Are your hospitalists paid by productivity or salary?

At nearly every EM job, you're going to be working closely with the hospitalists.

Some patients you admit to the hospitalist have obvious problems, and you'll get no pushback.

But some occupy a gray area that often leads to conflict with our inpatient colleagues. You know the usual suspect: weak elderly patients with no clear explanation, soft-call TIA presentations, intoxicated patients, etc...

If you're constantly arguing with a hospitalist about these admits, it adds a significant amount of stress to your job.

Not only does it lead to animosity between you and other physicians, it can also trigger anxiety related to the potential for bad patient outcomes.

Stress and anxiety are the arch-enemies of a long and healthy EM career.

A hospitalist who is paid by productivity has a financial incentive to admit patients, leading to a more collaborative work environment, less conflict, and better care.

The hospitalist's perspective

Think about this from the hospitalist's point of view.

If they're going to make the same salary no matter what, they have no reason to admit a patient who falls into the nebulous zone between "obvious admit" and "obvious discharge".

But if they are paid per admit, each page for admission represents money in their pocket.

You suddenly go from an annoying ER doctor calling with another(!) admission, to an ally in their attempt to provide for their family, pay off their mortgage, or buy a new boat.

A perfect example of this is an elderly patient with a hip fracture. If ortho balks at the admission, you may get stuck going back and forth between the hospitalist and orthopedic surgeon, desperately trying to convince someone to admit the patient. But if the hospitalist is paid per admission, they'll be much more willing to take it (even if they do roll their eyes).

This change in incentive is one of the biggest shifts that some young doctors face as they transition from resident to attending. Residents are universally paid a salary, which results in some academic centers being a breeding ground for unpleasant disputes. When a previously obstinate medicine resident graduates and joins an RVU-based hospitalist practice, they quickly change their tune.

When do I ask this question?

Talking about pay is always a sensitive issue.

This isn't a question you'll want to ask right off the bat.

It's also not the most important question, so its safe to save for later in the interview process.

You'll probably want to wait until you've had a discussion about *your* reimbursement first.

Any time after that is an appropriate time to ask... "Are the hospitalists paid on productivity or are they salaried?"

Disclaimer

You can have a happy EM career no matter how the hospitalists are paid.

A few clarifying points:

• The ED does not suddenly became a conflict-free utopia if your hospitalists are paid on productivity.
• You can't admit every patient. Just because you can admit a patient, doesn't mean you should.
• This question should not be a make-or-break issue when you're searching for a job.

Just keep in mind that your life will probably be somewhat easier if the hospitalists are incentivized to admit.

Also remember that hospitalists are not your enemy. In fact, the happiest ER doctors are those who can maintain good relationships, even when unavoidable minor conflicts arise. Always be professional and courteous.

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