Published in the September 2007 issue of Today’s Hospitalist
Call it the five-year itch: After a half decade or so, some hospitalists are discovering that there may be more to their career than full-time clinical care. For some, that means moving into a niche like perioperative care. For others, it means looking beyond clinical care and entering management.
While the choice to spend less time in direct patient care is a personal decision, it is forcing hospitalist programs “and the specialty as a whole “to take a hard look at the competing needs of career sustainability and workforce supply.
On one hand, physicians who can’t grow and evolve professionally risk burnout. On the other hand, chronically understaffed programs might be reluctant to encourage physicians to develop their careers if that means taking them away from the bedside.
Perhaps there’s no better example of how a program’s physicians and administrators alike are handling those challenges than what’s taking place within the hospital medicine section of Emory University in Atlanta. Several physicians at Emory, home to the country’s largest academic hospitalist practice, have taken “or are in the process of taking “the skills they’ve honed as hospitalists and applying them to new positions.
The good news for the physicians at Emory and elsewhere is that hospitalists looking to further their careers are finding burgeoning opportunities in quality improvement, case management and hospital administration.
Here’s a look at the challenges that both Emory and its hospitalists are facing “and the lessons they’ve learned “as they attempt to take hospital medicine beyond day-to-day patient care.
SUSTAINING A CAREER
If you’re looking for an example of a hospitalist who is making the move from full-time patient care, Alan Wang, MD, is a good place to start. Dr. Wang recently started in a new role as chief medical officer of Emory Johns Creek Hospital in Johns Creek, Ga., in addition to being the director of the hospitalist service there.
Dr. Wang’s decision to enter administration may exemplify how the country’s first wave of hospitalists deals with issues of career longevity. After working as a full-time hospitalist for eight years, the 37-year-old Dr. Wang loved practicing, but knew he needed more.
“Very little of it has to do with burnout, although working nights can be an issue,” he says. “But after hospitalists become comfortable with clinical care, they want to make more of their job and get more satisfaction out of it.”
His new position takes him far from his responsibilities as a hospitalist, into business and marketing strategies for the hospital. He also serves as a key negotiator, helping navigate the turf issues that arise among specialties. (See “Making the switch from pure hospital medicine to management,” below.)
But Dr. Wang says that the move from hospitalist program director “where he interacted with administrators and nursing staff “to chief medical officer was a natural one.
“Hospitalists are very well-primed to take on this role because they are already working in the hospital on quality initiatives, utilization management, marketing and educational opportunities,” he explains. In particular, hospitalists get on-the-job training for management roles as they move throughout the hospital, into surgical co-management roles, for instance, and clinical interactions with other specialists.
For hospitalists interested in making a similar move, he urges them to become active in the American College of Physician Executives. “Then network,” he says. “Your best opportunity is probably to go to the hospital that you’re currently working in because everybody knows you.”
A DIVERSIFIED CAREER PORTFOLIO
If Valery Akopov, MD, has learned one lesson in his transition from a full-time hospitalist to his new role in administration at Emory Crawford Long Hospital in Atlanta, it’s this: Keep one foot firmly planted in clinical care.
Dr. Akopov, who is 44, began as an academic hospitalist at Grady Memorial Hospital in 1998, then moved into the hospitalist directorship at Emory Crawford Long in 2002. Now, while he continues to direct the hospitalist program, he has moved into a new management position, with 50% of his time protected for work in utilization and care coordination.
Like Dr. Wang, Dr. Akopov says that his new role as medical director of the department of utilization management and social services is in many ways a natural extension of what hospitalists do on the floors every day.
In weekly meetings called long-stay rounds, for instance, Dr. Akopov “as well as hospital leaders from social services, nursing and utilization management “will hear nurses present on different patient cases, to help determine how and when a patient can be discharged.
“We just discussed a patient on a vent with hemodialysis who is probably ready to leave the ICU but is too sick for either the floor or a sub-acute nursing facility,” he says. “Probably the only place the patient can go is long-term acute care.”
But typically, instead of considering resources for individual patients, Dr. Akopov now deals with what he calls “high level data,” helping set monthly utilization targets for different units throughout the hospital, then drilling down with physician groups “or individual physicians “when those targets aren’t met.
While physicians in other facilities can view such utilization review with suspicion, the fact that Dr. Akopov still serves as a front-line physician gives him credibility. “The fact that we share the same patients helps bridge the gap between the purely financial ‘dark side’ of medicine and the good side,” Dr. Akopov explains. “I’m not viewed as a nemesis, but as someone who has perspective from both sides.”
Without that perspective, he adds, “this particular job would be very difficult.” As a result, “it is absolutely imperative that anyone who assumes this role does not give up clinical responsibilities.”
While he urges all hospitalists to consider taking their skills into new directions “”diversifying their portfolios,” he likes to say “he says an excellent start is directing a hospitalist group.
Make your own practice a success, he notes, and then approach your chief operating or financial officer to talk about other opportunities.
“You have to have,” he says, “a successful hospitalist program to use as a trump card.”
THE BUSINESS OF MEDICINE
For Bryce Gartland, MD, the decision to pursue a career in hospital medicine that’s not exclusively focused on clinical care mirrors an interest in the business of medicine that was established early on in his career. His first job out of residency was launching a boutique practice in Beverly Hills, where he refused to participate in any insurance plans, including Medicare.
But when Dr. Gartland, who is now 32, learned more about the burgeoning specialty of hospital medicine, he was hooked. “Here was a massive specialty in formation,” he explains. “It was too tough for me to stay out.”
He came to Emory in 2006 as a full-time hospitalist, but earlier this year took on a new role that mirrors Dr. Akopov’s: serving as medical director for utilization review, social services and care coordination at Emory University Hospital. With 50% of his time now carved out for those positions, he acts as the hospital’s liaison among physicians, nurses, social workers and hospital administrators, focusing on health care delivery efficiency.
One of the challenges of that role is navigating the nuances of health care financing. “Managed Medicare and Medicaid products are becoming an increasingly prevalent population base across the country,” Dr. Gartland points out. “You have to know the system to understand the nuances of transitioning a patient from an inpatient to an outpatient setting, while continuing to provide a high quality of care.”
He admits that most physicians don’t know about the types of barriers that insurers can raise, and says he must work against the stereotype of being “a bean counter.” Instead, Dr. Gartland says, he sees himself as part of a new wave of physician executives “whose ranks are now being joined by hospitalists “who are taking back control of medical care.
“Physicians started letting health care get out of their hands, probably in the late ’70s and early ’80s, and into the hands of the insurance industry and of federal and state regulators,” he says. “A lot of my inclination to move into the business of medicine was just pure frustration with trying to provide high quality care in the current system.”
While he thinks that it’s time for physician leaders to reclaim the business of medicine, he believes hospital medicine is a great staging specialty. “Hospitalists are the key, period.”
And while other physicians place a high value on keeping a foot in clinical practice, Dr. Gartland thinks his own career trajectory will lead to an even larger foothold in hospital administration. “Ideally,” he says, “I would love to end up running a large health care system.”
“PUT YOURSELF OUT THERE”
After practicing as a hospitalist for four years, Jason Stein, MD, decided to add a new career dimension by developing a skill set in quality improvement. Today, he directs most of the quality initiatives conducted by Emory’s hospital medicine section, and is co-chair of the department of medicine’s quality committee.
But getting there took a mix of good fortune and moxie. He initially pursued his interest in quality improvement by working as an online editor for quality resources for the Society of Hospital Medicine.
He then designed a one-year fellowship for himself in quality improvement. That entailed completing a 12-day advanced training program, spread out over four months, at Utah’s Intermountain Healthcare, as well as reading, writing and reviewing articles on quality for peer-reviewed journals.
He was fortunate to find a mentor: Mark Williams, MD, who at the time headed up Emory’s hospital medicine section. Dr. Stein also was able to work on projects with Gregory Maynard, MD, of University of California, San Diego, who Dr.
Stein calls “one of the nation’s leading QI teachers.” (For more on Dr. Maynard’s work in quality improvement, see “Theory and practice: a look at how to marry the two in quality improvement.”)
But Dr. Stein credits another factor in his move into leadership: confidence in his abilities, even when those were a work in progress. “Whether or not I actually had a mature skill set in quality improvement was less relevant than the fact that I was willing to move ahead as if I did,” he says. He could also carve out that niche, he says, because “there are not many physicians volunteering for this work. The QI skill set is still not one that most residencies have figured out how to teach.”
His program director volunteered him to lead a system-wide project to reduce preventable venous thromboembolism (VTE). Success with that project led to his writing one textbook chapter on VTE and another on quality improvement. He now co-chairs the quality committee for the department of medicine and has lined up two other quality initiatives: one on glycemic control, the other on inpatients with cystic fibrosis exacerbations. Just about 40% of his time now at the hospital is protected for quality improvement, which should scale back to about 30% next year.
Part of moving into quality initiative leadership is learning about data, he explains: where to find data, how to collect and track them, and use them in meaningful ways.
And the mind- and skill set for heading up quality initiatives, he adds, are very different from those related to providing clinical care.
“The vast majority of the work that a hospitalist does is one-on-one patient care,” he points out. While hospitalists are used to working in care teams, interacting with social workers, nurses and pharmacists, for instance, “that’s all patient-specific teamwork, not systems-specific,” he says.
Working on quality projects, however, is much more collaborative, as quality team members focus on the microsystems that make up performance in individual nursing units. “If we talk about hospital data, those are too big of a box,” Dr. Stein says. “You need to talk about specific nursing units.”
What’s been the most surprising finding from his move into quality improvement? How excited colleagues and hospital personnel feel about being involved.
“I’ll go to meet the people in the clinical data warehouse who never see patients, doctors or nurses,” he says. “They’ll stay after work to help us with this. People realize they can deliver better care in a collaborative way, and you see them go, ‘Aha! This is why I went into health care to begin with.’ ”
His advice for moving into a leadership is, first, find a mentor. Then, “I tell my slightly more junior peers that if there is something you’re interested in, put yourself out there,” says Dr. Stein, who is 36 and an assistant professor. “Volunteer to work on a project and get some on-the-job experience. You don’t have to be far along in the ranks.”
FOLLOW YOUR PASSION
For Melissa Mahoney, MD, making the transition from working as a full-time hospitalist to co-director of palliative care came easily, in part because of encouragement from her program’s leaders. After joining the Emory hospitalist practice in 2001, she realized she had an affinity for palliative care.
“As a hospitalist, you end up practicing palliative care because you’re working with patients who are chronically or terminally ill,” she points out. “I vividly remember feeling really satisfied if I was able to help walk a patient and family through a difficult time with their illness.”
She was primed to follow those feelings from a conversation she’d had with her program director when she first came on board, just having completed residency. “He told me that it was a good idea to develop some area of interest or expertise,” she recalls. “I initially thought to myself, ‘No, thank you.’ ”
However, when Dr. Mahoney realized her growing attraction to palliative work, she reminded her program director of that earlier conversation. That was right about the time that Emory University Hospital started to plan a palliative care service. By late 2005, she was named co-director of the palliative care consult service at Emory University Hospital and Emory Crawford Long Hospital.
While the transition was relatively easy, it was far from effortless. Dr. Mahoney notes that in preparation for her new duties, she started taking all her CME credits in palliative care. That included a 14-day program offered by the Harvard Medical School Center for Palliative Care. She also became boarded in hospice and palliative medicine.
Since she assumed the program’s co-directorship, she now devotes 100% of her clinical time to palliative care. About 25% of that time goes into program development “including marketing, education and working on team dynamics “and the rest is spent interacting directly with patients and family.
“It’s emotionally charged work,” says Dr. Mahoney, who is 35. “There’s a lot of debriefing and education.” She still struggles with having to teach colleagues “as well as nurses, hospital staff and families “that palliative care is not just about end of life, but includes patients with advanced and chronic illness in any illness stage.
Another big plus of doing palliative care: It allows a Monday-Friday schedule. “I have a family, and it was difficult for me to continue to work weekends and nights,” Dr. Mahoney says. “That was the major negative about hospital medicine, which I otherwise enjoyed.”
Phyllis Maguire is Executive Editor of Today’s Hospitalist.
Alan Wang, MD, jokes that his new position “as chief medical officer of Emory Johns Creek Hospital in Johns Creek, Ga., where he is also director of the hospitalist service “is all about meetings. While Dr. Wang spends about 40% of his day seeing patients, he devotes the rest of his time to his new administrative role.
But if much of his time is spent in meetings and conference calls, he says that the breadth of issues he now grapples with takes him far beyond his scope as a practicing hospitalist. That new range of responsibilities is the big payoff of his decision to branch out from hospital medicine.
“We discuss business and marketing strategies, how to bring more volume into the hospital,” he says. “We look at particular service lines that we want to develop, as well as quality initiatives that are part of strategic planning.”
In his new role, for instance, Dr. Wang says he now spends more time visiting physician offices in the community. “Even when I make my hospital rounds, I’m talking to different areas of nursing or different specialties,” he explains. “A typical hospitalist may not be down in the OR or the labor and delivery unit.”
Thorny issues that now land on his desk include physician credentialing and disciplinary concerns, as well as dealing with outliers in quality or length of stay. He also spends time navigating turf issues.
The new chest pain center accreditation process, for instance, entails negotiating among cardiology, emergency medicine and nursing. The endovascular lab has him maneuvering between cardiologists and radiologists.
And one challenge that’s closer to home, professionally, is getting the hospitalists and the anesthesiologists to see eye-to-eye on how to set up and staff a pre-op clinic.
“I have to step away from my role with the hospitalist service because it immediately introduces bias,” Dr. Wang points out. “I have to remind people that that’s not the hat that I have on right now.”
The most surprising aspect of moving into management, he says, is finding out that “things move at a much slower pace than when you’re doing purely clinical work.” In patient care, he points out, physicians have complete autonomy to determine treatment plans and write orders.
As part of administration, however, “I’m trying to influence people, not make hard and fast decisions,” says Dr. Wang. “That takes more time and sensitivity.”
Career revitalization: What’s in it for programs?
Most experts say that giving hospitalists opportunities for growth not only helps individual physicians further their careers, but increases their job satisfaction and career sustainability. But even as programs are being urged to provide physicians such opportunities, some are asking a simple question: What’s in it for them?
As veteran hospitalists move into specialized or executive positions, programs end up having to recruit more physicians in a notoriously difficult market. Some worry that as soon as their hospitalists have new skills, another program will lure them away.
Those are arguments that Michael Heisler, MD, interim director of the hospitalist program at Emory Healthcare in Atlanta, has heard from some in hospital administration.
His response, when administrators hesitate to put more money into physician development, is simple: “We want to be the kind of program that has faculty others are trying to recruit,” Dr. Heisler says. “For every person we might lose, we retain seven or eight who help build our program.”
As proof of how supporting career development can boost recruitment, Dr. Heisler points to the program’s recent and phenomenal growth spurt. Just one year ago, Emory’s hospital medicine program consisted of 52 hospitalists serving five hospitals.
“We’ve now grown to 82 hospitalists,” he notes. “As of October, we’ll be in seven hospitals, four that are community based and three that are linked to Emory University teaching sites.”
Behind that success has been an aggressive recruitment campaign that has focused on Emory’s reputation, its Atlanta location “and its commitment to career development.
“Investing in our faculty is just good business,” Dr. Heisler claims, “that adds strength and capacity to our program.” He notes that the chair of medicine at Emory has made “a substantial investment” in faculty development.
But Dr. Heisler insists that career development is not just for large research centers like Emory. “Two years ago, our program decided to make faculty development a budget priority,” he points out, saying that some of the revenue generated by the program is earmarked for career development. “Any program of whatever size, academic or non-academic, can make that same strategic decision.”
In fact, he adds, “career support may be even more vital for smaller programs to enhance recruitment and retention, ” Dr. Heisler says. “But if you depend on external funding, it will never happen. You have to make re-investment in your physicians a priority.”
Related link: Career options for physicians