Career

The Devil & the Details


 

Act I: The Negotiation

(A barren academic office, dimly lit, the pall of difficult negotiations afloat, backlit like dust in the air. Seated, under a strangely intense incandescent bulb, a man, who looks eerily like a good-looking version of me, sits uncomfortably adjusting himself in his seat. His eyes constrict on his counterpart, a miserly sort peering out from behind wire-rim glasses and a shock of hair improbably combed over from ear to ear. The tension crests.)

GOOD-LOOKING ME

(Voice cracking)

I’ve come to ask for a raise for our hospitalist group.

MISER

(Adjusts his clip-on tie)

We just gave you a raise in 2004.

GOOD-LOOKING ME

(Smiles uncomfortably)

That was very gracious, sir, but I think the numbers support another.

MISER

(Incredulous look at his watch)

But your work RVUs are thousands below what I’d like to see.

GOOD-LOOKING ME

(Dabs bead of sweat away from chiseled chin)

That’s because you’ve set your benchmark thousands above a reasonable number.

MISER

(Voice flitting with child-like condescension)

But those are the numbers my finance guy gave me. It’s the benchmark.

(Blackout and end of Act I.)

Mutual Agreement

Tony Award-winning stuff for sure—and based on a true story! In fact, this scene no doubt plays out annually for those of you unfortunate enough to have to negotiate with hospital executives for programmatic support. To be fair, hospital administrators deserve to know that they are getting what they pay for. Thus, the concepts of a benchmark are reasonable. The problem lies in setting mutually-agreed-upon standards.

The new survey rivals those old commercials in which a person walking with a piece of chocolate slams into another with a jar of peanut butter, resulting in the Reese’s Peanut Butter Cup.

Act II: Disbelief and Confusion

GOOD-LOOKING ME

(Unsteadily hands document to Miser)

Sir, I’ve highlighted the national benchmarks for you to see. Column four of this 2007-2008 SHM survey clearly shows that the average academic hospitalist should make $168,800 and achieve 2,813 work RVUs. We achieve the latter benchmark but are severely underpaid.

MISER

(Produces a folded cocktail napkin from his shirt pocket)

But look at this: My executive-friends-at-other-medical-centers-who-overwork-and-underpay-their-hospitalists benchmark shows that you should be well over 4,500 work RVUs. And besides, the SHM numbers are skewed; it’s a survey of hospitalists done by a group that represents hospitalists. I don’t believe them.

GOOD-LOOKING ME

(Eyes averted, adopts a tone of trepidation)

But sir, with all due respect, don’t your numbers reflect a survey of hospital administrators who might have a bias toward more expected productivity? Which benchmark should we believe?

(Blackout and end of Act II.)

A New HM Benchmark Arises

It’s all about the benchmark you choose to believe. For years, the best source of data regarding hospitalist compensation and productivity was that published every other year by SHM. It is a fair, but unfounded, concern that these data might tilt toward the benefit of hospitalists. Likewise, the hospital administrator I work most closely with (who, for the record, reads this publication and IS NOT miserly, has a FULL HEAD of hair, and is, for innumerable reasons, a TRULY GREAT man) will produce benchmarks from organizations like the Association of American Medical Colleges (AAMC) or the University HealthSystems Consortium (UHC), all of which show surprisingly disparate numbers dripping with a similar tilt toward the medical center.

Thus, the importance of the 2010 SHM/MGMA report. The Medical Group Management Association (MGMA) consists of administrators and leaders of medical group practices. Since 1926, they’ve been providing accurate, independent data on physician practice metrics. For most hospital administrators, it is the benchmark. The problem is that in the past, MGMA has struggled to identify hospitalists; the MGMA data were always underpowered and, therefore, suspect.

Enter SHM and its large database of HM groups. What has resulted in the new survey rivals those old commercials in which a person walking with a piece of chocolate slams into another with a jar of peanut butter, resulting in the creation of the Reese’s Peanut Butter Cup (apologies to those readers under the age of 35).

Act III: No Raise; Children Go Hungry

GOOD-LOOKING ME

(Unsheathing haloed document from his portfolio)

Perhaps we could agree to use these new SHM/MGMA numbers as our benchmark. It includes data from more than 440 HM groups and 4,200 hospitalists. And it appears to be fair and balanced.

MISER

(Eyes alight, peering through a shroud of compromise)

MGMA, huh? Let’s take a look. Hmmm. Well. But wait—this says the average hospitalist makes $215,000! That’s outrageous.

GOOD-LOOKING ME

(Smugly retorts)

Yes, sir, we are severely underpaid.

MISER

(Reading; a weasel-like countenance overtakes his face)

Let me take a closer look at this. Aha! Here it is. You see, this only included community hospitalist practices. You will be getting no raise!

(Blackout and end of Act III.)

A Cautionary Tale

Alas, the miser is right. It’s not always what the data say but also what they don’t say.

The one snag with the new data is that it only included a handful of academic HM groups (only 1% of respondents). In fact, the survey actively instructed academic HM practices to not complete the survey. Rather, we academic types were instructed to await the MGMA survey of academic practices completed every fall to be reported early next year.

This is emblematic of the need to dig deep when interpreting these data. As tempting as it is to use a sound bite or two of these data to your advantage, the truth lies in the details. It’s easy to say that all hospitalists should make $215,000, see 2,229 encounters, and achieve 4,107 wRVUs annually.

However, just as there is no average hospitalist, there are no average numbers. There are just too many variables (e.g., practice ownership, geography, group size, night coverage, staffing model, compensation structure) to say definitively what an individual hospitalist should look like or achieve. Rather, these numbers should be used as a guide, adapted to each individual situation.

Act IV: See You This Spring

(Standing, Good-Looking Me shakes his foe’s shriveled claw of a hand while looking him intensely in the eye—a look that says, “I’ll see you this spring.” In his rival’s eyes, the Miser sees his future—a future that involves another meeting, more practice-appropriate data, and a dusting off of his checkbook.)

(Blackout and end of Act IV.) TH

Dr. Glasheen is associate professor of medicine at the University of Colorado Denver, where he serves as director of the Hospital Medicine Program and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.

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