Earlier in his career, hospitalist David H. T. Kim, MD, used to tell physician applicants that his facility was “a swell place, and we all love each other.” Over time, though, Dr. Kim—now section chief for hospital medicine at Loma Linda University Medical Center in Loma Linda, Calif.—decided it was important not to gloss over collegial or departmental stressors.
Now, Dr. Kim invites applicants to attend a regular staff meeting. “If the guy who has got a big mouth or the lady who is frustrated with work hours expresses it, then [you're] going to know the true reality of how it is [to work here] and how [people] work through and resolve those problems,” he said. This is more effective, he noted, than “getting a hand-picked set of individuals to sit down and have a nice dinner at a restaurant far away from the hospital.”
When hospitalists vet a prospective job at a new facility, they can relatively easily gauge compensation, workload and other tangible benchmarks. But a growing body of research supports the idea that, to thrive in a new role, hospitalists also should scrutinize more subtle cultural and work-life dynamics before signing on.
Myriad factors might make or break the optimal job fit; these include the degree of collegiality among coworkers, the level of hospitalist autonomy, and the facility's attitudes toward patient care or medical errors.
Some of these elements can be difficult to evaluate amid the swirl of the interviewing process, but it is in a hospitalist's best interest to try, said Tosha Wetterneck, MD, FACP, a hospitalist at the University of Wisconsin at Madison. Dr. Wetterneck coauthored a study, published in the January 2012 Journal of General Internal Medicine, in which 29.9% of 816 hospitalists surveyed reported symptoms of burnout.
“We know that hospital medicine jobs can be very long hours, really hard and intense work,” she said. “So you want to create jobs that are sustainable for the long haul.”
Barriers to finding a fit
Physicians weighed down by loan debt and perhaps family obligations can become focused on the financial aspects of a potential job, said Dan Whitlock, MD, MBA, a consulting physician for Physician Wellness Services. “The monetary compensation part of it is something that really glitters in the sunlight and is very much an attractor,” he said.
But physicians should not skimp on exploring other job needs, and neither should physician leaders. If both sides don't determine whether the hire will work, “it really makes the organization vulnerable to losing these people,” Dr. Whitlock said.
A recent job fit analysis, based on the survey of 816 hospitalists mentioned earlier, found that only 21% reported they had achieved an optimal job fit. In cases of a poor fit, newly hired hospitalists—those on the job fewer than 2 years—were more likely to consider leaving that job than try to change things to improve their lot, according to the findings, which were published in the February 2013 Journal of Hospital Medicine.
One difficulty in finding a job fit is that administrators and doctors might bring different perspectives to the table, Dr. Whitlock said. He cited findings from a 2012 survey, conducted by Physician Wellness Services with recruiting firm Cejka Search, looking at how doctors and administrators ranked their organizations. Doctors gave their facilities an average score of 7.6 on a scale of 1 to 10 in regard to patient-centered care, while administrators provided a higher average score of 8.6.
Culturally, the 2 groups are trained to think very differently, Dr. Whitlock said, using patient-centered care perceptions as one example. “Physicians get very angry when they can't do absolutely the best for their patient, while the administrators are thinking about the resources of the organizations as a whole,” he said. “The net of it is that you come out with the administrators thinking that they're doing a better job than they really are, as ranked by the physicians.”
Since doctors and administrators are practically speaking a different language at times, it's incumbent upon the interviewing hospitalist to be direct about what aspects of work and hospital culture matter the most, Dr. Whitlock said. Dig past the jargon and surface talk to determine if both parties are culturally in sync, he said. Ask for specific examples. And whenever feasible, fade into the background and observe.
To get a better sense of collegiality, watch the changing of shifts to see how clinicians interact. Hang out near the nurses' station. Meet a doctor or nurse for coffee off the clock, and ideally off campus.
One difficulty for prospective hires is that they are frequently accompanied by another physician or an administrator, which can stymie frank discussions, said Mary Bylone, RN, MSN, a member of the board of directors at the American Association of Critical-Care Nurses.
Try to break away, she advised. Leaders at the hospital might say they practice team-based care, but a bit of shadowing on medical rounds will paint a better picture, she said.
“They can see the interaction right there,” said Ms. Bylone, who also is a regional vice president for patient care services at Hartford HealthCare in Hartford, Conn. “Does the nurse feel valued? Are they contributing? Or are they just treated like, ‘When I want to know, I'll ask you.’”
Ask if the doctors ever get together with the nurses or other clinicians for meals or events outside of campus, an indication of respect and collegiality across the unit, Ms. Bylone said. “I've been at places where we had the ICU staff picnic and the docs came,” she said. “I've been at other places and we invited them—you did it because it was obligatory—and you were actually hoping they wouldn't show up.”
Similarly, any claim of a commitment to patient-centered care is just jargon unless hospitalists can determine whether actions back up the words, Ms. Bylone said. Ask a hospital clinician about the facility's priorities, she suggested. “Staff will tell you that straight out,” she said. “They will say whether the organization is more focused on how many dollars you're spending versus making sure you give good care to patients.”
A warning sign is when clinicians discuss patients or medical issues with an edge of cynicism or demeaning humor, Dr. Whitlock said. If you encounter this, try to discern if the cynical attitude pervades the organization or if that particular person is just under stress.
Attending a morbidity and mortality conference also might help provide a window into how honest the facility is about problems, Dr. Whitlock and other clinicians said. Ideally, hospital leaders approach error as a learning experience rather than a blame game, so they can sort through what happened and develop preventive strategies, they said.
Another approach: Ask what sorts of processes and systems the hospital has incorporated to guard against errors, Dr. Kim said. Or delve into a particular pressure point, such as, “How do you guys do the [patient] handoffs where you are changing shifts, or weeks of doing shifts?”
Seemingly small details add up to a larger safety profile, Ms. Bylone said. For example, she said, are quality results and patient satisfaction data posted in an easily visible location? Do the nurses respond promptly when asked about the most pressing safety focus?
To shield against burnout, hospitalists should search for positions that are supportive in the short term and provide opportunities to grow professionally over the years, experts advised.
Drs. Whitlock and Wetterneck stressed the importance of mentorship, particularly for younger hospitalists. During the interview process, ask if the organization will assign a doctor whom an incoming hospitalist can call confidentially with questions or ask for advice, they said.
Also, watch for signs of mission creep, and try to clarify scope of practice prior to accepting a position, Dr. Kim said. Are the hospitalists sometimes in charge of the chest pain center or asked to cover the ICU overnight while the pulmonologist is on vacation? Are you comfortable with an expansion in workload, and does it align with your skill strengths?
Consider the demographics of the hospital staff, as that might play into the work-life balancing act, Dr. Kim said. If a lot of the hospitalists have young children, they might be more sympathetic to last-minute shift changes when ear infections or child care emergencies arise, he said.
In terms of staving off long-term burnout, the match between the job and meaningful work matters significantly, according to research published in the May 25, 2009, Archives of Internal Medicine. The definition of meaningful work varied among the 465 faculty members interviewed. Two-thirds of the faculty found the most meaning in patient care, while smaller percentages cited research, education or administrative activities.
Overall, 34% met burnout criteria, according to the findings. But those doctors who devoted less than 20% of their time to work they found meaningful were far more vulnerable, with 53.8% classified as burned out compared with 29.9% who had more flexible time to pursue their physician passions.
Even given their importance, however, it can be difficult or awkward to raise issues of cultural fit with a potential employer, experts acknowledged. For example, Dr. Whitlock said, a doctor might be reluctant to bring up certain subjects during the interview process, fearing that the questions might boomerang back. “As a physician if I ask, ‘How do you deal with mistakes and errors?,’ he pointed out, “it may have the implication that I make a lot of mistakes and I make a lot of errors.”
But hospitalists, he added, have the luxury of being bold in their line of questioning and really determining whether a job is right for them.
“You probably have a lot of offers,” he said. “Surfacing these questions about the culture of the organization should not raise eyebrows. If it does, I think that's a real red flag.”