Perspectives of Hospitalists in an Academic Health System

Objectives The primary outcome of this study is to assess the perspectives of Hospitalists on their workload and their perceived effects on patient care. The secondary outcomes are to evaluate the satisfaction of the Hospitalists with their compensation, quality of life, scholarship activity and promotion in their department and the support received to achieve this, Methodology We developed a 49-question questionnaire. The questionnaire was based on (a) Oldenburg Burnout Inventory and (b) topics specific to census, compensation, academic support with desire for promotion, and the effects of workload on patient care and teaching. All questions were formatted with a 4-point Likert-type response scale. The questionnaires were distributed electronically using an online survey platform to all 32 of the Hospitalists at our institution. Conclusion Each institution needs to do a self-assessment based on clinician feedback: Hospitalists workload, burn-out and satisfaction to reduce the high turnover rates and brevity of this role. From this study in this academic institution, the perspectives of Hospitalists revealed a high level of burn out (exhaustion and disengagement) and high assigned patient censuses that negatively impact their ability to deliver optimal patient care. Most Hospitalists reported lack of mentorship and inadequate time allocated for scholarly activity. The majority reported not having their input on decisions made by the administration that directly affect them. Most were unsatisfied with their compensation and the lack of PTO (paid time off). The majority would like to be promoted in this academic institution but feel unsupported to achieve this goal.


Introduction Objectives
The primary outcome of this study is to assess the perspectives of Hospitalists on their workload and their perceived effects on patient care. The secondary outcomes are to evaluate the satisfaction of the Hospitalists with their compensation, quality of life, scholarship activity and promotion in their department and the support received to achieve this.

Study Background
The Hospitalist model for inpatient care has significantly impacted inpatient medicine and is especially evident in academic medical centers.
Studies have shown that Hospitalists decrease the overall cost and length of stay for patients and readmission rates. Additionally, studies suggest superior teaching evaluations among Hospitalists, citing accessibility and provision of immediate feedback as strengths. [1] The concept of the Hospitalist remains novel, with no standardized guidelines with regards to compensation or workload (number of encounters per day, complexity of patients and work hours, and the effect these factors may have on the quality of care of patients).
One study reported that the high workload of the Hospitalist contributes to incomplete discussions with patients and families, the ordering of unnecessary tests or procedures, delay in admissions or discharges, lower patient satisfaction, poorer handoffs, and other problems. For a recent survey posted on the-hospitalist.org, 51% of respondents picked "11 to 15" as the most appropriate patient census for a full-time Hospitalist.
From this study the researchers concluded that increasing the number of patients being seen or having high census numbers could paradoxically be increasing the costs of healthcare. [2] Another study concluded that increasing Hospitalist workload is associated with clinically meaningful increases in LOS and cost, suggesting the need for methods to mitigate the potential negative effects of increased Hospitalist workload on the efficiency and cost of care.
One study done to focus on productivity elevated the age-old question to the organizational finance department: "Is it better and financially more productive for the organization to lower the average starting census and to pay for the extra physician?" The answer was a resounding "Yes. [5]" Compensation of Hospitalists vary widely across the nation. A report done with the 2020 State of Hospital Medicine (SoHM) partnering with the Medical Group Management Association (MGMA) provided data on Hospitalist compensation and productivity. The report offers significant and compelling evidence that Hospitalists continue to be compensated at rising rates due to the continued supply-and-demand mismatch and recognition of the overall value that Hospitalists generate rather than strictly the volume of their productivity. [3] In an academic institution where Hospitalists teach medical students and residents, the number of patients that should be seen by Academic Hospitalist can become a contentious issue, focusing on the workload of the Hospitalist and the teaching and mentoring provided with high censuses. One study suggests that internal medicine clerkship student evaluations of Hospitalist faculty are negatively influenced by high clinical service intensity. 6 The involvement in academia and the ability or desire for promotion, which depends on factors such as research and involvement in the University community, were all included in the study as most people are driven to become Hospitalists in academic centers by the desire to be involved in academics (teaching, education and research) rather than community hospitals. [6] "Each institution needs to do a self-assessment based on clinician feedback. Is the workload manageable? What do their satisfaction surveys suggest? What are the turnover and burnout rates?" Ruth M. Kleinpell, PhD, RN, FAAN, FCCM, Professor of Nursing at Rush University Medical Center in Chicago and a nurse practitioner at Mercy Hospital and Medical Center. [7,8] How many patients a Hospitalist should see in one day depends on many factors, including the Patient Case Mix Index (CMI), teaching or non-teaching service, admitting service versus consultative service, advanced practice providers, day-shift versus night-shift, observation versus regular admission patients, non-clinical duties, and hospital geography (where it can take a Hospitalist caring for 15 patients on 6 different nursing stations more time per day to manage than a hospitalist caring for 20 patients on a single nursing station and the patient demographic [4]).
Another factor to take into consideration of Hospitalist workload is the complexity of the patients. This study involves Hospitalists that are in a Health Network which includes an NCI designated cancer institute; thus, many admissions are complex cancer patients with complications of their malignancy or therapy.
Hospitalist burnout has become of growing concern with resultant high turnover rates; we experience this within our own institution. We thus thought it pertinent to incorporate an Oldenburg Burnout Inventory. "Burnout" is defined and measured as a work-related syndrome that is characterized by emotional exhaustion (i.e., a state of energy draining), cynicism (i.e., a sense of disengagement and gradual loss of concern about the contents or the recipients of one's work), and reduced professional efficacy (i.e., feelings of incompetence) that individuals experience in relation to their work. [9] Nurse practitioners (NPs) are increasingly employed by hospital medicine groups and contribute to the care of the hospitalized adult patient. Prior research indicates NP hospitalists are empowered in their role. In this academic institution, the NPs admit and follow patients, but under the name of a Hospitalist and their admissions and discharges must be seen and signed by a Hospitalist, who is ultimately responsible for that patient. [10] The goal of this study is to quantify the comfort level of the Hospitalist with their current census, to see if this impacts the quality of care for their patients, the desire and support in scholarly activities, their compensation, and their overall well-being at this institution.
This study will investigate the following interrelated questions as related to the Hospitalist:

1.
The comfort level with the current census and the proposed census.

2.
The effects that their current census has on overall patient care.

3.
Their satisfaction with their involvement in scholarly activity, including teaching medical students.

4.
Their satisfaction with their current compensation..

5.
The favorability of having an ARNP.
From this study, we hope to achieve a better understanding of the above and implement and standardize changes that will lead to an overall and better outcome for the Hospitalists, patient care, teaching/mentoring at this academic institution.

Methodology
We developed a 49-question questionnaire. The questionnaire was based on (a) Oldenburg Burnout Inventory [9] and (b) topics specific to census, compensation, academic support with desire for promotion, and the effects of workload on patient care and teaching. All questions were formatted with a 4-point Likert-type response scale. The questionnaires were distributed electronically using an online survey platform to all 32 of the Hospitalists (Faculty and Non-Faculty) in the University of Miami Health system, which consists of two academic inpatient facilities, a 560-bed tertiary hospital and a 40-bed cancer facility.
Hospitalists working for less than one year were excluded from this study as we did not think they had sufficient time working in this institution to give valid answers. We collected responses from the Hospitalists in our inclusion criteria, consisting of 24, representing a 98% response rate. This study was exempted by our local IRB.
From this, potential conclusions were derived from the perspectives of the Hospitalists on that intended in the objective.

Results
Most respondents have been Hospitalists for 1-3 years (eleven of the 24). Only two respondents had greater than ten years in the current role of a Hospitalist and seven respondents had between 5-10 years' experience on the role. Twenty-one respondents were Faculty at our academic institution.
All Hospitalists agreed that the "seven days on and seven days off" work schedule was favorable. Fifteen Hospitalists preferred to start their work week on a Monday, whereas four Hospitalists opted for Tuesday or Wednesday.
Only two Hospitalists agreed that their financial compensation was adequate; most Hospitalists disagreed, with the majority indicating that a $50,000-$74,000 per annum pay increase would be reasonable and desired. See Table 1.
From the Oldenburg Burnout Inventory's 16 questions, the median response rate was used to calculate the total score of 48 points, with a subtotal Disengagement of 23 points and Exhaustion subtotal of 23 points. Results indicate significant burnout amongst this group of Hospitalists. In addition, Hospitalists indicated missing 21-50% of important family events). See Table 2.
The following results are related to Hospitalists' current census, views on census and ARNPs and suggestions for an appropriate patient census.
With regards to having an ARNP,43.48% of Hospitalists did not find this favorable and 30.43% of Hospitalist reported this being conditional, the most cited reason was: depends on ARNP and one Hospitalist mentioned having a structure and delegation of tasks.
Hospitalists reported currently having a census of 20-22 with an ARNP and a census of 16-18 without an ARNP. The two Non-Faculty personnel reported a census of 20.
With an ARNP, ten Hospitalists reported that an appropriate census would be 18; six Hospitalists thought that an appropriate cap would be 16; three Hospitalists answered 17 and three answered twenty.
One Hospitalist reported the current cap of 22 to be ideal. Table 3.
Without an ARNP, twenty Hospitalists indicated a cap of 12-14 as suitable. Nineteen of the hospitalists suggested that the cap should be adjusted for teams caring for > 50% progressive care or patients with malignancy or complications of chemotherapy. 100% of the Hospitalists suggested a lower cap with or without an ARNP. Table 3 96% of Hospitalists indicated that patient care is compromised by the high caps that they carry, taking the form of delayed discharges, communicating with patient and family (100%), paying closer attention to medical detail (100%), and the ability to utilize less consultative services (87%). Table 4 While twenty of the 22 faculty Hospitalists enjoyed teaching medical students, all 22 Hospitalists reported that their cap was not adjusted to accommodate teaching of these students and that this made their job more demanding. Table 5 Eighteen of the Hospitalists felt that they had no input in the decisions made by administration that directly impacts them, and 20 of the 22-faculty reported that there was inadequate support to perform scholarly activities (18 of whom cited that there was not enough time allocated to do so).
21 of the 22 faculty Hospitalists reported that they did not have a senior faculty mentoring them, with 18 of the 22 hoping to be promoted in the University in the future and 19 responded that there was "inadequate support to making promotion possible" Table 6.

Discussion
The Hospitalist model for inpatient care has significantly impacted inpatient medicine and is clearly more evident in academic medical centers.
The survey conducted among Hospitalists in our academic medical center revealed high levels of burnout (disengagement and exhaustion) using the Oldenburg Burnout Inventory's 16 questions, with a total score of 48 points, with a subtotal Disengagement of 23 points and Exhaustion subtotal of 23 points. In addition, Hospitalists indicated missing 21-50% of important family events The overwhelming majority of Hospitalists in this institution indicated that their high census compromised patient care with longer length of stays, inability to pay closer attention to medical detail, and the inability to communicate with the patients and their families as the Hospitalist would wish to. The overwhelming majority reported a desire for a lower cap with or without an ARNP.
43.48% of Hospitalists did not find working with an ARNP to be favorable and 30.43% of Hospitalist reported working with an ARNP is conditional, the most cited reason was: "depends on the specific ARNP".
All Hospitalists agreed that it was more demanding to have medical students and, due to the lack of accommodations for this, such as a lowered census. This made having medical students on their service, an activity that they enjoy, an added burden to their workload.
Most Hospitalists also reported not enough time for scholarly activity. Faculty Hospitalists also indicated lack of mentorship, and though the vast majority wanted to be promoted they did not feel supported in their desire to do so.
Most Hospitalists reported that the administration made decisions without their input and that they should have 2-3 weeks PTO (paid time off) and that they were receiving a lower than preferred compensation.
This study was to gain the perspectives of the Hospitalists. The results are not surprising considering the literature review in the study's background.
This high level of dissatisfaction leads to a high turnover rate and brevity in the position.

Conclusion
Each institution needs to do a self-assessment based on clinician feedback on Hospitalists workload<burn-out and satisfaction to reduce the high turnover rates and brevity of this role. From this study in this academic institution, the perspectives of Hospitalists revealed a high level of burn out (exhaustion and disengagement) and high assigned patient censuses that negatively impact their ability to deliver optimal patient care. Most Hospitalists reported lack of mentorship and inadequate time allocated for scholarly activity. The majority reported not having their input on decisions made by the administration that directly affects them. Most were unsatisfied with their compensation and the lack of PTO (paid time off). The majority would like to be promoted in this academic institution but feel unsupported to achieve this goal.
Clarke et al.    education to administration and the department/HR regarding salaries for Hospital Medicine based on current and ongoing responsibilities placed on the division, complexity of care of our growing census of patients, and the ever-increasing workload placed on hospital medicine department, amid inflation and increasing prices in Miami.
Having the ability to progress in career or being given equal opportunity to all the staff w both teaching and non-teaching irrespective of how many years of your experience is with UM Options for more than 1 week vacation block

Geographic location of patients/teams
Actual vacation days Get more support staff Better nursing support Stability of chair and administrators.
collective bargaining agreement with administration about decisions