Editor’s note: This is the first of a two-part series addressing large HM group issues.
In the mid-1990s, when I first became interested in how other hospitalist groups were organized, I started surveying by phone all the groups I could find. It was really unusual to find a group larger than four or five full-time equivalent (FTE) hospitalists. Since then, the size of a typical hospitalist group has grown steadily, and data reported in SHM’s “2007-2008 Bi-Annual Survey on the State of Hospital Medicine” shows the median number of FTE physicians in HM groups is 8.0 (mean of 9.75). So in just a few years, our field has grown in such a way that half of all groups in operation now have more than eight physician FTEs. I think most future growth in numbers of hospitalists will be due to individual practices getting larger, rather than new practices starting up.
I work regularly with groups that have more than 20 FTEs, and I have found that large groups tend to have a number of attributes in common.
Separate Daytime Admitter and Rounder Functions
Large groups almost always staff admitter and rounder functions with separate doctors around the clock. That means patients arriving during regular business hours are admitted by a different doctor (the admitter) than the doctor who will provide their care on Day Two and beyond (the rounder).
Although such a system is popular, I suggest every group challenge itself to think about whether it really is the best system. Most groups, regardless of size, have about a quarter to a third of their new admits and consults arrive between 7 a.m. and 5 p.m. If the group did away with a separate admitter during the day and moved all daytime admitters into additional rounder positions, all the daytime admissions could be rotated among all of the daytime doctors, and those patients would typically be seen by the same hospitalist the next day. That would improve hospitalist-patient continuity for the patients who arrive during the day, which might improve the group’s overall efficiency as well as quality and patient satisfaction. Each rounder would become responsible for seeing up to three new consults or admissions during the course of the daytime rounding shift, and the list of new patients to take over each morning—patients admitted by the evening and night admitters—would be smaller.
Of course, one significant benefit of having a separate admitter shift during the day is relieving the rounding doctors of the stress of interrupting rounds for an unpredictable number of new admissions each day. And if the new admissions arrive in the morning, throughput may suffer as it might mean the rounding doctor may see “dischargeable” patients later in the day.
I think there is room for debate about whether it is best for large groups to have a separate admitter during the day, but whatever approach a group chooses, it should acknowledge the costs of that approach and not just assume that it is the only one that is feasible or reasonable.
Who Is Caring for Whom?
The larger the hospitalist group, the more difficulty nurses and other staff have understanding exactly how patients are distributed among the doctors. When one hospitalist rotates “off service” to be replaced by another the next day, or when overnight admissions are “picked up” by a rounding doctor the next morning, it can be difficult for nurses to know which hospitalist is responsible for the patient at a given moment.