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Working with short-timers

June 2008

Published in the June 2008 issue of Today’s Hospitalist

Craig Tsuboi, MD, still gets a little hot under the collar when he thinks back to the young doctor his group hired a few years ago. The physician indicated that he was looking forward to a long relationship with the Sutter Health hospitalist program. But less than a year later, he announced that he was headed off to a cardiology fellowship in another state “a development that clearly had been in the works for a while.

“I can understand some doctors using hospitalist work at a transition point when they’re not sure what they want to do,” says Dr. Tsuboi, director of the hospitalist program at Sutter Roseville Medical Center in Roseville, Calif. But when physicians “aren’t honest and leave early,” he adds, “that creates bad feeling among the team.”

While the incident left Dr. Tsuboi with a jaded view of “short-timers” and made him ask much more pointed questions about candidates’ future plans “he still hires hospitalists who will commit to only one- or two-year stints. In fact, two doctors are about to leave his 12-member group after only a year.

“Without these physicians,” he explains, “I’d be in trouble. But it’s not ideal, even though the two physicians who are leaving us for fellowships worked out great.”

Like a growing number of program directors around the country, Dr. Tsuboi often has little choice but to hire short-timers. But like many colleagues, he wonders if by hiring short-timers, he’s setting himself “and the specialty” up for problems down the road.

Logistically, for instance, short-timers raise concerns about the expense of recruiting and training physicians who stay only a year or two. And there are also concerns about how hiring physicians who plan to use hospital medicine as only a pit stop will affect the morale of hospitalists who commit to the specialty long term.

Half-full or half-empty staffing?
One challenge of working with short-timers is that even when they’re up-front about their intentions, things don’t always work out as planned. Eric Rice, MD, lead hospitalist at Methodist Physicians Clinic in Omaha, Neb., for example, is wrestling with a major revolving door at the moment. That’s because two fellowship-bound physicians who planned to stay two years got “fill-in” slots a year early.

Because he was already expecting two other short-timers to leave this year, “We’re losing four of our 12 FTEs to fellowships this summer,” Dr. Rice explains. “Historically, it’s been only two each year.”

Though he’s not pleased, Dr. Rice is realistic. “With the hospitalist shortage being what it is,” he explains, “you have to provide all options, from part-time to three quarters time. I see physicians who are going onto fellowships as just one group of physicians I need to reach to be successful in staffing a program.”

Dr. Rice’s pragmatism is echoed by other industry leaders. “It’s the difference between looking at the glass as half-empty or half-full,” says Stacy Goldsholl, MD, president of TeamHealth Hospital Medicine in Knoxville, Tenn. “With the intense demand and workforce shortage, we’re fortunate to be an industry that actually can take folks who are interested in coming for only a year or two.”

Dr. Goldsholl adds that most of the medical directors she meets these days are “glad to have a physician in there, even for a year, because it’s still a slot that’s filled.”

Maintaining team chemistry
Erik DeLue, MD, medical director of the hospitalist program at Virtua Memorial Hospital in Mt. Holly, N.J., is of two minds about the transient-doctor issue. On the one hand, he fears that it makes hospital medicine look like the “minor leagues” instead of the respectable career path he thinks he’s chosen.

And for small programs, dealing with a succession of short-timers can drain resources and morale among “committed” hospitalists.

“For one thing,” Dr. DeLue explains, “it really does take at least six months to get someone up to speed. And on the backside of that year, depending on the person, a certain degree of ‘senioritis’ can set in. Their exuberance starts waning.”

There is also a large financial consideration on the back end, Dr. DeLue contends, when programs have to absorb malpractice tail coverage. “When a hospital organization is self-insured,” he says, “hiring someone for the short term isn’t as painful as it is for the small groups who potentially can’t afford to bring in someone for a year and then cover their tail insurance.”

But Dr. DeLue’s biggest concern is that a revolving door creates an image issue for the specialty. “It makes more prevalent the idea that ‘good hospitalists’ don’t stick around,” he says. “The other thing is that it is hard to maintain the chemistry you build among the team if you have people leaving every year.”

John Nelson, MD, a hospitalist in Bellevue, Wash., acknowledges that turnover is a problem. But he thinks the fact that some physicians opt for hospital medicine as an interim undertaking presents “only a little bit of an image issue.” He reminds his colleagues that a certain degree of transience goes along with being in a field that has relatively low barriers to entry and exit.

“If you join a primary care practice, it’s like a marriage,” explains Dr. Nelson, who co-founded the Society of Hospital Medicine. “Some hospitalists see themselves as dating their practice rather than being married to it. That can be a negative for our field in that some people are always thinking about other options rather than committing themselves fully to the program.”

Referral and productivity problems
There are also more subtle problems that can arise when programs bring in non-career hospitalists. Dr. Rice, for example, says that physicians in both his multispecialty group and his community aren’t too pleased when short-term hospitalists move through.

“The image issue, if it exists,” he explains, “is mostly with our referring providers. A couple have told us that they’d prefer only long-term people in the program.” Referring physicians have patience with “newbie gaffs” like incorrect referrals, says Dr. Rice “as long as these new physicians will be around long enough to learn provider preferences and become engaged in the group.

And while Dr. Goldsholl has heard of instances where short-timers create morale issues, she wonders how these physicians affect hospitalist groups’ bottom line.

“First-year hospitalists are not going to be as productive as seasoned ones,” she says. (See “Experience counts: the productivity difference,” left.) But because most programs are scrambling to meet their workload, she explains, most tend to accept new physicians’ decreased productivity.

Besides, Dr. Goldsholl adds, what’s even worse for morale is asking existing hospitalists to work too many shifts because the program is understaffed. “A physician coming in for one year will not be as productive or efficient as a three-year hospitalist,” she says, “but it’s certainly better than the alternative.”

Different duties and pay?
How should hospitalist programs approach short-timers? Most industry veterans suggest pushing for a two-year commitment to help reduce disruption and find some return on the training investment. But they agree that the market and the program’s location are deciding factors in whether programs can afford to turn one-year hospitalists away.

For programs that have accepted the need to hire one- or two-year hospitalists, the question then becomes: Should they structure short-timers’ duties, schedules or compensation differently than they do for career hospitalists?

At Sutter Roseville Medical Center, for example, Dr. Tsuboi relegates short-term hospitalists to rounding duties only, having them work alongside and assist the permanent team. He avoids giving those physicians ER duties or night shifts.

“We try to keep it simple,” he says. “We have a couple of career hospitalists who actually like the night shifts, and they get paid a differential for doing them.”

And at the University of Wisconsin, the hospitalist program puts most of its short-timers in nocturnist positions, explains Julia Wright, MD, director of the University of Wisconsin-Madison hospitalist program. “This works well for both the program and the physicians,” she says, because many fellowship-bound doctors “like having some daytime hours to pursue their research interests.”

Dr. Nelson doesn’t believe in modifying patient care duties for transient physicians, which is why the hospitalists at his program all “do the same work.” But he supports the notion that hospitalists who commit to longer service should possibly “have their salary or benefits structured a bit differently” to recognize their commitment to the program.

Compensation for commitment
That’s the approach being considered at Methodist Physicians Clinic in Omaha. Dr. Rice notes that short-term hospitalists do the same work as long-timers, including sharing night shifts, and are paid roughly the same basic salary. But the physicians who stick around should have access to multiyear bonus structures.

“This is something we’ve talked about a lot as a group, trying to figure out what’s fair,” he says. “People coming in want equal pay for equal work these days. But there’s no question that our hospitalists who’ve been here for four years bring more to the table than somebody who’s been here only a year.”

The “long-timer” bonus structure is still evolving, but Dr. Rice notes that it will theoretically involve a modest bonus for a two-year commitment, with more substantial money for committing to three or four years.

And at Dr. DeLue’s program at Virtua Health, career hospitalists and short-timers do the same work. But those who plan to stay on are compensated slightly better, for committee work, for example. Long-timers also receive more vacation time.

“The expectation is that if you’re just coming here for a year or two,” Dr. DeLue says, “you won’t be taking as much time off as someone who is doing this for a career.”

Attracting potential “converts”
While short-timers may be a resource that some hospitalist programs use grudgingly, industry veterans point out that if you can keep these physicians for two years, there’s a possibility that they may stay in the specialty.

Anecdotally at least, physicians who stick with a hospitalist program for two years have a 50% chance of remaining in the field. Some physicians find that they appreciate the lifestyle offered by hospital medicine, while others realize their earning potential is much higher than if they worked in outpatient medicine.

Dr. Nelson, for example, was on track to become an endocrinologist when he got hooked by hospital medicine two years into his first job. Dr. DeLue also thought that he was “just passing through” when he became a convert. “I really liked the job, and I think I made the right decision,” he says. “If you can keep people for two years, I think there’s more potential that they’ll become permanent.”

That’s the view Dr. Goldsholl shares with TeamHealth program directors. “Ultimately, the hope is that they’ll find a niche in hospital medicine,” she says. “They might see that hospital medicine will give them lifestyle advantages that perhaps are better than those in their alternative subspecialty.”

Bonnie Darves is a freelance health care writer based in Lake Oswego, Ore.

Should you turn short-timing into a recruitment tool?

JOHN NELSON, MD, A HOSPITALIST in Bellevue, Wash., who co-founded the Society of Hospital Medicine, suggests making lemonade out of the dilemma of what he calls “non-career hospitalists.” Programs seriously strapped for help, he explains, may want to sell themselves to physicians who are interested in a short stint as a hospitalist. Explain why your program is a nice place to learn and how it can bolster their resume for whatever they have planned for the future “and try to establish a two-year commitment as a reasonable expectation.

“Programs might specifically recruit for those two-year positions,” says Dr. Nelson, who directs the hospitalist program at Overlake Hospital Medical Center and consults to hospitalist programs nationwide. “In fact, I think programs should run ads that scream across the top: ‘If you have only two years to give us, this is the place for you, because no matter what you do after this, we’ve created an experience that’s almost like a fellowship “but pays much better.’ ”

And hospitals that don’t have residency programs as a pipeline for new recruits may need to be the most aggressive, Dr. Nelson points out. To lure new doctors, they might have to offer additional enticements such as housing help, CME stipends or even a practice management course in year two.