I am presently doing locum tenens shifts in a lovely community in Oregon as a hospitalist. I have been to this hospital before and was glad to return when they needed some help. I like this place and noticed on my first go around that patients got good care and that physicians and nurses all seemed to get along pretty well together.

When I first worked here, 2 years ago, they had just transitioned away from a national company that organized and provided hospitalist coverage. The company was expensive for the hospital and refused to work with the doctors to allow them to have reasonable workloads. Not having a reasonable workload as a doctor is not just an irritation, it is dangerous. An overworked physician is not available to respond to, or ideally avert, emergencies. Because doctors are primarily overachievers, being unable to provide good care because of being responsible for too many patients is incredibly demoralizing and often results in burnout, with its associated depression, anxiety and sometimes substance abuse. We hurry through our visits with patients because there are so many to see, missing important clues to diagnoses and ignoring social issues that are vital for providing appropriate treatment.

At this hospital, the doctors met with the administration and came up with a plan that involved getting rid of the hospitalist company, managing the staffing and billing themselves with the help of a hired coordinator. They still have days when there are too many patients to see, but they have hired enough staff that this is rare and they are free to adjust in order to maintain good patient care. This was not possible when they were employed by the national company.

Hospitals, though, often balk at the idea of managing their own hospitalist groups. This is for good reason. Hospitalists are expensive. Even though we take care of many patients, the money we bring in as revenue to the hospital does not cover our salaries. In fact, it doesn’t even cover half of our salaries. Partly this is because many of the patients we see are unable to pay anything for their care. The sickest of patients often have poorly paying Medicaid or state funded insurance or have no money or insurance at all, which is partly why they are so sick, or at least strongly associated. Hospitals are willing to subsidize a hospitalist service, though, because having hospitalists attracts many of the physicians that do make a hospital money, such as surgical subspecialists. These folks need to be able to do operations and be available for emergencies requiring procedures without worrying that they will be called away by hospitalized patients who have complex medical problems outside of their area of expertise. Hospitalists are mostly internal medicine physicians who are good at managing all kinds of chronic medical problems and are in the hospital all the time, ready to take care of any patient who needs urgent help.

There is risk associated with managing a hospitalist program. Doctors sometimes get sick (God forbid) and replacements are needed, which can be difficult at the last minute. Occasionally a doctor who is hired for a position as a hospitalist, who sounded really good on paper, turns out to be pretty awful. They have a terrible temper and yell at nurses or they never do their documentation or they have bizarre practice styles. Whoever is in charge of a hospitalist group must find somebody to fill in, super quick, plus try again to find the right permanent member of the group. Running such an organization is not for the faint of heart.

Intrepid, expensive and mostly mercenary companies have arisen to fill the void. “Afraid to run a hospitalist program? We will do it for you and it will only cost millions or dollars a year!”

A California hospital where I have worked answered just such a clarion call. Their hospitalist group had formed out of community physicians and new hires and had even involved a merger. The doctors kept track of their patients’ billing information and billed them directly, and never worked particularly well together. Nobody was boss, so standards of care were a bit haphazard. They made considerably more money if they saw more patients, so even though they hated being overworked, they tended to end up with overly-large patient loads. They knew exactly how much hiring doctors to fill in cost, since it came directly from their pockets, and they were loathe to do it. They became burned out. The overwork and burned-outness made other physicians not want to work there. So they agreed to have a national hospitalist company take over. This is looking like a disaster, though only time will eventually tell. They will take a pay cut, and the company will expect them to continue to maintain higher than safe patient loads. Many have already quit.

Just recently I heard about a hospitalist group in Eugene, Oregon, which has decided to unionize because of overwork (local paper article here, with excellent commentary). Thirty-six doctors at PeaceHealth hospital in Eugene and Springfield have decided to form a union, which will be part of the American Federation of Teachers. This large group also is a home to nursing unions, so the connection is not all that weird. Attempts to reduce costs associated with the hospitalists by the hospital administrators lead to unmanageable patient loads. The hospital dealt with the doctors’ complaints by proposing having a national company take over the program. The doctors voted to unionize, a strategy that has helped nurses have a voice in the past, when reduction in staffing and salaries made them very unhappy.

I’m not quite sure how this will play out. The hospital can still hire an outside company to provide hospitalist services, though they will have to negotiate with the union if they want to use the local physicians who really know the patients and the system. Well-paid scabs might fill the void.

I have worked for two national hospitalist organizations in the last 3 years, and although I appreciated some of their good ideas in areas like communication and education and patient safety, the workloads were mostly just awful. My very first locum tenens position was with Sound Inpatient Physicians, a large hospitalist company. After 1 day of orientation with 16 patients to see, I accelerated to the usual patient load of 19 patients who I didn’t know, many of them complex, during an outbreak of norovirus, so I had to gown up for about a third of them, and got 2 new admissions. I rarely finished my 12-hour shifts in less than 14 hours, and barely had time to go to the bathroom. A well deserved high level of anxiety plagued me most moments of each day, as I rushed from acutely ill patient to acutely ill patient while receiving multiple pages on my beeper.

The other company, Cogent, employed me as a locum tenens physician in a PeaceHealth facility in Washington. The doctors were great, though not happy. At all. The administrators were ninjas of awesome skills, but the workload was ridiculous. Just a few days ago the large German health care company Fresenius, which had bought a majority share of Sound Inpatient Physicians earlier this year, purchased Cogent as well. I would like to believe that good qualities of German health care will now perfuse these two companies, but I seriously doubt it. Fresenius also owns a large amount of American kidney dialysis capabilities, and hopes to combine their dialysis arm with their hospitalist business to better coordinate care. I will not simply assume that this will raise prices and result in overuse of their technology, since some good might come of it.  Fresenius did lose my vote of confidence, though, when they threatened to sue a researcher who wrote a scientific article that showed that a product they sell, hydroxyethyl starch, causes more death and kidney failure when used to resuscitate critically ill patients.

All this said, I should really admit to the fact that practicing as a hospitalist is a pretty good job. The patients are always interesting and they pay us well. There is no pay, though, that is adequate to make it OK to take care of too many patients at one time when doing so puts them at risk. Allowing doctors to have weighty input on work load, be it as part of a union or by being part of a well functioning independent hospitalist group, is vital to having good patient care and sustainable job satisfaction.

Janice Boughton is a physician who blogs at Why is American health care so expensive?