How to choose a Hospitalist practice

When looking for a practice, one can get bogged down with the mundane tails, thinking that they are the defining ones. Of course it matters where a practice is, city-wise, and hospital-wise. Of course salary matters. Of course contractual issues matter, like negotiating tail coverage, and non-compete clauses. But core issues are core issues – often standard from practice to practice – and not necessarily the deciding factors. Really, when it comes down to making a decision, I feel three independent factors may have make-it-or-break-it status,

The first is benefits. I can list a number of disappointing things I’ve seen regarding benefits. Some companies offer paltry medical insurance or have excessively high premiums for the insurance, making one wonder what the actual employer subsidy is. Some don’t offer short or long term disability, or make the physician undergo a waiting period for eligibility. Some play around with their 401K plans, not allowing you to contribute until you’ve worked a certain period (since when was deferring saving for retirement an incentive for working for someone?), or withhold their match until the end of the year preventing you from being able to take earlier advantage investment-wise. Some also vest you gradually, like indentured servitude. With retirement, one should be able to contribute from day one, receive one’s match in a timely fashion, and be vested immediately to recoup that for which one worked – especially given the phenomenal amount of money made by physician billing, as well as today’s uncertain economic climate. Again, regarding medical insurance, dental coverage can also be paltry, and eye care non-existent. It’s interesting that physicians might be shortchanged by their employers regarding their health care. In short, benefits are a crucial to deciding for or against a practice. I feel one should opt for a practice with comprehensive, fair, and reasonably generous benefits.

The second is flexibility, in schedule and in practice structure. People choose the hospitalist field because of the flexibility in schedule. My ideal is when needed time off can be put in for in advance, and a tailored schedule created. It may take more work on the part of whoever is doing the schedule but it is worth the effort in terms of physician satisfaction in getting needed days off, and not having a run of too many days. Five days on and off, and seven days on and off are seen relatively frequently, but I don’t think these are as great. Some people probably prefer the predictability, but such schedules often entail having the same people work together day in and day out, and although this ‘team’ approach can work well if there is a good team, I’ve seen it backfire and be stifling. Of note, a tailored schedule also means having varied options for part time. Life is demanding and people should be able to adjust their work life accordingly. Flexibility in practice structure means avoidance of micromanaging. Physicians are often well-trained enough to do well on their own, and the main guidance they need is in adhering reasonably to changing standards, and doing correct billing. Looking constantly over their shoulder as if they were still in residency may adversely affect retaining independent-minded doctors.

The last is how nights are covered – preferably by a night doc. As much as we all (contractually) agree nights need to be covered, and we have a certain level of masochism derived from medical school stating we must always go the extra mile, and do the hardest work, our instincts tell us we’d rather not do nights if we don’t have to. It’s a godsend to have night coverage, and good night doctors are worth their salt and should be paid as such.* Most day physicians have no problem seeing a good night doctor receive higher compensation, because they know how hard nights can be, and how radically the practice of night medicine differs from day medicine – you can’t just switch easily from one to the other, and good night doctors have a knack for what they do. Unfortunately, administrations often don’t understand this, and since they feel they can get nights on the cheap by having day physicians rotate through night coverage, that’s how they run things. Again, though, given the profits generated by physician billing, there is really no reason to forgo hired night coverage. I suspect there would be less burnout, if practices actively recruited good night physicians, and paid them handsomely for their work. I also suspect there might be more nocturnists, if groups were willing to pay for them.

Again, it’s important to look beyond the basic issues, and evaluate the ‘frills.’ Most practices are going to be relatively comparable in basics, and it’s the perquisites that create the nuances that we ultimate act on. Benefits, flexibility, and how nights are covered are definitely key issues which can enhance or detract from a practice, but which the average doctor, starting out, may be less inclined to focus on, because he or she is caught up in comparing salaries, and negotiating contractual issues. The key is to get a complete picture, do thorough comparative research, and at the end, as always, trust your gut.

Article by: Hospitalist--M Pujari, MD