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Don't Commit to Overcommit


 

There is never enough time, unless you’re serving it. —Malcolm Forbes (1919-1990)

Has this ever happened to you? You agree—months in advance—to write an article for The Hospitalist, thinking you will have plenty of time to research and write it. You hurriedly enter the item on your calendar and turn back to all your current commitments. Later, as the date approaches, you realize that you’re running out of time to do justice to the article to which you had committed.

Psychologists have explored the common human problem of overbooking and have found many contributing dynamics. A 2005 study in the Journal of Experimental Psychology suggested one explanation: Most of us, when accepting invitations weeks or months in advance, tend to view the future as more open and less busy than the present. “The nature of time fools us and we ‘forget’ about how things fill our days,” comment study authors Gal Zauberman and John Lynch.1

How do hospitalists weigh competing demands on their time? For answers to this question, naturally we asked several already-busy hospitalists to discuss the issue. They shared some lessons learned and a few strategies for managing their most precious commodity.

For more information on career development topics, such as the ones presented herein, attend “Career Satisfaction: What You Need to Consider in Your Practice,” on Thurs., May 24, from 1:10-2:25, at the SHM Annual Meeting in Dallas.

No Mystery

“Many things take longer than they’re supposed to,” points out S. Trent Rosenbloom, MD, MPH, a former hospitalist and currently assistant professor in the departments of Biomedical Informatics, Internal Medicine and Pediatrics, and the School of Nursing at Vanderbilt University Medical Center in Nashville, Tenn.

His situation on the morning of our interview necessitated a reschedule due to a longer-than-anticipated smog check the afternoon before. “I told myself, next year, I’ll take care of this before the deadline,” he says. “But I always end up doing this at the last minute because everything else gets in the way.”

“This interview is another example: overcommitting once more,” writes Michael J. Hovan, MD, when he agrees via e-mail to a telephone interview about the problem of overscheduling. Like most hospitalists, Dr. Hovan works with a perpetually full plate. He is inpatient director for the Hospital Family Medicine Service and assistant professor at Mayo Medical School in the Division of Family and Community Medicine at the Mayo Clinic in Scottsdale/Phoenix. Like his colleagues, Dr. Hovan has had to struggle with juggling multiple roles.

“The hospital is a far different practice environment than it was just a few years ago,” he remarks. The high intensity of patient management is now coupled with increasing administrative complexities due to a more heavily regulated environment.

As a relatively new specialty, hospital medicine requires more attention in order to establish its visibility and viability. Dr. Hovan feels this pressure keenly because, as a family medicine hospitalist, he’s in a minority position. (The majority of hospitalists trained in internal medicine, according to SHM’s 2006 Annual Survey.2)

“It’s even more important for my department, in a tertiary academic center, to maintain a visible presence on particular committees,” he says. The result of all these necessary roles? “There really are no weekends or defined time off,” says Dr. Hovan. “I’d estimate that 20% of what I do is done ‘off the clock.’ I have taken the Mayo computers to Hawaii, to family ski vacations, and [to] far less exotic locales away from the hospital setting.”

“Medicine Is Stressful”

Mary A. Dallas, MD, formerly medical director of the hospitalist service and currently medical information officer for Presbyterian Healthcare Services, an integrated healthcare delivery network in Albuquerque, N.M., noticed certain trends when she was creating schedules with the hospitalist group.

“Things sound really good on paper,” she says. “The reality is, the intensity of work is high, and sometimes you forget about that when you’re creating schedules. You might have set yourself up for three overnight shifts in order to compress work hours and expand off-time, and by the end of the second shift, you are really tired.”

Another factor is that employers expect hospitalists to see patients until the end of their shifts, and that’s when the off the clock paperwork occurs. A 40-hour workweek can easily balloon into 50 hours or more.

Physicians may also neglect to build in the emotional toll of their jobs when blocking in future schedules. “Medicine is stressful,” comments Sylvia C.W. McKean, MD, FACP, medical director, Brigham and Women’s Hospital/Faulkner Hospitalist Service in Boston. “It’s stressful to see people suffer and to deal with families who are stressed and sometimes not perfectly functional.”

In addition, she says, “Excellence in teaching and excellence in patient care require communication, and communication takes time. If physicians are up all night taking calls and then working all day so that there is continuity in patient care, you have to grapple with the issue of physician fatigue.”

Triage What’s Important

Most of the hospitalists interviewed for this article advised other hospitalists to learn to effectively weigh the risks and rewards of taking on new commitments. Here are some techniques suggested for stemming overcommitment and avoiding potential burnout:

  • Dr. Hovan has taken on roles that, in isolation, could be accomplished effectively, but which, when combined with his other responsibilities, became diluted. “There comes a point,” he says, “where you really have to triage what is most vital and most important and say no [to some offers].” He points to the Mayo Clinic’s triple shields logo—“Patient Care, Education and Research”—as a test for his decisions about whether to accept invitations to lecture, to do research projects, or to provide education to residents from another program. “Patient care comes first,” he avers. “Any other commitment must be consistent with the advancement of patient care. That simplifies decisions.”
  • Dr. Dallas emphasizes synchronization of appointment books. Her pocket PC device is connected with her Outlook calendar so that entries update in real time. To prevent double booking, she advises blocking in social and family commitments, and she advises turning down committee meetings while on shift.
  • “A hospitalist shift trumps everything, and it’s useless to show up knowing you’ll get paged out of the meeting in two minutes. This frazzles and disrupts you—why do that to yourself?” She also inserts small blocks of travel time between appointments, especially if she is going to another building on the hospital campus, to avoid being late to important meetings.


    Dr. Baudendistel believes it is important to have well thought-out reasons when declining project invitations. A young hospitalist can leave the door open while saying no, he advises, by having a Plan B ready. In that way, a hospitalist can explain that the current offer may not be in his or her bailiwick—but that the idea is appealing—and can offer an alternative scenario. It’s crucial, especially early in one’s career, he maintains, that “you project a willingness to participate without foreclosing all options.”

  • Dr. McKean urges hospitalists to set goals within a three-year framework. “It’s very easy to just say ‘yes’ to everything and then become overwhelmed, working extremely hard, just to stay afloat. But if you instead have a three-year plan, then when you’re asked to do something, you can consciously say to yourself, ‘Is this in accordance with my plan? Is this going to make it easier for me to get to that three-year goal?’ ”—GH

And Then There Are Committees

Even though committee participation is technically considered “volunteer” time, physicians who are elected chiefs of their hospital sections are automatically expected to participate. It behooves hospitalists to participate in committee work at their institutions, believes Dr. Dallas, because this is often where governance decisions are made about how they will practice in the hospital.

Tom Baudendistel, MD, is associate residency program director at California Pacific Medical Center, a community-based hospital in San Francisco operated by Sutter Health. The hospitalists in his group are very involved in committee work. “The committees are important, and we want the administration to match our faces to our names, especially when it comes to budget negotiation time,” he explains. “That is a direct benefit of being visible participants in committees.”

Committee participation may be handled differently in purely academic settings. The time Dr. Rosenbloom spends in committees related to department support is credited to his work schedule. The problem comes when, once again, that participation takes more time than expected. One of his weekly committees routinely runs a half hour longer than its one-and-a-half hour time slot and requires five to eight hours of preparatory work. As is common with his peers, Dr. Rosenbloom has sometimes used his allotted consulting time to cover extra commitments related to his primary job.

Temptations to Say Yes

Invitations to participate in extra administrative or educational duties often naturally flow to productive people, observes Dr. Dallas. “You may be dragged into a lot of different work that you didn’t necessarily need to be into,” she says. “You just have to step back periodically and ask, ‘Is this right for me? Am I the right person to be involved? Are there other people who can do this? And then, say no. Really, that’s OK!” (See “Triage What’s Important,” p. 15, for tips.]

“It’s easy to get overloaded,” admits Dr. Baudendistel. “I certainly found myself overextended more often earlier in my career.” Saying yes to additional commitments can be related to workplace power dynamics, he believes. “When people who are in positions above you approach you about a project that is going to take time—whether or not it’s your passion or skill set—there is pressure to want to please that person. Saying no is a skill, and if you say ‘absolutely not’ early on in your career, you will not be asked to do other things. You may be shooting yourself in the foot.”

Defining Trails

It’s natural enough for hospitalists to feel optimistic about the openness of the future, says Dr. Hovan. Hospitalists may feel that the time investments they make now to nurture their profession within their institutions are temporary and may not always be as intense. The hope is that “the specialty is going to be more mature and [will] become more self-sustaining in the near future. Yet you glimpse over the horizon, and that’s not really true,” he says ruefully. “Everything in hospital medicine has nascency about it. There are no established trails. When we define one role, another one emerges.”

Many hospitalist services, for example, are now expanding beyond the medical floor to the surgical floor to perform consults to provide post-surgical management of medical issues.

Dr. McKean sees the “overwhelming demand for service” as one of hospital medicine’s trickiest challenges. “Basically, because hospitalists are young and energetic and wanting to please, it’s very easy for them to feel like they have to meet all the service obligations.” But this propensity can derail the overall mission of and vision for the hospitalist service if physicians do not set clear goals for themselves and their groups.

Physician, Know Thyself

Building in time to set and re-examine career goals is a skill that hospitalists should practice regularly, says Dr. McKean: “I learned the hard way that a hospitalist’s most important strategy is to be very self-reflective.”

She confesses that, in the past, she has often said yes to the point that her obligations became unmanageable. She advises young hospitalists to reflect on what is important to them and also “to recognize that during different times in their lives, they’re going to either have less free time or more free time, depending upon their families and other demands. So what might seem like a great opportunity might be an unrealistic one when you have three children under the age of five.” On the other hand, someone who is single might set a goal to make as much money as possible in the short term by taking on additional work shifts.

Dr. McKean also suggests that young hospitalists seek out not just one but multiple mentors. For example, “someone who wants to be a superstar in hospital medicine relating to quality improvement might naturally pick as a mentor somebody who is already doing quality improvement.”

A person who is having difficulty juggling family roles in addition to intensive work schedules might want to seek out someone who has … grappled successfully with those issues. Hospitalists should also consider seeking mentors outside the discipline of medicine—those in business, for instance, can contribute valuable insights to someone seeking a career in hospital administration.

Given the nature of hospital medicine, guarding one’s time will always be a concern, agree most of those interviewed for this article. “I think the juggling act is always there,” says Dr. Baudendistel. “There are usually up to six or more balls that you can simultaneously be juggling: administrative duties, family obligations, society commitments, teaching duties, your own academic agenda, and your professional agenda. You just have to know which ones are your priorities. And, sometimes, you have to acknowledge that maybe it’s time to say no or to stop doing one of those things.” TH

Contributing Writer Gretchen Henkel thanks the hospitalists who reshuffled their commitments in order to discuss overbooking with her and thanks her editor, Lisa Dionne, for the two extensions that allowed her to complete this assignment.

References

  1. Zauberman G, Lynch JG Jr. Resource slack and propensity to discount delayed investments of time versus money. J Exp Psychol Gen. 2005 Feb;134(1):23-37.
  2. Society of Hospital Medicine 2005-2006 Survey: State of the Hospital Medicine Movement. 2006. Available at: www.hospitalmedicine.org. Last accessed February 19, 2007.

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