Published in the November 2011 issue of Today’s Hospitalist
In 2006, Surendra Khera, MD, section chief of hospital medicine at St. Francis Hospital and Medical Center in Hartford, Conn., proposed starting a nonteaching hospitalist service. That service, he suggested, could accept private admissions, accommodate the fast-growing unassigned patient pool and continue to work with residents.
The idea was that both services “teaching and nonteaching “could work together and share some duties. The response? Dr. Khera says his proposal was met with cynicism.
“Most people thought it was a joke and that we’d last only three months,” he says. “There was this notion that academic guys can’t do private work “and that private doctors are rushed and too busy handling high volumes to stand there and teach.”
Today, the nonteaching service at St. Francis numbers 16, up from two in 2007, and there are only four hospitalists on the teaching side. Over the past four years, total RVUs have jumped nearly 10-fold. That makes the academic inpatient medical service “a single group under one leadership that encompasses both the teaching and nonteaching physicians ” the hospital’s single largest inpatient group.
When nonteaching hospitalist services made their debut in teaching hospitals, they were often viewed as a sensible solution for both growing patient volumes and coverage problems due to resident work-hour restrictions. Within some hospitals, however, nonteaching services were seen as a necessary evil that threatened to dismantle the academic mission.
Today, many teaching hospitals embrace the big-tent view that Dr. Khera espoused four years ago. But that doesn’t mean that running two services (or integrating two separate programs) is smooth sailing.
Hospitalists on both sides of the aisle have had to navigate political, logistical and financial issues. But the reality is that many teaching hospitals that started with two separate services have found that the best way to maintain equilibrium is through consolidation, not segregation.
Second-class citizens vs. “bow-tie service”
Four years into managing both services, Dr. Khera says that he hasn’t pushed the two-hat model very hard.
“Not all physicians can do both well or want to,” Dr. Khera says. “We actually lost two hospitalists within a year of hiring them because they just didn’t want any private work.”
While that speaks to the dissatisfaction hybrid programs can create for academic hospitalists, Dr. Khera says that an even bigger challenge is carving out satisfying roles for nonteaching clinicians. “There is a dichotomy that’s hard to live with in an academic institution,” he explains. “There’s an unspoken elitist system that says that somehow academics are higher on the intellectual scale.”
Dr. Khera has tackled that perception by putting private hospitalists on center-wide task forces “targeting glycemic control, readmissions and infection control ” where they’ll stand out. He also chose a private hospitalist as co-director of the group.
Dan Hunt, MD, chief of hospital medicine at Boston’s Massachusetts General Hospital, has had to do the opposite: figure out how to incorporate 11 clinician-educators into an existing 22-hospitalist nonteaching program that started in 2005.
“The perception has always been that the direct-care hospitalist service cares for less acute patients than the teaching service,” Dr. Hunt explains, adding that in some ways, that’s probably true. “The teaching team clearly does better managing complicated patients than a single hospitalist trying to manage 10 or 11 patients on his own.” That in turn has fostered the perception among housestaff that patients treated by the nonteaching service aren’t interesting.
“The danger is treating them as second-class hospitalists,” says Dr. Hunt, speaking of the nonteaching physicians. As for the clinician-educators, “there was the danger that the direct-care hospitalists would perceive those folks as the ‘bow-tie’ service. We’ve done a lot of work trying to bring the two groups together.”
Integrating two groups
Both programs, in fact, were merged into one group in 2010, and several trends accelerated the need to integrate. The department of medicine found it increasingly hard to hire nonhospitalists to fill teaching slots. Plus, new duty-hour restrictions that took effect this summer mean that the entire hospital medicine group has to step up its direct-care coverage.
As a result, hospitalists who a few years back might have provided only direct care may have more teaching responsibilities based on personal interest, while clinician-educators will assume larger administrative roles.
“The key is finding out what each academic doc wants to achieve,” Dr. Hunt notes, “and making sure that fits with the mission of the group.”
As another route to integration, all new clinical functions that the group takes on “such as a new ED medicine boarder service “are established only after input from both the teaching and nonteaching physicians and with staffing from each.
Same patient volumes, acuity
Dahlia Rizk, DO, hospitalist program director at Beth Israel Medical Center in Manhattan, has tackled many of the same issues.
For one, she steers clear of the term “nonteaching” altogether, instead referring to the service managed by hospitalist/physician assistant teams as “attending-directed.” She finds that “there’s a stigma” attached to the nonteaching label.
And while patients for the two services are treated in separate units to maintain goals set by the residency program, Dr. Rizk makes sure that patients are allocated between the services equitably.
“There is no difference in the kinds of patients or volume of patients who go to a given unit,” Dr. Rizk explains. With 26 hospitalists total and more than 10,000 annual admissions, there are “plenty of challenging cases” for both teams. Because the department of medicine runs such a high census, “eliminating barriers for admitting patients to certain floors is crucial for throughput.”
“I am responsible for all the patients who come to us from the entire community referral base,” Dr. Rizk maintains. “So to me, there should be no difference in the quality or standard of care delivered on any unit.”
To further break down barriers between the two services, Dr. Rizk “like Dr. Hunt at Massachusetts General “has moved to incrementally integrate them. Now, for example, some hospitalists work 80% on the teaching unit and 20% on the attending service.
“When we first opened the units, we hired specific hospitalists for the attending directed service,” she says. “Now, hospitalist schedules are integrated so physicians get exposure to both services.”
All hospitalists, Dr. Rizk adds, are expected to do some teaching and to participate in academic activities such as lectures and morning report. While the attending directed service was created to accommodate volume surges, “all hospitalists and physician assistants are part of one unified program.”
Nonteaching time for teachers
At HealthPartners Regions Hospital in Minneapolis, hospital medicine chief Jason Robertson, MD, merged the two services some years back and changed role ratios to ensure equal opportunity.
Any hospitalist in the 45-physician group, for instance, can request time on the teaching service and receive feedback from residents. “Those who do well will get more teaching time; those who don’t will get less,” Dr. Robertson explains. He admits that occasionally a hospitalist is removed from the teaching pool “for bad grades.”
At the same time, teaching hospitalists are required to spend time on the nonteaching service. “Even our best teachers spend time on nonteaching,” Dr. Robertson says.
“We want them to know what that’s all about.” In addition, all hospitalists who join the group right out of residency must spend 18 to 24 months on the nonteaching service before assuming any teaching duties. (See “Training the teachers“)
Staten Island University Hospital in New York has taken a similar approach to integrating its two service lines. Although the two are separate geographically “the north campus is a teaching center while the south one houses the nonteaching service “all 24 hospitalists are required to work in both settings to some extent.
Some hospitalists are assigned to the teaching center because they’re associate residency or site directors. “Others simply prefer the nonteaching environment and are fixed there,” says Aaron Gottesman, MD, Staten Island University’s director of hospitalist services. “But the overwhelming majority spend time in both centers.”
Hospital leadership decided to integrate the two programs a few years ago. “As with any transition, there was resistance,” Dr. Gottesman recalls. Some hospitalists claimed they weren’t hired to work at the nonteaching center “or that their expectations weren’t being met. When we’ve hired physicians in recent years, it’s been made clear that the expectation is to work in both environments.”
Moving toward consolidation
Boston hospitalist and academician Joseph Li, MD, longtime director of the hospital medicine program at Boston’s Beth Israel Deaconess Medical Center and president of the Society of Hospital Medicine, supports the single-team concept in his own program. He says he recommends it for institutions still working out the bugs with nonteaching services.
“It doesn’t work to form a separate group any more,” Dr. Li says. “A lot of the larger programs that set them up are moving toward consolidation. In our program, every email goes to all 50 hospitalists, and everyone works on the nonresident service. That’s the dynamic we have.”
According to Dr. Li, it is in programs’ best interest to change the job description for everyone. “In the long run, it’s better for patients, trainees and ourselves than setting up a comparator group.”
The nonteaching hospitalist service created this summer at the Phoenix VA Healthcare System incorporates a similar model. The 13 hospitalists rotate teaching and direct patient care responsibilities, and patients are integrated geographically regardless of who cares for them.
“One month, I may be teaching on the resident team and the next managing the nonteaching service,” explains Darren Deering, DO, hospital medicine section chief. “In that way, we still keep our hand in everything and understand the challenges of the whole system. And since we’re all in the same group, that helps us assign patients to the correct service.” Patients presumed to offer more teaching value go to the teaching side.
Nursing, cross-coverage issues
According to Dr. Deering, nurses at the Phoenix VA have happily traded some confusion about who to call for nonteaching patients “a “hot pager” has resolved initial problems “in exchange for more robust back-up.
“When we started this,” Dr. Deering says, “nursing was excited from day one because they now have dedicated attendings in the hospital throughout the day.”
But in hospitals that have historically had teaching services, nursing issues definitely crop up. Nurses used to directing residents and handing off tasks like running TB tests or putting in IVs may balk at doing those themselves when solo attendings are on the scene.
“That continues to be the hardest part for us,” reports William Ford, MD, chief of hospital medicine at Temple University Hospital in Philadelphia, who’s now three years into managing two separate services. “Nursing isn’t used to or equipped to having attendings without residents.”
The who-to-call problem is particularly challenging for programs trying to integrate services and allow physicians to move more fluidly between teaching and nonteaching roles. “It’s an issue when you have dichotomous services, especially when a new group is going from a teaching service or adding nonteaching services,” Dr. Robertson reports. “And the nighttime cross-coverage thing “you really have to clearly delineate things for the nurses.”
Then there’s the issue of compensation. Adjusting compensation to varying duties and patient loads can be tricky even in integrated programs. But it’s especially tough when nonteaching services coexist with traditional academic structures. That’s when battles regarding the “relative value” of different types of work erupt.
At Temple, compensation for both services was equivalent in 2007 and 2008. But Dr. Ford notes that the hospital raised compensation for the private-care hospitalists in 2009 to be competitive with community hospitals. While Temple established RVU, quality and citizenship incentives for both services, a difference of about 8% persists between the private-care hospitalists and their academic colleagues.
“The academic side continues to feel that is not fair because they have a different skill set,” says Dr. Ford. “They say teaching should be rewarded, but compensation surveys don’t reflect that. That small gap remains a challenge.”
Dr. Gottesman hears similar grumbling, but in reverse. His nonteaching hospitalists have big swings in daily census, which can range from six to 12 patients per hospitalist. Low census, which is caused by referral and admission patterns that hospitalists don’t control, wreaks havoc with the RVU incentive and bonus payouts, despite the fact that both groups have the same base pay.
The nonteaching hospitalists “think it’s unfair because there’s more physical work and paperwork for the same amount of incentive credit, but potentially lower pay when volumes are low,” says Dr. Gottesman. He has tried to even that score by scheduling nonteaching hospitalists for shorter shifts (eight hours) and more days per year (250). In addition, he’s developed a nonclinical RVU system that gives nonteaching hospitalists a chance to “catch up” by giving lectures or working clerkships.
Allocating teaching dollars
At HealthPartners Regions where the two services have been combined in one group for almost a dozen years, Dr. Robertson says the group has tracked volume and RVU patterns for several years. He has concluded that, at least for the two arms of his group, it all comes out in the wash.
The teaching service takes care of slightly fewer patients but bills more history and physicals. In the end, there’s “no real RVU difference,” he says. “The income differential between any two hospitalists depends more on years of experience than on whether they’re teaching or nonteaching.”
That doesn’t mean there aren’t potential inequalities. That’s why Dr. Robertson decided to distribute the Medicare teaching dollars to all hospitalists, not just the teachers, raising base salaries across the board.
“Because nonteaching doctors take a few more patients, that helps teaching doctors teach,” he says. “It’s a team effort, and we think of those teaching dollars as a team resource.”
Bonnie Darves is a freelance health care writer based in Seattle.
TEACHING HOSPITALS with both teaching and nonteaching services say that it’s crucial to make expectations about hybrid roles clear from the get-go when hiring new physicians.
That’s particularly true for physicians right out of residency who want to teach. Many teaching programs slot new physicians in direct-care positions ” almost exclusively “for one to three years.
Isn’t that a huge career dissatisfier for physicians who want to teach? “I worry about that,” says Dan Hunt, MD, chief of hospital medicine at Boston’s Massachusetts General Hospital, “but the jump from being a senior resident to being an attending is a large one. Jumping to attending teaching physician is even more challenging.”
Doctors just out of training need to figure out how to care for patients without the safety net of another attending, Dr. Hunt points out. According to Jason Robertson, MD, hospital medicine chief at HealthPartners Regions Hospital in Minneapolis, brand new doctors also need to get up to speed on coding, documentation requirements and quality metrics.
“It would be unfair to the new staff physicians and to students and residents to add to that burden by having them figure out how to teach as well,” Dr. Robertson notes. “Teaching is a learned skill, and teaching staff have to be comfortable with other parts of their job before taking that on.”
According to Dr. Hunt, junior faculty at his hospital are relieved to be given the time to gain clinical chops and confidence. Even when junior faculty become teaching attendings, he says, they are paired with more senior attendings to lead ward teams.
Dr. Robertson likewise says that once new recruits understand the rationale for his group’s policy “that all staff physicians have to work at least 18 months only on direct care before they start to teach ” they’re on board. “I can think of only one recruit,” says Dr. Robertson, “that we ever lost because he did not want to wait to teach.”
Assigning patients: who decides?
When managing both a teaching and nonteaching service, deciding which patients go to which service can cause conflicts, even when the services are housed separately.
Beth Israel Deaconess Medical Center in Boston has addressed the issue by giving both services high-acuity patients. “We do it in the ED, by assigning patients to the next available bed because acuity is the same on both services,” explains Joseph Li, MD, longtime director of the hospital medicine program. “That reduces bickering.”
The merged teaching and nonteaching services at HealthPartners Regions Hospital in Minneapolis likewise opts for an impartial party to allocate patients.
“We want to ensure there is no cherry-picking, so we have a nonphysician patient-flow coordinator determine which patients go to which team,” says hospital medicine chief Jason Robertson, MD. The program also uses an admitting roster to spread out resident-team admissions and ensure that neither team gets a bolus of admissions.
“You don’t want either side to feel it’s getting dumped on with all the uninteresting or difficult patients, or most of the late admissions,” Dr. Robertson notes. “Undesirable work needs to be shared.”