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Pay now, profit later

Training programs for new hires can pay off in higher retention, productivity

From the April ACP Hospitalist, copyright © 2010 by the American College of Physicians

By Janet Colwell

Sidebar: Academy offers guidance to junior faculty

Maria Ranin-Lay, MD, had already heard good things about Hudson Valley Hospital Physicians in Middletown, N.Y., when she applied for a job as a staff hospitalist. But one benefit in particular made the firm stand out in the field of potential employers: a whole month of training at full salary.

“I had never heard of this type of training from other programs, even from friends who were going to large hospitalist groups,” said Dr. Ranin-Lay, who joined Hudson Valley Hospital Physicians (HVHP) in March 2009 after leaving a job as assistant professor of medicine at Texas Tech University Health Sciences Center in Lubbock. “The training program was just a huge plus.”

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Maria Ranin-Lay, MD, Diane S. Pine, ACP Member, and Adrian Paraschiv, MD, of Hudson Valley Hospital Physicians. Photo courtesy of Orange Regional Medical Center.

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The month-long training helps the 16-physician group practice attract and retain talented physicians, said HVHP founding partner Diane S. Pine, ACP Member. But it also makes good financial sense for HVHP and its client Orange Regional Medical Center, which has been using the group’s services since 2003.

“[The training program] is a $20,000 loss per hospitalist purely on the books because the hospitalist isn’t productive during that month,” said Dr. Pine. “But when you look at it over a year’s time you’re getting that money back because they’re capturing correct billing and appropriately documenting charts. It’s not a cost, it’s an investment.”

HVHP’s initiative highlights the training gap between medical residency and hospitalist employment. Newly hired hospitalists may be clinically competent, but they typically have no experience with coding or documentation and only a vague idea of how to navigate the political and business aspects of the system. HVHP and other employers are discovering that initial training—whether it lasts a few days or a few weeks—can make a crucial difference in a hospitalist’s long-term productivity and career satisfaction.

Well-trained docs more likely to stay

When Robert C. Treadwell, DO, joined IPC The Hospitalist Company eight years ago, he underwent a whirlwind two-day orientation before being thrown into full-time patient care. Dr. Treadwell, now an IPC practice group leader in the Dallas/ Fort Worth region, weathered the initiation by fire but some of his colleagues left in frustration, prompting him and others to rethink how to help new recruits adjust to the job.

“We used to provide very rudimentary basic training,” said R. Jeffrey Taylor, president and chief operating officer of IPC, which employs more than 1,000 hospitalists practicing in more than 400 facilities nationwide. “Not only was it a substandard way to on-board people, we were losing the hearts and minds of some of the new doctors in their first day at work.”

The company has gradually expanded the initial training period to two weeks, during which new hospitalists attend an orientation in the regional office, complete online training modules and shadow their practice group leader—all before seeing patients. After two weeks, the hospitalists, accompanied by a mentor, start seeing six to eight patients a day, then gradually ramp up to the goal of about 15 per day.

After one month, practice group leaders take all new hires out to lunch to discuss their initial experiences and answer any questions. Similar get-togethers occur again at three months, six months and one year.

Not everyone was happy with the new program in the beginning. Some existing employees “argued with the decision because all of a sudden we were paying doctors for two weeks when they were not actually seeing patients,” noted Dr. Treadwell. “But I promised them we would recoup those losses because we wouldn’t be training new doctors every six months.”

The cost of employing a hospitalist for two weeks without productivity is between $10,000 and $12,000, acknowledged Mr. Taylor, but he believes it pays off in the long run. Staff turnover has been steadily decreasing since the program began and attrition hit an all-time low of 15% in 2009, he said.

In the Fort Worth region, attrition has been close to zero since the program started, said Dr. Treadwell. “We’re hiring lots of doctors and not replacing any whereas before we were replacing one or two doctors every six months.”

Similarly, HVHP has experienced low turnover since starting its training program four years ago, said Dr. Pine. The only departures have been three physicians who announced at the time of their hiring that they were embarking on fellowships after two years, she said.

From residency to reality

Both HVHP and IPC leaders say that initial training gives new hospitalists an opportunity to adjust to the non-clinical side of practice—the things they didn’t learn in residency—before taking on full-time patient care.

At HVHP, new hospitalists are given a handbook on their first day that details every aspect of the group’s workflow and expectations. During the first two weeks of training, Dr. Pine and partner Adrian Paraschiv, MD, take physicians through a checklist of essential information—such as how to do a dictation, follow-up or transfer—and accompany them on patient visits.

On Day 2 of the orientation, trainees start seeing five patients a day, spending as much time as they need with each in order to go over the process in detail with a senior physician. They learn how to capture diagnosis-related group (DRG) payments, assign correct billing codes, and document charts. Every hospitalist is taught the same methods in order to facilitate seamless transitions of care, said Dr. Pine.

“We write and dictate our notes the same way and have the same workflow,” she said. “Doing things the same way each time ensures better compliance and transition when doctors are passing patients between each other. A training program ensures that we keep consistency.”

IPC’s Dr. Treadwell, who usually spends several days with new hires, noted that new hospitalists often need guidance on how to organize their time so that patient care is both effective and efficient.

“Doctors coming out of residency know how to take care of heart failure but they don’t know how to get the patient in and out of the hospital in three and a half days,” explained Dr. Treadwell. “Without the hands-on training and me being there for them, it’s hard for them to figure out how to do that.”

Newly trained hospitalists typically have no experience with the business side of medicine, added Mr. Taylor. “Why does throughput out of the ER matter? Why does length of stay matter? What’s the difference between a DRG and per diem rate? If you don’t have at least a basic understanding of these things, you never know where all these pressures are coming from and how to respond to them appropriately.”

Ultimately, training teaches new hires that they are not alone and that they can and should seek out support from their more experienced colleagues.

Dr. Pine encourages her staff to call her any time they need advice on a case, whether they are newly trained or have experience. “We never let anybody hang,” she said. “They learn from Day 1 that they will be supported and should never be afraid to ask.”

That’s a culture shift from residency, where physicians tend to view asking for help as a sign of weakness, noted Mr. Taylor.

“In residency they are still learning that you have to be an island and as a hospitalist you can’t be an island,” he said. “You have to have a little bit of your fingers in everything and work with the medical staff, nursing and administration—if you don’t, you won’t be as effective as you could be.”

Janet Colwell is a freelancer writer in Miami.

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Academy offers guidance to junior faculty

Academic medical centers also are starting to recognize the long-term benefits of training new hospitalists. Last fall, a collaboration of the Society of Hospital Medicine (SHM), the Society of General Internal Medicine (SGIM) and the Association of Chiefs in Internal Medicine (ACGIM) held its first Academic Hospitalist Academy (AHA), a four-day program geared toward junior faculty. Sessions covered topics like teaching, research, career planning and quality improvement—all areas that attendees said were lacking or missing from their residency training.

“I would have loved to have had this training five years ago because it focused on a lot of the skills not taught in residency,” said Cuc Mai, MD, a hospitalist at the University of South Florida in Tampa, who attended the AHA last fall in Atlanta. Although she’s now in her fifth year with USF’s six-physician hospitalist group, Dr. Mai said the course was still very helpful in providing advice about teaching, research and setting career goals.

“Before I went to this academy, I wasn’t paying attention to what is required for promotion,” she said. “I was focused on doing a good job with patient care and teaching but I wasn’t adequately documenting my time. The facilitators spent time going over things we need to do in order to get promoted.”

The idea for the academy grew out of a session called “Teaching Hospitalist Educators” held at the 2008 and 2009 SHM annual meetings. The one-day pre-course was so popular that organizers began planning for an extended version, said Mark V. Williams, FACP, chief of the division of hospital medicine at Northwestern University’s Feinberg School of Medicine in Chicago, who co-directed the initial 2008 pre-course with Jeff Wiese, president-elect of SHM.

“There was no program in the past targeted towards providing a skill set in medical education for hospitalists,” said Dr. Williams, a former president of SHM. “One of the strongest aspects of the course was meeting other academic hospitalists who are in the same boat and learning the steps you should take to succeed in academic medicine.”

Organizers set out to provide a comprehensive overview of what it takes to achieve academic success, said Jeffrey J. Glasheen, MD, director of the hospital medicine group at the University of Colorado Denver, and director of the AHA. “It’s a full circle of understanding what drives the business decisions in academia and how you can influence that—through quality improvement and patient safety—in ways that the institutions will fund, such that you can find the time and resources to get promoted. It’s all linked together.”

The academy also presented an opportunity for junior faculty to meet with experienced, successful hospitalists, a relatively rare breed in the still-young field of hospital medicine.

“We hoped to provide attendees with a chance to pick the brains of those who’ve navigated the land mines in hospital medicine and could offer them pearls as well as open their eyes to what they should be looking for in a mentor,” explained Dr. Glasheen.

The facilitators were “very invested in all of us as the next generation of young hospitalists,” said attendee Nichole Zehnder, MD, a first-year hospitalist at the University of Colorado Denver. “Hospitalists in general are very young cohorts so in terms of career guidance and mentoring, there is not a lot of senior faculty for us to get information from.”

One session that stood out, said Dr. Zehnder, focused on the key business drivers of hospital medicine and where hospitalists fit. The session included discussions of how to negotiate hospital administration, how to work effectively as part of a team, and how to provide more efficient, financially sound patient care.

“It’s something that we never get in residency but that is very important for our overall career and how we work in the hospital,” she said.

Lalit Verma, MD, an associate director of the hospitalist group at Durham Regional Medical Center in Durham, N.C., attended the academy as a refresher on academic medicine. He had been a hospitalist for nine years before coming to Durham, but most of that time was spent outside of academia.

“There is a lot of basic information that you can infer from your job but not fully develop or conceptualize until you step back and take a look at it from a different perspective,” said Dr. Verma. “I would encourage everyone to attend this to get the basics down as a teaching attending.”

Attendees of the academy left with a list of the steps they would need to take to achieve their short- and long-term career goals.

“At the end of each session, [the facilitators] had us write down one personal goal we took from that session and how we would apply it,” said Saumil Chudgar, MD, a second-year hospitalist at Duke University Hospital in Durham, N.C. “After about 25 sessions over four days, I took that sheet, typed it up and I have it sitting by my desk.”

Ultimately, organizers wanted attendees to leave with a clearer sense of where they were going and how they could get there, said Dr. Glasheen.

“If you’ve never been given a road map for how to do this it is very nearly impossible to be successful,” he said. “We hope that we demystified a lot of the early career barriers to success, such as publishing, promotions or teaching, so that they can learn in four days what it took most of us four years to learn.”

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© 2010 ACP Hospitalist and American College of Physicians

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