Published in the March 2014 issue of Today’s Hospitalist
SOME MAY CALL IT hospital medicines “dirty little secret”: hospitalists who don’t work all 12 hours of their shift. But in reality, the practice is not very secret “and many hospitalists think there’s absolutely nothing wrong with it.
Leaving early has its share of critics, who claim that not working a full shift is bad PR for a profession that puts availability at the top of its list of selling points. Besides, critics add, hospitalists ducking out early can delay or even endanger patient care as people cut corners to leave early.
But defenders of a more relaxed approach to hospitalist hours say leaving early is a non-problem. Doctors are salaried professionals, they point out, not clock-punchers. They are paid for their work, expertise and results, not just for their time. Forcing hospitalists to stay when all their work is done is wasteful and makes recruiting even tougher than it already is. And it may contribute to burnout and drive good people from the field.
“Hospitalist work is shift work, but we don’t want a shift mentality,” says Rachel Lovins, MD, chief of hospital medicine at Middlesex Hospital in Middletown, Conn. The majority opinion, as far as Dr. Lovins is concerned, is that hospitalists should work until the work is done “sometimes more, but sometimes less. She points out that her hospitalists work hard and are more often than not staying late to get their work done.
“It’s not acceptable to dump on your colleagues,” Dr. Lovins says. “But if you get everything done early and you are available by phone or pager until the end of your shift, I think you should be able to go home. I feel the risk of burnout is huge.”
The last (day) hospitalist standing
The reality is that many practices either permit “or turn a blind eye to ” hospitalists on the day shift leaving early. While that may make the practice of ducking out early seem legitimate, hospitalists who think that being casual about work hours doesn’t cause any harm may not have the full picture.
Just because their colleagues don’t complain out loud, for instance, doesn’t mean they don’t feel put upon. Some years ago, Viviane D. Alfandary, MD, found herself resenting the fact that, as “a slow person,” she was likely to still be in-house after her colleagues had rushed through their rounds and left early. She ended up fielding all the calls from nurses when issues popped up in the late afternoon.
“The nurses knew I was there,” says Dr. Alfandary, a hospitalist at the John Muir Medical Group’s Walnut Creek, Calif., campus. “They’d say, ‘I’ve been calling so-and-so, and he’s not answering.’ The ED docs were also calling to say they needed someone down there,” only to learn that many hospitalists were already gone for the day.
“Only the slow people were getting called down to help,” says Dr. Alfandary. “I would end up staying until 8 or 9 many days when other people had left at 3.”
Repercussions with administration
Practice consultants also point out that a cavalier approach to work hours is often a red flag that something more fundamental is wrong with a hospitalist group. It could be a sign of weak leadership that doesn’t enforce rules fairly, or it could indicate that management may not be putting patient care first. Or it may be a sign that the group is ignoring the needs of its other client: the hospital.
Martin Buser, MPH, founding partner of Hospitalist Management Resources LLC, a national hospitalist consulting firm based in Del Mar, Calif., says he encounters work-hour issues in “100%” of the dysfunctional practices he works with. He frequently has to disabuse hospitalists of the opinion that being casual about hours “if they have set shifts “is “normal for hospitalist programs.” It is not, he says, at least “not for the good ones.”
“Sometimes, hospitalists think they are doing great,” says Mr. Buser, “but I have to tell them what the rest of the hospital, including the specialists, thinks of them: ‘They don’t respect you because they think you are never here.’ ”
There are other repercussions, Mr. Buser notes. Hospitalist groups frequently argue that they need more doctors, but administrators think otherwise. If physicians are leaving after eight hours when they’re paid to work 12, they must not have enough work to do, executives counter. So why hire more?
Administrators also complain that physicians playing fast and loose with work hours can sabotage hospital goals. A hospital may want discharge orders in charts by 10 a.m., for instance, so patients can be discharged before new admissions begin clogging the ED. But achieving that goal evaporates if hospitalists don’t arrive on time.
With hospitals subsidizing each hospitalist at more than $150,000 a year, Mr. Buser points out, expecting accountability is a given. Compared to other in-house physicians “ED doctors, surgicalists, intensivists “the hospitalists give the impression that they want to play “by a different set of rules, and hospital CEOs aren’t buying it,” he says. Instead, groups should develop more flexible hours up front “so no one has to sneak away.”
Less time with patients
Hospital staff aren’t the only ones who feel the effects when hospitalists leave early. Complaints about AWOL hospitalists used to be common at Salem Hospital in Salem, Ore., according to Marty Enriquez, RN, the vice president of patient care services. “Nurses, social workers, care managers and other specialists” insisted that they could never reach some of the hospitalists, six of whom were supposed to be on duty from 7 a.m. to 7 p.m., Ms. Enriquez says.
“One poor physician was on the floor covering for everybody else,” she recalls. And “families complained that the doctors were not available.”
That highlights what may be the biggest negative in letting hospitalists know they can leave when they finish their work. “Doctors will likely spend less time with patients and move at a faster speed than they need to,” says David M. Grace, MD, senior medical officer in charge of medical leadership and clinical operations for The Schumacher Group, a physician staffing company based in Lafayette, La. The company runs 35 hospitalist practices around the county.
“If there is a requirement to stay for 12 hours,” says Dr. Grace, “doctors will more likely slow down. There is no sense rushing, so you might as well spend 30 minutes on each patient rather than rush through them in 10 minutes.”
But there is a flip side to that argument, points out John Nelson, MD. Dr. Nelson directs the hospitalist program at Overlake Medical Center in Bellevue, Wash., and is a consultant with Nelson Flores Hospital Medicine Consultants.
It is human nature, Dr. Nelson says, to “let work fill the time available.” In his view, having strict in-house hours for hospitalists does not “add value, and I would rather not create rules that doctors aren’t going to follow.”
Here’s the problem he sees with requiring hospitalists to work set schedules without any flexibility: “When it’s slow in the summer and you have to work 12 hours, you just slow down,” he points out. “Then in the winter, when there may still be a reasonable patient volume but you can’t take a 40-minute coffee break and a long lunch like you could in the summer, you think, ‘This is ridiculous! I am getting killed!’ But part of the problem was that you let yourself fall into a slow work pace.”
He advocates instead for paying physicians to meet work expectations, including covering some defined shifts “but not basing those expectations solely on hours.
How are hospitals dealing with the issue of whether to let hospitalists leave their shifts before the full 12 hours are done? At Salem Hospital, Ms. Enriquez says the solution feels “a little embarrassing”: The hospital asked each hospitalist to sign a commitment letter that spelled out the “expectation to work 12-hour shifts” among other things, like showing up by 7:15 a.m. for “a daily huddle.” Everyone signed, she says, and the action didn’t cause any turnover. And Ms. Enriquez notes that she no longer hears any complaints.
Other hospitals that have implemented policies to keep hospitalists around for their full shifts have been surprised to discover that flexible schedules work both ways. That was the lesson learned at central Pennsylvania’s UPMC Altoona after hospitalists were required to swipe in and out as they started and ended their shifts. The push to document hours began during last year’s merger between the hospital “formerly Altoona Regional “and the large University of Pittsburgh Medical Center.
The merger ushered in a debate about appropriate staffing levels and whether to add a swing-shift hospitalist, explains Gregory S. Martinek, DO, medical director of Lexington Hospitalists, the hospital-owned group of 15 physician and eight midlevel hospitalists at UPMC Altoona. The administration “wanted to know, ‘Why do we need to have a swing-shift doctor if some doctors are leaving at 4 p.m.?’ ”
But requiring the group to punch a time clock revealed that the hospitalists were in-house more than many suspected: nearly 11 hours a day. They made themselves available by pager the rest of the time.
“The administration wanted to know what they were purchasing,” Dr. Martinek says, an understandable concern as “subsidies continue to climb.” It helps, he adds, that administrators understand that hours aren’t everything.
“Productivity counts,” he says, “but it’s important to track encounters and billings in addition to hours.”
Ground rules and incentives
In California, Dr. Alfandary’s practice continues to allow physicians flexibility, within limits. Now, leaving early is no longer a secret or even a problem, and hospitalists spend between eight and 13 hours in-house each day.
The fix was to set firm ground rules and to add financial incentives. One doctor each day, for instance, must be in by 7 a.m., one must stay until 6 p.m. and a third can’t leave before 7 p.m. Everyone must turn on his or her cell phone by 7 a.m. and be onsite no later than 8 a.m., a sign-in policy that’s strictly enforced.
In addition, no one can leave before 4 p.m. when the dedicated admitter arrives. And before hospitalists duck out, they have to get a formal OK from another rounder who agrees to cover for them.
Doctors also have to keep their cell phones on until 7 p.m., and they may have to return to the hospital. They rotate who is required to be in-house to back up the dedicated admitter in the ED “and they can earn bonus money by doing a certain number of patient “revisits” each day, an incentive to stay longer.
Reem Ann Habboushe, MD, chief of hospital medicine services at Main Line Health’s Paoli Hospital in suburban Philadelphia, devised another way to get hours worked out in the open: Offer hospitalists who don’t want to work a full 12 hours the choice of an alternative schedule with shorter “shifts,” less-defined hours, but more eight-to-nine-hour-long days per month.
Doctors who choose that alternative aren’t working traditional shifts, Dr. Habboushe explains. Instead, they can leave when they finish their work “but they are required to stay until their work is completed, and they have fewer weeks off per year.
Some doctors within the group have eagerly embraced that option, Dr. Habboushe points out, while others still opt for the shift model. “The doctors who prefer working the longer shifts are inclined to complete them,” she says. “They know they have the benefit of working fewer shifts per year.”
Prompting doctors to stay
Dr. Habboushe adds that all the physicians in her group are pleased with the productivity bonus the group put in place last year. Now, more RVUs mean more money for the doctors.
“In theory,” she says, “if you are going down to the ER and seeing more patients, your RVUs will go up and you will have a bigger bonus.” This encourages the doctors who work prescribed shifts to stay their full 12 hours. It also, she notes, pushes those working the more flexible schedule to “stay a little longer to help the team.”
Reorganizing doctors’ workload is another way to enable doctors to exercise some control over how long they stay at work, Dr. Nelson points out. Assigning new admissions to a specific hospitalist in the afternoon or early evening “not just the hospitalist service and waiting until the next morning to divvy them up “gives hospitalists more pride of ownership in that patient’s care.
“Even if I am done in the evening, if I know our evening shift is admitting somebody to me, I may want to meet that patient tonight rather than wait for the morning,” Dr. Nelson says. “It makes my tomorrow easier, and I think it’s also a patient satisfaction thing.” Geographic staffing seems to produce the same effect. (See “The unintended consequences of geographic staffing,” below.)
“The key is balancing the local hospital culture and the local market, particularly for recruiting,” says Schumacher Group’s Dr. Grace. “If there are two comparable programs, and one says when you are done with your work you can go home and the other one says you can’t leave before 12 hours, hospitalists will choose the one with more flexibility.”
Dr. Grace adds that hospitalists need to be aware that hospitals are paying attention. At the same time, he notes, “we have to educate hospital CEOs about this. There may be some degree of decreased service by not being there the full shift, but there is a tradeoff in terms of burnout and recruiting problems.”
Deborah Gesensway is a freelance writer who covers U.S. health care from Toronto.
THE HOSPITALISTS at Montefiore Medical Center’s Moses Campus in the Bronx, N.Y., implemented geographic staffing in 2012 “a difficult transition, but one that made it possible for clinical teams to provide more efficient care. But then people noticed one unintended consequence: Hospitalists now stay later.
Working longer hours was in no way a goal of reorganizing the hospitalist service, explains Jeff Ceresnak, MD, director of medical services, who oversees the center’s 25 hospitalists. But since hospitalists started being assigned to dedicated wards, the physicians “who generally worked until 5 p.m. ” have been sighted in-house as late as 6 or 7 p.m.
Why? With unit-based care, says Dr. Ceresnak, all admissions that come in before 8 p.m. are now assigned to a particular bed and a particular hospitalist, not just to the hospitalist service.
“There is a psychological aspect to it,” he says. “The patient is listed under your name and you are responsible for that patient. When a patient isn’t under your name until the next morning, you don’t feel the same level of responsibility.”
And, Dr. Ceresnak adds, anything that encourages hospitalists to stay longer and attend to patients sooner can improve patient care.
“It helps move care along,” he says. If a patient is admitted Thursday afternoon but not seen until Friday morning when you decide to order an echo, that echo may not happen until Saturday or even Monday. But seeing the patient Thursday evening, he explains, can make the echo happen on Friday.
Another common benefit: “You get to speak to family members at the bedside along with the patient,” because families are often with patients during admission, Dr. Ceresnak points out. “Patients who have particular discharge needs can be identified earlier.”
But aren’t hospitalists complaining about working longer hours? “I think people are happier overall, even though they are staying a little later,” he says. “They feel more ownership, and they feel that what they are doing is safer and better for patients.”