Published in the May 2008 issue of Today’s Hospitalist
When it comes to finding external moonlighters to help staff the hospitalist group she manages, Sabitha Rajan, MD, often finds herself in a dilemma. While her group of 16 full-time hospitalists is 10 physicians short, she is very careful of whom she brings in to moonlight.
Dr. Rajan, who is co-director of the inpatient medicine division at Scott & White Hospital in Temple, Texas, recently interviewed an outpatient internist, for example, who was eager to pick up some shifts. While she’s hired outpatient internists before to moonlight as hospitalists, she decided to take a pass on this particular candidate.
“We didn’t feel her skills were up to being an inpatient physician,” recalls Dr. Rajan, who is also chief medical officer of Scott & White’s continuing care hospital.
Dr. Rajan’s experience illustrates the challenges that hospitalist programs that depend on moonlighters face. Even as they need moonlighters more than ever to solve staffing shortages, hospitalist groups are having a hard time finding qualified candidates.
In part, the problem is due to the nationwide shortage of hospitalists. But there’s another dimension: As hospital medicine matures, programs are having trouble finding candidates who can match the quality, continuity and efficiency of care that full-timers pride themselves on. Programs are finding that filling in as a hospitalist “particularly on nighttime or weekend shifts, when there may not be a lot of back-up “requires a proficiency in inpatient medicine that not every internist possesses.
That’s forcing programs to take a second look at who they hire as moonlighters and at what kinds of duties they give to those physicians once they’re through the front door.
The learning curve
To be fair, few of the program directors interviewed for this story say they’ve had disastrous experiences with moonlighters or major complaints about their care. The real headaches, they say, come in the form of systems issues and housekeeping details.
At a hospital where Dr. Rajan worked a few years back, for example, one moonlighter didn’t know the protocol that required keeping a patient NPO after midnight who was getting a particular procedure; it was done differently at that moonlighter’s other hospital. Another moonlighter didn’t know that hospital policy mandated an infectious disease consult before ordering a particular antibiotic.
At Swedish Medical Center in Seattle, Per Danielsson, MD, the adult hospitalist program’s medical director, has recruited moonlighters from three different sources. Fellows from the University of Washington comprise the largest group, but he also utilizes internal moonlighters from his own group, as well as two hospitalists who work full time for other programs and occasionally moonlight at Swedish. Moonlighters’ ranks are full, he says, because these physicians need the extra funds for medical school debt and child care expenses.
But while Dr. Danielsson has a roster of qualified moonlighters, he doesn’t expect them to function at the same level as staff physicians. As a result, he tries to give moonlighters shifts “particularly swing shifts and nights “where they predominately admit. Fellows, n particular, like the swing shift (5 p.m.-1 a.m.) because they can then go home and get enough sleep to function in their fellowship the next day.
And, Dr. Danielsson notes, he has fewer problems when moonlighters do admitting rather than rounding. He suspects that his staff physicians do a better job of rounding because that requires more knowledge of logistics, policies and procedures, as well as more interactions with consultants, social workers and discharge planners.
Rounders vs. admitters
Other programs, however, have found that moonlighters work out better rounding instead of admitting. That’s been the case at Norwalk Hospital in Norwalk, Conn., where the hospitalist program prefers to use moonlighters to work weekends.
As internal medicine chairman Eric Mazur, MD, explains, admitting is too important to be left to moonlighters. “You get to know the patient best when you are the admitting physician,” Dr. Mazur says. To promote better quality of care, the program recommends that staff hospitalists, not moonlighters, do the bulk of admitting.
And to further avoid problems with moonlighters, the program’s weekday hospitalists try to be diligent about developing detailed care plans and doing thorough and conscientious sign-outs. Jason Orlinick, MD, Norwalk’s chief of hospital medicine, says that effort helps ensure that nothing “is lost in the transition” to a weekend rounder.
Dr. Orlinick notes that because Norwalk Hospital has residents and one attending clinician-educator hospitalist on the weekends, the program can avoid giving the more difficult patients to the weekend moonlighter. “I go out of my way to not assign a patient we think is likely to need special attention or we anticipate will have problems over the weekend to the moonlighter,” he explains.
“In some ways, we have to pay more attention when we’re handing off to moonlighters,” Dr. Orlinick says. “They come in on a Saturday morning not knowing any of the 20 patients they will have to see over the course of that day.”
A small, well-vetted cadre
While program directors try to set up moonlighters for success, they also have to make sure that moonlighters live up to their end of the bargain. Staff hospitalists can make a moonlighter’s job harder through sloppy hand-offs and poor communication, but moonlighters can create extra work and unnecessary administrative hassles for staff hospitalists.
“The daytime docs knew that when a moonlighter was on just before them,” says Dr. Rajan from Scott & White, “they had to take a closer look at patients. Maybe they had to get a phone call into ID sooner rather than later, or they had to call cardiology, because it wasn’t called earlier.”
Matt Kolleck, MD, medical director at Deaconess Care Group in Evansville, Ind., says that his hospitalists have had to cover tracks and fill holes left by less-than-diligent moonlighting physicians who didn’t know, ask about or pay attention to hospital systems and protocols.
That’s one reason that Dr. Kolleck says clinical skills are not the only thing that matters when hiring moonlighters. In his experience, personality can count even more.
“Excellent people skills are essential,” he explains. “They are coming into an environment they don’t know.”
That’s why programs aim to build a small group of trusted, vetted moonlighters doing many shifts instead of having a larger group working only occasionally.
“For us,” says Dr. Orlinick from Norwalk Hospital, “it works out well to have a more stable group of people, whom our residents know and whom the consultants know, than to have people float in and out.”
Up-to-date with hospital medicine?
At Fairview Ridges Hospital in Burnsville, Minn., a Twin Cities suburb, Jamie Peters, MD, a hospitalist and vice president of medical services, says he has generally good experiences culling moonlighters from the ranks of community internists who until recently saw inpatients occasionally under a rounding model. But he is quick to add that he would be wary about hiring moonlighters among primary care physicians who haven’t done inpatient medicine for several years.
“Hospital medicine is different than it was three or four years ago,” Dr. Peters says. These physicians have probably lost their competence in “how to negotiate complex management of hospitalized patients, who are increasingly sicker and lengths of stay are shorter.”
Even with the competent moonlighters he trusts and regularly uses, Dr. Peters tends to assign them different jobs than he does his full-time hospitalists. For instance, he says, he doesn’t ask them to carry the code pager or to take responsibility for a rapid response team.
And while most of his hospitalists see ICU patients and manage ventilators, Dr. Peters adds, “we do not mandate that moonlighters do that.” The hospital has intensivists available to handle very sick, unstable patients during a moonlighter’s shift.
While he’s had good experiences with moonlighters, Dr. Peters says he would still prefer having more full-time staff and fewer moonlighters. He’s exploring the possibility of adding a permanent midlevel practitioner to pick up some work, like organizing discharges, which he says is best not done by moonlighting physicians.
Other industry veterans urge programs to take a step back and take a serious look at why they need moonlighters. Those who find themselves adding large numbers of moonlighters, they say, may be ignoring underlying problems.
“Are you looking at how to stabilize a potentially unstable situation? Is it a recruitment or retention problem?” asks Ken Simone, DO, a family physician in Veazie, Maine, who also works as a national hospitalist consultant. “I think more energy needs to go into planning and evaluation to find a long-term solution.”
According to Dr. Orlinick, programs also need to consider more permanent alternatives like part-timers, midlevels and even job-sharing. The hospitalist program at Norwalk Hospital, for example, has found one hospitalist who wants a half-time position working on weekends, and as soon as another one can be found that fits their needs, that person will probably be hired too. Other hospitalist programs are experimenting with job-sharing arrangements or flexible scheduling options as a recruiting and retention strategy.
Short-term solution or permanent fix?
But Niraj Mohan, MD, medical director for Hospital Associates of Pittsburgh, views moonlighters less as a stop-gap measure and more as a permanent recruiting and retention strategy. His goal is to incorporate regular moonlighting opportunities into the schedule to ensure a stable, happy group of hospitalists who provide 24/7 coverage.
“The way to have less function as more,” he says, “is to have moonlighters. You can ask a physician to work only so many nights or only so many consecutive hours or days.”
Dr. Mohan is currently advertising for outside moonlighters to cover the remainder of the nights, and he hopes to identify a small group of regulars. He says he’s been surprised by the different types of people looking for these jobs.
“One physician is a retired surgeon with nearly 30 years of experience,” Dr. Mohan says. “There are also recent trainees waiting to start fellowships, women taking time off with young children and people cutting back in preparation for retirement. There are a lot of talented individuals who can provide good care but who are in different places in their life and want a different kind of job.”
Because he’s had relatively good luck finding a steady supply of moonlighters, Dr. Mohan is able to give his practice a recruiting advantage by giving his full-time hospitalists contracts that guarantee no night work. If permanent physicians are interested in moonlighting internally, they can sign an alternative contract that commits them to working 26 nights over the course of the year for extra pay.
While Dr. Orlinick from Norwalk Hospital may approach moonlighters less enthusiastically than Dr. Mohan, he shares the view that an important goal of using moonlighters is to improve working conditions for the permanent physicians.
“The most important goal for us is retention of full-time hospitalists,” he says. “We want people who come here to stay.”
Deborah Gesensway is a freelance writer reporting on U.S. health care from Toronto, Canada.
Caveats about internal moonlighters
AN OBVIOUS WAY TO FILL holes in your practice schedule is to ask your full-time hospitalists if they want to pick up some extra shifts. They already know the hospital’s policies and procedures, after all, and many young hospitalists are looking for ways to pay off medical debt or save for a house.
But Ken Simone, DO, a family physician in Veazie, Maine, who works as a national hospitalist consultant, says that relying too extensively on internal hospitalists to moonlight can backfire by burning out your full-time doctors.
Dr. Simone says he has been called into programs because they are losing business from referring physicians. When he investigates, he sometimes finds that the primary care physicians feel that they aren’t getting good service.
“When you dig deeper,” Dr. Simone says, “the problem is one individual who is doing a lot of moonlighting. He is tired and burnt out because he worked all weekend. You have to watch out for this if you allow internal moonlighting.”
He has another caveat for programs that rely on internal moonlighters: Be careful about asking your physicians to moonlight. “Sometimes there are individuals who can’t say ‘no,’ ” Dr. Simone says, “and you may be overextending them.”