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Hospitalist practice: Could it work for you?

Many doctors find that becoming a hospitalist makes their professional lives more manageable and rewarding.

By Damon Adams, amednews staff. Nov. 11, 2002.

When in private practice, Paul Allen, MD, squeezed two days of work into one. He spent nine hours at his office in central Washington state, taking a two-hour lunch, which he usually spent visiting patients in the hospital. At the end of the day, the pulmonologist headed back to the hospital for several more hours. The long work days began to chip away at his enthusiasm and his health. Lower reimbursements translated into a salary that was shrinking 5% annually. And he was paying $22,000 a month to run his practice.

"I was tired all the time. I started having chronic headaches," Dr. Allen said. "I figured if I stayed in private practice, I would have serious health problems."

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Last year -- after 22 years of being his own boss -- Dr. Allen closed his practice. He heard Stevens Hospital in Edmonds, a Seattle suburb, was starting a hospitalist program. Dr. Allen applied, got the job and became a hospitalist on Feb. 1.

He is part of a growing number of physicians who are choosing to care only for hospitalized patients. There were a few hundred hospitalists in the mid-1990s, but their ranks have grown to more than 6,000 today, said the National Assn. of Inpatient Physicians. By 2010, that amount may triple, the NAIP said.

"There are probably two job openings for every hospitalist," said Larry Wellikson, MD, executive director of the NAIP.

Like Dr. Allen, many hospitalists are physicians who have left traditional practice.

There were a few hundred hospitalists in the mid-1990s; there are 6,000 today.

"My best estimate is that half or two-thirds of them [in the mid-1990s] were traditional internists or pediatricians," said Robert M. Wachter, MD, who coined the term hospitalist in 1996 and is chief of medical service at the University of California's San Francisco Medical Center.

They had spent part of their days doing hospital rounds but liked the idea of working full time in the hospital. They savored the challenge of caring for the sickest patients. They enjoyed the flexibility of a hospitalist's schedule.

Dr. Allen, who now heads Stevens' hospitalist program, said becoming a hospitalist breathed new life into his medical career.

"I said, 'What do I like to do best and what do I do best?' I found out I'm not a very good businessman, but I'm pretty good at taking care of people in the hospital."

A shaky start

Initially, the idea of turning over the management of their hospitalized patients' care to another physician was not embraced by many in the profession.

Many office-based doctors worried about losing patients to hospitalists. They feared that continuity of care would suffer. They didn't want to be forced to make referrals. Some thought they would miss the collegiality of seeing other doctors at the hospital, or their hospital skills would start to slip.

Primary care physicians can save $40,000 a year by referring to hospitalists.

"When we first started, some of the [primary care physicians] were very threatened, particularly the pulmonologists who thought we would take their market away," said Don Krause, MD, who left an internal medicine practice to become a staff hospitalist at St. Joseph's Hospital in Bangor, Maine.

Now, much of the controversy has subsided. Shorter hospital stays and medical advances mean office-based physicians have fewer patients in the hospital, and the patients they do have in the hospital don't stay very long.

Doctors save time and money by concentrating their efforts on office visits. One study, Dr. Wachter said, showed that primary care physicians can save $40,000 a year by referring to hospitalists and swapping commute time for office time.

"Now the relationship is fine. There's a lot of teamwork that goes on, particularly in the ICU," Dr. Krause said.

Dwayne Thomason, DO, a family physician in Castle Rock, Colo., started referring to a hospitalist several years ago. With no hospital in town, he sent his patients to Denver, then made the 35- to 40-minute drive to visit them.

"It's not worth it to me to waste that much time in traffic when I can be in the office seeing patients," Dr. Thomason said.

Internists who become hospitalists make $10,000 to $30,000 more than those with office practices.

Instead, he refers patients to Michael McMillan, MD, a hospitalist at Porter Adventist Hospital in Denver.

"It's a lot more efficient to have someone in the hospital and that's what they do all the time. You get better patient care as long as there's communication between the primary care doctor and the hospitalist," Dr. Thomason said. "We're both dependent upon each other."

Dr. McMillan used to be a family physician in private practice. The practice of three doctors turned into a practice of 20 employees, which included the three doctors, two nurse practitioners and staff. Managed care requirements and 18-hour days got to be too much.

"The burden of running the practice was just huge. We had two full-time people just to deal with referrals," Dr. McMillan said. "Every year my income would go down and my stress would go up."

In 1995, he and a partner started an inpatient practice to treat hospital patients. Business was good enough that Dr. McMillan sold his partnership in the private practice in 1996. "Best day of my life, except for my marriage and the birth of my kids."

To get his inpatient practice started, Dr. McMillan asked primary care physicians in rural areas if he could see their hospitalized patients, and he contracted with independent physician associations.

Last year his inpatient business was acquired by IPC -- The Hospitalist Company, which employs about 300 physicians and works with 4,000 referring physicians and 1,000 health plans nationwide. IPC handles the billing, so Dr. McMillan said his hassles and paperwork are few.

"My overhead is my briefcase, my pager and my stethoscope," he said. "If I want to come in and see patients at 5 [a.m.] and be done by noon and go play golf, I can do that."

Roberta Parks, MD, also enjoys the freedom a hospitalist lifestyle provides.

As a primary care physician, she felt bogged down by paperwork and high volumes of patients. Practice time demands impacted her personal life.

"With the lifestyle in primary care, being the mother of young children was becoming more and more difficult," she said.

She welcomed the opportunity to develop a hospitalist program for Beth Israel Deaconess Medical Center in Boston, where she was trained in internal medicine. She knew what it would be like to be a hospitalist because her sister serves as one in Virginia.

"I knew what the lifestyle was like and I knew what her physician satisfaction was," Dr. Parks said. "I knew the differences she went through leaving primary care and becoming a hospitalist."

Now Dr. Parks sees about 12 patients a day compared with the 30 she saw daily at her practice. She has designed a shorter work day, from 8:30 a.m. to 2:30 p.m., giving her flexibility for work and personal life.

"I'm just completely professionally happy," she said.

Internists who are hospitalists typically make $10,000 to $30,000 more than internists with office practices, the NAIP said.

A NAIP survey this July found that 60% of hospitalists are compensated on a salary basis and earn an average of $164,000 a year. Independent or self-employed hospitalists averaged $194,000 a year, more than those employed in other practice models, the survey found.

Another NAIP survey, released in May 2001, showed that 36% of hospitalists were employed by a hospital and 31% worked for a medical group. Another 12% were self-employed, and 11% worked for managed care companies.

About nine of 10 hospitalists are internists, said Dr. Wellikson of the NAIP. Most of the rest are pediatricians and family physicians.

Oncologists spend a lot of time at the hospital, so they don't typically use hospitalists. But about 80% of hospitalists care for their own patients in intensive care units, calling on intensivists as consultants, according to an article co-authored by Dr. Wachter in the Jan. 23/30 JAMA.

In Canada, the majority of hospitalists are family physicians, Dr. Wellikson said. In Great Britain, there are outpatient and inpatient doctors. China recently developed its first hospitalist program.

Hospitalist training springing up

In the United States, there were no specific training programs until recently, Dr. Wachter said. Now there are some training programs, such as a residency track and fellowship program at the University of California, San Francisco, he said.

Bill Atchley, MD, said his internal medicine training made it easy for him to switch gears, leaving a group practice to work as a hospitalist and head of hospitalist services at Sentara Hampton General Hospital in Hampton, Va. He said most outpatient doctors understand the value of hospitalists.

"One of the older family doctors said he felt he was on vacation all the time because he can focus on the office and not have his off hours interrupted," he said.

Satvir Singh, MD, made the switch from internist at a state-run clinic to a hospitalist because he preferred working in the hospital.

He now works 12-hour shifts: 7 a.m. to 7 p.m. or 7 p.m. to 7 a.m. His work week stretches over seven days, but then he has seven days off. That's the way he likes it.

"The seven days on are pretty tough, actually," said Dr. Singh, who works for Physicians East, a multispecialty group at Pitt County Memorial Hospital in Greenville, N.C.

His first two days off are usually spent catching up on sleep. After that, he has time for reading and golf. He welcomes the extra time he gets to spend with his daughter Devneet, 3.

"If I were working traditionally, I wouldn't have time to do as much with her," Dr. Singh said.

"I read that when you're dying, you never regret you didn't do more work. You regret you didn't do more with your loved ones."

ADDITIONAL INFORMATION:

Practice traits

Hospitalists have flexible schedules, but longer shifts.
Hospitalists focus on inpatient care, but without a history of a physician-patient relationship.
Hospitalists face fewer management hassles, but spend most nights and weekends on call.