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Dear Director,
I’ve been recruited to be the medical director/chairman for a 40,000 visit ED. My concern is that the hospital wants me to work 12-14 eight-hour shifts a month in addition to the administrative responsibilities, and there is no plan for an associate director. Is this too much?

Define the position and the expectation
The most common complaint I hear from hospital administrators when they’ve replaced a chairman is that the physician chairman was not around enough to do the administrative job and/or did not relate to the medical staff well. With that said, it sounds like the clinical requirement they are asking of you approaches full time, thus leaving little time in the week for administrative responsibilities. Therefore, it will be important to only agree to a job once the job is clearly defined. Don’t assume that you can do all of the standard administrative tasks (q/a chart audits, scheduling, following up on patient complaints, reviewing stroke and core measure data) and still have time and energy for a full shift load. I suspect most senior level hospital administrators work 50+ hours a week and that’s often what they expect from an ED chairman. However, given a clinical load, including evenings and nights, that may not be realistic on a weekly basis. It will be important to define in writing the percentage split between clinical and administrative and perhaps even the expectation of weekly hours.

The case for lowering your clinical load
The role of the department chairman has many facets. Besides clinical time, which is often the most fun part of the job, there is the responsibility for staffing and recruitment, quality, being the liaison to other departments and the hospital executive team, and ultimately the responsibility of improving the department. While the last one is nebulous, it’s one that comes with a combination of retrospective analysis and forward thinking and planning. It’s very difficult to accomplish this if you’re working too much clinically, particularly in a busy ED or a hospital that involves a lot of politics or committees to accomplish actions. You need to have enough non-clinical time to be in meetings, be available in your office and around the hospital, and be flexible enough to address urgent issues. These are more difficult with a high clinical load that reduces office availability and flexibility.

Importance of an associate director
The importance of an associate medical director cannot be over stated. This is the person who will perform at least some of the chart reviews but will also be your back-up for administrative call, will help out in a disaster, will sing the party line and give you unending support with the staff when you want to roll out a new project, and can substitute for you at certain meetings when you’re unavailable. Additionally, it gives you a colleague with whom you can discuss issues privately when situations arise.

My year, my month, my week
Most contracts start with an annual amount of hours of clinical responsibility. Most medical directors I talk to of mid-size EDs (40-80K annual visits) work about 750 clinical hours a year. This breaks down to about eight 8 hour shifts a month or about 2 per week. Here’s how my week usually breaks down. It starts with a Monday morning meeting with my nursing leadership team to discuss the issues of the prior week and plan for the upcoming week. This usually gives me a few tasks to follow up on through the day and the week. Reviewing my own calendar, I have about 5-10 meetings a week. While it would be nice if they were all on the same day or two, they’re usually scattered by time and day of the week. Depending on how easy it is to do chart reviews and how robust your q/a program is, you probably need about one half day a week for Q/A and CQI (Continuous Quality Improvement). With 3500 patient visits a month, you can count on at least a few physician complaints a week that will require follow up. These can vary from 15 minutes to more than 3 hours to resolve but I generally budget about an hour for chart review, investigation, and follow up with the patient, other physician, which might involve a phone call or writing a letter. You need to have the flexibility and availability in your schedule to meet with the risk manager, CFO, or anyone else who’s important in the hospital who calls you and tells you to find an hour or two. More importantly, is the time to deal with a root cause analysis or other significant time commitment that unexpectedly pops up. Finally, having time to plan, creat, innovate--which might be rewriting policy, preparing a lecture, building order sets, or anything else that will improve the ED--is critical. If your head is in the weeds with too many meetings, dealing with last weeks problems, or even working clinically, you won’t be able to improve your department.

Now is the time to negotiate
It sounds like you know it’s a bad situation. Don’t take the job thinking you will change your agreement after you get started. Your best opportunity to negotiate is when the hospital is recruiting you for the position. It may involve you educating them to the role of the chairman and the time commitment that administrative responsibilities take each week. It’s rare to find the ED that is functioning with all cylinders running perfectly but just needs a chairman to jump in and fill clinical shifts. More than likely, there are challenges ahead, and while clinical time up front will give you credibility with the staff and your colleagues – not to mention real-time insight into some of the problems – the solutions will likely be achieved by work in your office and around the hospital. Set clinical and administrative expectations in the contract and also negotiate for the associate director before signing the contract.

Be ready to walk away
While you’re hopefully not signing a 10-year contract, you probably need to commit (a least mentally) to this job for 2-3 years. At the end of the day, you will be judged on results. I’ve always been a believer that with enough hard work, positive results are obtainable. However, the question is at what expense. I caution you to make sure that you have maximized your opportunities to be successful and happy at this position. If the hospital won’t negotiate and you think you’re setting yourself up for failure, or several years of 60+ hour work weeks, now is the time to politely bow out and keep looking. There are great administrative jobs out there with supportive administrations, good work environments and interesting challenges that will promote your growth as an ED leader.

Michael Silverman, MD, is chairman of emergency medicine at Harbor Hospital in Baltimore, MD and is on TEAMHealth’s Medical Advisory Board.

 

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