At sold-out HM09 in Chicago in May, I had the pleasure of moderating a panel discussion titled “Who Says 15 Patients a Day is the Right Number?” As you might guess, each panelist (including me) said, in effect, “No one says 15 patients a day is the right number.”
Despite being a very important issue to SHM, the society doesn’t have an official position on the “right” or optimal daily patient volume or workload for a hospitalist. SHM generates and disseminates a lot of information to help each practice make decisions about workload, including SHM’s 2007-2008 “Bi-annual Survey on the State of the Hospital Medicine Movement,” articles available at www.hospitalmedicine.org, and articles in The Hospitalist. But all practices, and individual hospitalists, will have to decide what level of patient volume enables safe care, a sustainable and satisfying workload, and reasonable economic performance.
A problem that makes any workload discussion difficult is that many terms are sometimes used to mean different things. For example, “daily census” is used when comparing workloads between practices, but “daily encounters” is nearly always a more informative metric. Remember, daily encounters for a practice will always be higher (though on rare occasion, the same) than daily census.
The only definition of encounters that can be reliably compared between practices is billable encounters. Confusion arises when one person is reporting billable encounters, and another person is counting as one encounter each time a hospitalist interacted with a patient (e.g., went into the patient’s room or made a chart entry) and reports a higher encounter volume despite having the same workload and patient volume. Of course, billable encounters fail to perfectly describe our workloads, but until someone comes up with a better metric that is universally understood and applicable across all settings, billable encounters is the best metric we have.
Both billable encounters and census can be tricky. We might be convinced that because she averages 17 billable encounters per day, Dr. Krause has a higher workload than Dr. Palmer, who averages 15. But it turns out that Dr. Palmer works 210 shifts annually, generating 3,150 annual encounters; Dr. Krause’s 181 annual shifts generate 3,077 encounters. So while Dr. Krause does indeed work harder on the average day, she has lower annual productivity. My experience is that by failing to compare workloads over long periods, such as a year, many attempts to compare workloads yield misleading conclusions.
Comparing encounter volume from one practice to the next fails to capture other ways workloads differ. Dr. Krause may be the principal caregiver for a number of ICU patients; Dr. Plant might turn such patients over to intensivists. For this reason, work relative value units (wRVUs), which attempt to capture the complexity of each encounter, usually are a more meaningful—though still imperfect—metric.
Apples vs. Apples
Any truly valid method of comparing workloads should sum the annual workload for the entire practice and divide by the total provider full-time equivalents (FTEs). Yet problems arise because night shifts usually are less productive than day shifts. Consider a practice that has a distinct night shift worked by a doctor who does no day-shift work the day before or after. There is a tendency to leave this night shift out of the analysis of average workload per FTE, which makes the practice appear more productive than it really is.