Practice Economics

What To Do When the Hospitalist Group Leader Refuses to See Patients


Dr. Hospitalist

My hospitalist group, which has nine employees, is hospital-employed in a small Midwest town. We use the traditional seven-on and seven-off rotation and hire locum tenens to fill schedule gaps, as we have a couple of MDs who recently left the group. A few of us are concerned because our “boss,” who controls the schedule, does not put himself in rotation regularly. Instead, he puts locum or part-timers on the schedule, even on weeks when he is available. We all know that the hospital is paying him extra to take care of administrative work, and that it costs more for the hospital to pay part-time/locums. In your experience, is this a common occurrence? Should we be upset? Lastly, should we bring this issue to administration, because many of us think that they are not aware this is happening.

–Mismatched in the Midwest

Dr. Hospitalist responds:

Opinions vary when it comes to the amount of clinical time hospitalist leaders should devote to their groups. As we have become more involved in the administrative aspects of the hospital, there are increasing demands placed on directors. Along with increased administrative demands comes the desire of many of these physician-leaders to remain adept in the practice of hospital medicine. Without a strong clinical connection and familiarity with what the others experience day to day, the group leader risks losing credibility and whatever leverage the title might offer.

Many groups have devised formulas based on the number of members in the group to help them derive a “fair” amount of administrative time to allow the director. For example, for every five full-time equivalents (FTEs) on staff, the director receives 0.1 FTE in admin time; so, for a group of 25 members, the director would get 0.5 admin time. The remainder of time would be clinical, but again, how that clinical time is managed is also highly variable.

This seems like a reasonable formula to me, because those with larger programs will have larger hospitals, more people to manage, and more personalities to deal with. The potential rewards and job satisfaction are also greater. (Another potential scheduling issue: Does the group leader “fall right into” the rotation or only work the services with light census or teaching services in an academic institution?)

Some groups that work the traditional seven-on/seven-off schedule have allowed the hospitalist physician-leader to work Monday through Friday and carry a smaller census (10-12). This allows the leader to be in the hospital during those critical times when most administrative duties are fulfilled, while also allowing for a mechanism to place overflow patients on those high census days—as long as it is a rare occurrence. He or she should also occasionally work all the different shifts (nocturnist, admitter, teams, and so on) to best understand the group’s opportunities for improvement and its challenges.

There are likely as many iterations of how to devise a fair division of time as there are hospitalist groups, but, most importantly, the days of getting someone to volunteer to be a hospitalist director without some form of compensation are long gone. In most programs, the job has become much more complex.

Many believe it is a conflict of interest for the group leader to prepare the schedule. There is too much room for perceived favoritism or mistreatment by the members when the schedule doesn’t work in everyone’s favor (which it never will). There are proprietary programs on the market that allow for easy and reliable scheduling; they also remove the potential for bias. In a group as small as yours, an astute administrative assistant or associate director can be entrusted with the schedule.

With regard to speaking up, you say a “few” in your group are concerned, so I assume more than one but still a small number of your group has expressed some dissatisfaction. There may be other members with similar sentiments, so it is important to have a discussion with all the group members and solicit their opinions. Instead of approaching the administrators with your concerns, I suggest you and your colleagues have an open and candid discussion with your group leader. After the discussion, if you still remain dissatisfied with the director’s level of clinical involvement, you are left with several choices:

  1. Approach hospital administration and see if they approve of how your director is carrying out his clinical responsibilities. Be prepared for the director to find out.
  2. Continue to do your job and let this issue rest.
  3. Start looking for another job. If the situation really bothers you, I favor the latter!

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