It’s now been seven years. Seven exciting years of continuous hospitalist enjoyment with the same hospitalist program. Hospitalist programs are a dime a dozen. Every hospital on this earth is trying to incorporate the benefits of a hospitalist service into their long term business plan. Why? Because we are the present and the future of hospital based medical care.
Our value goes far beyond the direct economic impact of billing and coding in the madness of a relative value unit fee for service based payment system. As the economic realities of today’s bankrupt Medicare National Bank start to hit home, hospitalists will be looked to as leaders for quality and efficiency in the push towards bundled care.
With so many different hospitalist employment practice environments available, those internists interested in pursuing inpatient medicine need to arm themselves with the knowledge to find what works for them. From the private practice eat what you kill community hospitalist model to the salaried lecture circuit hospitalist at the Univeristy of Research Dollars, us hospitalists have a wide variety of opportunities from which to choose from. One recent reader asked me for my opinions on how to find the best hospitalist position.
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I’ve been following your blog for about a year now. I’m an internal medicine resident in Illinois, winding down my second year of residency, and am trying to organize a sensible post-residency plan. I was hoping I could pick your brain on some issues. I’m an IMG and am looking to settle down somewhere in the Chicagoland area (Chicago and its suburbs). I’m set on becoming a hospitalist, and at this point in time am pretty sure that what I want to do for the rest of my career.
I’m concerned about getting into a hospitalist position in which I’d be unhappy. The hospital I currently work at is great and I like it here a lot, but the town is too small for my taste and I’m keen on moving to a larger metropolis. I haven’t worked in other hospitals in the US, so I don’t know to what extent the good things I find in this hospital are going to be replicated in others. I’m wondering if there’s any advice you would give to residents looking to get into hospital medicine. What does one look for when seeking out positions? What should I try to avoid? I’m kind of sailing in uncharted waters and looking for any useful directives to guide my decision making. Thanks!
Congratulations on making the jump into hospitalist work as a career. There are certain things you must keep in mind before signing the contract. Before you even begin to figure out what kind of hospitalist model you want to pursue, you have to know what is important to you. Do you want the lifestyle of a salaried academic hospitalist working bankers hours or do you want the income potential of an eat what you kill model where patient volumes could get real high real quick.
Here are the basic hospitalist model opportunities:
- Community vs academic
Hospital employee vs local private practice vs national hospitalist corporation
Big city vs rural
The Coasts vs The South vs The Midwest
Salaried compensation vs productivity compensation vs a hybrid of both
Nocturnist work
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These are your basic hospitalist opportunities in a nutshell. In general, hospitalist salaries for community hospitalists will be more than for academic hospitalists. Productivity based compensation hospitalists will make more than pure salaried hospitalists. Rural hospitalists will make more than big city hospitalists (supply and demand). Nocturnists command premium pricing for their night shift differential. The midwest and south will generally pay better than the coasts (again, supply and demand and HMO infiltration on the coasts). As far as hospitalist compensation goes for the hospital employee vs the local private practice vs the national hospitalist corporation, that all depends on your hospital’s administration and how much they are willing to subsidize for the right to have 24 hour in house physicians at their hospital.
I know of several major hospital systems in Happy’s area that have struggled for years to get a hospitalist program up and running. The administrators at these hospitals have failed to understand what it takes financially to support a viable program with a long term commitment in mind.
What’s your best guage as to how happy you’re going to be with the hospitalist contract you sign? You have to find a group where everyone else is happy. And you do that by finding a group with many hospitalists that have many years of service within the organization. You want to find a group that has a strong core of dedicated hospitalists who have been around the block together. At Happy’s hospitalist group, we are now 18 doctors strong. Most of us have been together more than five years. Our group is only eight years old. Every year we lose folks who never intended to stay, and we gain folks who plan on staying forever. Eventually, we will have a cohesive group of doctors with every intention of staying together for life.
But to get there, you have to have the full faith and backing of an administration that understands what you bring to the table. It all starts with the administration of the hospital. I can’t stress that enough. Without the support of adminstration, most hospitalist programs would flounder. It’s WIN-WIN when both sides understand the symbiotic relationship they provide for each other. If your potential hospitalist opportunity is experiencing a high turnover rate (>10-15% per year) you need to understand why. The market in hospitalist medicine is a powerful one.
To remain competitive, programs must stay on their toes and understand what their competition is offering. Programs experiencing mass exodus of their members have, by default, failed to live up to the expectations of the hospitalist free market enterprise system. I can understand a hospitalist here or there leaving for a subspecialty fellowship. But a programs that consistently fail to maintain adequate staffing with a core membership of life long hospitalist physicians is a serious red flag institution in my book. This usually indicates either the work load is unbearable or the compensation is inadequate for the work being provided.
If you have the full faith and backing of a hospital’s administration, you are bound to succeed in a WIN-WIN relationship. And you can tell who’s got the backing and who doesn’t by how long the group’s core members have been together.
So let’s say you’ve found a tight knit group of hospitalists that have weathered the storm of rapid expansion by winning the recruiting wars. What do you want to make sure you get in your contract? Just some of the standard offerings these days:
- Health insurance of course
Retirement contributions, of course
Paid malpractice and tail coverage of course
Paid CME expense of course
Production incentives that are real and realistic
Time on and time off consistent with industry standards (2000 hours a year on average work schedule)
Paid vacation time may or may not be rolled into long stretches of time off
You can often negotiate moving expenses and a signing bonus (advanced payment) into your contract.
These are just some of the many standard benefits that come with today’s hospitalist contracts. Don’t get bogged down on the details and daily operations of the hosptialist program. Worrying about things like daily census is nice but don’t get turned off by programs that don’t cap or turn away patient referrals if the daily census numbers happen to get too high for a few weeks or months.
I am a firm believer that capping a hospitalist program destroys the value we bring to the table. If a doctor needs my medically necessary service, I want to be there to provide it for them. Our efficiency gains as hospitalists come by limiting our contacts, on average, but performing extremely well with those reduced numbers. We may not be able to pay for our own value in direct insurance compensation, but we more than make up for it on the back end with reduced length of stay, reduced resource utilization, improved nursing satisfaction, improved primary care referral patterns and word of mouth regarding excellence in quality care.
Hospitals that spend extra money on their hospitalists are rewarded on the back end when hospitalists can spend extra time to reduce length of stay and drive huge economic benefits to hospitals getting paid on the DRG platform.
Using 15-17 total daily encounters per FTE hospitalist as the benchmark, having administrators understand the value in maintaining that benchmark is imperative with respect to efficiency gains that are made by maintaining appropriately staffed hospitalist agreements.
Whichever practice environment you decide to park yourself in, remember, if your partners are happy and they’ve been there awhile, you too are likely to be happy as well. Happy’s hospitalist service is a testament to the cooperation that can be achieved for getting to WIN-WIN-WIN-WIN-WIN where hospitalists, other subspecialists, primary care doctors, nurses, patients and administrators all come out ahead.
The Happy Hospitalist is a board certified internist who works in the hospital and writes regularly on several blogs, including The Happy Hospitalist.
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