Published in the April 2004 issue of Today’s Hospitalist
It’s the end of a long week, and you’re feeling it. You no longer look forward to the aspects of your job you normally enjoy, your temper is short, and you have less energy to pursue activities outside of work. You may begin to cut corners on the wards, focusing solely on the critical aspects of care.
In short, you are burned out.
As a busy hospitalist, you’ve probably felt at least some of the signs of burnout. Working exclusively in the hospital, after all, poses challenges that you don’t find in many other specialties. The everyday routine of dealing with life-and-death situations, in addition to navigating hospital bureaucracies, can take a toll on even the most experienced physician.
Because hospital medicine is a relatively new specialty, many programs are still trying to determine the best workload for their physicians. As they see the ill effects of overworking their physicians, however, some are coming up with strategies to help keep their hospitalists from burning out “and leaving their programs.
Their motives aren’t entirely altruistic. The directors of these programs realize that losing an experienced physician can wipe out their hard-won gains in length of stay and quality of care almost overnight. As a result, they are finding new ways to make sure that their physicians not only work hard, but find satisfaction from their careers.
Here’s a look at some of those strategies, from creating family-friendly schedules to encouraging physicians to take on nonclinical duties.
To help address one of the major causes of burnout “the encroachment of hospital medicine into doctors’ personal lives “hospitalist services are trying to give their physicians some flexibility and control over their schedules.
David Meltzer, MD, PhD, a hospitalist researcher and director of the hospitalist program at the University of Chicago, says conflicts between work and home life may be more common among hospitalists than other doctors for a simple reason: Hospitalists as a group are young and starting families just as they are entering the specialty.
When hospitalists have children, Dr. Meltzer explains, old work habits and schedules simply don’t work as well. “Just when hospitalists are getting good at being hospitalists,” he adds, they need to change how they work.
Groups like IPC-The Hospitalist Company, a national hospitalist company that employs about 300 doctors, have developed schedules to try to accommodate the family needs of their young physicians. IPC hospitalists who regularly need to come to work late because they drop their children off at day care, for example, can regularly arrive later than other doctors and stay later.
“They can’t roll in at 10 in the morning, but hospitalists can come in at 7:30 and finish earlier, and they can come in at 8:30 and stay a little bit later,” says Mary Jo Gorman, MD, IPC’s chief medical officer.
And if some team members prefer to work weekends, they can take on more than the average share of those shifts in exchange for having more time off during the week, which they may want to spend with their families, adds Dr. Gorman.
“We believe that it’s important for work-life balance, and for retention, that people have some flexibility with their work day,” she says.
At the Kaiser Permanente Santa Clara Medical Center in California, one of the hospitalists has chosen to work only nights to free up more time during the day with her children, according to Diane Craig, MD, assistant physician-in-chief. This arrangement allows the approximately 30 hospitalists at Santa Clara to work less than one night per month, says Dr. Craig.
And if Santa Clara hospitalists prefer to log fewer hours, they can work as little as 60 percent of a full-time schedule and still become a partner in their medical group.
At IPC, hospitalists can also soften or beef up their patient load “within some reasonable parameters,” Dr. Gorman says. All doctors are paid in part based on their productivity, so they can opt to see fewer patients in exchange for less income.
Sharing the load
While shift work is popular among hospitalist programs, some services are moving to more conventional work schedules. At Strong Memorial Hospital in Rochester, N.Y., for instance, doctors arrive at work between 7 and 8 in the morning and generally leave before 6.
This schedule allows them to be home with their families in the evening. Physicians typically work Monday through Friday and share night and weekend call with other physicians from the division of general medicine.
For Andrew Rudmann, MD, general medicine unit hospitalist service director and a practicing hospitalist at Strong, making sure he is efficient enough at work to get home at a reasonable time every night helps ward off burnout.
“I know if I stay here until 8 o’clock and go home, I’m going to basically eat, say good night to my kids and go to sleep,” he says. “For me, that’s not a sustainable solution.”
To make sure that patient care duties are being evenly distributed, Strong hospital has devised a distribution system where new patients are worth two points and follow-up patients are worth one. The doctor with the lowest total points receives the next patient. This way, Dr. Rudmann says, “We all know we’re getting crushed equally.”
And Santa Clara Medical Center tries to make sure that its hospitalists who do not oversee residents see no more than 12 patients per day. Kaiser administrators track census information so they can beef up staffing during traditionally busier times like Mondays and the winter months.
And if Santa Clara hospitalists are caught off-guard by a spike in the number of admissions, they can recruit outpatient internists who moonlight to pitch in, says Dr. Craig.
To help hospitalists avoid burnout, some services are trying to give their physicians breaks from clinic work to help them stay focused and satisfied. This type of strategy is popular at some academic programs, which can offer hospitalists opportunities in research and teaching.
The University of Chicago, for example, offers training programs that allow hospitalists to work as both clinicians and researchers. Dr. Meltzer explains that the university currently provides a general medicine fellowship program in which doctors focus on learning research skills and spend almost no time in the clinic. The university is also developing a more mixed training program that will allow doctors to spend more time working on the wards while they are engaged in educational activities.
The goal of the fellowship is to provide practicing hospitalists with the skills they need to alternate clinical duties with research. Dr. Meltzer predicts that this type of career path will ultimately be more sustainable than full-time work in the clinic.
In addition, all hospitalists working for the University of Chicago are part of the academic hospitalist program, which means they spend typically only between three and four months each year on the wards. They spend the rest of their time working on quality improvement projects in the hospital and related research. After a few years, they can begin research projects exploring hospital medicine.
Although this system means hospitalists spend less time on the wards caring for patients and generating billable charges, Dr. Meltzer says that hospital administrators realize they need to protect their experienced hospitalists from burnout.
“If you leave people on the wards for too long, they get sick of it and they quit,” he explains. “The goal is to attract good people, and keep them happy in the long run.”
Because Strong Memorial is also a teaching hospital, its hospitalists must participate in teaching activities. This includes lectures, resident poster days and reviewing evidence-based diagnoses with residents, interns and medical students.
“I think having time to do those special projects definitely does help prevent burnout,” says Valerie Lang, MD, a practicing hospitalist and assistant professor of medicine at Strong and the University of Rochester in New York.
In addition, Strong hospitalists also receive a “synergy week” every quarter. This period contains built-in time away from the wards that allows hospitalists to do projects, scholarly work and catch up on neglected paperwork.
“I look forward to those down weeks,” says Strong’s Dr. Rudmann. “I’m here in the hospital, but not with a huge roster of inpatients.”
In Atlanta, Mark Williams, MD, director of the hospital medicine unit at the Emory University School of Medicine, says that two of his faculty are getting formal training in palliative care and plan to become board-certified. He says that he has heard of other programs that encourage hospital doctors to study perioperative care.
And at Kaiser’s Santa Clara Medical Center, six hospitalists spend a few days every other week at a nursing home. Another hospitalist spends two days every other week at an outpatient clinic he created to serve the Korean community. “We try to provide some variation for people, because it’s really hard taking care of sick people every day,” says Kaiser’s Dr. Craig.
Jeffrey Hay, MD, medical director of inpatient services for HealthCare Partners, a private multispecialty group based in Los Angeles that employs about 75 full-time hospitalists, agrees that hospitalist services need to help their physicians grow professionally.
“It’s getting beyond the next pneumonia, the next stroke,” he says. “If that’s all there is, that’s a job most people can learn in one or two years. And most high-functioning people will not be satisfied with that.”
One way to reduce burnout is to give physicians more control over their work environment. With their labyrinth rules and bureaucracies, hospitals can be frustrating places to work.
Long-time hospitalists say that feeling helpless to do anything to address ongoing problems is a source of burnout for many doctors who like action and want to see their efforts towards improving the system pay off. “You need a certain amount of institutional patience to be a hospitalist,” explains Dr. Gorman from IPC.
As a result, some hospitalist programs are encouraging their physicians to take on leadership roles within the hospital or their local communities.
Cogent Healthcare Inc., which operates hospitalist management programs across the country, encourages its hospitalists to participate in medical societies. The goal is to give them the opportunity to attend educational presentations and discuss the issues facing their profession that include burnout.
Participating in medical societies “allows them to network and learn from their colleagues,” says Naveet Kathuria, MD, Cogent’s national medical director.
Cogent’s hospitalist team leaders are also going to participate in a leadership pre-course being held before the national meeting of the Society of Hospital Medicine. Dr. Kathuria explains that he and his colleagues hope team leaders will learn about their roles as a leader, an added responsibility that may help them stay satisfied with hospital medicine.
Asking team leaders to participate in the course also lets hospitalists know that Cogent appreciates their work and is willing to take an “active role” in helping them realize their professional goals, Dr. Kathuria adds.
Participating in hospital committees also allows hospitalists to step away from clinical work and feel like they are making headway in changing the hospital system, says Emory’s Dr. Williams, who is also immediate past president of the Society of Hospital Medicine.
Like doctors in other specialties, many hospitalists find it hard to put aside their worries about patient issues when they leave at the end of the day. “The same qualities that make us good physicians also make us stew over the uncertainties of what we’re dealing with in hospitals,” says Dr. Rudmann from Strong Memorial.
Because Kaiser’s Santa Clara Medical Center provides 24/7 coverage, at least one hospitalist or internist stays in the facility overnight. That helps other hospitalists go home at night with a clear conscience.
“When you leave at the end of the day, you know that your patient is going to be taken care of,” says Santa Clara’s Dr. Craig. “And you are not going to be paged overnight.”
The stress of clinical work can be especially draining for hospitalists, in part because the specialty’s newness can make them feel like their actions are being highly scrutinized by everyone from quality assurance nurses to managed care plans. As a result, many hospitalists live with a constant fear of making a mistake, says Emory’s Dr. Williams.
“I think hospitalists feel much more under a microscope than physicians in private offices,” says Steve Nahm, vice president of physician services at The Camden Group, a consulting firm that works with hospitalist services.
To cope with the anxiety and stress of being a hospitalist, some services are encouraging their physicians to develop a support network of other hospitalists. Cogent’s Dr. Kathuria says that practicing hospitalists act as mentors to newer hires, visiting new programs and advising physicians about what they can do to change their environments.
He explains that the company’s lead physicians also participate in a conference call each month in which they talk to and learn from one another. The topic of the next conference call is coding and billing, and Cogent has asked a behavioral scientist to lead a later conference call on identifying the signs of burnout.
Networking is a key to helping strengthen the specialty, says Strong’s Dr. Lang, who heads her local chapter of the Society of Hospital Medicine. Meetings are held every three months and start with 30 to 45 minutes of socializing time.
That gives physicians a forum to discuss their problems and learn from what their colleagues are doing. “We’re interested in how people are running their programs. So if we hear something that sounds good, we can try to incorporate it into our program,” says Dr. Rudmann.
These solutions all demand time and resources, but hospitalist leaders worry that if they do nothing, they’ll pay an even bigger price.
Dr. Lang, for example, says one of her biggest concerns about burnout is that young doctors considering the profession might see their exhausted colleagues and opt for another specialty. That, she notes, would bring the current shortage of hospitalists to a critical level.
“One of the biggest dangers of hospitalists burning out is that there won’t be hospitalists,” she says.
Alison McCook is a freelance writer specializing in health care. She is based in Brooklyn, N.Y.
Program directors talk about the effect of losing a hospitalist
Hospitalist programs have a good reason to be concerned about keeping their physicians from burning out. Data show that losing an experienced hospitalist can hurt their services.
A paper in the Dec. 3, 2002, Annals of Internal Medicine, for example, found that hospitalists can help control costs in their second year of experience, but not their first. As a result, hospitalists worry about the impact of replacing an experienced physician with a less experienced clinician.
Jeffrey Hay, MD, medical director of inpatient services for HealthCare Partners, a private multispecialty group based in Los Angeles that employs about 75 full-time hospitalists, has seen data supporting that idea. Based on a review of internal cost data, he says, an inexperienced hospitalist costs payers an additional $1 million per year when compared to an experienced hospitalist. The patients of inexperienced doctors also typically spend one day more in the hospital than those overseen by more seasoned hospitalists, adds Dr. Hay.
David Meltzer, MD, PhD, a hospitalist researcher, director of the hospitalist program at the University of Chicago and lead author of the Annals paper, says that one likely reason experienced hospitalists save money is that they are more knowledgeable about the diseases patients typically develop in their facility. “Physicians keep learning after they leave medical school,” Dr. Meltzer says.
Diane Craig, MD, assistant physician-in-chief at Kaiser Permanente’s Santa Clara Medical Center in California, says that, in her experience, hospitalists need a couple of years on the job to develop the skills needed to make efficient decisions. And as hospitalists learn, she adds, they become more confident in front of patients, which also helps with their care.
Steve Nahm from the Camden Group, a consulting firm that works with hospitalist programs, explains that the added cost of an inexperienced hospitalist also likely stems from a lack of familiarity with the systems and procedures of a particular setting. New doctors, for example, may not be as familiar with the availability of outpatient resources, with procedures for moving patients to appropriate levels of care–such as ICU vs. step-down vs. acute care beds. As a result, he explains, they may use more ancillary and physician consulting services.
“There’s nothing that hurts a hospitalist group more than losing highly trained, skilled people,” says Dr. Hay.