Organizers and Facilitators: Brad Monash, Sarah Apgar, Andrew Dunn, Rebecca Jaffe, Ed Vasilevskis, Mark Williams, Andy Auerbach

Background

Clinical work is a core component of an academic hospitalist's career. Within academic medical centers, hospitalists engage in a diverse range of clinical duties, including teaching services, direct care services, consultative roles, triage roles, and more. The structure and variety of these clinical responsibilities play a critical role in faculty satisfaction and retention. At the same time, divisions must navigate resource constraints, both in terms of personnel and finances.

This summary highlights how hospital medicine groups approach assigning and compensating clinical work and provides insights on how to design equitable and fulfilling clinical jobs in academic hospital medicine.

Standard Clinical Job Structure

Approximately 20 hospital medical programs were represented in the focus groups, ranging in size from small programs (fewer than 30 faculty) to large programs (more than 100 faculty). Programs that were represented included academic, academic-affiliated, VA, adult, and pediatric. Significant variation amongst groups was noted making a "standard" hard to define. However, some common themes were noted:

• The median full-time clinical FTE for an academic hospitalist is 170-180 shifts of 10-12 hours of length per year; however, the range was large from 160-210 shifts per year with programs noting shorter shift length and/or clinically focused roles resulting in more shifts per year.
• The majority of groups have dedicated nocturnist teams. Nocturnists typically work 20%-30% few shifts for the same FTE with a range of 120-150 shifts per year for full-time FTE.
• There is a trend toward moving to shorter shift lengths (8-10 hours) and later start times (7:30 am–8 am) to accommodate work-life balance.

"If you have 10 different programs, we do things 15 different ways."

Assigning Clinical Work

One of the strongest themes across all groups was a consensus on the value of faculty autonomy in scheduling, both for types of clinical shifts and time off requests. Meeting these requests was a point of pride for many programs and explicitly noted as key to higher faculty satisfaction and retention.



• Annual surveys are the most common approach to ascertain clinical work preferences.
• Majority of groups ask for "like to do" when asking about specific clinical assignments and find that the natural diversity in preferences for clinical work allows for matching people with their interests.
• Formal track systems, such as academic and clinical tracks, are less common and typically found in larger programs.
• Clinical time spent on resident teaching services was a highly valued but limited resource. Assigning this time was noted as a challenge, and programs commonly used experience, evaluations, and/or demonstrated interest in medical education to guide allocation.

"The importance of autonomy in scheduling really came through. When faculty have a say and there are divisions where there's a lot of effort to achieve faculty requests, that contributes to longevity and satisfaction."

Compensation for Clinical Work

Compensation models varied across groups with the most common model being salary base with RVU incentives. In terms of compensation for individual clinical shifts, a few themes emerged:

• Most programs have all day shifts valued equally.
• Night differentials were universal, either with higher pay or fewer shifts.
• At some programs, teaching services are assigned a lower value, though this approach was noted to decrease faculty interest in the shift.

"I used to credit teaching shifts less and then people didn't want to do them when that should be the best people."

Challenges With Assigning Clinical Work

Equity concerns: The tension between individual customization and fair distribution of desirable/undesirable shifts was noted as a challenge. Strategies employed for assigning less popular shifts included equal distribution of the shifts, using RVU based financial incentives to guide self-selection, and shift improvement for less popular shifts.

Back-up roles: Compensation for back-up roles was a common challenge, as many programs do not count them towards the scheduled shift count or count them lower than other shifts which is a faculty dissatisfier. One innovation that was described was the creation of flex roles, which were typically admitting roles that could be redirected to cover sick calls or other schedule gaps and is counted as a full shift.

Administrative burden: All programs noted that assigning and scheduling clinical work is a significant administrative burden which becomes exponentially more complicated as divisions grow and add service lines. Most programs use Qgenda, but all noted that this is not enough with multiple groups mentioning having a "scheduling savant."

"Most of our sites did use QGenda, but I think if there's one takeaway, they only work with someone, I think the term savant came up several times. So, you need a savant plus QGenda to make the whole thing work. That doesn't seem like the highest use of Qgenda or that person."

Take-Home Points

1. There is no single "right" way to assign and compensate clinical work for academic hospital medicine groups.
2. Most programs strongly value faculty autonomy and aim to meet faculty preferences, despite the significant administrative burden required to do this.
3. Areas for future study include solutions such as flex roles instead of back-up and developing structured systems for assignment of more/less desirable shifts.

Our next HOMERuN meeting will be on November 14, 2025.

Image Attributions: Icon images from https://www.flaticon.com and https://www.vecteezy.com.