An Open Letter to Hospital Executives about Their Hospitalist Programs

Dear Hospital Executive,

If you are like many of the hospital leaders with whom I regularly talk, you’re probably concerned that your hospitalist program isn’t delivering the value you need in this metrics-driven and cost-constrained environment. You may see your hospitalists as disengaged free agents who either don’t know, or care too little, about contributing to the success of your organization beyond seeing the patients on their list. They may complain repeatedly about being overworked, underappreciated, or dumped on, and you worry they will leave soon for greener pastures.

As a former hospital executive myself, I sympathize. You have a lot of important challenges to manage, and the hospitalists are highly educated, well-paid professionals, for Pete’s sake. Whether your hospitalists are employed by your organization, a local private group, or a management company, you are paying a lot for a vital service that ought to run more or less on auto-pilot. Unfortunately, it often doesn’t, and for good reason.

Being a hospitalist is really hard work. It’s mentally and emotionally draining: hospitalists are de facto acute care geriatricians, caring mostly for elderly patients who suffer from multiple complex illnesses and are frail, confused, and often near the end of their lives. Many have confounding social issues or difficult family members. Further, care delivery systems on inpatient units are generally designed to support nursing workflow, often at the expense of physician workflow. Hospitalists spend a disproportionate amount of time on documentation and other unsatisfying tasks well below their pay grade. The need to discharge early and admit late has led to the widespread adoption of 12-hour shifts, which are grueling even when you only work every other week. And hospitalists are often at the bottom of the medical staff pecking order when it comes to prestige and influence.

Add in the fact that a high proportion of hospitalists are early in their careers – many still navigating the transition from residency to practice – and haven’t yet honed the work habits and political skills of more experienced colleagues. And keep in mind that many doctors are drawn to hospital medicine in part because they see it as a low-commitment, mobile specialty, and that the supply of hospitalists nationally still falls well short of demand. With all these factors in play, it should be no surprise that your hospitalists aren’t as engaged as you might like and are experiencing high rates of dissatisfaction, burnout, and turnover.

Maslow’s hierarchy of needs suggests that your hospitalists are unlikely to self-actualize by engaging with broader organizational goals if their basic needs for well-designed work, belonging, and esteem haven’t been met. With that in mind, it’s in your interest to invest some time and energy in proactively supporting your hospitalists’ wellbeing. While many determinants of hospitalist wellbeing are beyond your direct control, here are some things every hospital leader can and should do:

  • Provide your hospitalist group with reasonable decision-making autonomy. Having reasonable control over one’s own work life is a major contributor to job satisfaction in any field. Too often, hospitalists find that decisions about everything from their schedule to daily work flow and operating procedures are dictated by others outside their group. Consider delegating many operational decisions to the group, with the proviso that they must perform well and keep customers happy. You’ll reap benefits from a heightened sense of collective “ownership” among the hospitalists.
  • Invest in building relationships. I know you can’t have a personal relationship with every employee and medical staff member. But your hospitalists have a unique and far-reaching impact (for good or ill) on how your hospital functions. It’s worth getting to know them and making sure they feel like they know you and can approach you. I know some hospital executives who periodically invite their hospitalists over to their house for dinner or take them out to a nice restaurant, just for an opportunity to interact socially.
  • Recognize and appreciate hospitalists’ contributions. One of the most commonly-voiced frustrations from hospitalists is that they only hear from hospital leaders when they’ve done something wrong, or when leaders want more from them. They need to know that you value their efforts and will publicly acknowledge the difficult but vital work they do.
  • Conduct an annual survey of hospitalist job satisfaction and wellbeing. This could be part of a broader medical staff satisfaction survey, or specifically targeted to the hospitalists (for example, SHM’s Engagement Benchmarking Service). There is value in periodically taking the hospitalists’ temperature in a structured, confidential way; but it should go without saying that if you’re going to do this, be prepared to act on the results.
  • Ensure hospitalists have real influence in redesigning patient care unit workflow. Clinical workflows need to support hospitalist efficiency as well as nursing and ancillary staff activities. Hospitalists spend too much time in inefficient and “not-top-of-license” work; some is inevitable, but much can be mitigated if hospitalists have a seat at the table.
  • Go to the mat for your hospitalists with the medical staff. Nobody likes modifications to their scope of work, particularly when changes are driven by others. Sometimes what is being asked of the hospitalists is reasonable, and you can serve them best by coaching them on how to manage uncomfortable change. But sometimes requests aren’t reasonable or are being forced on them in a way that is disrespectful and demeaning. Demonstrate that you are willing to support your hospitalists when they are being taken advantage of, and engage medical staff leaders to ensure the hospitalists are treated with professional respect and collegiality by other medical staff members.
  • Provide opportunities for job growth and enrichment. Be on the lookout for ways to promote both short-term hospitalist engagement and long-term career sustainability. One of the best is to offer hospitalists opportunities to learn and do more than simply coming in to work each day and picking up a list of patients to see. Sometimes opportunities exist within the hospitalist group for building leadership skills or specialized expertise, but hospitalists are increasingly being tapped for broader roles like CMO, UM physician advisor, Health IT advisor, and QI specialist. Others are seeking variety in their clinical work by branching out into urgent care, wound care, or post-acute care. Ensure that systems are in place to identify hospitalists’ interests and talents, and match them with opportunities to do something other than routine inpatient care. Then support them by funding necessary training and non-hospitalist time to pursue these activities.

Thanks for being willing to consider a perspective from the field. I wish you well in your efforts to foster a stable, high-performing hospitalist program.

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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