Practice Economics

Tips for Hospitalists on Spending More of Their Time at the Top of Their License


I think arranging post-hospital appointments should be no more difficult for the hospitalist than ordering a CBC.

Image Credit: SHUTTERSTOCK.COMI think arranging post-hospital appointments should be no more difficult for the hospitalist than ordering a CBC.

Hospitalists spend too little time working at the top of their license. Put differently, I think a hospitalist often spends only about 1.5 to two hours in a 10- or 12-hour workday making use of the knowledge base and skills developed in training. (I wrote about this and referenced some hospitalist time-motion studies in my December 2010 column.)

The remaining hours are typically spent in activities such as figuring out which surgeon is on call and tracking her down, managing patient lists, filling out paper or electronic forms, explaining observation status to patients, and so on.

When I first became a hospitalist in the 1980s, there was already a lot of talk about the paperwork burden faced by doctors across all specialties. I recall the gnashing of teeth that ensued—lots of articles and seminars, and it seems to me even a few legislative proposals, focused on the topic. It appears that nearly every recruitment ad at the time mentioned something like “Let us take care of running the business, so you can focus solely on patient care.” Clearly, doctors were seeking relief from the burden of nonclinical work even back then.

I can’t recall reading or hearing anyone talk about the “paperwork” burden of physician practice in the past few years. This isn’t because things have gotten better; in fact, I think the burden of “non-doctoring activities” has steadily increased. We hear less about the problem of excessive paperwork simply because, more recently, it has been framed differently—it is now typically referred to as the problem of too little time spent practicing at the top of license.

Search the Internet for “top of license” and a number of interesting things turn up. Most are healthcare related—maybe other professions don’t use the term—and there are just as many links referring to nurses as physicians. Much is written about the need for primary care physicians to spend more time working at the top of their license, but I couldn’t find anything addressing this issue specifically for hospitalists.

What Can Be Done?

Moving your work as a hospitalist more to the top of your license isn’t a simple thing, and our whole field will need to work on this over time. The most effective interventions will vary some from place to place, but here are some ideas that may be relevant for many hospitalist groups.

Medication reconciliation. I fully support the idea of careful medication reconciliation, but, given that such a large portion of hospitalist patients are on so many medications, this is a time-consuming task. And, in many or most hospitals, the task suffers from diffusion of responsibility; for example, the ED nurse makes only a half-hearted attempt to get an accurate list, and the hospitalist believes that whatever the ED nurse entered into the record regarding patient medications is probably the best obtainable list.

A pharmacy technician stationed in the ED and charged with recording the best obtainable list of medicines on patient arrival can address both of these problems (for more information, the American Society of Health-System Pharmacists offers webinars and other resources on this topic). This would include calling family members, pharmacies, and physician offices for clarification in some cases. Hospitalists working in such an environment nearly always say it is extremely valuable in reducing inaccuracies in the pre-hospital medication list, as well as saving hospitalists time when they are admitting patients.

Unfortunately, hospitals may resist adding pharmacy technicians because of the expense or, in some cases, because of concerns that such work may exceed the legal scope of work for technicians.

Post-hospital appointments. I think arranging post-hospital appointments should be no more difficult for the hospitalist than ordering a complete blood count (CBC). It shouldn’t matter whether I want the patient to follow up with the PCP he has been seeing for years, or see a neurologist or diabetes educator as a new patient consult. Any treating doctor in the hospital should be able to arrange such post-hospital visits with just a click or two in the EHR, or a stroke of the pen. And the patient should leave the hospital with a written date and time of the appointment that has been made for them.

Few hospitals can reliably provide this, however, so, all too often, hospitalists spend their time calling clerical staff at outpatient clinics to arrange appointments, writing them down, and delivering them to patients. This is far from what anyone would consider top of license work. (I wrote a little more about this in last month’s column.)

Medicare benefits specialist. Many hospitalists end up spending significant time explaining to patients and families the reason a patient is on observation status and trying to defuse the resulting frustration and anger. As I stated in my November 2014 column, I think observation status is so frustrating to patients that it is often the root cause of complaints about care and, potentially, the source of malpractice suits.

Physicians have an unavoidable role in determining observation versus inpatient status, but I think hospitals should work hard to ensure that someone other than the doctor is available to explain to patients and families the reason for observation status, along with its implications, and to provide sympathy for their frustrations. This allows the doctor to stay focused on clinical care.

Limit reliance on a “triage hospitalist.” Hospitalist groups larger than about 20 providers often have one provider devoted through much of a daytime shift to triaging and assigning new referrals across all providers working that day. For larger practices, this triage work may consume all of the provider’s shift, so that person has no time left for clinical care. It is hard for me to see this as top of license work that only a physician or advanced practice clinician can do. In my December 2010 column, I provided some potential alternatives to dedicating a physician or other provider to a triage role.

Your list of important changes that are needed to move hospitalists toward more time spent working at the top of their license will likely differ a lot from the issues above. But every group could benefit from deliberately thinking about what would be most valuable for them and trying to make that a reality.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at

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