Orthopaedic Hospitalist Roles Offer ‘An Unusual Kind of Balance’

Kurt Ehlert, MD, served his country and his practice, but more than a decade ago he realized he wanted a different option that allowed him to serve his own needs as well. For him, working as an orthopaedic hospitalist fit the bill. In an interview for AAOS Now, Dr. Ehlert described his experience with this mode of practice, discussed pros and cons, and shared what led him to the model.

Burnout without the term
Burnout was not talked about as openly 15 years ago, but in retrospect that was what led Dr. Ehlert to explore the hospitalist alternative. After orthopaedic residency, he fulfilled his commitment to the Air Force and returned to join a practice as a general orthopaedic surgeon. Eventually he moved to North Carolina, continuing to work as a generalist.

“As I got busier, even though I didn’t recognize it at the time, I was approaching burnout,” Dr. Ehlert recalled. Surgical practice had become a grind, and he had lost joy in the profession. An advertisement to “cover call” sparked his interest. To test the waters, Dr. Ehlert started with a few days per month while maintaining his practice. After a few months, he took the plunge, leaving his practice for full-time hospitalist work.

“This is an unusual kind of balance,” Dr. Ehlert reflected. “It’s not day-to-day balance. It’s all in on work, and when you’re done, it’s all in on your life.” For Dr. Ehlert, this unusual balance enabled him to coach football; a typical orthopaedic practice would not have allowed him to commit to his players and be on the field at 2 p.m. Other surgeons in his group pursued travel or participated intensively in a hobby or vocation.

The hospitalist model
Generally, this practice model applies most frequently in level 3 community hospital settings and less commonly in level 2. For many years, Dr. Ehlert worked in a common “traveling” hospitalist model in states far from his home. Those hospitals often need to provide orthopaedic coverage but are unable to engage local surgeons due to a lack of surgeon interest or insufficient numbers to cover all emergency department (ED) calls. Responsibilities typically include providing acute operative and nonoperative care for ED patients, as well as staffing follow-up clinics.

In the “traveling” hospitalist model, three to five surgeons provide rolling coverage to a hospital as a “trauma group.” Each 24-hour period is considered a “shift.” If the hospitalist position is a surgeon’s sole practice mode, they may do 10 to 12 shifts per month. Typically, a traveling surgeon will cover about 5 continuous days at the hospital and more rarely up to 10 sequential days at a quiet hospital. Hospitalist surgeons augmenting another core practice may do about 5 shifts per month.

Dr. Ehlert stressed that when a shift starts, the surgeon is on call the whole time, covering clinic, operating room, and ED. At the end of a shift, after a warm hand-off of active patients, the surgeon is free. As he described it, hospitalist positions are more stable than a locum tenens model. The team is a small, focused group with one identified medical director. “Eventually, you develop a very close relationship with the other partners, even though you aren’t co-located, because you are all sharing a patient population,” Dr. Ehlert noted. The trauma team surgeons align their practice models to support each other, the patients, and the hospital by standardizing implants, equipment, and postoperative protocols.

When a hospital brings in a traveling “trauma group,” the surgeon group establishes these systems themselves, striving to make transitions efficient and effective. If new team members are needed, the interview process includes transparency about the need to work within the established protocols. There are several companies that contract with hospitals and surgeons to provide coverage. In Dr. Ehlert’s experience, compensation is targeted so that 10 to 12 shifts per month hits the 40th to 50th percentile of Medical Group Management Association’s reported salary for orthopaedic surgeons.

Pros and cons
As with any practice, benefits and drawbacks exist. Control of life and a long stretch of free time when not at the hospital present the clearest advantages.

The variety of cases can be stimulating, but Dr. Ehlert considers the position best matched to a general orthopaedic surgeon. “A fellowship-trained surgeon really wouldn’t get level 1 experience,” he noted.

A candidate must consider other downsides. Free time to focus on life comes at the cost of a stretch of several to many days per month away from home. The multiple days of continuous call can be physically and emotionally exhausting, without colleagues, family, or friends for support. Furthermore, it is rarely as financially lucrative as a private practice. Additionally, for the team to work, an individual surgeon must be willing to compromise personal preferences to provide efficient, consistent patient care.

Dr. Ehlert believes success in this mode of practice requires understanding the model and your own personality. A hospitalist surgeon must feel comfortable working independently and confident handling the variety of cases in the ED. Simultaneously, there is a need to collaborate and communicate effectively with other team members; Dr. Ehlert described the role as “individual yet together.”

“Typically, this position works best for a mature rather than early-career surgeon,” Dr. Ehlert shared, noting that the average age of applicants to his program was more than 50 years.

For Dr. Ehlert, the match worked. He has continued hospitalist work since making the change, including serving for 6 years as the national medical director for the company with whom he originally contracted. Since 2018, he has continued in an administrative role as national medical director for Surgical Colleagues while continuing hospitalist work in his hometown of Raleigh, North Carolina. In this model, the practice members all share overnight calls, but the following day, Dr. Ehlert assumes responsibility for the cases that came in, allowing his partners to focus on their elective practices.

“Finding this type of practice model most likely saved my career,” Dr. Ehlert reflected. “I was able to continue to practice in a high-need area with a type of practice that suited my personal and professional interests.”

Alexandra E. Page, MD, FAAOS, is a foot and ankle specialist in private practice in San Diego and the deputy editor of AAOS Now.