Equal Time for Hospital Execs

Last month, I wrote a letter to hospital executives, urging them to deliberately invest their own personal time and effort in fostering hospitalist wellbeing. I suggested several actions that leaders can take to enhance hospitalist job satisfaction and reduce the risk of burnout and turnover. Following publication of that post, I heard from several hospital executives and was pleasantly surprised that they all responded positively to my message. Several execs told me that they gained valuable new insights about their hospitalists’ challenges and needs or that they planned to take action on one or more of my suggestions that had never occurred to them before.  Especially useful to them was the idea of a hospitalist “hierarchy of needs,” in which basics such as well-designed work (including adequate staffing), belonging, and esteem must be addressed before expecting hospitalists to undertake “self-actualizing” work, such as engagement in organizational performance improvement initiatives.

Their feedback reinforced my belief that most hospital leaders actually do care a lot about promoting healthy, stable, and sustainable hospitalist programs. However, the hospital leaders I talked with also had some messages for their hospitalist colleagues, and I think it’s important to share them in the spirit of fostering a healthy exchange of perspectives. Your hospital’s leaders would be delighted and encouraged if you would engage them in dialogue about these issues.

Help us help you. Several hospital leaders told me that their hospitalists grumble about being treated by the medical staff (and even nurses) like second class citizens or glorified residents. But the same hospitalists routinely show up for work dressed in scrubs and tennis shoes rather than professional attire. They rarely come in early when it’s busy or invest more time than is absolutely needed to see the patients on their list, making it easy for others to dismiss them as shift-workers. They are unwilling to come in on their own time to attend a medical staff meeting, something other doctors do as a matter of course. And instead of interacting as social peers with other physicians when opportunity arises – such as in the cafeteria or doctors’ lounge – the hospitalists just grab food to go and head back to eat together in their work room.

The execs said they want to help enhance the stature of their hospitalists within the medical staff, but the hospitalists are shooting themselves in the foot by adopting resident-like behavior and isolating themselves from the broader medical community. Here’s a typical comment: “They also need to be willing to participate in hospital and system committees. Although this may require them to interrupt their work flow and stay late on some days they are working or come in on days off, they will never garner the respect of their colleagues if they are unwilling to do so.”

Come with solutions, not just complaints. Another common theme was that hospitalists are often quick to point out what is wrong with their work life and look to others to solve their problems. I sympathize with the feelings of powerlessness and victimhood that occur when others routinely make many decisions about how the hospitalists should do their job. But the hospital leaders told me they would be more prepared to grant their hospitalists greater decision-making autonomy if the hospitalists displayed some initiative to propose reasonable, realistic solutions to their complaints that take into consideration the political and fiscal environment in which they operate. In my view, this seems to be kind of a chicken-and-egg thing; it’s hard to say which needs to come first.

Embrace a broader definition of what it means to be a hospitalist. By far the most common comment I received from hospital leaders was that they need their hospitalists to engage around process and quality improvement at the level of the whole organization and not be satisfied with just being good doctors to their individual patients. One exec told me, “As their volume continues to grow, their total alignment with our goals and strategic objectives becomes increasingly critical to our organization’s overall success. We need them to assume the lead in helping to drive improvements in quality, patient safety and operational performance and they can’t do this without feeling engaged.” Of course, the problem with this is that few organizations are willing to fund dedicated non-clinical time to pursue such activities.

I have long felt that it’s not fair for hospital execs to place greater expectations on hospitalists for quality improvement work than they have of other similarly situated physicians – unless they are willing to pay for this effort either in the form of a reduced clinical workload or extra pay. When I asked the execs whether they expect more from their hospitalists in terms of this type of extra-curricular work than they do from other members of the medical staff, most admitted that they do – whether or not that’s “fair.” One particularly insightful exec told me, however, “Sure we expect more of them than we do of the private non-employed medical staff. But we don’t expect more of them than we do any other employed doctor – all of our employed doctors, including the orthopods and cardiac surgeons, routinely invest extra unpaid time to participate in activities related to improving their service lines.”

More recently, I’ve started to wonder whether paying hospitalists to engage in quality improvement work and other forms of citizenship may actually serve to undermine intrinsic motivation and devalue hospitalist professionalism. Shouldn’t all of us who consider ourselves professionals in any field want to invest some of our own time and effort in making the places where we work safer, better, and more satisfying? I can’t imagine that many of us would find fulfillment in a job that devolves to piece-work, knowing that others feel we are nickel-and-diming them for each little thing they ask us to do.

What is the best way to engage hospitalists deeply in the important quality and process improvement work that needs to be done in hospitals? This is an exceptionally tricky issue, and I don’t see a clear answer. I fear it is and will continue to be a defining challenge for the field of hospital medicine and will impact the sustainability both of hospital medicine as a specialty, and of individual hospitalist careers.

Ultimately, whether or not we see the hospital leaders’ requests as reasonable, their desire to see these attributes in their hospitalist groups isn’t going to change any time soon. I’m convinced that hospitalist career satisfaction and longevity depends in part on how each individual responds to these types of “asks” from their colleagues in hospital administration.