“This is a big factor,” Nahm says. “You should have a policy that a part-timer who has an outpatient practice cannot accept hospitalist patients into their practice for a period of at least one year. That’s the biggest concern for using part-timers, because they are a potentially competitive threat.” Even the suspicion that it might happen can be enough to persuade local physicians to refer their patients elsewhere. To ward off concerns, the hospital can implement a policy to instruct patients upon discharge to make an appointment with their primary physician. Some hospitals go so far as to book the appointments on behalf of patients.
“It gets tricky sometimes because patients may really like their hospitalist,” Flores acknowledges. Some programs bring in only part-time hospitalists who don’t have a private practice, or hire specialists who want to keep up their general medicine skills but aren’t a threat to primary care physicians. But what about levels of commitment?
“Part-timers, just by the nature of being part-time, aren’t as emotionally connected to the practice,” Flores says. “You don’t get the same level of buy-in, or maybe the same kinds of camaraderie.”
Dr. Gupte, the job-sharing physician at Gaston Memorial, says she and her partner may be even more focused and intense than full-time hospitalists because they know they have just three or four days to care for their patients.
“We just kind of go in and say, ‘Now I need to know this [and] this; this needs to be done,’” Dr. Gupte says. “I need to get them discharged in two or three days, what’s the plan? The weekend’s coming.”
To encourage commitment to the program, Nahm suggests including dedicated part-timers—those who work a significant number of shifts per month—in your productivity and quality compensation plan. Part-timers should also have the same orientation and training as full-timers, and be required to attend all hospitalist group meetings, Nahm says.
“One of the benefits of the hospitalist is that they know the ins and outs, the ups and downs of the hospital,” Dr. Simone says. “If I’m not going to the medical staff meetings and to my committee meetings, I’m not going to have adequate information—and that may make me less effective as a hospitalist.”
Continuity of Care
Job-sharing works well for Hudson Valley Hospital Center, but allowing physicians to come in for just a few shifts a month doesn’t sound as appealing, Dr. Becker says.
If a hospital uses part-timers only sporadically, “that opens the chances for errors and for patient dissatisfaction,” he says.
To counter this, a hospital might hire only part-timers who can work consecutive shifts. Or it might use doctors who are available sporadically to support the program other ways.
“Dr. A is willing to provide 12 shifts per month but only wants to work two or three days a week,” Dr. Simone says. “You probably want to utilize him or her as an admitting doctor or a float, not a rounder, since patient continuity may be negatively affected.
“Dr. B is willing to provide 12 shifts per month and doesn’t mind working several days in a row; for example, six or 10 or 12 consecutive days. That schedule offers wonderful continuity, and this provider can be utilized as a rounder, following patients from admission through discharge.”
Even physicians who fill in only when volume is high—perhaps in four- or six-hour shifts in the evenings or on weekends—can benefit some hospitals, Abbott says; that support might make it easier to recruit full-timers.
Johns Hopkins Medicine in Baltimore supplements its nine full-time hospitalists with part-timers.