ARTICLE IN BRIEF
Neurohospitalists say they don't think they will be unionizing any time soon, but they can relate to the pressures of a group of hospitalists that did organize to address financial and organizational pressures and mandates.
When 36 hospitalists at an Oregon medical center faced the prospect of being outsourced to an external management company in the spring of 2014, many of the 36 in-hospital physicians balked. They were already feeling the pressure to see more patients and work more hours in a way they felt compromised the quality of patient care, and the prospect of tying their salaries in with the number of patients they saw represented to them a loss of autonomy and professionalism.
And so while the hospital entertained bids to outsource their services, the hospitalists that remained (one-third left to find other jobs) with the PeaceHealth Sacred Heart Medical Center in Springfield, OR, made a novel choice: they voted to form a union to negotiate on their behalf.
The hospital administration stopped its outsourcing plans after the doctors unionized, but the story about their struggles to negotiate with the hospital in subsequent months, reported in a New York Times article in January, hit a nerve among neurohospitalists — a much smaller subset, numbering about 1,600, of the estimated 52,000 hospitalists in the US, according to the Society of Hospital Medicine.
THE NEED FOR ADVOCACY
In interviews with Neurology Today, neurohospitalists who work in different practice settings said they sometimes feel similar pressures (as did the physicians in Oregon). None of the people interviewed were aware of any discussions among neurohospitalists to unionize, but they said they were watching the Oregon situation with an eye toward the future, possibly their own.
“I am not entirely surprised to hear that about the unionization efforts reported in the New York Times article,” said Joshua P. Klein, MD, PhD, chief of the division of hospital neurology at Brigham and Women's Hospital and the chair of the AAN Neurohospitalist Section. “I think these efforts reflect a growing frustration among clinicians regarding ominous trends in how the quality of their work is measured and valued.”
Dr. Klein, who is also an associate professor of neurology and radiology at Harvard Medical School, said neurohospitalists are ideally positioned to help improve the care of hospitalized patients, but are constantly reconciling the opposing forces of wanting to do what is right for the patient in providing good care, versus what is said to be right for the practice or the hospital in improving its “value.”
Although he said he was not aware of a movement among academic neurohospitalists to unionize, he noted that major advocacy efforts had been initiated on behalf of the subspecialty and neurologists in general. He cited efforts, for example, by the AAN toward protecting the ability of neurologists (including neurohospitalists) to provide high-quality care in an environment that is focused on financial gains.
STAFFING, FINANCIAL PRESSURES
David Likosky, MD, the medical director of the EvergreenHealth Neuroscience Institute in Kirkland, WA, and the director of neurohospitalists at EvergreenHealth and Overlake Medical Center, said he knows those financial pressures well. His hospital has 240 beds, and 2.5 full-time neurohospitalists are required to provide full coverage.
“Financial pressures are real,” and hospitals face tough choices, said Dr. Likosky, a member of the AAN Neurohospitalist Section. “When you're staffing a program that is getting very busy, at what point do you hire two neurohospitalists to cover each day, or do you have a separate night shift? That's a tough financial choice for a hospital.”
A neurohospitalist can often make a dramatic difference in meeting some of the administration's goals, Dr. Likosky pointed out. Having neurohospitalists on staff means that patients are seen much more quickly, he said, because emergency doctors and staff know that there is someone there to directly handle neurological issues. They also see admitted patients earlier, instead of bringing in someone at the end of the day, which can lengthen patient stays by delaying care.
Although hospitalists have a relatively constant number of patients coming into care, Dr. Likosky said, it's harder to anticipate the number of specialists that will be needed to handle certain types of neurologic emergencies, for example, the number of strokes that will happen, or how many people will come in with seizures.
“As a neurohospitalist, part of your job is to improve care for all patients in that hospital or system with, or at risk for, neurological disease,” said Dr. Likosky. “Some of your productivity is not just based on numbers but on process improvement and systems of care.”
“As head of a stroke program, a neurohospitalist would take care of an individual patient presenting with stroke as well as oversee the education of the physicians and nurses in the hospital about stroke care and help coordinate radiologists and the laboratory services,” he said. “It's not just about the number of patients you see; the neurohospitalist's' job should be structured so that is recognized.”
Penelope Edwards-Conrad, MD, a neurohospitalist in Valposta, GA, said she worked at a hospital that brought in an outside company and another hospital that tried to create a hospitalist program within the hospital itself. One company had a rule that all doctors must get to the patient's bedside in fifteen minutes from the time they are called to see the patient.
“There was no consideration for the fact that it was simply impractical for community physicians with offices to get to a patient's bedside in that time frame, or that someone with a disability may not be able to do so even if within the hospital itself-without using an assistive device,” Dr. Edwards-Conrad said. “Perhaps the rule was written that general because the ‘rule writers’ did not anticipate that there is a difference if you are a hospitalist based in the hospital instead of a physician with hospital privileges based in an office that may be located say, 20 minutes away.
“Then, of course, the ‘rules’ were not uniformly enforced because if they were, the impracticability would have been evident and challenged immediately. In addition, when the hospitalists themselves (as employees or independent contractors with the outside company) had any mishap occur, they would be ‘rotated’or sent to a different facility, literally overnight...almost like a shell-game of sorts.”
She said that, for the most part, these challenges do not affect patients, simply because most physicians make patient care the top priority.
A HIGHER BAR FOR NEUROLOGY ADMISSIONS
S. Andrew Josephson, MD, director of the University of California, San Francisco Neurohospitalist Program and medical director of inpatient neurology, said that nationally, it's very clear that neurohospitalists, whether in an academic or community setting, have increasing pressure to see more patients and deliver more efficient care while being cost conscious. It creates a lot of frustration for the doctors trying to balance care with the pressure to discharge patients in a timely manner.
Part of the challenge is that, in the past decade, the bar for neurology admissions has been set much higher by hospitals and insurance companies. Those who might have been admitted in the past are sent home.
“That means that the patients who are admitted are a much sicker group then they were 10 years ago, adding pressure for physicians who are caring for sicker patients,” he said.
In addition, he said often neurosurgeons release patients to neurohospitalists once the surgery for a brain tumor or brain bleed is finished.
Dr. Josephson said that he has not seen any neurohospitalists unionizing, but it's still a very small group within the hospital structure. But he worries that the challenges faced by hospitalists today will soon be a matter of course for neurohospitalists.
“We're always very attentive and interested in internal medicine hospitalists and their challenges, because a few years later, that's probably what we'll face,” he said.
Dr. Klein said academic medical centers, including his own, have seen a “massive” expansion in administrative hierarchy over the last two decades. The administration includes both doctors and business people, including some from outside management companies, who are far removed from the front lines of the ward and clinics but nonetheless dictate what they believe is the best way for patient care to occur, he said. These administrators have championed many initiatives, both homegrown and externally mandated.
“The initiatives are presented to clinicians as ‘innovations’ in patient care, but often prove to be ill-conceived attempts to ‘improve the healthcare value equation,” that is, to directly or indirectly make clinicians take care of more patients who are sicker for less cost and less reimbursement,” said Dr. Klein.
“As these initiatives are rolled out, clinicians are typically first incentivized toward compliance, but later penalized for failure to maintain compliance. If an initiative ultimately fails, as many have, there never seems to be accountability on the part of the administrators for all the clinicians' time and resources wasted, let alone that the initiative had any positive effect on patient care in the first place.
For clinicians, this produces frustration and measurement fatigue,” he said, concerns shared not only by neurohospitalists by neurologists in general.