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Your next hire could be right down the hall
High-performing hospitalist teams embrace mix of age, experience
By Stacey Butterfield
From the October ACP Hospitalist, copyright © 2008 by the American College of Physicians
Chintu Sharma, ACP Member, realized he wanted to be a hospitalist during his residency, when he first worked with critically ill patients and their families. “For me, that’s a blast. I love it,” said Dr. Sharma, who’s now a hospitalist at Hanover Hospital in southeastern Pennsylvania.
Mid-career hospitalist Scott L. Oxenhandler, ACP Member, with medical assistant Denise Adams.
His boss, Paul F. Dende, ACP Member, might have made the same early career decision but he didn’t have the option. “When I started practice in 1986, there was no such thing as hospitalists,” said Dr. Dende, now director of Hanover’s hospitalist program. Instead, Dr. Dende worked as a solo practitioner for 17 years before entering hospital medicine.
The average age of a hospitalist is 37, and the average group leader is 41 years old, according to the latest statistics from the Society of Hospital Medicine. But this apparent uniformity of the population masks a wide variety of experiences. Many of today’s hospitalists came straight from residency as Dr. Sharma did, but they often have at least a colleague or two with a primary care background, like Dr. Dende.
"Probably about 25%–30% [of hospitalist groups] will include physicians who have already been in practice."
“Probably about 25%-30% [of hospitalist groups] will include physicians who have already been in practice,” estimated Steven A. Nahm, vice president for The Camden Group, a hospitalist consulting company. “Quite often, it’s even higher. A lot of hospitalist groups will be formed by physicians who have been in the community.”
Physicians who move from the community to the hospital mid-career present a potential solution to the hospitalist field’s perennial workforce shortage. They also offer some benefits and challenges that differ from those of their hospitalist-track peers. Hospitalist leaders who note those differences, and find the means to take advantage of them, are on track to building well balanced, high-functioning hospitalist teams, experts said.
The advantages—to both parties—of hiring a hospitalist from the local community can be apparent from the very first interview. Andrea M. Kielich, FACP, had been a primary care internist in Portland, Ore., for 29 years. “I found myself getting exhausted and decided it was time for a change in career focus,” she said.
Dr. Kielich talked to the hospital system where she had admitted patients for her entire career and as it happened, they were looking for a full-time hospitalist. “It just sort of fell into place very nicely. I had been on staff for 29 years, so I already knew the specialists and I knew the computer system. It was very easy for them, a very minimal amount of training,” she said. “Plus, because I (have) had many years of inpatient and outpatient experience, when working with primary care doctors I know the continuum. I know the medications. I know the follow- up,” Dr. Kielich said.
That basis of knowledge and understanding of the outpatient world are some of the biggest assets offered by career changing physicians, experts said. “I myself—and I believe others— will encourage a hospital to look for those types of physicians because they’re familiar with the hospital, the specialists, the politics. They’re familiar with the disease states in the community. They bring trust and confidence from the medical staff. It’s a good way to build a core,” said Mr. Nahm.
The familiar working relationship between a PCP-turned hospitalist and his community colleagues can also smooth transitions of care and improve efficiency. For example, an inpatient physician who has worked outside the hospital may be more willing to leave some diagnostic challenges for later follow-up. “There is a comfort level with having a problem worked up out of the hospital” among hospitalists with prior outpatient experience, said Kenneth R. Epstein, FACP, a hospitalist and consultant in Colorado.
Local experience is particularly helpful, but even physicians who relocate to become hospitalists bring side benefits, said David P. Chen, ACP Member, director of a 20-physician hospitalist group in Tacoma, Wash. “We’ve made a decision not to hire any docs right out of residency,” he said. “Statistically, most doctors end up changing their job two or three times.” He tries to hire physicians who have already made those job switches and thereby keep his program’s turnover as low as possible.
Their worldly experience also makes these physicians more adept at the business side of medicine. “They have been involved in or at least aware of the management of the practice so often they can bring a little more business focus to the practice,” said Jeanette M. Abell, ACP Member, a hospitalist and group leader in Columbus, Ohio.
Dr. Dende agreed. “Now that I’m insulated I’m not so naive as to think everything is free. I know what the costs [of overhead] are. I know it’s included in my pay and I’m appreciative of that,” he said.
Physicians who have worked for themselves may also be more prepared to dig in when the hospital gets overwhelmed, said Mr. Nahm. “A lot of the older physicians I know are used to working really hard and juggling. They just know how to handle a busy schedule.”
Some cons, too
Of course, not every mid-career hospitalist brings all positive attributes along or even fits these generalizations at all. “Especially at the beginning, some of them had the notion that ‘I’m working too hard as an outpatient and I’ll go in and round and that’ll be much easier.’ If they came in with that attitude, they didn’t last,” said Dr. Abell.
Even physicians transitioning with the right attitude can be behind in some areas, she added. “Often what they are a little rusty on is taking care of the more acute patients. You can get up to speed pretty quick on that, but you need to put a little effort in.”
Dr. Kielich found that to be true in her career change. “I had for years, as an outpatient physician, thought that hospitalists were the way to go because we couldn’t completely keep up with inpatient medicine when you only admit a few patients a year. I’m learning a lot more about all the quality improvement measures and all the protocols for different diseases, and it is a fascinating new challenge,” she said.
Less fascinating for many of the new hospitalists is the prospect of working nights. “A lot of times you get to be midlife and you don’t really want to be working night shift,” said Dr. Kielich, who is glad that her hospital offered a schedule of all dayshifts.
Scheduling is one of the ways that moving into hospital medicine can be easier for just-graduated residents. “Being a hospitalist is certainly a continuation of the lifestyle of being a resident so it’s an easier transition. In terms of efficiency and being used to spending the day in the hospital, there’s a comfort level,” said Dr. Epstein.
New docs may also be more accustomed to the hospital’s technology, hierarchy and collaborative work environment than their older peers, the experts said. “It requires a mental shift that you’re now working with colleagues, you’re going to have group meetings, you’re handing patients off to one another,” said Mr. Nahm. But, he added, these issues are definitely not insurmountable. “I find that most of these physicians that are coming from private practice are willing to make those changes. They’re not as unwilling to change as you might think,” he said.
With their honed management techniques in hand, hospitalist leaders said that they’ve had good experiences hiring private practice physicians from a variety of backgrounds. “As a profession, we have to be very open to nontraditional hospitalists coming in,” said Dr. Abell. “Because demand is so high, we’re looking at physicians who’ve been in practice and loved inpatient medicine. Traditionally, the majority is internal medicinetrained but there are a lot of family practitioners who have had good training in hospital medicine.”
The switch is also good for the new hospitalists. “For many people a mid-career change is just a shot in the arm of energy. I think a lot of times people feel stuck that they’ve chosen one thing and it’s certainly nice to know that there are different career paths that people can choose in different times of their life,” said Dr. Kielich.
However, physicians filling the hospitalist career path are leaving an absence in their old track, and in many communities, the primary care shortage is at least as intense as the hospitalist shortage. “If it’s someone already in practice [that you hire], how are you going to replace him or her? What’s going to happen with those patients?” asked Mr. Nahm. “You have a concern when you’re recruiting somebody out of the community that you’re taking a resource away.”
“I’ve seen that in smaller communities, where the hospital’s very clear saying ‘Don’t recruit from our primary care pool because we need those physicians,’” said Dr. Epstein.
It’s not in the hospitalist program’s interest to draw down the primary care population, either, he added. “A big issue when we discharge people from the hospital is not having them have adequate follow-up. If there’s a shortage of primary care physicians in the community, it makes a hospitalist’s work much more difficult.”
The only real fix for the problem is a national realignment of reimbursement and salaries, the experts said. But there’s also always the possibility that primary care practice leaders, or the excitement of variety, will lure some of the PCPs-turned-hospitalists away again. Jeffrey Frank, FACP, spent 15 years practicing primary care before he became a hospitalist in Berkeley, Calif., and although he enjoys his current job, he’s not sure the switch is permanent.
“I don’t see myself working as a hospitalist for another 25 years. I definitely plan on either doing other things along the way or changing back to private practice toward the end.”
Lead to succeed
The key to inspiring change and fitting mid-career physicians into a hospitalist group is good leadership, according to experts, who offered the following tips:
Delegate appropriately. If you have experienced primary care physicians who have worked well with specialists and hospital staff, have them represent your group on committees, said consultant Steven A. Nahm, vice president for The Camden Group. On the other hand, younger physicians might be better suited to implementing new computer programs, like order entry or handoffs.
Acknowledge strengths and weaknesses. “Have the younger physicians out of residency realize that the older physicians bring clinical experience and efficiency,” said Kenneth R. Epstein, FACP, a hospitalist and consultant in Colorado. “Conversely, the mid-career physicians need to accept the fact that residents may bring some new clinical knowledge and that the way to manage things may have changed since they were residents.”
Provide the tools for success. Flexible scheduling, regular case study discussions, and standardized protocols for care can also help diverse groups of hospitalists work together smoothly, Mr. Nahm noted. Mentorships between physicians of different ages and backgrounds are another valuable resource, said Scott L. Oxenhandler, ACP Member, director of a hospitalist program in Hollywood, Fla., whose program has some physicians fresh out of residency and others who are in their mid-70s.
Anticipate conflicts. Conflicts can occur when an older physician comes on board and expects to lead by virtue of his experience, yet he is not the best choice to be the group’s medical director. Conversely, others may look to an experienced new hospitalist as a mentor, when he or she may not want that responsibility, said Dr. Epstein. Keep an eye out for these potential conflicts during the interview and hiring process, and make sure physicians have realistic expectations of what the job entails.
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