An Update on the Rural Hospitalist Conundrum

A while ago I wrote about the ending of my hospitalist program and my options to join another group. Here's a brief recap of the choices, and a discussion of the factors influencing my decision:

• Join whatever solution Gimbels--the small hospital where I've worked for four years--put in place after our hospitalist group dissolved.
• Join Revenue-Keepers, an extension of a private practice wishing to retain the income generated by following their patients in the other local hospital, Macys.
• Join Hospitals-R-Us, a national staffing company specializing in ER and hospitalist programs.

As I talked to parties within each solution, a few things became clear to me and influenced my decision:

• Being part of a start-up group is fraught with difficulties: financial, organizational, interpersonal, political, etc. Even though the months of managing my original hospitalist group was a valuable learning experience, I decided I didn't want to suffer through the growing pains of yet another group. Therefore, Revenue-Keepers is out.
• Hospitalist-R-Us is the highest paying of the three options and correspondingly hard to turn down. They offered me a moderate sign-on bonus to join their organization. I investigated further and found differing opinions about how they treat their physicians. Their business model is steeply tipped towards volume, as are all hospitalist groups, but HRUS seems to generate volume at the expense of physician morale. Furthermore, I made a decision not to work at Macys--more about this next. Therefore, HRUS is out.
• I suppose I'm an idealistic fool, but I realized I don't want to leave Gimbels. Macys is a larger, stronger institution in many ways, but Gimbels fills an essential niche in the community's medical care. I feel comfortable occupying this niche. I also have to admit I'm influenced by several years of feeling in competition with Macys. I drove past it recently and felt a physical revulsion at the idea of working there. In contrast, the vibe at Gimbels is much closer to my original vision of rural medicine. So I've decided to sign on with the new hospitalist management company who has the contract to provide services at Gimbels, Xpress Hospitalists.

There are pros and cons to this decision. Xpress doesn't pay as much as HRUS, because their wage structure is tipped heavily towards daytime rounds and RVUs produced. As a group, we'll have to work hard at increasing the volume of the program so that night shift work will pay better than the initial structure promises. However, on the plus side, my original hospitalist colleagues--my friends--have all decided to stay on with Xpress, so it's going to be nice and matey. Furthermore, when I read Xpress's info packet, I saw they are working from a business model that makes a great deal of sense, based on staged growth and dedicated physician recruiting. They also have a good track record running an ER and hospitalist program at another regional hospital about 90 minutes from Rural.

I tried to be ruthlessly practical in making my decision, but I have to admit I failed. If the decision came down to making the most money for time worked, I should have gone to HRUS. If it had come down to prestige, I should have chosen Revenue-Keepers. But the possibility of keeping my old group together, staying at Gimbels, and working for a firm who appears to think about things the way I do, when it comes to providing health care services, ultimately swayed my decision. Is it the right one? I don't know, but I can tell you the day after I made up my mind is the happiest I've been in months. Cross your fingers for me.

Comments

[Theresa]

ddx:dx--I agree absolutely that a foundation in business concepts and personal finance should be built into the curriculum of medical school, although the earlier the better--an undergraduate seminar would be perfect.

In all honestly, I've never found any good books/articles on this subject. Plenty about business/finance in general, but few directed towards physicians. Medical Economics covers some of these issues, but not in depth.

I'll keep looking and let you know.

[ddx:dx]

I find your discussions of "business" decisions in medicine reflective, informed and mature. My experience is that such thinking in docs is not common. Often docs recoil from such problems or throw up their hands.
I am working to arrange an Undergraduate seminar in the honors program(premeds?) with the working title "Business and Medicine". My concept is that business decisions/ practices are an integral part of the practice of medicine(some settings more than others) and need to be understood.
Do you have any recommended reading?

[Jessica Bond]

Interesting that your challenges as a hospitalist are similar to other stories around the nation including your employment options.

Your decision reflects a person that is connected to purpose and can see beyond the quick win options. There is no perfect option or solution except for the option that best serves your true purpose in this life.

~ Jessica Bond

[momwithastethoscope]

When all is said and done - your gut feelings and intuition are most important in this decision. Both of these worked for me when I started my practice 5 years ago, and they continue to guide my decisions. So if you feel good about the decision - it's a good fit for you.
I am in the midst of a Coke and Pepsi kind of hospital war in my fertile southeastern home. So far I have maintained my generic status, but at some point I will have to join a side to survive.
Great post! Your community is lucky to have you. Can you be cloned?

[rlbates]

Best wishes, Theresa!