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New research offers insight into turnover among hospitalists: Over a 7-year period prior to the COVID-19 pandemic, nearly a quarter found full- or part-time jobs in other healthcare settings, acetaminophen blood levels toxicity such as nursing homes. Even so, many of these physicians kept working at least some hours at hospitals.

“Many hospitalists practice in settings outside of the hospital, at least part time. We need to understand how these shifts in practice affect the quality of patient care in all of these settings,” said lead author and hospitalist Kira Ryskina, MD, of the University of Pennsylvania, Philadelphia, Pennsylvania, in an interview.

The study was published on November 5 in JAMA Health Forum.

“From surveys, we know that hospitalists switch jobs or practices more often than physicians in other specialties. That could mean they go to a new group or that they leave the field altogether and no longer work as a hospitalist,” Ryskina said.

Researchers used Medicare data to track 16,985 hospitalists from 2012–2018 (mean age, 41 years; 36.2% women). To be included in the study at baseline, at least 90% of the individual’s billing visits had to have occurred in a hospital, and he or she had to have had more than 100 visits a year.

Over the 7-year period, 23.9% of the hospitalists worked at least some of the time outside the hospital. By 2018, 83.4% of the physicians were still billing at least 90% of their visits at hospitals; 3.5% worked mostly at hospitals (accounting for 50% to 90% of billing) and had some office work on the side; 2.7% worked mostly at hospitals and had some work at skilled-nursing facilities on the side; and 2.7% worked mostly in other settings.

“Hospitalists from smaller practices and/or located in rural areas were more likely to shift practice to other settings,” Ryskina said. This could reflect hospital closures and consolidations, she indicated.

The investigators did not examine motivations for leaving full-time hospitalist work. Weill Cornell Medical College health services researcher Hye-Young (Arian) Jung, PhD, a co-author, said in an interview that the findings of an ongoing study of nursing home physicians offer some hints. When the physicians were asked why they had accepted work at nursing homes, “a common response was that the skills of hospitalists may be well suited for the nursing home ─ though some interviewees disagreed with that point ─ and that it is a less stressful and more desirable setting to practice in.”

Why do the findings matter? “There is some early evidence that patient outcomes like mortality and readmissions are better for hospitalists with more experience and those who work full time in the hospital,” Ryskina said. “Those findings suggest that hospitalists who move in and out of hospital medicine may have worse patient outcomes. If true, then this is not a benign phenomenon, and interventions that aim to reduce it could reduce inpatient mortality.”

University of California, San Francisco, hospitalist Charlie Wray, DO, said the findings aren’t surprising in light of the problem of burnout in hospital medicine. The hours are often grueling, he said in an interview. Hospitalists often work 12-hour shifts 7 days in a row. “Over a month, you’re working half the weekends. When your kids are playing softball and baseball, you’re still stuck at work,” he said.

The pandemic has hit hospitalists especially hard. “I talk with my colleagues about how sustainable this job is if this is what we’ll be doing for years and years,” Wray said.

Work at senior nursing facilities can seem especially appealing to hospitalists, he said. “You’re really comfortable in that environment. You can take care of patients when they’re sick and also take care of their chronic conditions. A lot of general internists don’t have that capacity. They lose the ability to take care of an acutely sick individual.”

Hospitalist Benji Mathews, MD, MBA, of Regions Hospital/HealthPartners and the University of Minnesota, in Minneapolis, Minnesota, said in an interview that it’s important to remember that hospitalist burnout may be only part of the picture, even during the pandemic. Other factors, he said, include hospital closures, financial constraints, changing and evolving skill sets, changes in the specialty, and health system trends toward growth in other kinds of facilities.

The study was funded in part by the National Institute on Aging. The study authors, Wray, and Mathews have disclosed no relevant financial relaitonships.

JAMA Health Forum. Published online November 5, 2021. Full text

Randy Dotinga is a freelance journalist who covers medicine and health.

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