Pay now, profit later

Initial training, whether it lasts a few days or a few weeks, can make a crucial difference in a hospitalist's long-term productivity and career satisfaction.

Maria Ranin-Lay, MD, had already heard good things about Hudson Valley Hospital Physicians in Middletown, N.Y., when she applied for a job as a staff hospitalist. But one benefit in particular made the firm stand out in the field of potential employers: a whole month of training at full salary.

“I had never heard of this type of training from other programs, even from friends who were going to large hospitalist groups,” said Dr. Ranin-Lay, who joined Hudson Valley Hospital Physicians (HVHP) in March 2009 after leaving a job as assistant professor of medicine at Texas Tech University Health Sciences Center in Lubbock. “The training program was just a huge plus.”

Maria Ranin-Lay MD Diane S Pine ACP Member and Adrian Paraschiv MD of Hudson Valley Hospital Physicians Photo courtesy of Orange Regional Medical Center
Maria Ranin-Lay, MD, Diane S. Pine, ACP Member, and Adrian Paraschiv, MD, of Hudson Valley Hospital Physicians. Photo courtesy of Orange Regional Medical Center.

The month-long training helps the 16-physician group practice attract and retain talented physicians, said HVHP founding partner Diane S. Pine, ACP Member. But it also makes good financial sense for HVHP and its client Orange Regional Medical Center, which has been using the group's services since 2003.

“[The training program] is a $20,000 loss per hospitalist purely on the books because the hospitalist isn't productive during that month,” said Dr. Pine. “But when you look at it over a year's time you're getting that money back because they're capturing correct billing and appropriately documenting charts. It's not a cost, it's an investment.”

HVHP's initiative highlights the training gap between medical residency and hospitalist employment. Newly hired hospitalists may be clinically competent, but they typically have no experience with coding or documentation and only a vague idea of how to navigate the political and business aspects of the system. HVHP and other employers are discovering that initial training—whether it lasts a few days or a few weeks—can make a crucial difference in a hospitalist's long-term productivity and career satisfaction.

Well-trained docs more likely to stay

When Robert C. Treadwell, DO, joined IPC The Hospitalist Company eight years ago, he underwent a whirlwind two-day orientation before being thrown into full-time patient care. Dr. Treadwell, now an IPC practice group leader in the Dallas/ Fort Worth region, weathered the initiation by fire but some of his colleagues left in frustration, prompting him and others to rethink how to help new recruits adjust to the job.

“We used to provide very rudimentary basic training,” said R. Jeffrey Taylor, president and chief operating officer of IPC, which employs more than 1,000 hospitalists practicing in more than 400 facilities nationwide. “Not only was it a substandard way to on-board people, we were losing the hearts and minds of some of the new doctors in their first day at work.”

The company has gradually expanded the initial training period to two weeks, during which new hospitalists attend an orientation in the regional office, complete online training modules and shadow their practice group leader—all before seeing patients. After two weeks, the hospitalists, accompanied by a mentor, start seeing six to eight patients a day, then gradually ramp up to the goal of about 15 per day.

After one month, practice group leaders take all new hires out to lunch to discuss their initial experiences and answer any questions. Similar get-togethers occur again at three months, six months and one year.

Not everyone was happy with the new program in the beginning. Some existing employees “argued with the decision because all of a sudden we were paying doctors for two weeks when they were not actually seeing patients,” noted Dr. Treadwell. “But I promised them we would recoup those losses because we wouldn't be training new doctors every six months.”

The cost of employing a hospitalist for two weeks without productivity is between $10,000 and $12,000, acknowledged Mr. Taylor, but he believes it pays off in the long run. Staff turnover has been steadily decreasing since the program began and attrition hit an all-time low of 15% in 2009, he said.

In the Fort Worth region, attrition has been close to zero since the program started, said Dr. Treadwell. “We're hiring lots of doctors and not replacing any whereas before we were replacing one or two doctors every six months.”

Similarly, HVHP has experienced low turnover since starting its training program four years ago, said Dr. Pine. The only departures have been three physicians who announced at the time of their hiring that they were embarking on fellowships after two years, she said.

From residency to reality

Both HVHP and IPC leaders say that initial training gives new hospitalists an opportunity to adjust to the non-clinical side of practice—the things they didn't learn in residency—before taking on full-time patient care.

At HVHP, new hospitalists are given a handbook on their first day that details every aspect of the group's workflow and expectations. During the first two weeks of training, Dr. Pine and partner Adrian Paraschiv, MD, take physicians through a checklist of essential information—such as how to do a dictation, follow-up or transfer—and accompany them on patient visits.

On Day 2 of the orientation, trainees start seeing five patients a day, spending as much time as they need with each in order to go over the process in detail with a senior physician. They learn how to capture diagnosis-related group (DRG) payments, assign correct billing codes, and document charts. Every hospitalist is taught the same methods in order to facilitate seamless transitions of care, said Dr. Pine.

“We write and dictate our notes the same way and have the same workflow,” she said. “Doing things the same way each time ensures better compliance and transition when doctors are passing patients between each other. A training program ensures that we keep consistency.”

IPC's Dr. Treadwell, who usually spends several days with new hires, noted that new hospitalists often need guidance on how to organize their time so that patient care is both effective and efficient.

“Doctors coming out of residency know how to take care of heart failure but they don't know how to get the patient in and out of the hospital in three and a half days,” explained Dr. Treadwell. “Without the hands-on training and me being there for them, it's hard for them to figure out how to do that.”

Newly trained hospitalists typically have no experience with the business side of medicine, added Mr. Taylor. “Why does throughput out of the ER matter? Why does length of stay matter? What's the difference between a DRG and per diem rate? If you don't have at least a basic understanding of these things, you never know where all these pressures are coming from and how to respond to them appropriately.”

Ultimately, training teaches new hires that they are not alone and that they can and should seek out support from their more experienced colleagues.

Dr. Pine encourages her staff to call her any time they need advice on a case, whether they are newly trained or have experience. “We never let anybody hang,” she said. “They learn from Day 1 that they will be supported and should never be afraid to ask.”

That's a culture shift from residency, where physicians tend to view asking for help as a sign of weakness, noted Mr. Taylor.

“In residency they are still learning that you have to be an island and as a hospitalist you can't be an island,” he said. “You have to have a little bit of your fingers in everything and work with the medical staff, nursing and administration—if you don't, you won't be as effective as you could be.”