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Flexibility Is Key


 

When Manjusha Gupte, MD, had her second child, she realized that parenting and working full-time as a hospitalist was going to be too much.

“My husband is a hospitalist as well, so since there’s two in the family, we needed to get our time a little better situated with the kids,” she says.

She and another hospitalist, also a mother, approached their program director at Gaston Memorial Hospital, a busy community hospital in Gastonia, N.C., about going part-time.

Since then, the two physicians have shared a full-time job. Dr. Gupte works three or four consecutive shifts a week, two weeks a month. She still sees a full complement of patients—about 20 at a time—and she gets to spend more time with her daughter, 4, and her son, almost 2.

“Most hospitalist programs are scared,” Dr. Gupte says. “They think there won’t be continuity of care for patients, or it’s going to be disruptive to other doctors who are full-time. I have not yet heard of anybody complaining about continuity of care.”

Even though hiring part-timers and job-sharers raises these and other concerns, it’s increasingly important to offer this kind of scheduling flexibility, industry experts say.

“Hospital medicine, more than many other specialty, tends to attract people who care a lot about lifestyle,” says Leslie Flores, MHA, Nelson/Flores Associates. “A practice that isn’t willing to be flexible and consider part-time is sort of shooting itself in the foot.”

Before deciding whether to hire part-time or job-sharing hospitalists, there are many factors to consider, such as how to handle benefits and malpractice insurance and how to make sure a part-timer with a private practice doesn’t draw patients away from the hospital’s crew of referring doctors—intentionally or not.

There are benefits to the hospital: It’s easier to provide vacation and gap coverage, it’s less likely the full-time hospitalists will burn out, and in some cases, a part-time specialist can provide services the hospital didn’t offer.

“We’re real advocates of part-time hospitalists,” Flores says. “I think the benefits really outweigh the risks.”

Before You Hire

Questions to answer before hiring part-time or job-sharing hospitalists:

  • Does the hospital have a need for more flexibility in staffing?
  • Will the budget support the additions?
  • How would you use a part-time hospitalist? Will you have issues of continuity of care?
  • Will you require a non-compete agreement?
  • At what level will you offer benefits?
  • Will you have to pay as much malpractice insurance as if you were hiring a full-time hospitalist?
  • Do you have the support of your current staff?

Whom to recruit

  • A parent looking for fewer hours;
  • A resident or fellow;
  • A specialist who can offer extra service;
  • A respected local physician or leader in the medical community; or
  • A doctor in the prime of her career who wants a change from private practice. — LT

The Benefits

A part-time hospitalist can be anyone from a physician who cuts back to 75% of her hours so she can spend more time with her kids, to a resident or fellow who signs up for a few shifts a month. A job-sharer splits a full-time job with another physician, sometimes sharing office space and even a malpractice insurance policy.

Part-timers can free full-time hospitalists to participate on committees, conduct research, teach, attend a conference or seminar, take a sabbatical, or simply pursue outside interests, says Kenneth Simone, DO, who founded and served as director for 10 years of a hospitalist program in Maine. He is now president of Hospitalist and Practice Solutions, a consultancy, in Brewer, Maine.

“Also, they’re extremely helpful when the practice is in an expansion mode,” Dr. Simone says. “If they want to bring in two or three more referring providers’ practices, you can utilize the part-timers to help with the extra work so you don’t overwork your staff.”

Though it’s less common these days, a new hospitalist program may meet with resistance from local doctors. Offering those doctors part-time shifts can help ease the transition.

“They’re worried about what’s going to happen to their inpatient skills, what their patients may think, and their income,” says Steven Nahm, vice president of the Camden Group, a hospitalist consultancy and management company with offices in Chicago and El Segundo, Calif. As part-timers, these doctors keep current with inpatient care and can gauge the impact of the program on their practices.

A respected local physician who comes in part-time also lends credibility and gives medical staff a greater sense of confidence in the program, Nahm says. Dr. Simone calls these part-timers ambassadors.

One Example

The hospitalist program at Hudson Valley Hospital Center in Cortlandt Manor, N.Y., began in July 2005 at the request of local doctors. The program, Hospital Medicine Associates, contracts with the hospital and has its own billing system. It has eight full-time hospitalists, and as of about six months ago, four hospitalists sharing two full-time positions. They even share malpractice insurance because New York state law allows for half-policies. The part-timers work under pro-rated policies because they work fewer hours.

Allowing doctors to job-share seemed like common sense, says Richard Becker, MD, who leads the program.

“If you have good physicians, you want to keep them,” he says. “Having two doctors share shifts gives you flexibility. If one is sick or ill or on vacation, the other can come in and take care of it. You never have to worry about that position.”

While most programs have a few part-time physicians, it’s rare to see a program fully staffed by part-timers or job-sharers, Nahm says.

“Generally, they’re transition steps toward a program staffed by full-time hospitalists,” he says.

It can take more than a year to staff a program, especially for medical centers that aren’t in a city with a medical school. Now that more hospitals want to start hospitalist programs—and quickly—it helps to bring in part-timers to support an incomplete team, says Betty Abbott, chief operating officer of Eagle Hospital Physicians in Atlanta, Ga., a hospitalist consultancy that serves the southeast and Atlantic states.

“It used to be you had three to nine months to start a program, and now many people are saying, ‘We’d like to have it next Monday,’ ” Abbott says.

Some smaller or rural hospitals run part-time-only hospitalist programs because it’s the only option that makes economic sense, or because they have trouble recruiting full-time hospitalists. In these cases, part-timers can give a much-needed boost to admissions.

“The doctors typically in the community don’t want to work on weekends,” says Alan Himmelstein, FACMPE, president of Hospital Care Consultants Inc. (HCC) in San Antonio, Texas. “So if they see a patient in their office on a Thursday that has pneumonia, they will opt to either transfer to a bigger city, or treat the patient in an outpatient setting, which is not optimal. With the hospitalist there, the hospital can take that patient.”

Competition, Commitment

Two of the major concerns about part-time and job-sharing hospitalists are that they won’t be as committed to the program as other hospitalists, or that they’ll attract patients to their own private practice—away from referring physicians.

“This is a big factor,” Nahm says. “You should have a policy that a part-timer who has an outpatient practice cannot accept hospitalist patients into their practice for a period of at least one year. That’s the biggest concern for using part-timers, because they are a potentially competitive threat.” Even the suspicion that it might happen can be enough to persuade local physicians to refer their patients elsewhere. To ward off concerns, the hospital can implement a policy to instruct patients upon discharge to make an appointment with their primary physician. Some hospitals go so far as to book the appointments on behalf of patients.

“It gets tricky sometimes because patients may really like their hospitalist,” Flores acknowledges. Some programs bring in only part-time hospitalists who don’t have a private practice, or hire specialists who want to keep up their general medicine skills but aren’t a threat to primary care physicians. But what about levels of commitment?

“Part-timers, just by the nature of being part-time, aren’t as emotionally connected to the practice,” Flores says. “You don’t get the same level of buy-in, or maybe the same kinds of camaraderie.”

Dr. Gupte, the job-sharing physician at Gaston Memorial, says she and her partner may be even more focused and intense than full-time hospitalists because they know they have just three or four days to care for their patients.

“We just kind of go in and say, ‘Now I need to know this [and] this; this needs to be done,’” Dr. Gupte says. “I need to get them discharged in two or three days, what’s the plan? The weekend’s coming.”

To encourage commitment to the program, Nahm suggests including dedicated part-timers—those who work a significant number of shifts per month—in your productivity and quality compensation plan. Part-timers should also have the same orientation and training as full-timers, and be required to attend all hospitalist group meetings, Nahm says.

“One of the benefits of the hospitalist is that they know the ins and outs, the ups and downs of the hospital,” Dr. Simone says. “If I’m not going to the medical staff meetings and to my committee meetings, I’m not going to have adequate information—and that may make me less effective as a hospitalist.”

Continuity of Care

Job-sharing works well for Hudson Valley Hospital Center, but allowing physicians to come in for just a few shifts a month doesn’t sound as appealing, Dr. Becker says.

If a hospital uses part-timers only sporadically, “that opens the chances for errors and for patient dissatisfaction,” he says.

To counter this, a hospital might hire only part-timers who can work consecutive shifts. Or it might use doctors who are available sporadically to support the program other ways.

“Dr. A is willing to provide 12 shifts per month but only wants to work two or three days a week,” Dr. Simone says. “You probably want to utilize him or her as an admitting doctor or a float, not a rounder, since patient continuity may be negatively affected.

“Dr. B is willing to provide 12 shifts per month and doesn’t mind working several days in a row; for example, six or 10 or 12 consecutive days. That schedule offers wonderful continuity, and this provider can be utilized as a rounder, following patients from admission through discharge.”

Even physicians who fill in only when volume is high—perhaps in four- or six-hour shifts in the evenings or on weekends—can benefit some hospitals, Abbott says; that support might make it easier to recruit full-timers.

Johns Hopkins Medicine in Baltimore supplements its nine full-time hospitalists with part-timers.

“The nature of our job is such that it’s fairly easy to coordinate that,” says Daniel J. Brotman, MD, FACP, director of the hospitalist program there. “It creates sort of auxiliary staffing.”

The hospitalist program at Johns Hopkins started in 2002. Part-timers tend to work nights and weekends and get a lot of flexibility; they sign up for shifts instead of working a guaranteed schedule. Continuity of care is rarely an issue because full-time staff provides that, Dr. Brotman says.

“We divide labor into somebody who’s doing admissions and someone who’s taking care of the patients day to day,” he says. “The person who’s doing admissions can be anybody who’s competent to do so and doesn’t need to be someone who’s available the next day to take care of the patients.”

So far, hand-offs have been smooth, Dr. Brotman says, partly because the transfer of information about Hopkins’ complex tertiary-care patients is thorough by necessity. While good communication is important for all hospitalists, it’s especially important for part-timers and job-sharers, Dr. Simone says. In addition to requiring thorough notes and communication, he suggests finding out ahead of time whether a part-timer will be available to answer questions during off hours.

“Are they flexible so they can come in a heartbeat if you need them?” Dr. Simone says. By the same token, referring physicians have to commit to doing a verbal hand-off to the hospitalists, and hospitalists have to commit to sending a report when the patients are handed back, Abbott says.

When HCC tried establishing a hospitalist program that covered only weekend shifts, Himmelstein says, tight turnarounds on Monday mornings and spotty cell phone service in rural areas made it too hard to coordinate hand-offs.

Other Issues

There are other factors to consider before bringing in full-time hospitalists or job-shares, such as billing.

“They’re working as a hospitalist for a week, and one of their private patients comes in to be admitted,” Nahm says. “Are they seeing that patient as a hospitalist or are they seeing that patient outside of the program, as their own patient?”

The same issue can come up with a pulmonary or infectious disease specialist, for example. If she consults on other patients during her shift, is she doing so as a hospitalist or in her private practice?

“I find it best if you just take the philosophy that you’re buying this physician’s time, and anything this physician does on the clock for you is considered a service of the hospitalist group—and all billing and collection and revenue, in other words, go back to the hospitalist group,” Nahm says.

Also, a part-time hospitalist may face competing demands for his or her time.

“Sometimes they come in and they’re lacking focus because they’re tired—they’ve been up all night moonlighting in the ED,” Dr. Simone says. “Or they pace themselves because they know tomorrow and for the next four days, they’re on call for their private practice.”

Despite the practical issues part-timers bring, Dr. Simone points out, they tend to increase a program’s flexibility and efficiency, allow the hospital to offer more value, lower burnout, and increase job satisfaction.

Dr. Gupte wants more programs to start hiring part-time hospitalists—especially to help families like hers, where both parents are busy physicians.

“I think that makes a big difference in family care,” she says. “People sometimes think that we won’t be as intense or as focused when you’re doing the part-time thing. I don’t think that’s true.” TH

Liz Tascio is a freelance journalist based in New York City.

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