Published in the November 2017 issue of Today’s Hospitalist
A PHYSICIAN working for little more than a year in his first hospitalist job realized he was burning out. In that particular job, he says, seeing 20 patients a day wasn’t unusual. Further, after reading through compensation surveys, he realized his workload was higher than the national average while his compensation was lower.
But when he raised those issues, he was told that his group needed to keep on seeing more patients before the hospital would approve hiring additional hospitalists. Instead, he quit and now works two part-time hospitalist positions. He also plans to pursue an MHA or MBA.
“I feel much less burnout now because of the flexible schedule and fair workload and compensation,” says the physician, who wants to remain anonymous to maintain a good relationship with his former employer. “As a profession, we need to be more vocal about defending work-life balance, or burnout will increase.”
“What I think fuels much of the burnout is missing so much with the week-on/week-off of 12-hour shifts.”
~ O’Neil Pyke, MD
Medicus Healthcare Solutions
In this year’s Today’s Hospitalist Compensation & Career Survey, more than three-quarters of respondents describe burnout as “significant” or “very significant” for their colleagues, while 54% predict that burnout will become “much more significant” for hospital medicine over the next five years. According to this year’s survey, a sizeable minority—41%—have had a personal experience with burnout themselves.
While hospitalists have long recognized the burnout potential for themselves and their field, the topic, along with its dire clinical and financial implications, may finally be getting the scrutiny it deserves. One thing that’s changing: “It’s OK right now for people to admit to being burned out,” says Evan Soderstrom, MD, hospitalist medical director for Tri-County Medical Associates at Massachusetts’ Milford Regional Medical Center. “Before, it felt like a weakness, and you had to be a good boy or girl and just do the work and not complain.”
“A national health crisis”
The gloomy outlook for burnout in hospital medicine is the same for the medical profession overall. According to an article in the Sept. 25 issue of JAMA Internal Medicine, it’s “widely recognized” that “50% of U.S. physicians are afflicted by an occupationally induced syndrome associated with profound personal and professional consequences.”
Moreover, the CEOs of 10 large health care organizations in a May 28, 2017, Health Affairs blog wrote that the “substantial increase” in physician burnout is “becoming a national health crisis,” one prompting many previously engaged doctors “to retire early, reduce the time they devote to clinical work, or leave the profession altogether.”
That’s exactly how veteran hospitalist Kimberly A. Bell, MD, division director of hospital medicine for CHI Franciscan Health System in Tacoma, Wash., sees burnout manifesting itself. “A growing number of providers are asking to decrease their hours from full time to something less,” she says. “It’s increasingly obvious that we have larger numbers of providers who want to be locums or per diem, not employed.”
“It’s OK right now for people to admit to being burned out. Before, it felt like a weakness.”
~ Evan Soderstrom, MD
Milford Regional Medical Center
In addition, Dr. Bell points out, “We have huge numbers of highly skilled locums and per diems, and they are very clear that they don’t want a full-time or permanent job. They want maximum flexibility. They are saying, ‘When I feel I need to back off, I need to be able to back off and not have to beg or negotiate.’ ”
The threat of burnout drives other physicians to diversification. “Burnout happened more when I was in the same clinical job day in and day out,” says O’Neil Pyke, MD, hospitalist and chief medical officer at the staffing company Medicus Healthcare Solutions. For him, the solution is transitioning to working as a part-time clinician along with full-time administrative roles.
“I can be busy all day,” Dr. Pyke points out, “but with different responsibilities that are managed well, I come home with more energy for my family. When I was working only clinically, I was constantly stressed and anxious.”
Still others fixate on the money, thinking they can outrun burnout if they only negotiate more pay. “The money piece is important because people need to feel they are being paid fairly and competitively,” says Dr. Bell. “But beyond that, more pay doesn’t necessarily lead to less burnout. Typically, you have to work more to get more.”
Fewer hours, less commitments
For some hospitalists, that tradeoff just isn’t worth it. A year ago, Illinois hospitalist Tammy Homman, MD, succumbed to burnout. She did come back to hospital medicine (and to her same hospital) this fall, but only after she negotiated shorter shifts and two weeks a year of paid vacation. The experience taught her that while money is important, particularly with children in college, time is even more precious.
“A growing number of providers are asking to decrease their hours from full time to something less.”
~ Kimberly A. Bell, MD
CHI Franciscan Health System
When Dr. Homman quit a year ago, she had been working, she says, “130%” as a full-time hospitalist plus part-time manager. She switched to an outpatient primary care job and spent more time with her family, but realized she preferred hospital medicine to primary care. So she came back to her old post.
She hopes her new resolution to work fewer hours and to say “no” more often—especially to administrative tasks—will make this second go-round more sustainable. “I did take seven weeks o_ between the outpatient job and coming back, and that was helpful,” Dr. Homman notes. “You do a better job if you can take a break and remember why you fell in love with this work to begin with.”
But she worries about relapse. Like others concerned about the cynicism, emotional exhaustion and decreased work efficiency that experts say define burnout, Dr. Homman is uneasy about the growing proportion of hospitalist work that has to be spent on increasingly burdensome administrative requirements. She is also concerned about the state of U.S. health care. Some days, she says, it seems like most of her patients are in the hospital because they can’t access appropriate care in the community.
Hours of clerical work
“The tipping point was the widespread adoption of electronic medical records (EMRs) by hospitals,” explains Lisa Kaufmann, MD, director of hospital medicine at Appalachian Regional Healthcare System in Boone, N.C. While EMRs are great for retrieving and sharing information and have improved patient safety, she says, “they are very inefficient to actually use at the time of patient care. Using paper, I could see a patient load that was around 30% higher than what I can handle using an electronic record.”
Part of the reason many hospitalists don’t feel valued is because they are asked to do hours of clerical work built into the EMR that is well below their skill level, Dr. Kaufmann says. Further, many administrators across the country who’ve never personally used an EMR don’t understand why nurses and doctors are so much less efficient since the advent of electronic records.
“The tipping point was the widespread adoption of electronic medical records by hospitals.”
~ Lisa Kaufmann, MD
Appalachian Regional Healthcare System
“They still expect the old levels of productivity, which we will see only when EMRs become as user-friendly as the apps on our phones,” she points out. Another problem administrators don’t understand: “The EMR causes a lack of good communication with the nursing staff.
That’s because nurses also have excessive, EMR-required clerical work that makes them less available to both the patients and to us.”
Unfortunately, adds Dr. Soderstrom from Massachusetts, hospitalists in some facilities are so worn down that they become skeptical about anything new, even changes that could ease pressure or improve patient care.
“Every time I need to introduce a new idea to our group, it is met with huge resistance because everybody is already stretched too thin,” he says. That’s true whether it’s a new billing requirement from the Centers for Medicare and Medicaid Services (CMS), a hospital mandate on warm hand-offs, or a colleague’s proposal to try using scribes.
“Every idea comes with yet one more task we need to do in the same amount of time and with the same number of patients,” Dr. Soderstrom says. “I think hospitalists are so used to people adding more work that when a new proposal comes up, they put their defenses up to protect themselves.”
He’s no exception. After a dozen years, Dr. Soderstrom is feeling burned out and is considering changing from full-time clinical care to working as a consultant with a clinical documentation improvement company. “Probably,” he says, “I will end up moving toward a fulltime career in that and being a part-time clinician” on the side. “This has given me a new lease on life.”
Family physicians at higher risk
Then there’s this problem: Hospitalists are constantly being measured and asked to prove themselves. This “pressure of being judged all the time” also contributes to burnout, says David J. Goldstein, MD, a hospitalist at Natividad Medical Center in Salinas, Calif.
As the assistant director of his center’s family medicine residency program, Dr. Goldstein also wonders why burnout appears to be worse for hospitalists who train in family medicine than in internal medicine. According to the Today’s Hospitalist survey, 53% of family medicine-trained hospitalists reported having a personal experience of burnout vs. 41% of internists.
He also worries that part of the problem may be the fact that smaller and more rural hospitals, where more family medicine-trained hospitalists may work, tend to have trouble with full staffing. “The docs there are overworked and tired, and maybe burning out more,” he notes. And based on what he’s seeing in California’s central coast, Dr. Goldstein also wonders if hospitalist programs in smaller hospitals are experiencing a lot of management and ownership churn. “That,” he says, “is stressful to work under.”
In addition, some subspecialists still “show a bit of attitude toward family physician” hospitalists and do not trust the intensity of their training in the inpatient setting, says Martin Buser, MPH, founding partner of Hospitalist Management Resources LLC, a national hospitalist consulting fi rm. In many professions, working where you aren’t respected is associated with burnout. And there are still many hospitals that are “a little reluctant” to consider hiring family medicine-trained hospitalists, Mr. Buser says.
Finding the right balance between work and home and patient care and paperwork will depend on individual hospitalists’ personalities. But looking out for No. 1 can’t be the whole answer. As Dr. Kaufmann puts it, “If you are the only one, then you need to focus on self-care. But if others are burning out too, you need to fix the system.”
For many, the schedule is the place to start to look for solutions. In this year’s survey, 55% of respondents say they work seven-on/seven-off blocks. Surprisingly, those hospitalists report lower burnout rates than those working “flexible schedules” (38% vs. 46%). Still, many hospitalists agree with Dr. Bell’s contention that the “feast and famine cycle” of “squeezing two weeks worth of work into one week” is not sustainable long-term for most people.
Instead, hospitals and physician groups “need to recognize that the way hospitalists work is abnormal in many ways,” Dr. Pyke says, even if such a schedule benefits continuity of care. As a consultant, he recommends that groups try to figure out how to accommodate “staggered departures” rather than insisting on strict hours, giving physicians “a certain amount of flexibility.” He recalls one colleague who broke down in tears when his wife sent him a clip of their child’s piano recital because he couldn’t leave work for an hour.
“That’s essentially what I think fuels much of the burnout,” he adds. “You are missing so much with the week-on/ week-off of 12-hour shifts.”
Fixing compensation and incentives could also help. In this year’s survey, 32% complained that they have added responsibilities that they’re not compensated for, while 24% said they work too many hours for too little money and 16% said their bonus targets weren’t achievable. When it comes to compensation and incentive plans, says consultant Mr. Buser, reducing the number of incentive components to around four is something he regularly recommends.
Another approach comes from Dr. Kaufmann, who this fall added an item to her group’s incentive plan aimed squarely at addressing questions of engagement and satisfaction. Instead of asking hospitalists to see even more patients to get more money, the new plan will reward them financially for doing a project of their choice to improve quality or to serve the community. That could entail working in the free clinic, volunteering to do sports medicine at the university, writing order sets to make their work day more efficient or leading an initiative to reduce hospital delirium.
“I read that Microsoft and Google both discovered that people can work enormous hours and be highly productive as long as you let them work on something they want to work on 20% of the time,” she notes. “That energizes them to do the other 80% of their job.”
There’s also the idea of allowing sabbaticals. “It sure wouldn’t have hurt” if she could have taken a few months off when she was feeling too stressed to continue, says Dr. Homman. Perhaps a way to reward long-time hospitalists, she points out, could be to “give hospitalists three months off and let them be rejuvenated.”
Money not the (complete) answer
Another solution, according to Dr. Pyke, may be to “reduce the heavy-handed management” common in many hospitalist groups and allow for more autonomy, underscoring the connection he sees between “micromanagement and burnout.” In too many hospitals, management treats hospitalists “like children,” he says, unable to be trusted to figure out how to do their jobs in a way that serves them, their patients and the facility.
“Hospitalists are confident in taking care of patients, but they are frustrated because they keep running into these brick walls of hospital operations,” Mr. Buser says. “In the past, when doctors also had outpatient practices, there was a place to escape to that they could control. Now, they are in the ‘swamp’ full time, and they see ways it could improve and they are very frustrated that change is so difficult to achieve.”
“People often think that money will fi x burnout,” says North Carolina’s Dr. Kaufmann. “But you get the money, and it usually still doesn’t fix it.” While you may have more fun vacations, “it doesn’t make up for the fact that your spouse isn’t seeing you because the EMR, excessive patient loads or a dysfunctional system make it hard to see your patients properly and still leave work on time.”
As proof, she notes, “look at the health systems that pay really high salaries or pay out a lot to locums. Typically, they pay high wages because they have high turnover due to burnout from being such difficult places to work.”
Deborah Gesensway is a freelance writer who covers U.S. health care from Toronto.
The (burnout) gender gap
ACCORDING TO OUR most recent data, female hospitalists face a persistent gender gap in not only compensation, but workplace satisfaction as well.
Full-time female hospitalists who treat adults in a nonacademic setting report earning 10% less than their male colleagues. That’s according to the 2017 Today’s Hospitalist Compensation & Career Survey in which women describe a mean annual income of $260,846 vs. $290,738 reported by their male colleagues. (While survey results show that women are as likely as men to serve as program directors, their added compensation for that leadership role is slightly more than that of men: $47,510 for women vs. $44,394 for men.)
A big gender gap also pops up in responses related to burnout. While 36% of men say they’ve personally experienced burnout, that’s the case for 57% of women respondents. In addition, more women than men—42% vs. 29%—complain about “responsibilities added for which I am not compensated.” They also are more likely than men (29% vs. 23%) to report working “too many hours for too little pay.”
Female respondents who work full time did report working about eight fewer hours a month than their male counterparts. But both men and women have the same average number of patient encounters per shift: 16 during the day and between nine and 10 at night. In addition, women respondents were more likely than men to say their jobs have them working at two hospitals rather than one. That may be significant because hospitalists working at two hospitals are more likely to report a personal experience with burnout than those working at only one location.
Who admits they’re at risk for burnout?
WHILE 41% OF HOSPITALISTS responding to the 2017 Today’s Hospitalist Compensation & Career Survey report having had a personal experience with burnout during their careers, some subgroups were even more likely to acknowledge that personal impact. Those groups include:
- Women (57%).
- Hospitalists trained in family medicine (53%).
- Hospitalists who take beeper call at night (48%).
- Those who work in the Mountain region (64%) and, to a lesser degree, in the Northeast (44%).
- Hospitalists who have added responsibilities in group management (44%), hospital leadership (43%) or as “program director” (48%).
- Hospitalists who work flexible shifts (46%), rather than on block schedules (38%).
- Those whose shifts exceed 12 hours (57%).
- Nonacademic hospitalists whose jobs include some teaching responsibilities (52%).
- Hospitalists who say they “work too many hours for too little pay” (54%), those who say their “bonus targets are not attainable” (47%) or have “added responsibilities that are not compensated” (48%).
- Physicians who report that their compensation decreased last year (61%).