Medicolegal Issues

Group Growth


This is the last article in a series on the four pillars of career satisfaction in hospital medicine.

What kind of support do you get from your hospital medicine group? From your hospital? How cohesive is your group? Do these things really matter?

The answers can be found in the SHM white paper “A Challenge for a New Specialty: A White Paper on Hospitalist Career Satisfaction” (available online at SHM’s Career Satisfaction Task Force (CSTF) drafted the document to be used by hospitalists and hospital medicine practices as a toolkit for ensuring or improving job satisfaction. It outlines the four pillars of career satisfaction: autonomy/control (see the June edition of The Hospitalist, p. 14), workload/ schedule (July edition, p. 10), reward/ recognition (August edition, p. 10), and community/environment. This article looks at the last of these.


Does Pay Influence Performance?

The Physician Compensation Research Project, conducted by investigators at the University of Washington School of Public Health and Community Medicine, Seattle, examined how different methods used by managed care organizations to compensate primary care physicians affected the utilization and cost of healthcare services, as well as physician productivity.

Contrary to their expectations, the investigators found that the method of compensation for physicians, whether fee-for-service or salary, had a negligible effect on treatment decisions for patients. Their research also showed that physician compensation methods tied to productivity increase individual productivity.

An Inside Opinion on Burnout

“Hospitalist Careers: A Field of Growing Opportunity” by Niraj L. Sehgal, MD, MPH, assistant professor of medicine at the University of California, San Francisco, and Robert M. Wachter, MD, professor and associate chairman of medicine at UCSF, states: “One of the factors that could contribute to hospitalist burnout is a mismatch between optimal staffing and patient volumes. A hospitalist caring for too many patients may generate more clinical revenue, but at the cost of prolonged patient hospitalization, since the hospitalist cannot take the steps to facilitate a timely discharge under such circumstances. Another potential contributor to hospitalist burnout is the ever-increasing expectations of employers, hospitals, consultants, primary care physicians, and payers. … These expectations, though validating the need for hospitalists, also increase risk for burnout if not managed carefully and proactively.”

The article appeared in the January 2007 issue of Resident and Staff Physician.—JJ

The Fourth Pillar

Hospitalists belong, in some sense, to four communities and must address the expectations of each group: administration, referring and nonreferring physicians, house staff and other healthcare staff, and medical students.

The hospitalist’s community includes his/her practice as well as hospitalists from other groups. The patient community is not just patients and their family members, but the broader public community served by the hospital medicine group and the hospital. The home community, consisting of the hospitalist’s family and friends, is also a vital part of the individual’s environment.

Each of these communities contributes to job satisfaction. A sense of shared values and connection with others, as well as social and work support, can ensure satisfaction; a sense of isolation, lack of support, and unresolved conflict can lead to unhappiness with a job.

Working within a strong community “makes everything else easier,” says CSTF member Noah Harris, MD, a hospitalist at Presbyterian Hospital, Albuquerque, N.M.

“Twenty years ago, there was a medical community in hospitals where physicians came together,” recalls Dr. Harris. “With managed care, physicians have become much less invested in the hospital and you see fewer [primary care] physicians there. Hospitalists have filled that gap. The question is how to restructure the hospital medical community.”

A hospitalist might struggle with the issue this way:

“I’m one of only three hospitalists at a hospital in a rural community. I feel it’s important to work as a team with primary care physicians, the emergency department, and other medical subspecialists.”

“How do hospitalists come in as the new kid on the block and reach out to other physicians?” asks Dr. Harris. “This is important, and if hospitalists feel like they’re more a part of the community, then that makes [their work] easier.”

According to Dr. Harris, the key to building a community in your workplace is communication. Strengthen it or establish it where there is none. When you communicate, focus on common goals with the other parties.

“Community has to do with shared expectations,” Dr. Harris points out. “Everyone—particularly the various types of physicians in the hospital—has to know what they expect from hospitalists.” It may be up to individual hospitalists to educate others as to what those expectations should be.

Of course, communication should start at the top. “On one level, there has to be formal communication with administrators and [physician leaders],” says Dr. Harris. “There has to be some sort of ongoing communication with the hospital administrators because they work with all the other groups as well.”

However, less formal communication is up to the hospitalist. The more you communicate with others, the more you’ll build your community.

Here are tips for how the hospitalist in the aforementioned example might work with each group of physicians:

ED doctors: “This hospitalist needs to get to know the other physicians and healthcare professionals,” Dr. Harris advises. “Make yourself available. When you have a minute, go down to the emergency department to update the ED physicians on admissions they’ve seen. Make a point to chat.”

Primary care physicians (PCPs): It may be more difficult to initiate informal communications with these docs if they’re not often in the hospital.

“One thing that helps is for the hospitalist to focus on communicating by phone, fax, or e-mail to PCPs when their patients are in the hospital,” says Dr. Harris. “In our office, we assigned a secretary to make sure PCPs get discharge summaries. That really helped with the community.”

If you want to strengthen ties to your community PCPs, issue an invitation to an event. “Our group would have an annual holiday party and invite all our referring physicians,” says Dr. Harris. “We’d have a speaker and get to know each other a little better.”

Surgeons: Dr. Harris suggests hospitalists can guide surgeons’ expectations for their working relationship with you and strengthen a sense of community.

“If there’s a particular issue, you can use that,” says Dr. Harris. “We were seeing a lot of elderly patients admitted with hip fractures. One thing we did to get a working relationship [with orthopedic surgeons] is we came up with a set of orders for these patients. The surgeons welcomed this because they wanted help with elderly patients who had multiple conditions. This was a way to work with them in a kind of formal way that helps patients. “It’s good to come up with order sets, but the big part of this is the negotiation with the other physicians that leads up to the order sets,” Dr. Harris says.

If you’re doing something like this to help in obstetrics, neurosurgery, or orthopedics, make it a two-way conversation.

“Above all else, it’s important to work with nonphysician healthcare workers,” says Dr. Harris, “especially nurses and physical therapists.”

The Rural Factor

The example above involves a small hospital medicine program in a rural area. Are there built-in problems with building community in this environment?

“I don’t think [it’s] necessarily more difficult” to build community in this setting, says Dr. Harris, “particularly if the hospital and physicians are on board with bringing in hospitalists. They might even be easier because you have fewer folks to deal with.”

But there may be an underlying problem with working at a smaller hospital. “If you’re the only hospitalist, or even the only hospitalist on a given shift, you’re practicing in a vacuum,” says Dr. Harris. If this is the case, you can broaden your hospitalist community by establishing a network with nearby hospitals and/or hospital medicine groups, and by becoming active in a regional or national group. TH

The White Paper Online

“A Challenge for a New Specialty: A White Paper on Hospitalist Career Satisfaction,”

is available for download at under the “News” section. The white paper, prepared by SHM’s Career Satisfaction Task Force in December 2006, details the four pillars of job satisfaction. Find more information on guiding your career at SHM’s Career Center ( Browse opportunities and post or view resumes.

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