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Intensivists and ICUs


Intensivists and ICUs

Question: What is your opinion on a closed ICU that already has a hospitalist program but now has a new intensivist program? Certainly some patients should be cared for by critical care physicians. However I feel we play an important role throughout the hospital, including the ICU. As physicians who specialize in hospital care, I do not want to lose opportunities to care for patients in the ICU. Do you feel medicine may move toward that, especially in the larger hospitals? Or have you found a happy medium?

Eric Marsh, MD,

Carolinas Healthcare System,

Charlotte, N.C.

Dr. Hospitalist responds: In many small and rural hospitals throughout the country, generalists remain the frontline providers for ICU patients.

There is a shortage of critical care physicians in this country. Many small and rural hospitals have a difficult time recruiting sufficient numbers of critical care physicians to their medical staffs. This is not the case in most academic tertiary care medical centers, where pulmonary/critical care providers routinely care for the ICU patients.

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In fact, during the past two decades, many hospitals, particularly tertiary care medical centers, have “closed” their ICUs to generalists and now use specialty-trained physicians, such as pulmonary/critical care physicians, to care for ICU patients. The reason is quality. Evidence suggests intensivists provide higher-quality, more evidence-based care to ICU patients than generalists.

Quality organizations, such as the National Quality Forum and The Leapfrog Group have actively promoted the role of intensivists in the ICU and labeled them as a marker of quality care. Hospitals are under increasing scrutiny to increase the quality of care they give patients. Reimbursement is increasingly tied to performance and quality.

I expect to see more and more hospitals “close” their ICU to generalists. To be fair, the data comparing intensivists and generalists came out before the widespread role of hospitalists in our nation’s hospitals. It would be interesting to compare the care provided by hospitalists versus intensivists in the ICU. It may be we find hospitalists fare comparably to intensivists. Until that data exist, I agree with the quality organizations. Hospitals, and more importantly patients, should rely preferentially on physicians with additional critical care training to provide care for their ICU care.

If your hospitalists are interested in continuing to provide care for patients in the ICU, I suggest you speak with the leader of the intensivist group to see how your hospitalists can work with—not in lieu of—the intensivists in the care of ICU patients.

In Pursuit of More Pay

Question: I am writing to get your advice on how to go about negotiating base pay increases. I come from a four-physician hospitalist program at the New York Hospital of Queens that has tripled its annual number of discharges since 2005 without a commensurate increase in base pay and no bonus or incentive pay. If this keeps up, we’ll continue to have high turnover always manned by junior attendings. Also, what is reasonable pay for the director of a hospitalist program?

Anne Park, DO,

hospitalist faculty,

New York Hospital of Queens

Your supervisor will consider how your groups' compensation compares to other hospitalists with similar job descriptions in the same geographic region.

Dr. Hospitalist responds: I am writing to you from the lovely Manchester Grand Hyatt in San Diego, where I am attending the SHM Annual Meeting. I am here with nearly 1,600 of my closest friends in hospital medicine.

Meeting attendees heard SHM Senior Vice President Joe Miller reveal the results of the latest “Society of Hospital Medicine 2007-08 Survey: The Authoritative Source on the State of the Hospitalist Movement.” I refer to this survey not only because I believe it is the latest, most accurate, and comprehensive data on hospitalist productivity and compensation, but also because I think it is the objective data you need before you start discussions about compensation for you and your hospitalist staff.

Before discussing compensation, I suggest you make sure your supervisor is well-informed of your hospitalists’ roles and responsibilities. Discussions will be more productive if your supervisor understands the value of your hospitalists. Be careful because how you go about informing your supervisor will influence the response you get.

It’s important for your supervisor to know the hospitalist marketplace is highly competitive. There are more jobs than hospitalists. Many hospitals are developing hospitalist programs, and existing programs continue to expand. There are many signs of this competition for hospitalists. For example, I counted 130 vendors exhibiting at this year’s SHM Annual Meeting. About two-thirds are vendors recruiting hospitalists. This suggests hospitalists are in higher demand then ever. I didn’t need to come to San Diego to figure this out. One glance at the numerous ads in the pages preceding this section of The Hospitalist is sufficient evidence. Another sign of the times is the rise in hospitalist compensation since the results of the last survey two years ago.

Try to present this information to your supervisor in a nonconfrontational manner. Discussions will start poorly if this information is viewed as a threat the hospitalists will depart the program if you do not get your way. You alluded to “high turnover” in your group. Let your supervisor know you are presenting this information because you are concerned the cost of replacing hospitalists may exceed the cost of retaining experienced staff. Before discussions, I also suggest you think about why hospitalists have left your program. Your comments about increased discharges suggest a mismatch between compensation and job description. It is possible the discussion should be about changing the job description rather than adjusting compensation.

Once discussions begin, your supervisor will consider several factors when entertaining your request for additional compensation. Aside from individual performance, your supervisor will consider how your groups’ compensation compares to other hospitalists with similar job descriptions in the same geographic region. This is where the survey data are helpful. Most hospitalist compensation contains some element of incentive compensation. Do your best to compare apples to apples by looking at the entire compensation package, including benefits.

Your supervisor also will ask you to compare your groups’ job description to others in the area. Your hospitalists have tripled the number of discharges they did in 2005. Did other groups in the area see the same rise in productivity? What happened to their staffing and compensation? Expect these types of questions from your supervisor.

After your preparation, you may find that your hospitalists are being paid more, less, or about the same as what others are being paid for a comparable level of productivity. The latest SHM survey will assist you in preparing for your discussion. But please remember the survey just reports data. It does not indicate how much SHM thinks you should be working or how much money you should be making. It is merely a snapshot of what the market bears for hospitalists in our country. TH

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