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The number of physicians, including oncologists and hematologists, who practice within a hospital setting 50% or more of their time has grown significantly in recent years. As many as 19,000 physicians may be hospital based by 2010.1
A 1999 survey of hospital-based physicians found that fewer than 3% were dissatisfied with the level of autonomy they had. The physicians also described a high level of camaraderie, with 75% agreeing that their team of nurses, support staff, and others worked effectively and cooperatively to provide patient care.2
Nevertheless, the relationship between hospital-based physicians and their support staff is significantly different from that of community-based physicians and their office staff. Some of these differences arise from being a coworker, albeit a senior one, rather than an employer.
“In my private practice, I wrote the job descriptions and decided whom to hire or fire,” said Michael A. Goldstein, MD, an assistant clinical professor at Boston's Beth Israel Deaconess Medical Center (Massachusetts), working in the center's outpatient oncology clinic. “The staff tried to meet our needs and conform to our office style—for example, the way we wanted the telephones answered.”
Hospital-based oncologists have, at best, an advisory role in staff decisions, especially of front-office support staff. Without authority to hire or fire, when problems with staff arise, hospital-based oncologists may feel somewhat frustrated.
“I can articulate a problem as I understand it,” said Denis Hammond, MD, director of medical oncology at Exeter Hospital in Exeter, New Hampshire, “and I can advocate for a particular solution.”
Ultimately, someone else decides if and how a problem will be resolved.
“One of the hardest things to learn when you transition from private practice to a hospital-based one is that you can't control the situation,” said Goldstein. “You have to be able to let go.”
On the other hand, the lack of responsibility for hiring relieves hospital-based physicians of other responsibilities, in particular, generating enough revenue to meet payroll and providing competitive benefits.
“I am involved in hiring oncology nursing staff and the clinic's administrative managers and supervisors,” said Leon H. Dragon, MD, medical director of Kellogg Cancer Care Center at Highland Park Hospital in Highland Park, Illinois. “I'm not responsible for designing and providing the employee benefits package, so I can focus on an applicant's credentials and whether this person would work well with our team,” he said. “Human Resources has the responsibility of handling the salary and benefits issues.”
Some physicians find that building a cohesive team is easier in a private practice setting. Particularly in large institutions, support staff may have a loyalty to the institution but little or no commitment to the unit or their coworker. Absenteeism, low morale, and lack of cooperation can interfere with both physician and staff productivity.
By clearly delineating expectations before joining a hospital's staff, physicians may find that they are better able to develop an effective team. Especially if they are assuming director or other leadership roles, they can set ground rules with the hospital administrators related to patient care and staff functioning that can be referred to when problems arise.
Hammond, for example, practices both at Exeter Hospital and in a private office setting at New Hampshire Oncology-Hematology PA. He and his colleagues have worked to create a unified sense of mission and values at the hospital's oncology clinic that are consistent with the mission and values of the office practice. Thus, the clinic's working environment is actually very similar to that of the private practice with regard to employee relations.
Inevitably, the vastly different level of resources and resource utilization process affect employee issues. Hospitals have many more resources for patients and physicians than most private practices, from on-site laboratories to the ability to shift staff to cover a temporary shortage.
But the institution's closely monitored budget blocks the addition of new, unbudgeted permanent staff. Even in the face of a significantly increased workload, neither the physician nor the oncology clinic administrator has authority to hire beyond the budget, noted Dragon. Requests, with cogent justification, must go up the administrative hierarchy, which takes time. In the meantime, the unit must rely on overtime or temporary staff.
The complexity of hospital financing puts the physician at a disadvantage when he or she needs to justify additional staff or services or wants to advocate for a particular solution to a staffing problem. Most hospital-based physicians have little or no role in the budget process, and the hospital administrator may be reluctant to explain which services generate revenues, how costs are allocated, or what the “profit” is for a particular service.
“It's sometimes hard to criticize an activity or advocate for one because I don't fully understand the financial consequences of any change,” said Hammond.
As in private practice, some hospital settings will be staffed by dedicated, caring people who work together as a unit, and others will experience almost constant tension and conflict. Physicians who stay informed about their institution and who are willing to advocate for their units can play a significant role in building a cohesive team.