Published in the April 2018 issue of Today’s Hospitalist
IMAGINE THIS SCENARIO: It’s 7 a.m., and three hospitalists come on duty. They are joined at 9 a.m. by a nurse practitioner assigned to take histories and physicals in the behavioral health unit and admissions from the ED. The physicians will be responsible for all inpatient follow-up and discharges, and because the census now stands at 57, each hospitalist has 19 inpatients.
The morning goes well until 10:45 a.m., when three patients in the ED need to be admitted. The NP, who is doing her fifth time-sensitive psychiatric history and physical, can handle only one. Four more patients present at 1 p.m., and admissions then continue coming in waves.
We need a flexible system to cover last-minute surges.
The day team ends up with 17 admissions, with several complex patients who require more than an hour each to work up. While the nocturnist starts helping with admissions at 7 p.m., one day-shift doctor doesn’t leave until 10:30 p.m.
Possible solutions and drawbacks
This is not a hypothetical example, but a day shift I experienced. As a locum who works in several different hospitals, I see unexpected surges in every one. This is also the kind of recurring problem that fuels another crisis: burnout.
Possible solutions that are always being tried include bringing in locums, hiring a “swing” admitter on days when a surge is expected, hiring more NPs/PAs, decreasing ED admissions by diverting ambulances, and paying off-duty full-time hospitalists to be on call.
Although such remedies may look good on paper, most have drawbacks in practice. Locums are a great asset for temporary coverage of a full-time position, such as for maternity leave. But locum agencies require a financial commitment at least 30 days in advance and are not known for being flexible.
Hiring a swing physician on shift-changeover days may make sense to let doctors coming on duty familiarize themselves with their new cases. But surge is unpredictable, so swing shifts and census spikes may be out of sync. And while hiring more advanced practice providers may help, but I need to carefully review each NP’s work-up and perform my own physical exam on ED admissions. That takes time and, when surges occur, we have to admit patients an NP can’t handle. In such situations, another autonomous physician would be more helpful.
Hospitals don’t want to divert patients (and revenue) to other facilities. I recall one hospitalist program director who refused ED admissions due to an extremely high inpatient census. ED staff responded by caring for potential admissions in the observation holding area until the surge resolved. That really strained relations among the ED, hospitalists and administration.
Another solution—having full-time, off-shift hospitalists on call—works well if a program is large enough to make such call infrequent. But even then, physicians may resent needing to be available during their days off and not being able to travel.
Making part-time options available
Another possible fix, especially for smaller programs, could address both surge and physician burnout. The Medscape Lifestyle Report 2017 listed burnout rates of 50% or greater in the following six specialties, in this order: emergency medicine, obstetrics and gynecology, family practice, internal medicine, infectious diseases, and rheumatology.
These physicians are at greater risk of leaving practice early due to pressure and dissatisfaction. Experts (as well as the American Medical Association) note that, for many doctors burning out, part-time opportunities may alleviate the stress of full-time practice and enable them to continue working.
Crisis is opportunity. For doctors in four of these six specialties, the solution might very well be a part-time, post-practice hospitalist career. (Hospitals likewise have ob-gyn hospitalists, or laborists.) Family practitioners, internists, infectious diseases specialists and rheumatologists all had years of inpatient training during residency. And all four still need to remain current in general medicine because the illnesses they treat span all organ systems.
Most of the conditions we see in hospitalized patients—pneumonia, sepsis, acute coronary syndrome, COPD—are still very similar to what we experienced as residents. While treatments have changed, doctors can learn new modalities in a refresher course.
This is where what I’m calling “Surgeguards,” or part-time hospitalists, come in. Physicians already living in the community who plan to retire from full-time practice—for whatever reason, including burnout—may be recruited. Once trained and credentialed, they could become an on-call reserve workforce in times of surging census.
Like in systems where full-time hospitalists take call on some days off, these doctors would receive an on-call stipend and would have to be available on an hour’s notice. Once activated, they would receive an hourly rate for time worked and leave when patient volume is again under control.
It’s likely that these experienced community physicians are already familiar with the hospital and medical staff. Many may even have hospital credentials.
Obviously, the success of such a program would depend on how up to speed these specialists are in terms of hospital medicine. One program I work with already uses specialists (a nephrologist, an oncologist and a family physician) to augment staffing, and they do a fine job clinically.
However, that program schedules them to work Mondays, Tuesdays (the shift changeover day) and Fridays, which all typically have a higher census. Further, the doctors are scheduled a month in advance and are guaranteed a 12-hour shift. Because this results in an “overstaffed” program some days, it is not the most cost-effective solution.
Instead, I envision a more flexible system to cover last-minute surges. As an older physician myself, I’ve been approached by other doctors my age who are interested in hospital medicine post-practice. Surgeguards could meet a hospital’s high-census needs with available, affordable physicians. And all parties might very well benefit.
Stephen L. Green, MD, is a locum hospitalist who maintains a telemedicine infectious disease consulting practice. Dr. Green, who previously practiced for more than 30 years as a primary care internist and infectious diseases specialist, can be reached at email@example.com.