A Perfect Storm

What’s a hospitalist leader to do when everything seems to be conspiring against your efforts to ensure a stable, successful hospital medicine practice? I talked recently with a hospitalist leader who is dealing with just such a scenario right now.

When I visited his hospitalist practice at a small private health system of around 300 beds in a very attractive – but fairly rural – part of the country a couple of years ago, the hospitalist group of 21 docs and 5 NP/PAs was stable and high-functioning. They wanted help primarily with a few schedule and compensation issues, and they also wanted to be proactive in addressing some nascent angst related to a couple of recently-piloted work flow changes. Through our work together the group made several adjustments that were well received by the providers, and the last time I talked with the medical director things seemed to be going well.

Fast forward to this summer. The group’s workload has increased steadily year over year, and while hospital leaders have approved staffing additions, it seems like it’s always too little, too late. By the time those resources are hired and onboarded, volume has jumped up yet again. At the same time, the group is facing increasing pressure to reduce costs, become more involved in committee and quality improvement work, and expand its scope in the ICU. The hospitalists are being bombarded with low-value interruptions and ever-increasing demands for more documentation. They feel like they are losing influence over things like the EHR, protocol and order set development, and how multidisciplinary rounds are structured. The rapidity with which things are changing has everyone stressed out, and the hospitalists are much less satisfied with their work.

Over the last year the hospitalist group has seen high attrition. Some providers have left for the usual family or health reasons. A few cited the rural nature of the community (though it is only two or three hours’ drive from three major metropolitan areas). None of those leaving said they didn’t like the work or the organization. As a result, this group now needs to quickly hire at least eight new doctors, and in the meantime is filling as many as half of each day’s shifts with moonlighters and locums. Recruiting new docs is just plain hard, despite a very competitive compensation and benefits package. Sound familiar yet?

Here’s the interesting kicker. Some hospitalists employed by a nearby hospital recently left to form a local private group, working as freelance hospitalists at various hospitals in the region. So many of my friend’s open shifts are now being covered regularly by doctors who once were employed full time at the neighboring hospital but are now independent free agents. Other shifts are being filled by a former member of his own group who now works only as in independent contractor and has no interest in re-joining as an employed hospitalist.

This arrangement has many costs, not all of which are financial. Sure, paying independent contractors is a little more expensive than paying employed hospitalists to cover the same shifts. But there are additional costs related to the increased administrative burden (contracting, credentialing, schedule management, trouble-shooting with an outside organization), as well as the loss of continuity when moonlighters often only want to work a day or two at a time. There may also be costs related to performance on length of stay, patient satisfaction or other metrics, though it’s too soon to say.

By far the most important cost, however, is being borne by the hospitalist group itself – and this is the cost to the group’s social fabric. The moonlighters don’t feel at all connected to the life of the hospitalist group or the larger organization in which it practices, and even the remaining employed hospitalists are feeling less connected to each other. My friend is worried about losing the rest of his group to a burgeoning free-enterprise model that could potentially see all hospitalist shifts covered by a series of independent contractor free agents.

Within our specialty, we have been talking a lot about the importance of hospitalist engagement and alignment and about reducing the risk of burnout. I continue to believe that a healthy hospitalist group culture is the single most important contributor to a group’s success. My friend says that his hospital’s leaders are beginning to pay more deliberate attention to issues of hospitalist well-being and retention, including conducting surveys, providing more overt appreciation and working on improved medical staff relationships.

But what are we to do when what we think makes for a healthy, successful hospitalist practice doesn’t appear to be what the hospitalists themselves are looking for? How do we compete with the opportunity these freelancers have to be their own boss, to work where and when they want to, and to be paid handsomely for it? And how can we know whether this is an anomaly playing out in one small region of the country, or whether this is harbinger of future trends?

Sadly, I don’t have good answers for my friend’s dilemma. But it sure raises a lot of questions that deserve more careful consideration and discussion.

Post-script: Since I wrote my first draft of this post, my friend has had brief conversations with two of the hospitalists who left his group earlier in the year. Both indicated that their new positions aren’t what they had hoped for and that my friend’s group is definitely the better group to work with. But neither has plans to return, despite finding that the grass isn’t always greener somewhere else. Frustrating as that may be, my friend is taking the positive view and treating it as confirmation that his group actually has a pretty good thing going; they just need to do a better job of getting the word out to the right people. I hope he’s successful.

Leslie Flores

Leslie Flores is a founding partner at Nelson Flores Hospital Medicine Consultants, a consulting practice that has specialized in helping clients enhance the effectiveness and value of hospital medicine programs as well as those in other hospital-focused practice specialties since 2004. Ms. Flores began her career as a hospital executive, after receiving a BS degree in biological sciences at the University of California at Irvine and a Master’s in healthcare administration from the University of Minnesota. In addition to her leadership experience in hospital operations, business development, managed care and physician relations, she has provided consulting, training and leadership coaching services for hospitals, physician groups, and other healthcare organizations. Ms. Flores is an active speaker and writer on hospitalist practice management topics and serves on SHM’s Practice Analysis and Annual Meeting Committees. She serves as an informal advisor to SHM on practice management-related issues and helps to coordinate SHM’s bi-annual State of Hospital Medicine Survey.

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