Academic Inefficiencies and Workload
Much of what residents do on a day-to-day basis involves pushing their patients through the inefficient and complex maze of an academic medical center. It seems ridiculous to think that one faculty member can replace the work that was previously performed by an attending, a senior resident, and two interns, yet this is what many programs are actually proposing when they suggest that the “established” work load of 15 patients per day per hospitalist could work in academia.
What is an ideal workload in academia? Our answer is based both on our experience and on work-flow analysis of residents, which suggests that less than 20% of their time is actually spent in direct educational activities (4). We suggest that the acceptable workload for a hospitalist in a major academic center managing patients of equivalent complexity as the residents is slightly higher than what a senior resident alone can reasonably handle. In our institution we have had a service without interns, staffed with senior residents and one attending for several years. In institutions without this structure, one could look at what senior residents do on their intern’s days off. In our experience approximately 8-10 patients/day seems to be an acceptable workload that allowed the residents to provide quality care within the confines of a 10 to 12 hour day. This translates into an attending workload of 9-11 patients/day. We acknowledge that with time, an attending may develop more efficient practices than a senior resident but do not think a workload much higher than this is reasonable during the start-up phase.
The Role of Physician Extenders
Many hospitalists rely on physician extenders such as physician assistants and nurse practitioners. In academia, physician extenders have traditionally worked only in specialty areas of inpatient care such as orthopedics, oncology, or cardiology. The great unknown, however, is how extenders perform in an environment where they are asked to work with both complex and varied patients. We have seen that the training of many extenders is often not enough for them to take on the role envisioned for them in this kind of service. Over time they may develop the skill set, but there is much on-the-job learning that requires dedicated physician time. A realistic census for a physician assistant (PA) taking care of complex academic medical patients is likely to be 4 to 6. The incremental impact of extenders on a service’s total work capacity is not entirely additive, given the need for physician oversight and the need to maximize revenue by using shared visit billing. Despite these limitations, however, we believe that extenders are helpful, especially given the inefficiencies of day-to-day patient care in academic centers.
The University of Michigan
Medicine Faculty Hospitalist Service
Our own program was designed around an original goal of moving 2000 patients from the resident services. This figure was derived from a per-intern workload target of 25 to 30 admissions per month. Based on our modeling of various ways to share admissions, we ultimately settled on a system that alternates admissions with the resident services after each service admits a “baseline” number of patients. This allowed us to variably offload patients based on day-to-day variation in admission volumes. Our service is staffed 24 hours a day with a total of eight full-time physicians and four physician assistants. We have three physicians and two‑three physician assistants during the day (7 a.m. to 7 p.m.) to coincide with the bulk of the workload. There is one doctor at night (7 p.m. to 7 a.m.) for our entire service, and our hospitalists work an average of 50-55 hours a week during 18 shifts a month. Each hospitalist (working with a PA) averages from 8 to 12 billable encounters a day. We maintain a maximum daily census of 30-35 patients and admit up to 10 patients a day. Given these workloads, we do not come close to financial self-sufficiency, but this is not unique to our program.