Practice Management

To be, or not to be ... on backup?

A staffing backup system is essential


It was late 2011. We were a practice of around 20 physicians, and just starting to integrate advanced practice providers into our practice. Our average daily census was about 100 patients and slightly more than 50% of our services were resident services.

Dr. Romil Chadha, associate division chief for operations in the division of hospital medicine at the University of Kentucky and UK Healthcare, Lexington

Dr. Romil Chadha

My boss, colleague, friend, and mentor – Charles “Chuck” Sargent, MD, and I were on service together early one Saturday morning; Chuck gets a phone call that one of our colleagues was ill. With just 10 physicians working and 10 off, it was an ordeal for Chuck to call all 10 colleagues. Unlike most times, no one could come to moonlight that day. In the end Chuck and I took care of our colleague’s patients.

Yes, it was an exhausting few days, but illness and family needs do not come announced. Now, close to a decade later, we are a practice of 70 physicians and 16 advanced practice providers, our average daily census is about 270 patients, and we have two backup physicians every day – known as Jeopardy-1 and Jeopardy-2. Paternity leave, maternity leave, minor illness, minor trauma, surgery, and family needs are common for our practice. We considered it a good year when we utilized our Jeopardy-1 and Jeopardy-2 for 10% and 1% respectively; and for the past year with a lot of needs, we employed Jeopardy-1 and Jeopardy-2 for 25% and 10%, respectively.

A staffing backup system is a necessary tool for almost every practice. Not having a formal backup system doesn’t mean you don’t need one or you don’t have one – it is just called “no formal backup system.” The Society of Hospital Medicine’s State of Hospital Medicine Reports (SoHM) have been providing data about staffing backup systems every other year. Backup systems come in three flavors. The first system is no formal backup, which means the leaders of the program scramble for coverage every time there is a need. The second is a voluntary backup system in which clinicians volunteer to be on a backup schedule, and the third is a mandatory system in which all or most clinicians are required to be on the backup schedule.

The cumulative data reported in the 2014, 2016, and 2018 SoHM for hospital medicine groups serving adults only, children only, and both adults and children (weighted for number of groups reporting), suggests that 48.3% of respondent practices had no formal backup system, 31.7% had a voluntary system, and 20% had a mandatory backup system.

When we look at different populations served, the trend of “no formal backup system” responses is in decline. The 2014, 2016, and 2018 SoHM reports for hospital medicine groups serving adults, children, and both adults and children, reinforce such trends. The SoHM 2018 report shows 65.6% of hospital medicine groups serving children, 41.6% of groups serving adults, and only 25% of groups serving both adults and children have “no formal backup system.” Our medicine-pediatrics colleagues seem to be leading the trend and have already deduced that, for a solid practice, a backup system is a necessity.

It is also important to see the trend of “no formal backup system” based on geographic area, employer type, academic status, or total number of full-time employees. As we would have predicted, the larger the group the more likely they are to have a backup system. For academic practices a similar trend was seen; they had a higher percentage of some type of backup system year after year.

When it comes to compensation for backup work, four patterns were explored by the SoHM over the years. The most common type of arrangement was “no additional compensation for being on the backup schedule, but additional compensation was provided when called into work.” This kind of arrangement would be easiest to negotiate when the hospitalist and the employer sit across a table. There is nothing at risk for the employer when there isn’t a need, or when there is a need to fill a shift.

The least common method was “additional compensation for being on the backup schedule, but no additional compensation if called into work.” From employers’ perspectives, this is an extra expense and is not ideal for the hospitalist either. In the middle of the pack were “no additional compensation associated with the backup plan” (the second most common model), while the third most common model was “additional compensation for being on the backup schedule, as well as additional compensation if called into work.”

Once you have seen one hospital medicine practice, you have seen one hospital medicine practice. There are different needs for every group, and the backup system – as well its compensation model – has to be designed for it. Thankfully, the SoHM reports reveal the patterns and trends so that we don’t have to reinvent the wheel. For our practice, we decreased a week of clinical service for 2 weeks a year of backup. Every time we activate our backup system, the person coming in receives extra compensation or a similar shift off. In the long run, our backup system didn’t kill us, but rather made us stronger as a group.

Dr. Chadha is interim division chief in the division of hospital medicine at the University of Kentucky HealthCare in Lexington. He actively leads efforts of recruiting, scheduling, practice analysis, and operation of the group. He is a first-time member of the SHM Practice Analysis Committee. Ms. Babb is administrative support associate in the division of hospital medicine at University of Kentucky HealthCare.

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