Case in Point
Let me briefly illustrate with a hypothetical example from an outpatient primary care practice. Doctor A opens a solo office and decides to work 4.5 days a week and see 22 patients each day (11 on the half day). He’s chosen this workload because it seems reasonable, safe for patient care, and rewards him with what he regards as a reasonable salary. In other words, he feels like he has found the sweet spot for workload and income (productivity and compensation).
Dr. A then recruits a partner, Doctor B, whom he pays the same salary as himself and tells Dr. B he must work 4.5 days a week and see the same patient volume as he does. Dr. B is able to conform to this, but isn’t so sure he’s working in his own productivity and compensation sweet spot. Over the next few years the group grows to 10 doctors, all making the same salary, working 4.5 days a week, and seeing the same number of patients each day.
Are all 10 doctors in this practice likely to be happy with their workload? I don’t think so. I’d recommend they look for a way to let each individual doctor decide independently (within some broad boundaries) to work different amounts, varying the number of days worked, or daily patient workload.
A single parent might work only three days a week when childcare is available; an energetic doctor might decide to work five full days a week, and so on. In fact, this is how most private primary care practices operate. And they do this despite complicated decisions about how to allocate overhead between doctors with different levels of productivity, an issue that is usually much less difficult for hospitalists than primary care offices.
But a significant number of hospitalists are in a practice that looks like Dr. A’s. They’re hired at a predetermined salary and then are urged, or required, to see a specified number of patients and work a specified number of days or shifts. A great deal of effort often goes into getting each doctor to handle a workload that is similar to others in the practice. This patient volume/workload target is usually vague until the hospitalists want to add a new doctor and the employer must be convinced the doctors are working very hard. At this point the SHM survey data and other tools often come into play, and patient volume expectations become much clearer through what is often a somewhat unpleasant negotiation.
So if you’re in a situation where a hospital executive or other employer decides the appropriate patient volume for you, think about changing to a compensation system that enables you to decide for yourself the sweet spot between patient volume, days or shifts worked (time off), and income. Most employers—especially hospital executives—are delighted to switch to production-based compensation and let you decide for yourself how many patients you see.
Switching to a salary based significantly—or entirely—on production often raises a number of questions that, again, I’ll address in a future column. But my point here is that it can be quite liberating because it lets you make your own decisions about productivity. It might be the thing that allows each member of your group to decide, within some generous boundaries, just how hard he or she wants to work. And the group as a whole can decide more independently when additional doctors should be added.
I encourage each group to operate in a way that maximizes individual doctors’ ability to decide where the patient volume sweet spot is—whether through a production-based salary or other methods. Don’t let this decision be based too heavily on things such as survey data and the decisions of hospital executives.