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On the road

November 2010

Published in the November 2010 issue of Today’s Hospitalist

Anticipating a management shake-up at the hospitalist group in Tennessee where she had worked for nearly three years, Constance Hardy, MD, started looking for a new job earlier this year. She found a great opportunity in New Mexico, where she had trained, and decided to take the job. There was just one catch: She still had an employment contract in Tennessee that she needed to complete.

As a result, Dr. Hardy decided to give long-distance commuting a try. She spent one week working in Tennessee, staying in a hotel close to the hospital. She then flew back to New Mexico so she could work at her new job and spend time with her family, which had moved west so her son could start first grade at his new school. She then repeated the cycle for several months in the summer and fall.

Long-distance commuting may sound professionally onerous, physically burdensome and psychologically difficult, but Dr. Hardy found it to be “liberating.” She felt like she was better able to balance work and family, and she was glad she could continue to help her old group even after she found another opportunity.

“There are lots of benefits in terms of quality of life,” she explains. It’s far less stressful to work 12-plus hours and flop at a hotel near the hospital, for instance, than to work a long day and drive home to face all the responsibilities of being a spouse and parent.

While Dr. Hardy’s contract in Tennessee has ended, she isn’t planning to stop commuting. For as long as she is needed by the Tennessee group, she intends to continue her cross-country commute. While Dr. Hardy probably won’t make the trek every other week, she does intend to fill in now and then.

Commuting has worked out so well, in fact, that Dr. Hardy urges other hospitalists to give it a try. “My advice is if you have a prospect of a better job offer and it means commuting, go for it,” Dr. Hardy says. “There are no downsides for patient care, none whatsoever.”

Taking advantage of shift work
Like Dr. Hardy, some hospitalists across the country are finding that working far away from where they live is an excellent option. Given the shift-work nature of many hospitalist jobs, these hospitalists say there’s no reason that they have to live in the community where they work on their days off.

Hospitalist groups, meanwhile, are finding that hiring traveling hospitalists “not temporary locum tenens workers, but permanent hospitalists who can’t or won’t relocate “is sometimes the best or only option to staff shifts. Given the geographic and economic diversity of the country, the only way to staff groups in smaller hospitals or rural communities, where professional spouses may have a hard time finding opportunities, may be by hiring long-distance commuters.

But the use of fly-in hospitalists raises some important questions not only for groups, but the specialty. Hospitalists, after all, have always positioned themselves as the go-to physicians in the hospital, ready to accept any and all challenges from hospital administrators. How well can hospitalists who have little attachment to an area actually serve patients from that community?

Some worry, for example, that commuting hospitalists who aren’t integrated in the community will be less likely to go the extra mile for patients. Skeptics also wonder whether traveling physicians will be less connected to the medical and nursing staffs and less likely to serve on important hospital committees.

Part of the concern “is the expectation that hospitalists have created for ourselves. We say we are different than emergency room doctors. We are not staffing solutions,” explains Stephen L. Houff, MD, president and CEO of the Ohio-based Hospitalists Management Group (HMG), which has more than 50 hospitalist groups in 18 states.

“But let’s be honest,” Dr. Houff adds. “If there is no other way to get staffing in place or to bring a level of expertise to a hospital, these are some of the realities of resourcing in a scarce specialty. And given the 24/7 nature of many of these programs, does it really matter where you are on your off week? When you’re off, you’re off.”

Dedicated “firefighters”
HMG is one of several large hospitalist groups that have hired permanent, full-time traveling physicians who rotate among the company’s sites. These 15 to 20 mobile hospitalists, which HMG calls “firefighters,” are generally used to staff start-ups, cover maternity or extended sick leaves, or bridge staffing gaps. A good example is a program that’s expanding its services but can’t find local hospitalists.

Dr. Houff says the group never has trouble hiring “firefighters.” Some are young hospitalists who want to try on a practice for a year or two before they pick a place to stay, similar to living together before marrying. Others are experienced hospitalists on track to become group leaders.

Janna Gelderman-Moffett, DO, falls into the second category, but for a different hospitalist company. She left an independent hospitalist group in Toledo, Ohio, to sign on more than a year ago as a full-time “roving” chief hospitalist with the Washington-based Sound Physicians, which has hospitalists in more than 40 hospitals throughout the country. Dr. Gelderman- Moffett has now worked as “chief hospitalist” “the equivalent of program director “for two different Sound Physician sites

She spent the first year in that job driving four hours every other week from Toledo, where she lives with her husband and 8-year-old daughter, to Grayling, Mich., where she worked a seven-day, 7 a.m.-to-7 p.m. hospitalist shift in a start-up group. Since that job ended, she has been driving nearly three hours in the other direction to a practice in Springfield, Ohio. She stays in a hotel for a week at a time before driving the three hours home.

Built-in flexibility
Like Dr. Hardy, Dr. Gelderman-Moffett says she never expected to love being a traveling hospitalist. But because she enjoys the challenge of learning new systems and meeting new people, she figured she had the personality to do it. “I didn’t know that I would enjoy it quite as much as I do,” she explains. “I don’t like being away from my family, but when I am home, I really am home. Everybody loves my week off.”

Besides, Dr. Gelderman-Moffett adds, all jobs have a downside. In her previous job with the independent group, she saw so many patients per shift that she felt like she was burning out. She likes the new opportunity ” but because her family didn’t want to leave Toledo, working as a traveling hospitalist seemed like an option worth trying.

“You have to compromise on something with any job,” Dr. Gelderman-Moffett says. “This is what I was willing to compromise on.”

An unexpected benefit of traveling, Dr. Gelderman- Moffett says, is that she now feels she is a better physician after working in different hospitals, each with different protocols, formularies and systems.

“Once you have a solid foundation,” she explains, “you can adjust to accommodate to each hospital. Traveling has made me a much stronger physician because it allows me to make sure all my patients get a good standard of care no matter what the process is.” And because Dr. Gelderman-Moffett works long periods of time at one hospital, most nurses, referring primary care physicians or consulting subspecialists aren’t even aware that she lives hours away during her time off.

The downsides
That’s also true for the long-distance commuters who staff the hospitalist program at Western Baptist Hospital in Paducah, Ky., says Ryan Frazine, MD, medical director of the two-year-old hospital-owned group. Of the group’s seven full-time hospitalists, one commutes from four hours away; another from 45 minutes away (far enough that he keeps an apartment near the hospital where he stays during work weeks to take call); and another flies in from New York.

“We never thought we would be hiring people who had no intention of moving here,” Dr. Frazine says. “We hired them out of necessity, to have enough doctors, and we hoped that the people we brought in would really like it and decide to move here permanently.”

What happened, however, is that for various personal reasons, these physicians have become permanent travelers. (Unlike Sound’s roving physicians or HMG’s firefighters, these hospitalists pay for their own commute and local housing, but earn enough to make it worthwhile.) Not only are they good doctors, Dr. Frazine says, but they are committed to the group. “I would guess that most nurses and other medical staff don’t even know they aren’t local,” he adds.

Dr. Frazine is quick to acknowledge that having so many out-of-towners is probably not optimal. The biggest downside is that there are so few physicians available to swap shifts here and there as needs arise.

In addition, Dr. Frazine explains, none of the travelers sits on hospital committees. “We have never even really made an effort to try to place these physicians in committees because we knew it would be difficult,” he says.

More turnover, but long-term value
But perhaps the biggest downside, at least in Dr. Frazine’s group, is the higher level of turnover among travelers than locals. The group used to have another long-distance commuter who everyone liked, but once his wife had a baby, that physician took a job that didn’t entail spending a week away from home. Other medical directors tell tales of former travelers in their groups whose marriages failed or who worked for them only until they could find a job closer to where they actually live.

There’s another downside that hospitalist programs that hire traveling physicians face: the perceptions of hospital administrators. Hospitalist consultant Martin B. Buser, MPH, of Hospitalist Management Resources, based in San Diego and Colorado Springs, Colo., describes being contacted this fall by administrators of a Northern California hospital where nearly 90% of the hospitalist group were itinerant physicians who flew in for their shifts.

“The sense of the medical staff and the hospital CEO was that they had a good program “the hospitalists were good doctors “but it was not a great program,” Mr. Buser notes. They thought it would never be great, he adds, unless they had hospitalists living there who were part of the community.

Or at least a substantial number of hospitalists living locally. With such a high percentage of travelers, Mr. Buser says, no one was around to consistently defend the program or represent it to other medical staff members.

“There is probably a sweet spot for travelers, and for sure, no one will notice if they work nights,” Mr. Buser explains. “But if the percentage of commuting physicians exceeds 50% during the day, that becomes apparent to both the medical staff and management.”

Dr. Houff from HMG agrees that some hospital leaders simply don’t feel comfortable with the idea of commuting hospitalists. “For some CEOs,” he explains, “a successful recruitment means that the doctor has agreed to move to town. That’s how they define victory. But if you ask about the staffing in the emergency department and ask where those physicians live, they will say, ‘That’s different.’ ”

But the idea that physicians like hospitalists have to be part of the community where they work may be increasingly viewed as old-fashioned, particularly given shift work and information technology that allows hospitalists to perform some work remotely by e-mail or smart phone. Is there really any difference if you commute 30 minutes to a hospital every day or four hours every week?

Whatever the arrangement, Dr. Houff says, “a traveling hospitalist better create long-term value for the hospital.” Given declining reimbursements and the uncertainty of looming health care reform, he explains, “Hospitals are being forced to take a hard look at all their vendor and employed relationships. If you’re flying in from out of town, hospitals want to be sure you are making it work.”

Deborah Gesensway is a freelance writer who covers U.S. health care from Toronto.

Putting an ocean between your home and your job

WHILE HOSPITALISTS who commute long distances aren’t exactly commonplace, most of their travel times likely pale in comparison to those of John Lin, MD. A nocturnist, Dr. Lin now commutes from Los Angeles to Hawaii.

He and his wife, who is also a hospitalist, originally started taking hospitalist jobs away from home after he left a hospitalist medical director job in downtown Los Angeles.

They wanted to try out new kinds of groups with different ownership models in different communities before deciding where (or if ) they wanted to move. Before his current job, he spent six months commuting every 10 to 14 days between LA and Alaska, where he worked as a nocturnist at the Alaska Native Medical Center in Anchorage.

His wife has found another job within California, Dr. Lin points out. But given the state of California’s economy, he adds, “You often now have to go out-of-state to make a living.” Several of the long-distance jobs he has commuted to have offered him permanent positions, but Dr. Lin says he doesn’t want to move his family until he finds the right situation.

While he may not have found that ideal situation yet, he says that working as a traveling hospitalist has helped him realize that he likes working as a nocturnist. “I am procedure-oriented,” says Dr. Lin, “and you get to take care of sicker patients at night when something happens.”