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Fight burnout while fostering experience

Investing in hospitalist programs now can pay off later

By Gina Shaw

From the July ACP Hospitalist, copyright © 2008 by the American College of Physicians

Do hospitalists really make a difference to patient outcomes—and how can the growing field of hospital medicine be sustained against potential threats like burnout? These were the central questions addressed by David O. Meltzer, ACP Member, in his presentation “Developing Sustainable Careers in Hospital Medicine” at Internal Medicine 2008.

Outcomes and costs

It’s been taken as almost a given that hospitalists improve outcomes and help to reduce costs for hospitals, Dr. Meltzer said. He pointed to a commonly cited 2002 review by Wachter and colleagues in the Journal of the American Medical Association, which demonstrated significant reductions in resource use as measured by hospital costs (average decrease, 13.4%) or length of stay (average decrease, 16.6%) with no adverse effect on outcomes.

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Dr. Meltzer: It's been taken as almost a given that hospitalists improve outcomes and help to reduce costs for hospitals, but that's not the whole story.

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But this doesn’t tell the whole story, according to Dr. Meltzer, who is director of the hospital medicine program at the University of Chicago.

“Almost all studies in this review were nonrandomized study designs, and had poor power for outcomes, with no data on the mechanism for improvement,” he noted. “If you think that hospitalists may work in some settings but not in others, it’s hard to determine from this literature if they will be valuable in your setting.”

While hospitalists can improve outcomes and resource utilization, it’s not as easy as simply hiring a few and watching length of stay decline.

Indeed, extensive research spearheaded by Dr. Meltzer indicates that while hospitalists can improve outcomes and resource utilization, it’s not as easy as simply hiring a few and watching length of stay decline.

In a multicenter trial funded by the Agency for Healthcare Research and Quality that involved more than 32,000 admissions at six centers over two years, Dr. Meltzer and other researchers found that overall, hospitalists had no statistically significant impact on length of stay and no effect on cost.

“There were audible gasps when I presented this data at the Society of Hospital Medicine,” Dr. Meltzer said. “What could this mean? How does this reconcile with the idea that sustainability of a hospitalist program matters?”

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The importance of experience

The answer, Dr. Meltzer said, lies in the details. His trial sought to examine not only hospitalist programs’ impact on resource utilization and quality, but more specifically the programs’ impact on individual disease management and the effect of particular elements, such as experience.

And that’s where the programs made a clearly significant difference—one not immediately evident from the overall data. “Experience had a huge impact,” said Dr. Meltzer. “For every doubling of a hospitalist’s experience, that led to a 3% decrease in cost and length of stay.” The impact of disease-specific experience was particularly strong; for example, management of community-acquired pneumonia by disease-experienced hospitalists led to a statistically significant 11.6% decline in length of stay.

“Just as [the hospitalists] got good at what they were doing, they burned out, got sick of it, left the program. That’s why the programs didn’t get better even though the doctors did.” —David O. Meltzer, ACP Member

But if the hospitalists were getting better, why weren’t the programs in the study showing an overall impact on resource utilization? “The doctors were leaving,” Dr. Meltzer said. “Just as they got good at what they were doing, they burned out, got sick of it, left the program. That’s why the programs didn’t get better even though the doctors did, and it’s a fundamental challenge to sustainability.”

Dr. Meltzer also pointed to another way in which hospitalists impact quality of care and length of stay: the “spillover effect.”

“We saw that interns and residents who worked with hospitalists had lower costs and shorter length of stay, even when they were no longer working with hospitalists,” he said. In other words, the hospitalists may have been raising the bar overall, not only with their own patient care but with the care given by other practitioners with whom they worked.

Dr. Meltzer suggested that hospitals with hospitalist programs could take advantage of this spillover effect by mobilizing hospitalists as opinion leaders. One such program at the University of Chicago, Curriculum for the Hospitalized Aging Medical Patient (CHAMP), which is funded by the Reynolds Foundation, pairs hospitalists with geriatricians to develop and disseminate knowledge to improve hospital care of vulnerable elders.

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Battling burnout

Programs like CHAMP and the sustainability of hospitalist programs in general—particularly in academic centers, which are the focus of Dr. Meltzer’s research—face some significant threats, however. Practitioner burnout is one of the greatest, Dr. Meltzer noted.

“The burnout issue is quite striking. Among our hospitalists, 60% of them agreed or strongly agreed that interruption by work of their personal lives was a problem, while only 30% of other physicians saw it as a problem,” he said. “This translated into what people saw as their future in their jobs: 17% of hospitalists said they were likely to or definitely would leave this practice within two years, versus only 8% of nonhospitalists.”

At the University of Chicago, after two hospitalists quit because of burnout—a loss that cost the hospital about $640,000 a year—Dr. Meltzer and his colleagues got funding to create an academic hospitalist program. The program is aimed at creating a sustainable, rewarding career for academic hospitalists by reducing time on service and number of patients, but most importantly, he said, giving doctors protected time for research and academic pursuits. The academic hospitalists spend only three to four months of each year on service, have limited or no outpatient time and spend approximately 50% of their effort on quality improvement and related research, informatics and cost containment.

Dr. Meltzer and his colleagues have also created a hospitalist scholars program, with about eight new faculty who have a strong academic focus. “The first four hospitalists [who went through the program] now have stable research positions with funding to balance their time between research and clinical care,” Dr. Meltzer said.

Dr. Meltzer concluded that hospitalists can improve a hospital’s cost and outcomes, but only if they’re able to accumulate sufficient experience. He suggested that “structured, supported programs that create a good career path for academic hospitalists” can help sustain the field.

Gina Shaw is a freelance writer in Montclair, N.J.

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ACP Hospitalist provides news and information for internists about the practice of medicine and reports on the policies, products and activities of ACP. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated