Organizers and Facilitators: Michelle Knees, Andrea Porrovecchio, Cat Callister, Nick Bianchina, Sam Murray-Bainer, and Claire Schmitz

Background

Hospitalists and APPs routinely care for patients whose needs extend beyond illness severity alone. In February, HOMERuN focus groups explored the concept of patient-specific workload, or the patient-level factors that make some patients disproportionately time-, attention-, and energy-intensive to care for. Across groups, participants described workload as arising not only from medical complexity, but also from communication barriers, behavioral and relational challenges, uncertainty, discharge coordination, and fragmented systems of care.

What Drives Patient-Specific Workload

Participants emphasized that patient-specific workload is not synonymous with acuity or census and high workload often stems from factors unrelated to physiologic instability. Rather, workload often reflects the amount of coordination, cognitive effort, emotional labor, and follow-up required for a given patient.

Contributors included complicated medication reconciliation, multiple consultants, diagnostic uncertainty, behavioral or psychiatric overlays, substance use, complex family dynamics, low health literacy, need for surrogate decision-makers, and discharge barriers related to housing, transportation, insurance, or other social needs. Geographic spread, patients boarding outside usual workflows, and procedures requiring unexpected coordination were also identified as major workload drivers.

Key Points:

• Patient acuity and volume alone does not reliably capture patient-specific complexity.
• Behavioral issues, relational conflicts, and misalignment around goals or expectations are major contributors to workload.
• Discharge complexity and social determinants of health also meaningfully intensify workload.

"It feels like it's possible for one patient to suck literally all of your time and energy for the entire shift."

Impact on Care of Other Patients

Participants reported that high-workload patients affect care well beyond the individual encounter. Time spent managing one complex patient can slow care progression, delay discharges, defer family communication, and reduce attention available for other patients. Several clinicians noted that stable-appearing patients may become unintentionally deprioritized, which can lead to missing early deterioration signs. Others described how difficult conversations may get pushed later in the day when multiple urgent demands compete for attention. A recurring theme was that even one or two unexpectedly intensive patients can change the trajectory of an entire shift.

Key Points:

• High-workload patients can consume disproportionate clinician time and attention.
• Care delays may occur for lower-acuity or stable patients.
• Clinicians worry about things "falling through the cracks" for other patients.

"I always worry about the patient that appears stable, that I don't have the time to think about because I'm managing other complex patients, and then at the end of the day, notice that something was off."

Impact on Clinician Experience and Fulfillment

The focus groups described patient-specific workload as having a complex relationship with burnout and professional fulfillment. Participants noted that highly demanding patients can be deeply rewarding when clinicians feel they made a meaningful difference. At the same time, prolonged time demands, lack of alignment with patients or families, and system barriers outside the clinician's control can be emotionally draining.

Several participants distinguished ordinary burnout from moral injury, particularly when they felt unable to provide the kind of care they believed patients needed because of staffing constraints, missing services, or discharge pressures. Participants also noted that the burden of high-workload patients often extends beyond service weeks by displacing administrative work into nominal "off" time.

Key Points:

• High-workload care can be both fulfilling and exhausting. Fulfillment is higher when effort feels effective and meaningful, but burnout increases when time demands do not translate into progress or patient benefit.
• Moral injury can arise when external constraints prevent clinicians from delivering the care they believe is needed.
• Clinical intensity may spill into off-service time by displacing administrative and scholarly work into these "off" hours.

"Really challenging patients that you feel like you made a meaningful impact and had a good outcome — that's super rewarding for me. Whereas other times where there are high tensions, you don't feel like you're aligned, and it's more of a contentious situation — those make me really miserable."

Systems that Help

Participants identified several work-design strategies that may better support clinicians. Suggestions included protected rounding time, rounder/admitter models, smaller censuses for teams with very high-needs patients, and better geographic cohorting.

Multiple groups proposed some form of flexible support role, such as a "firefighter: or "star" clinician who could step in when one patient unexpectedly consumes a large share of the day. Other proposed supports included stronger de-escalation resources, improved behavioral health and addiction medicine access, better coordination across consultants, team-based rather than unit-based ancillary support, and systems to identify or score complexity early, while acknowledging that many drivers of workload remain difficult to predict at time of admission.

Participants also emphasized the importance of good colleagues, debriefing, and structures that support coordination rather than simply pressuring hospitalists to achieve outcomes without adequate resources.

Key Points:

• Protected time, geographic cohorting, smaller censuses, and better access to behavioral health and addiction resources may reduce strain.
• Flexible clinician support roles could help when one patient dominates a shift.
• Clinicians and health systems broadly have the same goals, but health systems can create stress when pressuring clinicians to do more with fewer resources.

"It's a similar goal with these patients in the hospital, but it seems like everyone has their own metrics or how they're measuring that goal or how they want to get to it. And they're not aligned. And it's really frustrating."

Conclusion:



Patient-specific workload cannot be adequately measured just by patient census or acuity. Workload arises from the interaction of medical, relational, behavioral, and system-level factors, with important downstream effects on patient care and clinician well-being. Efforts to improve hospital work design should account not only for patient volume and acuity, but also for the hidden coordination, communication, and emotional labor embedded in certain patient encounters. Better recognition of patient-specific workload may create opportunities to design more equitable staffing models, strengthen support systems, and improve both care delivery and clinician experience.

Our next HOMERuN meeting will be on June 5, 2026.

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