For hospitalists, the universe seems to bend toward more work.
“When you have sicker patients who are staying for less time, the turnover of patients in the hospital is higher. With that turnover comes a lot more documentation,” such as admission notes, daily progress notes, and discharge summaries, said Majken Textor Wingo, MD, FACP, a general internist in Mayo Clinic's division of primary care internal medicine in Rochester, Minn., who has studied academic workload. “My impression is that workload is high and continues to increase.”
Changes in acuity, length of stay, and documentation affect all hospitalists, but the challenges of managing workload differ depending on practice environment. Academic hospitalists have to balance what one expert called the 3 shields: practice, teaching, and research.
It's the challenge that every hospitalist is experiencing but few want to talk about, said Henry Michtalik, MD, MPH, MHS, an assistant professor and clinical research scholar at Johns Hopkins University's hospitalist program in Baltimore. “I see that we are approaching a wall. We're seeing burnout on the rise, workload on the rise, and then what I see in the [hospitalist] community are attempts to adjust to this increase in workload and burnout.”
Hospitalists, researchers, and administrators are currently experimenting with solutions to the workload problem, from optimizing patient loads to delegating responsibility to reducing shifts.
An academic problem
Determining optimal workload is particularly challenging in academic hospitals, noted Robert M. Wachter, MD, FACP, professor and interim chair of the department of medicine at the University of California, San Francisco (UCSF), where he also directs the 60-physician division of hospital medicine.
“In academia, you're really trying to weigh the clinical workload against the desire for many faculty to have some academic activities on top of their clinical work.... There needs to be some time baked in to give people a chance to be successful in that,” he said.
Dr. Wingo agreed. “It tends to be a significant strain on time to try and balance those 3 shields: clinical practice, research, and education,” she said.
She began to study workload after colleagues who supervise inpatient services voiced concerns that higher patient turnover meant less time for teaching. Her study, published in the March Journal of Hospital Medicine (JHM), found that more admissions increase workload but don't necessarily hinder resident education. Attending physicians who handled more daily admissions actually had higher teaching scores.
“If something like a new admission is where the bulk of learning occurs, then that's what we should prioritize,” Dr. Wingo said. Continuity of teaching seems to provide benefits, too, as the number of days an attending spent with a particular team was associated with better teaching scores.
These findings can't definitively determine the optimal workload in an academic setting, however, Dr. Wingo noted. “We have to keep in mind that in an academic setting, we're always in a time crunch.... When we're in that constant race against time, we have to prioritize what's going to be best for the patient first, then what's going to be best for learning for the residents second,” she said.
Dr. Michtalik has researched hospitalists' perceptions of how workload affects patients. He surveyed hospitalists about how often they felt they had an unsafe patient census and then compared those answers to hospital, team, and physician characteristics, with results published in November 2013 by JHM.
The factors that were associated with a workload perceived as “safe” were more years in practice, more personal time, and having a census control system in place to assist with fluctuations in hospital capacity or the number of admissions or discharges. On the other hand, more clinical responsibilities and more time seeing patients without midlevel or housestaff assistance were associated with higher frequency of reporting an unsafe census.
In addition to the educational benefits of handling admissions, Dr. Wingo's study also found some negative associations with heavier workloads. Attendings with a higher midnight service census or more discharges per day had lower teaching scores.
An extrapolation from both studies is that attending physicians might be able to delegate tasks that increase workload without significantly improving education or patient care to clinicians other than residents. “If they're not learning much from something and it's taking a lot of their time and energy, it's probably worth looking into other options for who can do something like a patient dismissal,” said Dr. Wingo.
Many academic institutions, including Mayo, have begun to use nurse practitioners and physician assistants to complete some discharge paperwork, Dr. Wingo noted. “What, as far as I know, they haven't done is studied it: Does it help?”
Residents and midlevel clinicians may both play a role in expanding and prioritizing patient care, Dr. Michtalik said. However, within those team structures lie additional time requirements.
“Teams with midlevels or nurse practitioners involve supervision, so there's still time that needs to go into providing oversight and rounding, as well as the administrative paperwork or cosigning and cobilling,” Dr. Michtalik said. “Often, if you delegate all the different tasks, it might actually backfire and cause a lot more work because you then have to supervise and go back and check to make sure that everything has been done correctly as opposed to doing it yourself and maintaining the continuity and consistency.”
The same goes for delegating to housestaff. “Each of those structures can help in terms of efficiency or how workload is delegated or distributed, but then each of those also has different components that may have additional workload, so it's really finding a balance between those 2,” said Dr. Michtalik.
A procedure service could have increased efficiency with a midlevel, whereas care for medically complex patients, who need to be discussed with multiple consultants or in multidisciplinary meetings, could work better with residents, Dr. Michtalik suggested. “I would say that [combined services] can help in certain settings, but other team structures are more appropriate in different settings,” he said.
Dr. Michtalik recommended that facilities determine appropriate workload by looking at system-based needs rather than the needs of individual clinicians. “You set an expectation, you look at the workflow and the resources, and your workload depends on the resources, the individual needs of the particular service, and the structure itself,” he said. “[All of these factors then] determine the appropriate workload for the average provider on that particular floor or service.”
Models of note
Still, some researchers have tried to develop universal tools for answering the challenges of workload. Evan Fieldston, MD, MBA, an attending at Children's Hospital of Philadelphia (CHOP), and his research team developed the Care Model Matrix, a tool for measuring and predicting workload, and published it in July 2014 in JHM. The tool accounts for volume, turnover, and acuity and uses historical data on these measures to predict workload and staffing needs throughout the day.
The model has proved useful for identifying gaps in coverage, Dr. Fieldston said. “People would look at the tool and say, ‘Yes, Saturday and Sunday morning are real pain points for us, and the tool says we're out of balance during that time,’” he recalled. In response, CHOP's pediatric residency program bolstered its weekend staffing model. “So we have far more robust staffing on Saturday and Sunday during the day than we did in the past over the last several years, in part as a result of this tool [showing] that we couldn't go from 4 or 5 people on the weekdays to 1 or 2 on the weekends when the workload remained very similar.”
Dr. Michtalik and his research team have also developed a model that can help calculate appropriate workload “because someone seeing 15 patients in 1 hospital is not the same as someone seeing 15 patients in a different hospital,” he said.
The model, published in June 2013 in JAMA Internal Medicine, divides factors influencing attending workload into 4 groups: physician (e.g., years of practice), hospital (e.g., type of medical record system), team (e.g., inpatient service structure), and patient factors (e.g., illness acuity). Researchers conducted in-depth interviews with hospitalist program directors about these factors and also sought input from small groups of hospitalists, residents, administrators, and non-physician clinicians from private, academic, and community hospitals.
Now, Dr. Michtalik's team is working on a new, 3-phase research project that will culminate in the development of a model for assigning patients to particular teams, as well as structuring the teams themselves. The first and current phase is using frontline clinicians' perceptions to determine the predictors for burnout, as well as care quality and efficiency, he said.
“Then we're moving along to actually look at objective outcomes and how those outcomes change based on fluctuations in workflow and workload,” Dr. Michtalik said. “And the final phase is getting the different stakeholders to the table and coming up with a best practices solution from everybody's perspectives, with an understanding that everybody has their own interests or incentives and how to best align all those.”
As part of phase 1, Dr. Michtalik's team aims to involve more than 40 institutions throughout Maryland, “from a hospital that is the size of a small building to a 950-bed tertiary care hospital,” in order to capture different patient populations, programs, and structures. He hopes to publish results in the fall.
“We're looking to see what each of the individual institutions and programs are doing, what works, and what doesn't work,” Dr. Michtalik said. “As you can imagine, it's a very complicated picture because it really does depend on what the patient population is, what the incentives are of the institution, what the team structures are, and what the scope of duties is.”
Another solution to the workload/burnout problem is to allow academic hospitalists themselves to decide how many hours they will spend in the hospital and how to balance their schedules among competing priorities.
UCSF does that. “We've actually tried hard not to have a cookie-cutter schedule that locks everyone into a certain number of clinical days. Rather, we've erred on the side of providing flexibility because we think people have different clinical interests and preferences that may change over the course of their career,” said Dr. Wachter.
The process attempts to optimize 3 variables: filling all of the clinical service shifts, allocating money in a way that costs less than what's available (to allow for academic investment), and accommodating the hospitalists' career interests and preferences.
In general, clinical work adds up to 78% of a hospitalist's yearly schedule, with 22% allocated for academic activities. This means that the average faculty member works clinically for about 6 months a year, he said. Clinical services have different values based on how difficult or attractive they are rather than on relative value units or lucrativeness, Dr. Wachter said. If nobody signs up for a service, administrators will address any underlying issues and dial up its value (and dial down others) until it becomes enticing enough to choose.
For example, a month on the ward service is worth 9%, whereas a month on the non-resident service is worth 17%, and nights are worth about 0.8% each, Dr. Wachter said. A clinician with small children at home, for instance, could cobble together a schedule of just 135 shifts on the non-resident service and fulfill his or her clinical obligations for the year, he said.
Another solution to the burden of workload would be to find a way to make the work easier and faster. “We see a lot of creative things being done to help manage patient flow, as well as try to increase efficiency,” Dr. Michtalik said.
For example, to decrease boarding times, some hospitalist programs are using isolated admitters, clinicians responsible only for admitting patients from the ED, or geographical localization, where patients seen by a particular service are contained within 1 area of a hospital. But in order to make these innovations work, programs must find the right balance among efficiency, continuity, safety, quality, and patient satisfaction, Dr. Michtalik emphasized.
“I think a lot of the efficiency and the quality comes from continuity, and we're having to sacrifice that continuity to decrease burnout and try to increase flow,” he said.
Hospitalists also have to convince leadership to prioritize developing a model for physician workload. “I think 1 of the first key steps is to meet with all the stakeholders involved and come up with a single set of metrics,” Dr. Michtalik said. There are easier-to-measure, more visible metrics or outcomes, such as efficiency, flow, clinician turnover, and patient satisfaction, as well as more difficult, less visible effects to measure, such as culture, engagement, loss of productivity, and the cost of burnout or replacing staff members. “You really need to get everybody in the room to agree on how to define success and, together, work toward that success,” he said.