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One Size Does Not Fit All


When it comes to hospital medicine groups, size matters. Some physicians, like Jeffrey Hay, MD, senior vice president for medical operations and chief medical officer at Lakeside Comprehensive Healthcare in Glendale, Calif., say larger groups (i.e., those with 20 or more physicians) have the advantages of financial stability, better advancement opportunities and more support for physicians.

But Dr. Hay also sings the praises of smaller groups. A small hospital medicine group (HMG) can be a niche for those who seek particular geographic ties and a long-term commitment, he says.

Then again, a big hospital in an affluent coastal area of California, for example, has had a long-term relationship with its hospitalist group for more than 10 years. “The [hospitalists] made a decision,” Dr. Hay says. “They want to be there, they want to work and retire there. This is it; and it works for everybody.”

Which size works for you? The Hospitalist asked physicians who have experience with both large and small groups to comment about salary, shift coverage, advancement and research opportunities, and social networking. Perhaps their answers can help you decide.

Salary Expectation

Working at a smaller institution doesn’t necessarily mean receiving lower compensation, says Joe D. Metcalf II, MD, director of the five-physician HMG at Faith Regional Health Services in Norfolk, Neb. “Because recruiting hospitalists to any location is competitive, most recruiters understand they must offer a competitive salary and benefit package to their applicants.”

Salary discrepancies could, however, stem from geographic location of the group, differing workload expectations, or level of market saturation, says Brian Bossard, MD, director of Inpatient Physician Associates in Lincoln, Neb. “Salaries are increasing rapidly because of a rapid increase in the number of groups around the country,” he says.

In its annual survey of programs around the country, the Society of Hospital Medicine documents the normal salaries for different hospital medicine practices. The latest survey suggests the large-chain, independent groups have the highest average salaries. One factor affecting salary is the location: the farther away from an urban area a practice group is, sometimes the greater the salary because of added recruiting difficulties.

As a hospitalist moves from a small group to a large one, interest in the characteristics of an individual physician may be diminished. “The ability to negotiate a better salary by being a ‘good Joe’ is less important in a large group than in a small one,” Dr. Bossard says. In addition, fringe benefits of a small group might not be available in a larger group; in Dr. Bossard’s group of 20 hospitalists, an extra bonus is awarded as an end-of-the-year thanks for hard work. “That’s not part of contract, there’s no qualification for that except being a good member of the group. I doubt that would not happen in a large group,” he says.

If you are considering joining a large HMG, Dr. Hay suggests asking what role you will play in the direction of the organization and whether the possibility exists for eventual partnership or equity in the company.

The Right Size-Related Questions

John Vazquez, MD, a hospitalist at Emory University Hospital in Atlanta, suggests asking the following questions during the interview process:

1. How many people are in the group? What’s your rate of growth? Fewer than four hospitalists mean more frequent—but easier—night shifts. Not bad, if you want to earn money in your sleep.

2. Do you have a day admitter? No admitter means more interruptions. With an admitter covering admissions and codes, the day-team hospitalists can leave early when service is slow. When busy, the admitter can help out. However, a larger hospitalist group with an admitter usually experiences busier night shifts.

3. Is there a swing-shift person? Most any hospitalist will work some nights. A swing-shift person, someone who comes in during heavy hours in the afternoon to night, can cross cover and coordinate, so there is extra coverage until midnight. Having this role within a group means working more evening shifts, but easier night shifts. It also allows the hospitalist day teams more flexibility.

4. Can I work only nights if I want to? By asking this question, you’re essentially asking to be a “nocturnist.” Hospitalists who don’t like the hassle of dispositioning day patients may enjoy seeing patients at night. If you’re willing to work this shift, you may be able to negotiate a better salary and have more power to form your own schedule.

5. How many patients will I be expected to see? Consider your comfort level. Remember, smaller programs do not always have smaller patient census per hospitalist. Also, in small hospitalist groups, fewer total doctors share the increased numbers of a growing practice.

6. May I talk to other hospitalists before I make my decision? It’s important for hospitalists to have similar styles. Go out of your way to find out how the group is structured and what the work is really like.

7. Is there a case manager? If your patient load will be high, a case manager can help increase patient satisfaction. Some small hospitals do have operational supports, but it depends on the institution.

8. How difficult are your patients to disposition? If you will be working somewhere that sees a large charity population and there is no umbrella coverage, expect some difficulty in getting patients to follow up.

9. What is the incentive (bonus payment)? Will you be paid by the patient, quality initiatives, patient satisfaction ratings? This is important information to know ahead of time.

10. What is the extent of subspecialist support? Some hospitals have one number to call for consults on all incoming patients. Smaller hospitals typically don’t have such central coordination.

Shift Coverage

Ease and availability of shift coverage varies greatly between small and large groups. In the latter, for example, physicians experience a good deal of schedule flexibility because more people can cover shifts or do the work. When Donna Beeson, DO, a hospitalist at Kadlec Medical Center in Richland, Wash., worked at the large St. Luke’s Health System in Kansas City, Mo., she had help in most aspects of practice.

“There was interventional radiology for all procedures, eICU [technology] to help with intensive care patients, a more experienced ancillary staff available for emergency situations, more partners to help out when your load gets to be too much,” Dr. Beeson says. She also had strong ancillary support at St. Luke’s, where three nurses were available to the HMG at all times.

Having so many people, however, prevented Dr. Beeson from learning her staff’s strengths and weaknesses. That’s where a smaller group has its advantages. What it lacks in physician and staff availability, it makes up for in operating as a cohesive unit, Dr. Metcalf says. “A small group of physicians is more likely to be more relationally connected and, therefore, more willing to provide help to their colleagues when special needs arise and patient-care assistance is needed,” he says.

The hospital medicine group at Riverside Tappahannock Hospital in Tappahannock, Va., exemplifies the small, cohesive group. Randy Ferrance, MD, medical director there, says having a small group made it easier to work out a three-weeks-on, one-week-off schedule (necessary because the physicians sometimes work 100-hour weeks).

In addition, though there are fewer hands in a smaller program, certain tasks, such as X-rays, reports and lab tests get accomplished with fewer hiccups. Plus, knowing the staff’s idiosyncrasies means understanding when a matter needs immediate attention or when it can be addressed later.

Dr. Beeson believes this phenomenon has made her a stronger doctor. “You know that you cannot always rely on someone else,” she says. “You realize that you have to do something or you have to make the diagnosis, because the consultant may not [do so] and you do not have a willing IR staff to help you with procedures.”

That means wearing many hats, an aspect of working in a small HMG that Dr. Ferrance says he loves. “I get to treat a lot of clinical cases that in a large hospital, a specialist might be called in to treat, whether that is necessary or not.”

One drawback to a smaller HMG is the difficulty transferring patients to bigger hospitals. It is more time consuming and challenging, Dr. Beeson says, and you lose the ability to follow through with a patient to the end of a diagnosis or disease process.

Advancement and Research Opportunities

It may seem like a no-brainer that opportunities for research and career advancement exist more within larger groups. This isn’t always the case, however, says Brian Wolfe, MD, a hospitalist with Cogent Healthcare who practices at Temple University in Philadelphia. “The ability for a group to offer protected time to do research may be more linked to the setting and schedule than whether a group is large or small.”

Of course, it doesn’t hurt to work at an institution that conducts a good deal of research, such as UMass Memorial Medical Center in Worcester Mass. Elizabeth Gundersen, MD, a hospitalist there, says she enjoys the large group’s abundant opportunities to participate in quality projects in areas of medicine that interest her. “I also enjoy having a large and diverse group of colleagues,” she adds. “I get to interact with my fellow hospitalists during the workday, whether it is to bounce ideas off them or just to socialize. There is a great amount of energy within the group.”

On the other end of the spectrum, hospitalists at smaller HMGs may have fewer hoops to jump through to get projects approved. “A smaller institution is often more amenable to the introduction of change,” says Dr. Metcalf, of Faith Regional Health Services, “which may be attractive to a hospitalist who has an interest in medical processes, quality and safety.” Dr. Ferrance adds, “We have very tight control of the hospital’s quality control because there are only four people who have to buy into a policy.”

Plus, a hospitalist at a smaller HMG quickly can establish a strong reputation, “which, in turn, provides venues for influence through involvement in committees,” Dr. Metcalf says. “An interested physician may be offered a position as a committee chairman, chief of medical staff or even as the vice president of medical affairs.”

Social Networking

In any sized group, social networking is key. Before joining the group at Temple, Dr. Wolfe thought physicians in a smaller group would automatically be closer than those in a large one. “I was surprised that we are so inter-relationally dependent and responsible to each other,” Dr. Wolfe says, “but that’s because there are so many inter-service hand-offs and trade-offs, and we see each other so much.”

Scheduling social events for 20-plus doctors and their families can be a challenge. Some, like Dr. Bossard, say it’s a priority, though it could mean orchestrating events for 75 people. “When that social connection is lost in a group,” Dr. Bossard says, “it may reflect burnout on the leader’s part.”

What is most important for any group, no matter its location or size, is having a forward-thinking leadership with operational expertise and a strong infrastructure. “If they don’t have that,” Dr. Hay says, “they may get displaced by big organizations, leaving the hospitalists locked out and scrambling for jobs.” TH

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