Fifteen patients a day?

John Nelson writes…

At Hospital Medicine 2009, SHM’s sold out national conference in May, I moderated a panel discussion titled “Who says 15 patients a day is the right number?”  It was packed – so packed that it was one of a handful of sessions offered twice.

I don’t think a similar session at other specialty society meetings would be as popular.    Can you imagine a session on “How many cholecystectomies should you do annually” being so popular at the Amer. College of Surgeons?  Sure, nearly every medical society devotes attention to workload and its effect on patient safety, maintaining skills, career sustainability and economic health.  But I don’t think these are usually as popular as this session was at the SHM meeting.

Assuming you agree with my premise (based on my  experience and not hard facts), a question presents itself: why are hospitalists more interested in discussions about workload than other specialties?  Maybe it was the terrific panelists at this particular session?  They were really good, but I don’t think that was the biggest factor.

Clearly the fact that the meeting was sold out was a big part of the popularity of the session.  Everyone had to go somewhere.

But I’m guessing the biggest factor is that most hospitalist are paid such that a large (usually the largest by a long shot) portion of their compensation is fixed.  That means the party providing the compensation, usually a hospital, ends up caring a lot about how hard hospitalists work, e.g., how many patients they see.  So I suspect many in attendance were there to collect ammunition for their future conversations about how hard they should work for their pay.

Most other specialties still earn the majority of their income via fee for service payments, so they are able to decide for themselves how hard they should work and don’t need to convince others, like hospital executives, what is the right workload for them.

Mark Williams and Kevin O’Leary at Northwestern presented some really interesting time-motion studies of their hospitalists that you might want to review.  Go here, enter your SHM user name and password, then click on “Saturday, May 16″ at the top of the page, and search on “Who says 15 patients…”  Or try this link which might take you there directly.

2 Comments

  1. Erik DeLue on June 9, 2009 at 7:45 am

    John,

    I attended that session and it was fantastic. I also just read your most recent article in the Hospitalist about the lack of realization of economies of scale for larger groups, especially with 7 on off programs – no argument here. My question, admitted unrelated to this post, is given shift work is expensive (and unavoidable to my mind if you do not have nocturnists – believe me we have tried), have you seen any large shift work programs fuse a traditional hospitalist rounder schedule by still having all the docs work night shifts as well. Again, I know your own personal model in which you have a more traditional section for the day people, but you can do this because you have nocturnist to fullfill your need for 24/7 in house coverage. I was able to pull this off when I had a small group, with each doctor spending every 5th month working M-F and then the other months in the week on/off rotation (with the help of a few moonlighters). The bigger we get the harder pulling something like this off, which would obvious save a ton of money, seems so be. So as we grow, like all 7 on/off groups, I am stuck adding 2 FTEs for every expansion in volume that otherwise would require closer to 1 FTE. If you have come across a non-nocturnist large group hybrid done somewhere successfully I would love to know their staffing model. Part three of your large group column series?

    Regards,

    Erik DeLue

  2. Lenny Husen MD on June 11, 2009 at 12:35 am

    This one panel discussion was worth the fee for the entire conference. John Nelson is my personal hero for saying (tongue in cheek, perhaps) that the right number is “14”. I attended this talk not for “ammunition” as much as to reassure myself, as an early career hospitalist, that I am not hopelessly inefficient or behind the curve. The number does depend on multiple factors, such as level of experience, style, efficiency of data systems, time spent in direct patient or family contact, detail of documentation, etc. I do believe that Compassion takes Time, and that patient care must suffer and burnout must increase when we see too many patients, whatever number “too many” is for each one of us. A heartfelt thanks to the panel for a morale building event.

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