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Higher salaries are not sufficient
Hospitalist Rahul C. Borsadia, MD, had been working with Orlando Health Inpatient Medicine Group since the year of its founding in 2011.
The salaries of the practice’s physicians back then were based on relative value units (RVU) – the more patients that physicians saw, the higher their salaries. But a problem arose, Dr. Borsadia said. Physicians were trying to squeeze in two dozen or more patients a day “in a practice that is modeled for quality.”
“By the time the end of the day comes, it’s 9 or 10 p.m. and you are leaving but coming back at 6:30 the next morning. So, lack of sleep, more patients, striving to earn that higher salary,” he said. “The desire to perform quality work with that kind of patient load was not fulfilled and that lead to dissatisfaction and stress, which lead to irritation and exodus from the group.”
Three years ago, the practice transitioned to a throughput process with a census limit of 18 patients or less, without an RVU system, but with salary incentives based on patient satisfaction, billing, and documentation.
“We’ve not had anybody leave the hospital because of burnout or dissatisfaction” since the new system was put into place, Dr. Borsadia said. “Less burnout means more people are happy.”
Although symptoms of burnout still seem to be rampant across hospital medicine, hospitalists are putting potential solutions into place. And – sometimes – they are making progress, through tweaks in schedules and responsibilities, incentives suited to different goals, and better communication.
Scheduling problems
The need for continuing efforts to improve the work experience for hospitalists is apparent, said Henry Michtalik, MD, MPH, MHS, assistant professor of general internal medicine at Johns Hopkins, Baltimore, who led a workshop on the topic at the 2019 Annual Conference of the Society of Hospital Medicine (HM19).
A 2016 survey of academic general internal medicine clinicians – including about 600 hospitalists and outpatient physicians – found that 67% reported high stress, 38% said they were “burned out,” 50% said they felt they had “low control” over their work, and 60% said they felt high documentation pressures. Still, 68% said they were satisfied with the values of their departments.
Hospitalists surveyed were actually less likely to say they were burned out, compared with outpatient internists – 52%, compared with 55% – but they were more likely to score low on a scale measuring personal accomplishments, compared with the outpatient clinicians – 20% to 10%. The survey found no significant difference between the two groups in depression or suicidality. But with 40% reporting depression and 10% reporting thoughts of suicide, the numbers virtually cry out for solutions.
Hospitalists in the HM19 workshop, as in other sessions at the Annual Conference, questioned whether the standard 7-days-on, 7-days-off work schedule – seven 12-hour shifts followed by 7 days off – allows hospitalists to pair their works lives with their personal lives in a sustainable way. They described the way that the stress and fatigue of such an intense work period bleeds into the days off that follow after it.
“By the end of seven 12’s, they’re bleary eyed, they’re upset, they go home (for) 2 days of washout before they even start to enjoy whatever life they have left,” said Jonathan Martin, MD, director of medicine at Cumberland Medical Center in Crossville, Tenn. “It’s hard to get hospitalists to buy in, which increases their dissatisfaction.”
Dr. Michtalik had a similar perspective.
“You just shut the rest of your life down completely for those 7 days and then, on your 7 days off, you’ve scheduled your life,” he said. “But that last off day – day number 7 – you feel that pit in your stomach, that the streak is coming.” He joked that the feeling was similar to the dread inspired by the phrase “winter is coming” in the popular HBO series “Game of Thrones.”
Systematic reviews of the literature have found that it’s mostly changes at the organization level – rather than changes that an individual physician makes on his or her own – that tend to make significant differences. Changes to structure, communication, and scheduling tend to work better than working on mindfulness, education, or trying to improve resilience, Dr. Michtalik said.
In one study discussed at the HM19 workshop, researchers compared a schedule in which an intensivist works in-house for 7 days, with home call at night, to a schedule in which the intensivist is completely off at night, with an in-house intensivist covering the night shift. The schedule in which the intensivist was truly off for the night significantly reduced reports of burnout, while not affecting length of stay or patient-experience outcomes.
Dr. Michtalik said that another study compared 4-week rotations to 2-week rotations for attending physicians. Researchers found that the 2-week version resulted in lower reports of burnout, with readmissions and patient experience unaffected, although they noted that residents tended to prefer 4-week schedules because they felt it resulted in better relationships with the attending physician.
Perhaps the dominant factor in job satisfaction that’s been identified in surveys is how physicians, patients, and administrators relate to one another, Dr. Michtalik said.
“The important concept here is that relationships were really important in driving job satisfaction, whether that be with our colleagues, our patients, or with the staff that you’re working with,” he said. “It’s always easier to decline a consultation or have a bad interaction with someone over the phone than it is if you actually know them or you are communicating face to face. That’s why it’s important to develop these kinds of relationships, which also put a face to what’s going on.”
Beyond salary adjustments
Hospitalists attending the HM19 workshop said they thought that participating in administration committees at their own institutions helps keep hospitalists involved in hospital matters, limiting the effects of burnout and improving workplace satisfaction.
Kevin McAninch, DO, a hospitalist with Central Ohio Primary Care in Westerville, said a shift in work responsibilities has made an improvement at his hospital. There is now an “inpatient support center” – which has a physician and a nurse in an office taking calls from 6 p.m. to 7 a.m., so that rounders can stop taking floor calls during that time.
The system “takes the pressure off our admitters at night and our nurses because they’re not getting floor calls anymore, so they’re just taking care of the admissions from the ER,” he said.
A recurring theme of the discussion was that salary alone seems universally incapable of eradicating feelings of burnout. One hospitalist said that in surveys, higher-paid physicians insist that monetary compensation is their main driver, but still often complain of burnout because they must work extra shifts to earn that higher level of pay.
Instead, burnout and satisfaction indicators tend to have more do to with time, control, and support, Dr. Michtalik noted.
Mangla Gulati, MD, SFHM, chief quality officer at the University of Maryland Medical Center in Baltimore, said that there’s no big secret about what hospitalists want from their places of employment. They want things like getting patients to service faster so they can make diagnoses, making sure patients get the care they need, fixing the problems associated with electronic medical records, and having a work-life “integration.”
“The questions is – how do we get there?” Dr. Gulati wondered. She suggested that hospitalists have to be more assertive and explanatory in their interactions with members of the hospital C-suite.
“I think it’s really important for you to understand or ask your C-suite, ‘Where are you in this whole journey? What is your perception of wellness? Tell me some of the measures of staff wellness,’ ” she said.
If the C-suite says “we have no money” to make improvements, hospitalists must be willing to say, ‘Well, you’re going to have to invest a little bit.’ ” Dr. Gulati said. “What is the ROI (return on investment) on the turnover of a physician? Because when you turn a physician over, you have to recruit and hire new staff.”
Dr. Gulati said that hospitalists should provide C-suite leaders with a detailed walk-through of their actual workflows – what their workdays look like – because “it’s not something they’re familiar with.”
Aside from improving relations with hospital administration, Dr. Gulati suggested creating CME programs for wellness, offering time and funding for physician support meetings, supporting flexibility in work hours, and creating programs specifically to help clinicians with burnout symptoms.
She also touted the benefits of “Schwartz Rounds,” in which several medical disciplines gather to talk about a case that was particularly challenging, clinically complex, and emotionally draining for everyone involved.
At Cumberland Medical Center, Dr. Martin said he has two meetings a month with executives in the hospital’s C-suite. One is with his hospitalist group, TeamHealth, and one is more direct, between himself and hospital administrators. It’s just 2 hours a month, but these conversations have undoubtedly helped, he said, although he cautioned that “the meetings themselves don’t have as much meaning if you aren’t communicating effectively,” meaning hospitalists must understand how the C-suite thinks and learn to speak in terms they understand.
“When I go to the administration now and I say ‘Hey, this is a problem that we’re having. I need your help in solving it,’ the executives are much more likely to respond to me than if they’d never seen me, or only see me rarely,” Dr. Martin said.
As a result, a collaborative approach to such conversations tends to be more effective.
“If you go to the C-suite and say, ‘Here’s our issue, how can you help us?’ – as opposed to telling the administration, ‘This is what I need’ – they are more likely to work with you to generate a solution.”
Higher salaries are not sufficient
Higher salaries are not sufficient
Hospitalist Rahul C. Borsadia, MD, had been working with Orlando Health Inpatient Medicine Group since the year of its founding in 2011.
The salaries of the practice’s physicians back then were based on relative value units (RVU) – the more patients that physicians saw, the higher their salaries. But a problem arose, Dr. Borsadia said. Physicians were trying to squeeze in two dozen or more patients a day “in a practice that is modeled for quality.”
“By the time the end of the day comes, it’s 9 or 10 p.m. and you are leaving but coming back at 6:30 the next morning. So, lack of sleep, more patients, striving to earn that higher salary,” he said. “The desire to perform quality work with that kind of patient load was not fulfilled and that lead to dissatisfaction and stress, which lead to irritation and exodus from the group.”
Three years ago, the practice transitioned to a throughput process with a census limit of 18 patients or less, without an RVU system, but with salary incentives based on patient satisfaction, billing, and documentation.
“We’ve not had anybody leave the hospital because of burnout or dissatisfaction” since the new system was put into place, Dr. Borsadia said. “Less burnout means more people are happy.”
Although symptoms of burnout still seem to be rampant across hospital medicine, hospitalists are putting potential solutions into place. And – sometimes – they are making progress, through tweaks in schedules and responsibilities, incentives suited to different goals, and better communication.
Scheduling problems
The need for continuing efforts to improve the work experience for hospitalists is apparent, said Henry Michtalik, MD, MPH, MHS, assistant professor of general internal medicine at Johns Hopkins, Baltimore, who led a workshop on the topic at the 2019 Annual Conference of the Society of Hospital Medicine (HM19).
A 2016 survey of academic general internal medicine clinicians – including about 600 hospitalists and outpatient physicians – found that 67% reported high stress, 38% said they were “burned out,” 50% said they felt they had “low control” over their work, and 60% said they felt high documentation pressures. Still, 68% said they were satisfied with the values of their departments.
Hospitalists surveyed were actually less likely to say they were burned out, compared with outpatient internists – 52%, compared with 55% – but they were more likely to score low on a scale measuring personal accomplishments, compared with the outpatient clinicians – 20% to 10%. The survey found no significant difference between the two groups in depression or suicidality. But with 40% reporting depression and 10% reporting thoughts of suicide, the numbers virtually cry out for solutions.
Hospitalists in the HM19 workshop, as in other sessions at the Annual Conference, questioned whether the standard 7-days-on, 7-days-off work schedule – seven 12-hour shifts followed by 7 days off – allows hospitalists to pair their works lives with their personal lives in a sustainable way. They described the way that the stress and fatigue of such an intense work period bleeds into the days off that follow after it.
“By the end of seven 12’s, they’re bleary eyed, they’re upset, they go home (for) 2 days of washout before they even start to enjoy whatever life they have left,” said Jonathan Martin, MD, director of medicine at Cumberland Medical Center in Crossville, Tenn. “It’s hard to get hospitalists to buy in, which increases their dissatisfaction.”
Dr. Michtalik had a similar perspective.
“You just shut the rest of your life down completely for those 7 days and then, on your 7 days off, you’ve scheduled your life,” he said. “But that last off day – day number 7 – you feel that pit in your stomach, that the streak is coming.” He joked that the feeling was similar to the dread inspired by the phrase “winter is coming” in the popular HBO series “Game of Thrones.”
Systematic reviews of the literature have found that it’s mostly changes at the organization level – rather than changes that an individual physician makes on his or her own – that tend to make significant differences. Changes to structure, communication, and scheduling tend to work better than working on mindfulness, education, or trying to improve resilience, Dr. Michtalik said.
In one study discussed at the HM19 workshop, researchers compared a schedule in which an intensivist works in-house for 7 days, with home call at night, to a schedule in which the intensivist is completely off at night, with an in-house intensivist covering the night shift. The schedule in which the intensivist was truly off for the night significantly reduced reports of burnout, while not affecting length of stay or patient-experience outcomes.
Dr. Michtalik said that another study compared 4-week rotations to 2-week rotations for attending physicians. Researchers found that the 2-week version resulted in lower reports of burnout, with readmissions and patient experience unaffected, although they noted that residents tended to prefer 4-week schedules because they felt it resulted in better relationships with the attending physician.
Perhaps the dominant factor in job satisfaction that’s been identified in surveys is how physicians, patients, and administrators relate to one another, Dr. Michtalik said.
“The important concept here is that relationships were really important in driving job satisfaction, whether that be with our colleagues, our patients, or with the staff that you’re working with,” he said. “It’s always easier to decline a consultation or have a bad interaction with someone over the phone than it is if you actually know them or you are communicating face to face. That’s why it’s important to develop these kinds of relationships, which also put a face to what’s going on.”
Beyond salary adjustments
Hospitalists attending the HM19 workshop said they thought that participating in administration committees at their own institutions helps keep hospitalists involved in hospital matters, limiting the effects of burnout and improving workplace satisfaction.
Kevin McAninch, DO, a hospitalist with Central Ohio Primary Care in Westerville, said a shift in work responsibilities has made an improvement at his hospital. There is now an “inpatient support center” – which has a physician and a nurse in an office taking calls from 6 p.m. to 7 a.m., so that rounders can stop taking floor calls during that time.
The system “takes the pressure off our admitters at night and our nurses because they’re not getting floor calls anymore, so they’re just taking care of the admissions from the ER,” he said.
A recurring theme of the discussion was that salary alone seems universally incapable of eradicating feelings of burnout. One hospitalist said that in surveys, higher-paid physicians insist that monetary compensation is their main driver, but still often complain of burnout because they must work extra shifts to earn that higher level of pay.
Instead, burnout and satisfaction indicators tend to have more do to with time, control, and support, Dr. Michtalik noted.
Mangla Gulati, MD, SFHM, chief quality officer at the University of Maryland Medical Center in Baltimore, said that there’s no big secret about what hospitalists want from their places of employment. They want things like getting patients to service faster so they can make diagnoses, making sure patients get the care they need, fixing the problems associated with electronic medical records, and having a work-life “integration.”
“The questions is – how do we get there?” Dr. Gulati wondered. She suggested that hospitalists have to be more assertive and explanatory in their interactions with members of the hospital C-suite.
“I think it’s really important for you to understand or ask your C-suite, ‘Where are you in this whole journey? What is your perception of wellness? Tell me some of the measures of staff wellness,’ ” she said.
If the C-suite says “we have no money” to make improvements, hospitalists must be willing to say, ‘Well, you’re going to have to invest a little bit.’ ” Dr. Gulati said. “What is the ROI (return on investment) on the turnover of a physician? Because when you turn a physician over, you have to recruit and hire new staff.”
Dr. Gulati said that hospitalists should provide C-suite leaders with a detailed walk-through of their actual workflows – what their workdays look like – because “it’s not something they’re familiar with.”
Aside from improving relations with hospital administration, Dr. Gulati suggested creating CME programs for wellness, offering time and funding for physician support meetings, supporting flexibility in work hours, and creating programs specifically to help clinicians with burnout symptoms.
She also touted the benefits of “Schwartz Rounds,” in which several medical disciplines gather to talk about a case that was particularly challenging, clinically complex, and emotionally draining for everyone involved.
At Cumberland Medical Center, Dr. Martin said he has two meetings a month with executives in the hospital’s C-suite. One is with his hospitalist group, TeamHealth, and one is more direct, between himself and hospital administrators. It’s just 2 hours a month, but these conversations have undoubtedly helped, he said, although he cautioned that “the meetings themselves don’t have as much meaning if you aren’t communicating effectively,” meaning hospitalists must understand how the C-suite thinks and learn to speak in terms they understand.
“When I go to the administration now and I say ‘Hey, this is a problem that we’re having. I need your help in solving it,’ the executives are much more likely to respond to me than if they’d never seen me, or only see me rarely,” Dr. Martin said.
As a result, a collaborative approach to such conversations tends to be more effective.
“If you go to the C-suite and say, ‘Here’s our issue, how can you help us?’ – as opposed to telling the administration, ‘This is what I need’ – they are more likely to work with you to generate a solution.”
Hospitalist Rahul C. Borsadia, MD, had been working with Orlando Health Inpatient Medicine Group since the year of its founding in 2011.
The salaries of the practice’s physicians back then were based on relative value units (RVU) – the more patients that physicians saw, the higher their salaries. But a problem arose, Dr. Borsadia said. Physicians were trying to squeeze in two dozen or more patients a day “in a practice that is modeled for quality.”
“By the time the end of the day comes, it’s 9 or 10 p.m. and you are leaving but coming back at 6:30 the next morning. So, lack of sleep, more patients, striving to earn that higher salary,” he said. “The desire to perform quality work with that kind of patient load was not fulfilled and that lead to dissatisfaction and stress, which lead to irritation and exodus from the group.”
Three years ago, the practice transitioned to a throughput process with a census limit of 18 patients or less, without an RVU system, but with salary incentives based on patient satisfaction, billing, and documentation.
“We’ve not had anybody leave the hospital because of burnout or dissatisfaction” since the new system was put into place, Dr. Borsadia said. “Less burnout means more people are happy.”
Although symptoms of burnout still seem to be rampant across hospital medicine, hospitalists are putting potential solutions into place. And – sometimes – they are making progress, through tweaks in schedules and responsibilities, incentives suited to different goals, and better communication.
Scheduling problems
The need for continuing efforts to improve the work experience for hospitalists is apparent, said Henry Michtalik, MD, MPH, MHS, assistant professor of general internal medicine at Johns Hopkins, Baltimore, who led a workshop on the topic at the 2019 Annual Conference of the Society of Hospital Medicine (HM19).
A 2016 survey of academic general internal medicine clinicians – including about 600 hospitalists and outpatient physicians – found that 67% reported high stress, 38% said they were “burned out,” 50% said they felt they had “low control” over their work, and 60% said they felt high documentation pressures. Still, 68% said they were satisfied with the values of their departments.
Hospitalists surveyed were actually less likely to say they were burned out, compared with outpatient internists – 52%, compared with 55% – but they were more likely to score low on a scale measuring personal accomplishments, compared with the outpatient clinicians – 20% to 10%. The survey found no significant difference between the two groups in depression or suicidality. But with 40% reporting depression and 10% reporting thoughts of suicide, the numbers virtually cry out for solutions.
Hospitalists in the HM19 workshop, as in other sessions at the Annual Conference, questioned whether the standard 7-days-on, 7-days-off work schedule – seven 12-hour shifts followed by 7 days off – allows hospitalists to pair their works lives with their personal lives in a sustainable way. They described the way that the stress and fatigue of such an intense work period bleeds into the days off that follow after it.
“By the end of seven 12’s, they’re bleary eyed, they’re upset, they go home (for) 2 days of washout before they even start to enjoy whatever life they have left,” said Jonathan Martin, MD, director of medicine at Cumberland Medical Center in Crossville, Tenn. “It’s hard to get hospitalists to buy in, which increases their dissatisfaction.”
Dr. Michtalik had a similar perspective.
“You just shut the rest of your life down completely for those 7 days and then, on your 7 days off, you’ve scheduled your life,” he said. “But that last off day – day number 7 – you feel that pit in your stomach, that the streak is coming.” He joked that the feeling was similar to the dread inspired by the phrase “winter is coming” in the popular HBO series “Game of Thrones.”
Systematic reviews of the literature have found that it’s mostly changes at the organization level – rather than changes that an individual physician makes on his or her own – that tend to make significant differences. Changes to structure, communication, and scheduling tend to work better than working on mindfulness, education, or trying to improve resilience, Dr. Michtalik said.
In one study discussed at the HM19 workshop, researchers compared a schedule in which an intensivist works in-house for 7 days, with home call at night, to a schedule in which the intensivist is completely off at night, with an in-house intensivist covering the night shift. The schedule in which the intensivist was truly off for the night significantly reduced reports of burnout, while not affecting length of stay or patient-experience outcomes.
Dr. Michtalik said that another study compared 4-week rotations to 2-week rotations for attending physicians. Researchers found that the 2-week version resulted in lower reports of burnout, with readmissions and patient experience unaffected, although they noted that residents tended to prefer 4-week schedules because they felt it resulted in better relationships with the attending physician.
Perhaps the dominant factor in job satisfaction that’s been identified in surveys is how physicians, patients, and administrators relate to one another, Dr. Michtalik said.
“The important concept here is that relationships were really important in driving job satisfaction, whether that be with our colleagues, our patients, or with the staff that you’re working with,” he said. “It’s always easier to decline a consultation or have a bad interaction with someone over the phone than it is if you actually know them or you are communicating face to face. That’s why it’s important to develop these kinds of relationships, which also put a face to what’s going on.”
Beyond salary adjustments
Hospitalists attending the HM19 workshop said they thought that participating in administration committees at their own institutions helps keep hospitalists involved in hospital matters, limiting the effects of burnout and improving workplace satisfaction.
Kevin McAninch, DO, a hospitalist with Central Ohio Primary Care in Westerville, said a shift in work responsibilities has made an improvement at his hospital. There is now an “inpatient support center” – which has a physician and a nurse in an office taking calls from 6 p.m. to 7 a.m., so that rounders can stop taking floor calls during that time.
The system “takes the pressure off our admitters at night and our nurses because they’re not getting floor calls anymore, so they’re just taking care of the admissions from the ER,” he said.
A recurring theme of the discussion was that salary alone seems universally incapable of eradicating feelings of burnout. One hospitalist said that in surveys, higher-paid physicians insist that monetary compensation is their main driver, but still often complain of burnout because they must work extra shifts to earn that higher level of pay.
Instead, burnout and satisfaction indicators tend to have more do to with time, control, and support, Dr. Michtalik noted.
Mangla Gulati, MD, SFHM, chief quality officer at the University of Maryland Medical Center in Baltimore, said that there’s no big secret about what hospitalists want from their places of employment. They want things like getting patients to service faster so they can make diagnoses, making sure patients get the care they need, fixing the problems associated with electronic medical records, and having a work-life “integration.”
“The questions is – how do we get there?” Dr. Gulati wondered. She suggested that hospitalists have to be more assertive and explanatory in their interactions with members of the hospital C-suite.
“I think it’s really important for you to understand or ask your C-suite, ‘Where are you in this whole journey? What is your perception of wellness? Tell me some of the measures of staff wellness,’ ” she said.
If the C-suite says “we have no money” to make improvements, hospitalists must be willing to say, ‘Well, you’re going to have to invest a little bit.’ ” Dr. Gulati said. “What is the ROI (return on investment) on the turnover of a physician? Because when you turn a physician over, you have to recruit and hire new staff.”
Dr. Gulati said that hospitalists should provide C-suite leaders with a detailed walk-through of their actual workflows – what their workdays look like – because “it’s not something they’re familiar with.”
Aside from improving relations with hospital administration, Dr. Gulati suggested creating CME programs for wellness, offering time and funding for physician support meetings, supporting flexibility in work hours, and creating programs specifically to help clinicians with burnout symptoms.
She also touted the benefits of “Schwartz Rounds,” in which several medical disciplines gather to talk about a case that was particularly challenging, clinically complex, and emotionally draining for everyone involved.
At Cumberland Medical Center, Dr. Martin said he has two meetings a month with executives in the hospital’s C-suite. One is with his hospitalist group, TeamHealth, and one is more direct, between himself and hospital administrators. It’s just 2 hours a month, but these conversations have undoubtedly helped, he said, although he cautioned that “the meetings themselves don’t have as much meaning if you aren’t communicating effectively,” meaning hospitalists must understand how the C-suite thinks and learn to speak in terms they understand.
“When I go to the administration now and I say ‘Hey, this is a problem that we’re having. I need your help in solving it,’ the executives are much more likely to respond to me than if they’d never seen me, or only see me rarely,” Dr. Martin said.
As a result, a collaborative approach to such conversations tends to be more effective.
“If you go to the C-suite and say, ‘Here’s our issue, how can you help us?’ – as opposed to telling the administration, ‘This is what I need’ – they are more likely to work with you to generate a solution.”