Community Pediatric Hospitalist Workload: Results from a National Survey
As a newly recognized subspecialty, understanding programmatic models for pediatric hospital medicine (PHM) programs is vital to lay the groundwork for a sustainable field. Although variability has been described within university-based PHM programs, there remains no national benchmark for community-based PHM programs. In this report, we describe the workload, clinical services, employment, and perception of sustainability of 70 community-based PHM programs in 29 states through a survey of community site leaders. The median hours for a full-time hospitalist was 1,882 hours/year with those employed by community hospitals working 8% more hours/year and viewing appropriate morning pediatric census as 20% higher than those employed by university institutions. Forty-three out of 70 (63%) site leaders perceived their programs as sustainable, with no significant difference by employer structure. Future studies should further explore root causes for workload discrepancies between community and academic employed programs along with establishing potential standards for PHM program development.
© 2019 Society of Hospital Medicine
DISCUSSION
To our knowledge, this study is the first to describe clinical work models exclusively for pediatric community hospitalist programs. We found that expectations for clinical FTE hours, weekend coverage, appropriate morning census, support for nondirect patient care activities, and perception of sustainability varied broadly across programs. The only variable affecting some of these differences was employer model, with those employed by a community hospital employer having a higher expectation for hours/year and appropriate morning pediatric census than those employed by noncommunity hospital employers.
With a growing emphasis on physician burnout and career satisfaction,9-11 understanding the characteristics of community hospital work settings is critical for identifying and building sustainable employment models. Previous studies have identified that the balance of clinical and nonclinical responsibilities and the setting of community versus university-based programs are major contributors to burnout and career satisfaction.9,11 Interestingly, although community hospital-based programs have limited FTE for nondirect patient care activities, we found that a higher percentage of program site directors perceived their program models as sustainable when compared with university-based programs in prior research (63% versus 50%).6 Elucidating why community hospital PHM programs are perceived as more sustainable provides an opportunity for future research. Potential reasons may include fewer academic requirements for promotion or an increased connection to a local community.
We also found that the employer model had a statistically significant impact on expected FTE hours per year but not on perception of sustainability. Programs employed by community hospitals worked 8% more hours per year than those employed by noncommunity hospital employers and accepted a higher morning pediatric census. This variation in hours and census level appropriateness is likely multifactorial, potentially from higher nonclinical expectations for promotion (eg, academic or scholarly production) at school of medicine or children’s hospital employed programs versus limited reimbursement for administrative responsibilities within community hospital employment models.
There are several potential next steps for our findings. As our data are the first attempt (to our knowledge) at describing the current practice and expectations exclusively within community hospital programs, this study can be used as a starting point for the development of workload expectation standards. Increasing transparency nationally for individual community programs potentially promotes discussions around burnout and attrition. Having objective data to compare program models may assist in advocating with local hospital leadership for restructuring that better aligns with national norms.
Our study has several limitations. First, our sampling frame was based upon a self-selection of program directors. This may have led to a biased representation of programs with higher workloads motivated to develop a standard to compare with other programs, which may have potentially led to an overestimation of hours. Second, without a registry or database for community-based pediatric hospitalist programs, we do not know the percentage of community-based programs that our sample represents. Although our results cannot speak for all community PHM programs, we attempted to mitigate nonresponse bias through the breadth of programs represented, which spanned 29 states, five geographic regions, and teaching and nonteaching programs. The interview-based method for data collection allowed the research team to clarify questions and responses across sites, thereby improving the quality and consistency of the data for the represented study sample. Finally, other factors possibly contributed to sustainability that we did not address in this study, such as programs that are dependent on billable encounters as part of their salary support.
