Published in the April 2014 issue of Today’s Hospitalist
JOHN DICKENS, MD, MPH, intentionally vacations in remote places for a reason that has nothing to do with majestic mountains or picturesque beaches: Cell phone service can be spotty. Otherwise, as the medical director of the hospitalist program at Central Maine Medical Center in Lewiston, it’s hard for him to escape the daily pressures of running a hospitalist group.
“I’m the go-to guy and the one person available 24/7,” he says.
Dr. Dickens is passionate about his leadership role and he believes it has made him a better, more empathetic clinician. But like other hospitalists who wear both hats, he worries how he’ll meet rising expectations amid staffing shortfalls “and the very real risk of burning out.
“The daily grind of being a director takes its toll,” he notes. “We’re constantly being asked to take on more in the health system, but we’re not afforded time to do it.”
The pressure Dr. Dickens feels should come as little surprise. New regulations, core measures and quality initiatives are all squeezing group leaders who used to juggle clinical and administrative roles with little fanfare. Directors now have to maintain their clinical skills and find the time and enthusiasm for the leadership and administrative tasks they wanted to take on. At the same time, and often for modest stipends, they have to prove themselves to their groups.
It certainly doesn’t help that their job description is increasingly complex.
“The program director used to be the person who did the schedule and made sure all shifts were covered,” says Leslie Flores, partner in Nelson Flores Hospital Medicine Consultants in La Quinta, Calif. “Now, it’s more of a strategic role envisioning where the group is headed in the external environment of health care. Being a hospitalist medical director is one of the most thankless tasks there is.”
The real demands of the job
Part of what makes the job so tough is that leaders often work way more than a full-time job.
The rule of thumb holds that directors should devote 5% of their time to administration for every full-time equivalent (FTE). The director of a 10-clinician group, by that standard, should work 50% of a clinical FTE.
But directors say such formulas often go by the wayside, given the true demands of the job. Consider James O’Callaghan, MD. Fresh off a 24-hour clinical shift, the pediatric hospitalist rushes home to squeeze in four hours of sleep before heading back to Seattle Children’s Hospital by 2 p.m. for a meeting.
“That’s an example of where being both a clinician and administrator doesn’t work,” says Dr. O’Callaghan. He puts in up to four 10or 14-hour shifts monthly at the 254-bed Seattle Children’s as an attending and is lead hospitalist at Evergreen Hospital Medical Center in Kirkland, Wash., which is covered by Seattle Children’s’ regional hospitalist program. At Evergreen, he pulls six 24-hour shifts a month.
Theoretically, he spends just 20% on nonclinical duties, which range from hiring and firing to heading up clinical committees. However, the time split is just a technicality, he points out, and there’s never enough time.
“If I’m not working clinically, I come home, have dinner with the family, give my kids a bath and get them to bed,” says Dr. O’Callaghan. “For other people, it’s time to turn on TV. For me, it’s time to fire up the laptop.”
In Maine, Dr. Dickens is supposed to devote only 25% of his time to program administration, even though his group has 20 clinicians. But that can’t accommodate the growing list of hospital-wide initiatives that require hospitalist involvement. Add in factors like flu season that have him doing more clinical time, and there aren’t enough hours to fit everything in, even with all group members sitting on committees.
Protected time “or not
How to make dueling demands more manageable? Many directors try to protect certain days or hours for administrative work. Dr. Dickens, for instance, tried keeping Tuesdays open, but found that impossible because of constant understaffing.
It made more sense, he says, to schedule meetings on different days of the week or month and do work at home on nonclinical days to avoid the 35-minute drive to the office.
But in Ohio, George Mitri, MD, the medical director of Aultman Inpatient Medicine at Aultman Hospital in Canton, can reserve Tuesdays and Wednesdays for office work. That’s because he successfully made the case to add an associate medical director to the growing program. (The group now has 20 physicians.) That hospitalist, Muhannad Samaan, MD, MBA, rotates with Dr. Mitri, with both dividing their time equally between clinical practice and administration. One of them does administrative work four days a week while the other works clinically.
Together, they share a single clinical FTE, each working a week-on/week-off schedule and rotating through all shifts, including nights and weekends. While their clinical shifts are 12 hours, their administrative days typically run from 8 a.m. to 4:30 p.m.
That division of labor helps both physicians find balance. “After four days of patient care, I’m ready to go to a meeting. After four days of administrative work, I need to go see some patients,” Dr. Mitri says. “They both give you a different level of satisfaction.”
In terms of administration, Dr. Mitri tackles readmissions while Dr. Samaan focuses on coding and documentation. They divide staff evaluations, and “ask each other about the person we’re evaluating,” Dr. Samaan says. They meet once a week to compare notes.
And both physicians work with a practice administrator who protects their clinical time “which is scheduled six months in advance “while preserving an “open-door policy” when they’re on administrative time.
Setting expectations also helps. At Evergreen Hospital, Dr. O’Callaghan mentions to nurses that he’ll be in a meeting so they will hold pages that can wait. And he lets everyone know when he’ll be at Seattle Children’s, which is 12 miles away, to batch meetings by location.
He has also become creative in fitting in administrative tasks, holding meetings, for instance, at 8:30 p.m. That allows group members with young children to go home, put the kids to bed and come back. Six physicians recently met for a cardiology quality project, he notes, that required them all to be on computers for training from 8 p.m. to 10 p.m.
And Dr. O’Callaghan has gotten better at saying no. If a protocol needs to be changed, he now asks someone in his group to champion that initiative rather than taking it on himself.
In large practices, leaders may be able to choose clinical service lines with more flexibility to incorporate administrative time. That’s according to Jerome Siy, MD, department head of hospital medicine for HealthPartners Medical Group in Minneapolis, with more than 70 physicians.
“For a leader who teaches,” Dr. Siy says, “the teaching service might work better because it affords some flexibility during the day.” Perioperative services where comanagement is a major responsibility could be another option.
“While volumes tend to be higher,” he notes, “predictability during the day is higher too.”
But most group leaders may not have that choice. And figuring out how to juggle all the parts of the job often comes only with experience, says Roy Sittig, MD, medical director of hospital medicine and associate chief of general medicine at UCONN Health Center in Farmington, Conn.
Dr. Sittig, for example, schedules most meetings in the afternoons to leave mornings free for clinical work. When an urgent administrative issue comes up during that time, he makes a judgment call on whether it can wait an hour or two. That’s a skill he’s acquired after five years of directing hospitalist programs.
Short of gridlock in the ER, few emergencies force him to interrupt patient care. “You develop a feel for whether it needs to be handled now and, if it does, how you can meet that administrative need,” Dr. Sittig says.
No separate hours
But many group leaders say they don’t have the ability to separate their clinical and administrative time.
Take Steve Arvanitis, MD, associate medical director for the hospitalist program at Trinity Medical Center-West in Rock Island, Ill. While his administration “wants us to separate our administrative and clinical hours, we really can’t,” Dr. Arvanitis says. That’s particularly the case, now that he and his medical director are working extra shifts to cover slots they’re recruiting for.
“We are very limited,” Dr. Arvanitis notes, “in our ability to carve out administrative time. We often perform clinical and administrative activities together on the same days.” During a typical 12-hour shift, he explains, he’ll put in two or three hours of administrative work, catching time for it as he can.
That’s become a thorny issue in terms of his administrative stipend, which is paid on a per-hour basis, rather than being part of his base salary. His administration is pushing to not pay him and his medical director their stipends on days when they also do clinical work.
“The only way that would be possible,” Dr. Arvanitis says, “is to come in on our days off and work our administrative time then. But we already work full time.” Instead, he’s proposing that he and the group director restructure their clinical contract. Ideally, a new contract would include their administrative duties and “add our administrative stipend to our base salary,” he says. “That way, we wouldn’t have to carve out specific time for each.”
Making your case
That raises the question: How do you make the case to restructure your hours or pay, or lobby executives for more time, money or help?
Sometimes, circumstances make the argument for you. When Matthew Connolly, MD, became medical director for inpatient medicine and director of the palliative care program at Columbia/St. Mary’s Hospital in Milwaukee in 2012, his time split was supposed to be 50-50.
But Dr. Connolly immediately faced two crises. His group, which at full strength has 22 employed hospitalists and two physician assistants covering one 300-bed hospital and another with 182 beds, was down nine FTEs. In addition, a CPOE system was about to go live.
Making matters worse, a hospital 40 minutes away began offering $25 more than his overtime shift rates, luring away his chief overtime doctors.
Dr. Connolly helped get the CPOE up and running, bringing in locums to relieve the clinical pressure. But all that credentialing took time “and his hospitalists were suffering burnout covering excess shifts.
“The split fell by the wayside,” he says. Instead of taking off after a night shift, he found himself staying for morning meetings, going home at 1 p.m. to sleep, then coming back for another night shift.
That’s when Dr. Connolly says he met again with hospital executives. “They looked at the scope of the responsibilities I had,” he says. “I suggested an 80-20 split, and they were agreeable.”
But in less dire situations, hospitalist leaders may have to make a strong case. According to Ms. Flores, most administrators are “fairly willing” to dedicate administrative time and money to group leadership. But, “many administrators underestimate the amount of admin time required to manage and lead a group to high levels of performance.”
To justify a change in hours or pay, she recommends tracking your administration time.
“But that’s usually not enough to prove you need more time or help,” says Ms. Flores. “My approach would be to demonstrate what you’ve already accomplished, then list the things you couldn’t because of inadequate time or resources.” Then discuss “whether to adjust priorities or increase your time or resource allocation.”
Ms. Flores also points out that group leaders often have to convince not only their administration to help grow leadership, but their colleagues.
“The way medical culture works and doctors are trained, they don’t tend to value administrative work as much as clinical work,” she notes. That can make it hard to groom doctors for leadership slots.
In Dr. Mitri’s group, two more physicians are receiving leadership training and may assume some leadership roles by the end of the year. And Dr. Connolly at Columbia/St. Mary’s plans to increase hospitalist participation in chart review and other quality activities.
“I have a select group of hospitalists I am coaching in administration, such as DRG-based cost-of-care reduction,” he says. To encourage participation in hospital governance and quality assurance, Dr. Connolly has applied 37.5% of the hospitalists’ incentive compensation to rewarding those activities.
But many programs struggle to get other physicians involved, beyond offering the usual citizenship incentives. Dr. Dickens, for instance, recently asked for volunteers to take on one more committee and help him have protected leadership time. “No hands went up,” he says.
He knows it may come down to money. While a physician taking an extra clinical shift at his hospital earns 20% more pay, there is no extra compensation for taking on more committee work “at least, not yet. Dr. Dickens is now negotiating to begin to compensate other group members to take on some administration.
Otherwise, something will have to give. “At some point, I have to draw a line in the sand,” Dr. Dickens says. “I could be doing this longer if I have some help, but if I’m alone, six more months. The cycle has to change.”
Paula S. Katz is a freelance health care writer based in Vernon Hills, Ill.
How much clinical time is enough?
ALTHOUGH IT’S TEMPTING for group directors to whittle down clinical time to make room for administrative tasks, there are risks.
“How little clinical time is too little before you’re just not efficient anymore and you don’t know the nurses or protocols?” asks James O’Callaghan, MD, a pediatric hospitalist at Seattle Children’s Hospital and lead hospitalist at EvergreenHealth Hospital in Kirkland, Wash.
He points out that there are no accepted benchmarks and that one or two shifts a month may be enough to say, “I get it. The shifts are busy, calls are tough and we have trouble communicating with nurses on this unit. But you could argue you need more shifts to stay clinically relevant.”
Dwindling time at the bedside also makes it hard to gain other hospitalists’ respect.
“It’s very difficult not to be viewed as a suit by your team,” says Roy Sittig, MD, medical director of hospital medicine and associate chief of general medicine at UCONN Health Center in Farmington, Conn. He spends his 70% clinical time working a Monday-Friday schedule, while still doing some weekend shifts. “Day-to-day patient care issues really engender a sense of teamwork and can maintain your credibility with your team,” he adds. “Team members will often respect you more as their boss if they feel you know what challenges they face on a daily basis.”
At Columbia/St. Mary’s Hospital in Milwaukee, hospitalist director Matthew Connolly, MD, devotes 80% of his time to administration. With so little clinical time, Dr. Connolly tries to show he’s all in by taking three night shifts per month, typically on Fridays, Saturdays or holidays. “It’s the quality of that 20% that matters,” he says, “not necessarily the hours.”
Jerome Siy, MD, the department head of hospital medicine for HealthPartners Medical Group in Minneapolis, agrees. Dr. Siy started working a 0.2 FTE administrative-time job that grew to 0.55 FTE when he became department head of the 74-doctor hospital medicine department. (Site chiefs at each hospital in the system also have administrative time.)
He spends his nonclinical time working five days a week from 8 a.m. to 5 p.m., but he also does a seven-day shift once a month. “Proving your clinical competence is less about the number of hours you put in,” he says, “and more about how you work and what you accomplish.”
Dr. Siy is also very aware of how he comes off to the hospitalists on staff. Even when he’s in administrative mode, for instance, he makes a point to share workspace with his colleagues and not stay holed up in his office.
“That face time means they see me working, doing things that represent them,” he says. “If not, they might wonder if I’m home sleeping in every day.”