No matter how big a hospital medicine group is, the leader is likely to say “but we need a couple more.” As the fastest-growing medical specialty in the history of American medicine, there never seem to be enough hospitalists (see Figure 1, p. 28).
“The programs are getting larger and larger, ranging anywhere from 20 to 100 physicians in a hospitalist group,” says Jeffrey Hay, MD, senior vice president of medical operations for Lakeside Systems Inc. in Los Angeles.
Because of this rapid growth, two questions become apparent:
1. How is a big hospitalist group defined?
2. What does it take to manage a big group well?
How Big is Big?
Although what constitutes a big hospitalist group is relative, Leslie Flores and her partner, John Nelson, MD, of Nelson/Flores Associates, LLC, La Quinta, Calif., estimate with about 20-30 hospitalists, the role of the medical director becomes a different job than for the typical-sized practice of 10-15 hospitalists.
According to SHM Executive Advisor to the CEO Joseph Miller, this year’s “Society of Hospital Medicine 2007-08 Survey: The Authoritative Source on the State of the Hospitalist Movement” revealed only eight groups with more than 40 hospitalists (excluding the multistate hospitalist management companies). In the approximate 2,200 hospitalist groups in the U.S., Miller estimates there are perhaps 40 groups with 40 or more physicians compared with two in the previous 2005-06 survey.
Medical directors of hospital medicine groups (HMGs) ranging from 22-100 people offer varied insights about how the role of medical director changes as groups grow from big to bigger to biggest.
Jeffery Kin, MD, medical director of the private-practice group Fredericks Hospitalist Group PC, manages 22 hospitalists, and about 130-140 inpatients and 45 admissions a day at Mary Washington Hospital in Fredericksburg, Va. They began as a team of three in 2000 as the outgrowth of a hospital house-doctor program.
“The medical director’s role changes and evolves with the growth of the group,” says Dr. Kin. He and other medical directors of larger groups find it more difficult to retain the informal shift arrival or departure and lunches together that were possible when the HMG was smaller. “Now that we are bigger it is more ‘protocolized,’” Dr. Kin says, “but we try to maintain a family-like atmosphere because I think it makes physicians want to stay with the group long term and not move on with every little problem or challenge that inevitably arises in the changing filed of hospital medicine.”
William Ford, MD, program medical director for Cogent Healthcare and the chief of hospital medicine at Temple University in Philadelphia, considers his group of 28 hospitalists to be a “small” big group. Dr. Ford’s group, which covers three of the four hospitals in the university health systems, grew from five hospitalists in September 2006. He devotes about half his time on personnel issues, including recruitment, retention, and staff development.
As groups grow, so does diversity, requiring more flexibility to manage leaves of absence, scheduling, and day-to-day practice. “In a large group we tend to bring on new measures,” Dr. Ford says. “We change like the wind, so if you aren’t ready for that, you will have a lot of turnover.”
Jasen W. Gundersen, MD, MBA, division chief, hospital medicine, University of Massachusetts Memorial Medical Center, Worcester, grew his HMG from 3.6 FTEs three years ago to the 47.5 FTEs (40 physician FTEs and 7.5 FTEs nurse practitioners) they now employ. The group, which covers four hospitals ranging from a 30-bed community hospital to a 770-bed academic hospital, is the biggest HMG in New England. “Our budget numbers for charges and volume are 2.19 times what we projected in the budget,” he says.