Published in the January 2012 issue of Today’s Hospitalist
When the hospitalist in Raleigh, N.C., recently reached age 64 and found night call to be increasingly difficult, he asked his program director for some flexibility in scheduling.
The hospitalist group at Duke Raleigh Hospital, where the physician works, did just that, cutting his hours to three-quarters time and scheduling him for fewer nights “in return for a 25% pay cut. When the physician announced he would retire in July, he stopped taking nights altogether.
Trimming the physician’s work hours helped retain an experienced hospitalist, explains Charles Hodges, MD, the group’s medical director. But accommodating the needs of one hospitalist was a big change for the 16-physician group. That’s because everyone else “including the other seven hospitalists who are over age 50 “takes an equal share of the work (except Dr. Hodges himself, who contributes administrative time in lieu of working nights or weekends). And Dr. Hodges admits that with hospitalist schedules so tight, he’d be hard-pressed to accommodate a similar request unless “someone wanted to job-share and could come up with another physician to help split a full-time schedule.”
As physicians reach or approach age milestones (think 40 and beyond), the question of whether schedules should be tailored to individual doctors can become a dilemma. It raises the question of whether age is a factor when it comes to the rigors and schedules of hospital medicine.
The issue of age brings up other questions as well: To what degree can or should groups accommodate these physicians to minimize burnout, reduce turnover and keep experienced physicians on board? And how does tailoring schedules affect hospitalist pay and staff morale?
Longer to recover
It seems intuitive that age could affect schedules, and some data from the 2011 Today’s Hospitalist Compensation & Career Survey may bear that out. While compensation rises for hospitalists as they get older, for instance, compensation peaks for doctors between the ages of 41 and 50.
For doctors in that age bracket, mean compensation is $237,000, according to survey results. Hospitalists over age 50, however, report a mean compensation of $229,000. That may be due to them working fewer hours.
“We can’t have physicians in their 40s continue to work the same hours they worked in residency,” says Farhana Kamal, MD, clinical director of the hospitalist program at Glens Falls Hospital in Glens Falls, N.Y. Age is an important issue for her because many of the 10 physicians in her group soon will reach 50.
Dr. Kamal says that her goal is to make the practice work not only for doctors with young families, but also for physicians working what may be the last position in their career. “My challenge is to look for ways to not burn these physicians out,” she notes. “Even the ones who were keen to do nights five years ago don’t want to now. It’s a recovery issue.”
She adds that she can relate to their concerns. “I’m 45,” she says. “I can manage two or three nights a month “but working two consecutive nights in a row kills me. It takes two days to recover.”
Dr. Hodges, who is 57, maintains that being 50 or older doesn’t have to mean a slower pace or a different schedule. “There are plenty of doctors over 50 with lots of energy who could handle anything you throw at them,” he says. He points out that one hospitalist in his group who’s not much younger than the physician who is about to retire recently volunteered to work five nights in a row over the holidays.
Al Saliman, MD, chief medical officer and director of the hospitalist program at Valley View Hospital in Glenwood Springs, Colo., agrees that hospital medicine isn’t necessarily a young person’s game. But he says that practices that work together as a team can make scheduling compromises. Because of his administrative duties, for instance, Dr. Saliman doesn’t work night shifts. But that works out because some younger hospitalists in the group prefer to work at night.
“We started off with the same scheduling expectations for everybody,” Dr. Saliman says, “but some prefer one type of shift over the other.” Because the day and night schedules have equal value, he adds, everyone gets paid the same.
His service includes two physicians in their 30s as well as one full-time and two part-time physicians in their 40s. “If I hired an older physician, I would make some allowances because of fatigue,” he admits. “But I don’t know that that would make me not want to hire him or her.”
At the same time, Dr. Saliman acknowledges that the long hours can take their toll. “I’m 57, and it’s really hard working 12-hour shifts when you’re nearly 60,”he says. “At this age, I can handle three or four 12-hour shifts in a row, but that’s it.”
Dr. Hodges says he prefers to distribute the so-called “bad shifts” “those over the weekend or at night ” equally. He tries to make parity less onerous by sticking to a simple rule: Hospitalists can’t work more than six days on, although he prefers to keep that number to five.
For Aultman Inpatient Medicine in Canton, Ohio, it was easier to keep the schedule simple “seven-on/ seven-off “when the group was smaller. But when it exploded from four staff members last year to 20 this year, the ages and years of experience of the group’s physicians became much more varied.
A “cookie-cutter schedule” wasn’t going to meet the needs of the program nor the doctors, says practice manager Jason P. Blevins, RN, MSN.
When one physician in his early 60s wanted to scale back, the practice moved him into a consult position on Mondays through Fridays from 8 a.m. to 4 p.m. That physician also covers consults one weekend a month.
Other strategies being considered include working more days but fewer hours, Mr. Blevins says. That could translate to working 10 out of 14 days but only seven to eight hours a day.
Dr. Saliman points out that he got some pushback initially from other physicians when he stopped taking what they saw as his fair share of nights. He held firm that he couldn’t do both administrative work and night shifts. That resistance also faded over time, he notes, as the upsides of having someone play an active role in developing the program became clear.
In fact, many younger physicians are willing to pick up the extra shifts that older doctors want to let go “if they get paid more. That’s been the experience at Lakeshore Health Partners in Holland, Mich., which uses a reimbursement model based in part on productivity.
“Newer physicians have more enthusiasm and probably more debt,” explains Jan Layman, the group’s practice manager of adult hospitalist services. “They want to earn the income and be productive now.”
In Glens Falls, Dr. Kamal notes that there’s no rule at her practice that physicians who turn 50 can opt out of nights. But she notes that the differential paid for working nights inspires physicians of all ages to volunteer.
But for some young physicians, she adds, family life trumps extra pay. Ms. Layman agrees, noting that one physician at Lakeshore has young twins. “There’s no time in his life for extra shifts,” Ms. Layman says.
At Aultman Inpatient Medicine, Mr. Blevins worries that flexible scheduling for more experienced physicians could set a problematic precedent “particularly because everyone in the group is paid the same.
“How do we handle the next person who says these nights or swings or 12-hour shifts are becoming too much for me?” he asks. “It’s a position we still struggle with.”
Any changes might very likely be tied to pay. “We’re in very initial conversations about compensation,” Mr. Blevins points out. But a change in scheduling would likely mean a hit to some degree for physicians who want to consult instead of taking nights. “Opting out of more difficult physical shifts should mean less compensation,” he says.
Hospitalist groups are finding other ways to meet the challenges of physicians “of any age “who might want modified schedules.
Part of the solution for Dr. Kamal’s group was the recent addition of a nocturnist, who now covers 13 nights a month and has taken some of the pressure of working nights off the other doctors in the group. Dr. Kamal notes, however, that she’s worried that the nocturnist might burn out. In that case, she says, he’ll switch to being a full-time rounding physician during the day and the group will go back to sharing nights.
Another option is hiring midlevels. According to Dr. Kamal, physician assistants (PAs) handle the bulk of the typically 10 to 15 floor admissions each night while the physician handles the ICU and code blue coverage and backs up the PA. The 10-physician practice has six PAs.
Lakeshore Health Partners in Michigan also uses a midlevel to provide night coverage, while the physician who takes the 4 p.m. to midnight shift that day takes call from home. And according to Mr. Blevins at Aultman Inpatient Medicine, his group just approved hiring midlevels to assist night-shift physicians as well.
Beyond scheduling hassles
Even if it takes a bit of juggling in pay or scheduling, having experienced hospitalists on staff pays dividends, Dr. Hodges says.
Those physicians can not only function as mentors, he notes, but they may be more likely to stick with the job. “We shy away from doctors who just graduated because of their lack of solid plans to remain career hospitalists,” Dr. Hodges says. “After a year, they may think, ‘It’s not good for me.’ ”
Plus, older physicians often have additional skills honed during years of outpatient care. That experience pays off when dealing with problem patients “and in terms of understanding what primary care physicians need from hospitalists.
For example, one primary care physician recently called him to complain that he saw the name of one of his admitted patients in the obits in the local paper. The attending hospitalist never told the primary that the patient had died.
That was a mistake, Dr. Hodges says. “I was in primary care for 12 years,” he explains. “It would have been a priority of mine to call if somebody died.” It’s a good example of how something that is second nature for experienced physicians may not even be on the radar of younger doctors who’ve never worked in primary care.
Some groups think that the best plan may be to hire physicians of different ages, especially if a service has to move staff around to fill in for physicians who want to shorten their hours.
“Experience is worth its weight in gold,” Dr. Saliman says. “However, doctors just out of residency are so well trained and are at the height of their skill level, especially with critically ill patients.”
Mr. Blevins says his group takes generational mix into consideration in hiring for the growing program. “If we bring in some experienced physicians, then we also get younger ones,” he says. Over the next year, he plans to add four or five new physicians, but only half will be just out of residency or relatively new in their careers.
Those additions will mean having to take a closer look at schedules and how both patient and physician needs “age-related and otherwise “are met.
And for physicians who think they’re getting “too old” for the rigors of hospital medicine, Mr. Blevins says that good practice management can play a critical role.
“These are very good physicians and we want to extend their careers as long as we possibly can,” he says. “Flexible scheduling will definitely help extend careers. But whether that is 55, 60, 65 or some other age depends on the person.”
Paula S. Katz is a freelance health care writer based in Vernon Hills, Ill.
DOES A HOSPITALIST’S AGE MATTER? The answer depends on who you ask.
“Older physicians tend to take more time with a patient, and that’s by virtue of being in outpatient practice before,” says Jan Layman, practice manager of adult hospitalist services at Lakeshore Health Partners in Holland, Mich. She stresses that she’s not being negative about younger physicians. “They just practice differently.”
Charles Hodges, MD, medical director for the hospitalist group at Duke Raleigh Hospital in Raleigh, N.C., goes further, saying that he sees an important cultural difference. “Younger people are less willing to work harder and longer without vocalizing,” he says. “They complain more. They signed up for 12-hour shifts and sometimes it’s 14. I hardly ever hear that from older folks.”
Baby Boomers are always on time or even a little early and expect the same from their colleagues, says Jason P. Blevins, RN, MSN, practice manager of Aultman Inpatient Medicine in Canton, Ohio. But he notes this counter argument from some doctors from Generations X or Y: Boomers’ sense of time is too rigid. He intervenes when younger doctors are more than 25 or 30 minutes late, explaining where the Baby Boomer generation is coming from.
“To Generation X or Y, ‘on time’ is five to 10 minutes late,” he explains, “whereas Boomers say, ‘If I’m 10 minutes early, I feel like I’m late.'” But generational stereotypes don’t necessarily hold when it comes to technology. There are still varying degrees of interest even among younger doctors, says Dr. Hodges, who is in charge of EMR implementation within his group. And Al Saliman, MD, chief medical officer and director of the hospitalist program at Valley View Hospital in Glenwood Springs, Colo., says he finds older physicians are more skeptical of CPOE.
But that generation is in its comfort zone at Lakeshore Health Partners where physicians don’t carry a pager but instead text through a secure network. They also use iPhones and iPads to communicate within the hospital, and dictate in real time using EMR voice recognition.