the most difficult, and vice versa.”

A bigger team
When it comes to teams, HealthPartners’ Dr. Siy points to another factor driving the evolution of collegiality in hospitals: generational change.

“Millennials have embraced team care, and they have very different expectations than older physicians about their circle of colleagues,” he says. NPs and PAs, for instance, are now welcomed in the lounge in his hospital (which is alive and well) that was once reserved strictly for physicians. “That’s a recognition that our team has grown.”

Michael Janjigian, MD, the associate chief of medicine at New York’s Bellevue Hospital, says that embracing a culture of interdisciplinary care is “the reason why hospital medicine is as successful as it is.” But over his 12 years as a practicing hospitalist, Dr. Janjigian has also noticed that “the sense of community among hospitalists has grown very strong.”

That’s due in part, he says, to efforts by hospitalist leaders, including himself, to foster what literature calls “the community of practice.” A key ingredient of that community for his group is having a large, shared workspace with eight workstations adjacent to his own office. Hospitalists not only spend time together there doing documentation, but they chat, vent and bounce challenging cases off each other.

“Even though they’re working hard and suffering a little, they realize they’re not doing it alone,” says Dr. Janjigian. While hospital administration initially wanted other services to be able to use it, “we fought very hard to preserve that workspace solely for general medicine. We wanted to promote this sense of community and shared identity.”

Interactions with other specialties
Dr. Janjigian notes that the physicians in his institution are also fostering what he calls better “cross pollination” with specialists. One innovation adopted from the Manhattan campus of the VA NY Harbor Health Care System is called “Open Consult,” a riff on Open Table. “We book time with specialists to round together,” he explains. “The specialty attending and fellow tell us what times they have available, and general medicine teams sign up for a slot.” While the hospitalist service had several “failed iterations” of trying to incorporate specialists into hospitalist rounds, this model has been “very successful.”

In addition, the infectious diseases services have adopted an open-door policy between 9 a.m. and 10 a.m. every weekday. “People can just walk into their workspace and discuss cases.” Cardiology has likewise set up a time when fellows are available in a telemetry unit.

“Those help prevent pages and late consults,” Dr. Janjigian points out. “They also improve education and the sense of a shared community.”

Dr. Sowti has for years held medical socials, once-a-month events to try to bring medical staff together for drinks and conversation. Those socials are now open to advanced practice providers, who—as in Dr. Siy’s hospital—are also welcomed in the hospital’s “providers’ lounge.” Dr. Sowti is also boosting the number of social events to which spouses and partners are invited.”

As I remember from growing up around physicians, families were a big component of that community,” he says. “I am really trying hard to keep that.”

And in an effort to bridge the disconnect between inpatient and outpatient physicians, Dr. Sowti has opened the grand rounds held on Fridays to primary care doctors, “so we could at least have a coffee together.” He’s pitched the idea to his administration, pointing out that better relations are important financially—”our revenue steam comes from these outpatient doctors”— as well as collegially.

But “it’s been hit or miss,” Dr. Sowti reports. “While our administration is very thoughtful and supportive, I’m not hearing, ‘Fine, we will buy you all lunch.’ I’m not sure there is a strategic plan on the administration’s part to help bring staff together.”

While concentrating on patient experience is necessary, he points out, “I want to define patient experience as patient satisfaction, quality of care and provider experience, and I think all three are equally important. We fail if we forget about provider experience.”

Further, Dr. Sowti feels it is up to doctors to actively push to foster better collegiality—and to take on the leadership roles that allow them to set organizational priorities.

“We must network and come together,” he says. “With no engagement, we lose power and respect, and without power, we lose participation and representation in leadership.” Without participation, he adds, “our burnout rate will just increase

The role of administration?
In Lansing, Mich., Dr. Nwelue likewise doesn’t see “physician collegiality” as a big (or conscious) priority of her administrators. But “they are looking very closely at physician burnout,” she says, and taking seriously internal survey findings that doctors don’t believe they’re being listened to. As of Nov. 1, the hospital established a physician hotline, just like it maintains for patients, to allow doctors to air their concerns.

“The goal is to have your question or concern answered within seven to 10 business days,” she says. “It can’t be, ‘We’ll get back to you,’ and then you don’t hear anything for a year. Requests must be answered with a ‘yes and when’ or a ‘no and why.’ ”

In Minneapolis, Dr. Siy notes that physician engagement has long been a priority of HealthPartners, a seven-hospital integrated system that grew out of a group practice. While he as a hospitalist leader spends a great deal of time interacting with individual physicians both in the hospital and after hours, “we were very early on measuring things like employee engagement and physician satisfaction,” he says. And since 2016, the hospitalists’ wellness committee has weighed in on operational changes—like new observation unit management—to gauge what impact those might have on physician wellness.

Administrators who don’t pay attention to physician connectedness will learn the hard way, says Dr. Dhand. “Doctors have a very portable skill set, shared identity.” they are very smart and they push back,” he says. “I think that’s something that many people in the MBA world are not used to.”

According to Dr. Wachter, his administration does get it. It is holding more social events and open houses, and “there is a recognition that, just like there is a science behind patient engagement, we can identify the incentives, geographies, digital strategies and marketing we need for physicians.”

Both UCSF’s administration and doctors have identified collegiality as an issue “we need to invest in, not just money but time and political capital,” Dr. Wachter says. As proof: A newly designed, amenity-filled lounge, just for physicians, opened there this year.

Phyllis Maguire is Executive Editor of Today’s Hospitalist.

Connecting rural practice and academia
NOEMI DOOHAN, MD, PhD, a family physician and hospitalist based in Ukiah, Calif., believes there is a strong educational component to physician collegiality.

That became very clear, she says, when she moved from a more urban environment to a rural one three years ago. While rural physicians do band together to collectively deal with physician shortages and limited resources, “there’s a lack of academic networking here,” Dr. Doohan says. “You don’t have many opportunities to participate in group learning.”

And rural doctors need more than just being able to dial into a webinar. “We need more connections with academic centers for interactive life-long learning,” she says. “I believe the technology is getting to that point.”

“I’ve had internists my first day on the job say, ‘You don’t belong here.’ “

~ Noemi Doohan, MD, PhD
Adventist Health Ukiah Valley

One thing that did surprise Dr. Doohan was running into the same prejudice in rural practice that she’s faced in urban settings: Some internists don’t accept or respect family medicine-trained hospitalists. That prejudice, she says, has torn away at collegiality in many hospitals where she’s worked, and it’s a fact of professional life for hospitalists who are family physicians.

“I’ve had internists my first day on the job say, ‘You don’t belong here,’ ” she notes. She’s found that it’s the hospitalist director who sets the tone for the group. “The director can really make a difference in terms of how family doctors are treated.”

To gain better access to academia and boost the strength in numbers among family physicians, Dr. Doohan has worked to bring a family medicine residency program to rural Ukiah. With a launch date of 2019, the program will have residents in the rural training track spend one year at the University of California, Davis, then two years in Ukiah’s community hospital and affiliated critical access hospitals and rural health clinics.

“That connects not only the residents but the faculty here to the academic center,” Dr. Doohan says. “Faculty development is a great way for academic centers to be collegial toward rural colleagues.”