Succeeding as a new hospitalist

You can't completely avoid stress while transitioning from trainee to full-time hospitalist, but you can mitigate it.

It's your first morning on the job as a hospitalist. As you lead a team of residents and medical students on rounds, calls are coming in from the emergency department, the ICU and physical therapy with urgent questions about several patients. As you reflexively look around for guidance, it hits you that there is no one to defer to—you are in charge.

“You realize that you are the backup,” said Justin Penn, MD, ACP Associate Member, fourth-year chief resident in internal medicine at the University of Rochester and a hospitalist at Strong Memorial Hospital in Rochester, N.Y., since July 2011. “You go from having a comfort level as a resident that you can always ask your attending for advice, to you being the one everyone turns to, and that can be stressful.”

Illustration by David Cutler
Illustration by David Cutler.

There's no way to completely avoid stress during the transition from trainee to full-time hospitalist but there are ways to mitigate it, according to both experienced hospitalists and recent hires. They offered advice on how to succeed in one's first job as a hospitalist, such as finding experienced colleagues to act as mentors. Preparation can also help with some of the most daunting challenges of starting the job, which aren't covered in residency, such as dealing with hospital administration and learning the complexities of documentation and billing.

Find the right culture

A prospective new hospitalist's first challenge is getting through the interview phase and sifting through the pros and cons of competing job offers. The stakes are high—knowing what to look for in a potential employer can pave the way for a satisfying career while missteps can set a course for burnout.

One moment stood out for Dan Markley, DO, during interviews for his current position as a hospitalist at Vanderbilt University Medical Center in Nashville, Tenn. It was when Vanderbilt's chief of hospital medicine, Sunil Kripalani, MD, ACP Member, made a point of promising to be an advocate for his professional development.

“That made a big difference, that he was willing to help me grow as a faculty member,” said Dr. Markley, who joined Vanderbilt in July 2011. Knowing that the head of the division placed a high priority on mentoring new staff and investing in professional growth was a major factor in choosing Vanderbilt over several other job offers, he added.

Dr. Markley also was impressed by how the group was organized and how it encouraged communication. “Some of the groups I talked with [at other institutions] didn't have any central meetings or ways to communicate among one another or a good leadership hierarchy or opportunities to grow,” he said.

Getting a sense of the hospitalist group's culture and overall mission is key to determining whether it is a match with your career goals, said Edward Ma, MD, ACP Member, medical director with Apogee Physicians at Brandywine Hospital in Coatesville, Pa. Ask about the hospitalist group's interaction with hospital administration. Do the two parties have a good working relationship and do they share the same goals? One simple indicator of the depth of their relationship is if administrators know all the staff hospitalists by name, he advised.

Ask about retention, said Michelle L. Rossi, MD, FACP, associate residency program director at the University of Florida and a hospitalist at Malcolm Randall VA Medical Center in Gainesville, Fla. “A high turnover says either there is a problem with the hospital culture embracing the [hospitalist] group, or with the group and how they are structured,” she said. However, remember that in an academic institution some turnover may be due to other causes, she noted, such as graduating residents staying on as hospitalists while they wait to start a fellowship.

The best way to pick up on red flags that may signal problems with the work environment is to spend time in the hospital, she added. “Go on rounds with someone. By getting informal perspectives from staff hospitalists and observing interactions within the hospital, you can learn a lot about how they are valued by the hospital,” said Dr. Rossi, who is governor of ACP's Florida chapter.

Job candidates also should ask about what the group does when the patient census is consistently high, said Dr. Ma. Do they call in backup or expect the existing physicians to absorb the extra work, thereby risking eventual physician burnout? Also ask about how the group accommodates physician illnesses, the birth of a child or requests for extended vacations, he added.

“How a hospitalist group accommodates the personal needs of its physicians speaks to whether the group is interested in retaining talented employees,” Dr. Ma said.

Career-oriented groups should be willing to accommodate scheduling requests due to individual priorities, such as attending a child's special event, said Jeanne M. Farnan, MD, ACP Member, assistant professor and hospitalist at the University of Chicago Medical Center.

“There's much more to think about than salary and benefits” when starting a new position, said Dr. Farnan. “You have to ask yourself, what will my day-to-day life at this hospital be like?”

Know what's expected of you

Before you start a new job, make sure you know exactly what the expectations are in terms of schedule and workload, and get all promises in writing, advised Dr. Rossi.

“I had one former mentee who was told verbally she would have no nocturnal coverage requirement, but when the need arose it wasn't explicit in her contract to exempt her so she had to do night coverage,” she said. If nocturnal coverage is required, she added, knowing about it upfront will allow you to negotiate for higher pay or at least establish what the maximum number of shifts will be.

Also, don't assume you'll have a seven on/seven off schedule. Many hospitalist groups have adopted alternative schedules, such as five days per week, five on/five off, or swing shifts, said Dr. Rossi. Smaller hospitals often require that hospitalists take call as well, she noted. If that's the case at a facility you're considering, find out if you would stay in the hospital while on call or cross-cover from home.

Some hospitalist jobs require covering multiple services or hospitals, which can be positive or negative depending on your preferences, said Dr. Markley, who was looking for a variety of challenges that would keep his job interesting.

“At Vanderbilt, I attend on four different services—general medicine consults, co-management at the VA hospital, attending on the teaching service with residents and students, and the traditional non-teaching service with nurse practitioners,” he said. “Knowing the different services you're going to work on and what the expectations will be is critical. One of the things that brought me here was having so much versatility.”

Vishal Chaudhary, MD, ACP Member, who joined the hospitalist group at PeaceHealth St. Joseph Medical Center in Bellingham, Wash., in August 2009, was open to a schedule that included night work and swing shifts but he also appreciated that the hospital group at St. Joseph's was flexible enough to accommodate individual hospitalists' needs. “They ask if we have preferences when making up schedules three to four months in advance, so you can plan ahead and ask for any needed days off,” he said.

On the flip side, be alert to overly demanding expectations that can lead to burnout. “You need to quantify the number of patient encounters—how many patients you'll be expected to care for each day,” said Dr. Rossi. “If it's too high, that's a red flag.”

Expectations will also vary depending on whether you work at a university teaching hospital or a community hospital, said Vercin Ephrem, MD, ACP Member, director of hospital medicine at Lakes Region General Hospital in Laconia, N.H. In the university setting, you will be the admitting physician coordinating care with specialists, whereas in a community hospital you will be expected to take care of the patient “A to Z,” often including performing procedures and staffing the ICU.

One expectation is certain no matter where you work: good documentation for billing. Dr. Ephrem recommended taking a quick online course or attending a conference session on this topic before starting a new job, since coding and billing are a whole new frontier for most physicians coming out of residency.

“I was afraid and nervous at first about how I was billing,” said Dr. Penn. “My program did a good job putting on coding workshops for the first-year hospitalists but it took a long time to get used to it. It's good to have a contact person or liaison to help you answer questions about documentation.”

The first months on the job

Once you've accepted a job, the next challenge is making it through the first few months without any serious missteps. Not only will you be taking on a greater leadership role, you likely will be handling a heavier workload in an unfamiliar environment.

“Looking for a mentor is the most important advice I would give someone,” said Allen Johnson, MD, ACP Member, physician director at PeaceHealth St. Joseph Medical Center. “You need to establish mentor relationships where you can role model and get feedback from people who have already been down this road.”

New hospitalists are sometimes reluctant to ask a lot of questions for fear that they will be perceived as lacking confidence or leadership abilities, said Dr. Johnson. However, supportive supervisors and mentors encourage questions, he said, and often can be instrumental in helping younger physicians correct mistakes before they grow into bad habits.

“A couple of my younger hospitalists didn't convey themselves very well at first to nursing and ancillary staff,” recalled Dr. Johnson. “They were coming across as arrogant or top-down. We identified that right away, and once they knew how they were coming across, they made changes.”

Another way to establish your credibility is by building rapport with physician colleagues, both other hospitalists and specialists, he said. “Use people's names and stop to talk sometimes.”

Getting to know colleagues and administrators on a social level helps enhance your professional interactions, said Dr. Ma. “In hospital medicine, there are multiple layers of collaboration—with colleagues, specialists, primary care physicians and administrators,” he said. “It's important to create strong relationships with all of them.”

It's also a good idea to forge connections with liaisons from other departments you'll be working with, such as surgery, Dr. Farnan said. You might also volunteer to become a liaison to a subspecialty group that you work with, such as oncology, she said.

New hospitalists should also be thoughtful in their individual interactions with these colleagues. “If you call in a specialist, let them do their job. One way you can have problems is by not listening to advice after you've asked for it,” said Dr. Johnson.

It can take up to a year to gain real confidence in your decision-making as an attending physician, said Dr. Ephrem. New hospitalists often carry over habits from residency, such as overusing subspecialist consults or ordering too many ancillary services like computed tomography scans and electrocardiograms.

“You have to remember why you're getting the tests,” he said. “Is it just for your own satisfaction or is it the best thing for patient care? New hospitalists often want to overdo things just to be on the safe side instead of sticking to what actually needs to be done.”

Personal and career goals

Many new hospitalists are anxious to get involved in committees or work groups in their new institutions. More experienced hospitalists agree with the value of committee work but had mixed advice about when to jump in and how much time to invest.

“In the first year or two, you should concentrate on your clinical skills because it's a huge learning curve,” said Dr. Johnson. “Don't jump on committees right away… get things tight in your head, figure out the workflow, work with your mentor, and once you have your core job down, then it's a great time to start looking to do other functions.”

Dr. Ephrem, on the other hand, encourages new hospitalists to get involved with committees right away because “it makes them feel like they have a voice and helps them get out of the residency mentality.” He recommended starting with groups dealing with utilization review or infection control because they familiarize you with things like working with care managers and patient flow.

“Only get involved in things you are interested in and passionate about,” advised Dr. Farnan. “Getting involved may help you find out what you want to focus your career on and help you meet people from other parts of the hospital, but you have to be able to say no, too.”

While it's wise not to overcommit yourself at first, knowing what opportunities are available is important, said Dr. Ma. If administrators encourage hospitalists to take leadership roles on hospital-wide issues, it suggests that they value the hospitalist group and are interested in nurturing individuals' careers at their institutions, he said.