Physician leadership during the pandemic: reflections from hospitalist leaders in British Columbia
Vandad Yousefi, MD, FHM, DRCPSC
KEY WORDS: hospitalist medicine, relationships, leadership training, staffing
Yousefi V. Physician leadership during the pandemic: reflections from hospitalist leaders in British Columbia, Canada: a mixed-methods evaluation study. Can J Physician Leadersh 2023;9(2):46-57
Background: Hospitalist physician leaders play an important role in how health care organizations deliver acute care services. Understanding the challenges they face can be important in preparing them for future crises. Methods: We conducted a mixed-methods evaluation study to explore the challenges faced by hospitalist leaders and the impact of the COVID-19 pandemic on their ability to address them. Results: Our findings suggest that staffing issues are a major concern, along with the quality of relations between physicians and health authority managers. Moreover, our findings suggest a need for more leadership training for hospitalists. Conclusions: Hospitalist physician leaders in British Columbia face significant challenges in staffing their programs, as well as difficult relations with administrators. Efforts to improve collaboration and physician engagement should be a high priority for health system leaders in the province.
KEY WORDS: hospitalist medicine, relationships, leadership training, staffing
Yousefi V. Physician leadership during the pandemic: reflections from hospitalist leaders in British Columbia, Canada: a mixed-methods evaluation study. Can J Physician Leadersh 2023;
The impact of the COVID-19 pandemic on Canada’s health care system is well described.1,2 Facing this unprecedented challenge, organizations had to rapidly adapt to manage increasing demands. This required many sectors of the health care industry to pivot to address pressing challenges, such as large-scale testing, procurement, and deployment of personal protective equipment; development of effective therapeutics; and implementation of treatment and triage protocols.
Such a massive transformation in health care delivery services requires strong leadership across the board. In particular, during the early stages of the pandemic, physician leadership proved crucial, as the expertise of physicians was required to develop triage protocols and infection control practices. As the pandemic response evolved to incorporate treatment guidelines, physician leadership was again needed to ensure that such therapeutics could be deployed rapidly to the front lines of the fight against COVID-19.3-6
One group of physicians who were particularly affected by the pandemic were hospitalists.7,8 Hospitalists are physicians with generalist training who specialize in the care of patients in hospital.9 In Canada, hospitalists care for a large percentage of general medicine inpatients.10,11 As most hospital patients with COVID-19 did not require critical care in an intensive care unit,12 but instead were cared for on the general medicine wards, Canadian hospitalists were on the forefront of fighting COVID-19 in the hospital setting.13-15
Hospitalist physician leaders faced particular challenges as the pandemic evolved. Like their counterparts in other jurisdictions,16 they had to rapidly reorganize their teams to accommodate the constantly changing state of the COVID-19 response.17 From creating dedicated COVID-19 physician teams, building contingencies into schedules, and training staff, to protecting vulnerable group members from getting ill and providing peer support, the pandemic highlighted the important role of hospitalist leaders in facilitating a robust response to COVID-19 in hospitals.
In British Columbia (BC), hospitalist programs exist at 21 (out of 84) acute care hospitals that are operated by four of the province’s seven regional health authorities. In early 2022, physicians in the Doctors of BC Section of Hospital Medicine embarked on an evaluation project to better understand the demographic breakdown, workload concerns, and job satisfaction of the hospitalist workforce in the province. We also aimed to identify specific challenges faced by hospitalist physician leaders, as well as the impact of the pandemic on their ability to perform their operational responsibilities and promote relations with other stakeholders. In this paper, we focus on the findings that relate to hospitalist physician leadership. Other aspects of the evaluation will be reported separately.
The evaluation included an online survey of all individuals practising hospitalist services in the province, with a subset of questions specifically addressed to hospitalists in leadership positions. We also conducted a series of semi-structured interviews with physician leaders from various hospitalist programs across BC. The interviews aimed to supplement the survey findings by focusing on the current state of partnerships between hospitalists and other stakeholders (both within and beyond their health care institutions).
The online survey was created and distributed to potential respondents over a two-month period from 17 January to 14 March 2022. Survey questions were designed in collaboration with the members of the executive of Doctors of BC’s Section of Hospital Medicine, the professional organization that represents hospitalists provincially. We pilot tested the survey with a subset of respondents and used their feedback to revise the questions before launching to the broader target audience.
The survey contained a set of questions targeted only to those in leadership roles. These included exploration of the volume of services provided by each hospitalist group; workload capacity; recruitment and orientation of new hospitalists; models for shift coverage; and connections to hospital medicine groups across regional health authorities and more broadly. They also explored the main challenges that hospitalist physician leaders faced in overseeing their programs.
Hospitalists were invited to participate in the survey through customized SurveyMonkey (San Mateo, CA, USA) email invitations. All respondents were required to give informed consent before commencing. Participation was voluntary and respondents could withdraw at any time. All respondents were automatically entered into a prize draw to win one of three $100 Visa gift cards.
Thirty hospitalists were also invited to participate in semi-structured telephone interviews. These physicians were current or recent leaders of their programs. They were identified through members of the Section of Hospital Medicine, the online survey, and recommendations by other leaders. We purposefully attempted to identify people from across the province and across a range of hospital sizes and communities. A total of 11 interviews were completed (response rate 37%), at which time we reached thematic saturation. The interviews were 20–30 minutes in length. All individual responses were kept anonymous.
De-identified survey data were exported to SPSS (v. 14.0) for analysis. General descriptive statistics and frequencies were run. Cross-tabulations were also prepared to examine various factors associated with key variables of interest. Chi-squared tests and corresponding p values were calculated to test for independence between two categorical variables. Fisher’s exact test was used with small cell counts and when contingency tables were larger than 2 × 2, p values were computed by Monte Carlo simulation. Measures and directions of association were calculated using odds ratios (OR) and 95% confidence intervals (CI). Thematic analysis of qualitative data from interviews was completed in NVivo 12 (QSR, Burlington, MA, USA) to identify key themes emerging from open-ended responses.
Because this was an operational evaluation project of the members of the Section of Hospital Medicine of a physician association, we did not seek ethics approval.
Table 1. Involvement of survey respondents in leadership activities and roles
The survey was sent to 609 hospitalists; 374 completed the survey for a 61% response rate.
A subset of survey questions explored the involvement of respondents in leadership activities, either currently or in the previous five years. Roughly three-quarters of survey respondents (n = 277) indicated that they had participated in non-clinical leadership activities, including sitting on hospital committees (61%); participating in quality improvement or innovation projects (58%); sitting on a committee or working group not related to the hospital (52%); and participating in leadership training (31%) (Table 1).
Figure 1. Challenges reported by hospitalists in leadership roles (n = 71)
Figure 2. Factors that could facilitate hospitalist shift coverage (n = 69)
Almost a quarter of respondents (n = 80) also indicated that they held or had held formal leadership roles, which ranged from site-level program or departmental leadership, to regional administrative positions. These respondents were asked additional questions related to their formalized leadership responsibilities.
Hospitalist physician leader challenges
Hospitalist leaders identified continuous staffing of their programs, relations with their health authorities, and recruiting new hospitalists as their top challenges (Figure 1).
Half reported significant challenges in ensuring adequate staffing. Most indicated that evening/overnight and weekend shifts were more challenging to cover (77% and 61%, respectively), compared with daytime shifts (33%). They most frequently identified insufficient workforce of hospitalist physicians, excessive workload, and burnout associated with the COVID-19 pandemic as key factors. Other common challenges identified were hospitalists experiencing illnesses, funding uncertainties, and retirement of senior physicians.
According to survey respondents, the top three factors that could help facilitate hospitalist shift coverage included financial incentives for undesirable shifts, hiring more part-time or full-time staff, and using more temporary/locum providers (Figure 2).
Over half the hospitalist physician leaders also identified recruitment as a significant challenge. On average, respondents estimated that 82% of new hospitalists for their programs were recruited from BC, 15% from elsewhere in Canada, and 5% from other countries. When all respondents were surveyed, they speculated that the top three factors deterring physicians from choosing to practise as a hospitalist were high patient complexity/acuity, heavy workload, and the burden of after-hours work (Figure 3).
Figure 3. Factors deterring physicians from choosing to practise as a hospitalist (n = 107)
COVID-19 and hospitalist leadership
Of hospitalist physician leaders in the survey, 59% reported that they had been involved in planning activities related to COVID at their hospitals and/or health authorities. These leaders described various responsibilities, such as developing COVID protocols, procedures, and workflow modifications, sitting on hospital COVID planning/response committees, and advising on vaccine rollout plans. Most reported that COVID-19 made it somewhat more challenging (46%) or much more challenging (37%) to ensure shifts were covered.
We conducted semi-structured interviews with a sample of hospitalist physician leaders in the province. Most interviewees (9 out of 11) did not have formal leadership training to prepare them for their roles. A few explained that they had been informally mentored by senior hospitalist leaders. Others noted that their health authorities offered various leadership training opportunities, but they had not been able to find the time required to participate. One hospitalist participated in negotiations training offered by the Doctors of BC, which validated their on-the-ground experience supporting regional contract negotiations.
Connection and partnerships with decision-makers
We asked hospitalist physician leaders a series of questions about their connections to decision- or policymakers at various levels: within their local hospitals, with their regional health authorities, with decision-makers at the provincial level, and with other physician groups.
Most described strong partnerships with administrators and medical leaders at their local site. Interviewees often indicated that they had direct communication and standing meetings with site-level administrators, medical directors, and other physician leaders to manage hospital operations and administrative issues, discuss challenges and potential solutions, and make progress toward common goals. Relations appeared stronger in smaller community hospitals that tended to foster more collaboration.
“We have these dyad partnerships within the hospital. We’re connected with the administrative facility managers, with the chief of staff and the site medical director. They are hospitalists as well. We have direct access to communicate with them.”
“I feel pretty connected with local admin and leadership here. So, I have good a relationship with the site medical director. Every week I meet with the clinical director whose responsibility is the inpatient side of things. All of that is good in terms of the relationships.”
“We are quite integrated with the daily events around the hospital, such as managing overcapacity and things like that. Generally, we have good to quite good relationships. Although, that hasn’t always been the case here. Now we have a strong program and we are collaborative. We built those relationships.”
“In my experience, smaller community hospitals tend to have more collaborative relationships. More intimate environments lead to better relationships with site medical directors and administration. There are just better dynamics with hospitalist groups. We take care of 90% of inpatients in the hospital. We have a good dynamic with the site medical director.“
A more mixed picture emerged when we explored relations between hospitalists and administrators at the regional health authority level. Although some interviewees described somewhat positive relations, others noted challenges or a complete lack of connection. Interviewees explained that relations with health authorities had been strained because of a variety of factors, such as frequent turnover among administrators, misunderstanding of motives and priorities, lack of appreciation for services provided, disrespectful behaviour during negotiations, and toxic relations.
“I don’t have any meaningful connections to the health authority. We get a lot of information and communication pushed on us. They aren’t working with us and the relationships are now quite toxic.”
“One challenge is the turnover in the health authority roles. You get people put in who don’t know about our program. You develop those relationships with the health authority leaders, but then they leave the roles.”
At the macrosystem level, unifying and amplifying the voice of hospitalists at provincial tables, with direct lines of communication to provincial decision-makers was identified as a gap.
“I think the major concern is that we have become a substantial part of medicine in BC, we are approaching almost 40% of inpatient beds in the province. But the fact is, we don’t really have an avenue to have a voice at a higher, provincial level. Our communication is through the HA at best. Nothing beyond that at a meaningful level. Since we are not a formal specialty, our voices get lost in the GP dynamic.”
“Connections to the provincial level need to be strengthened, otherwise we’re completely in the dark.”
“Thinking about provincial relationships, it’s a difficult thing to consider. It’s always someone else’s problem. With the family practice crisis, the ministry doesn’t have money. Everyone has siloed themselves into their own stressful circumstances. Others are adding to their burden. There needs to be some way to be brought together. We have the same goal here. Let’s work towards that. The system is overloaded already.”
On the other hand, most interviewees indicated that current relations between their hospitalists and other physician groups were positive, collegial, and collaborative. They explained that such partnerships were fostered through advocacy and support for other physician groups when they needed it and translating the goodwill generated through this to support for hospitalists.
“Relationships with FPs have gotten better over time. During the time of transition in inpatient care models, the relationships were wounded. We have built strong relationships with them since.”
“Our relationships with other physician groups are also very collegial, like emergency doctors. We have lots of physician leaders that we work with here.“
“We need to not just advocate for ourselves. We need to help emergency work better, and other subspecialties. That attitude to help others helps our reputation in the hospital. There are still GPs who talk about how we’re the reason there are no GPs in the community. More and more, that is going away, but still there.”
We asked interviewees to identify mechanisms to strengthen relations with decision- and policymakers. Some interviewees indicated that standing meetings between administrators and hospitalist physicians were necessary to discuss how both sides could make progress toward common goals. When fostering relations between hospitalists and health authority administration, in-person events rather than virtual communications were identified as preferable, with conversations focused on collaboration and cooperation.
Interviewees also highlighted the importance of hospitalist involvement with non-clinical activities (e.g., quality improvement and access initiatives) and assumption of leadership/administrative roles as a way to gain exposure and build relations to enhance opportunities for collaboration.
Finally, some respondents identified a need for formal training on how to build relations with administrative leaders. Although interviewees were also asked if they would benefit from media training or support from public relations specialists to strengthen stakeholder partnerships, a large majority did not see value in this type of support.
Impact of COVID-19
The interviews also explored whether hospitalist physician leaders experienced any changes during the COVID-19 pandemic. Many interviewees explained that, as the pandemic unfolded, the demands on hospitalist leaders increased. They were more involved in virtual meetings and communications related to determining new protocols and procedures, optimizing patient access and flow, and general clinical operations. Others indicated that their clinical workloads increased and included direct care of COVID-19 patients, while non-clinical activities were largely paused. Some interviewees expressed concerns that high patient volumes negatively impacted patient safety and quality of care. Two years into the pandemic, interviewees highlighted that hospitalists were experiencing high levels of burnout and stress, resulting in staffing issues at their sites.
“COVID created more solidarity. The early pandemic helped with that. Now we have lots of burnout, not enough doctors, beds.”
Some interviewees explained that, while COVID-19 dramatically increased hospitalists’ clinical workloads, their commitment to “step up to the plate” demonstrated their value in their hospitals and placed them at the forefront of decision-making. Others indicated that the pandemic resulted in enhanced relations and solidarity with other physician groups, site administration, and health authority leadership. On the other hand, some explained that COVID-19 negatively impacted relations with their local health authorities given workload issues experienced by hospitalists.
“Any time you have a crisis, whoever is willing to do work gets the prize of having more influence at the end. Our CTU didn’t want to be involved with COVID, FPs didn’t want to see COVID, we took it on instead… we are a more integral part of the hospital now.”
“[COVID] certainly forced us into spending significant amounts of time in meetings as leaders. Lots of crisis management that, in a way, brought us closer with leadership. It allowed us, as hospitalists, another opportunity to demonstrate value.”
“I am quite disengaged from my [health authority] because of COVID and workload issues…. It lasted a few weeks with extreme congestion. I had to save myself. I reduced my work time. Workload is getting worse. COVID soured our relationship with [the health authority].”
Some interviewees explained that they could have benefited from crisis management and leadership training to better support them in their leadership roles during the initial onset of COVID-19.
We believe that this study is a first attempt to understand the perspectives of a group of hospitalist physician leaders in Canada on the roles and challenges they faced operationally, as well as in establishing relations with other decision-makers and health care system managers during the pandemic. Because it was conducted at a time when the COVID-19 pandemic was still at its height, it allows for a timely assessment of its impact on hospitalist leaders across BC.
Although staffing issues are common to many physician groups, they are a significant challenge for hospitalist physician leaders. The burden of ensuring evening, overnight, and weekend coverage is a major barrier in recruiting new staff. Hospitalist staffing levels have been associated with overall hospital outcomes.18 Moreover, lower staffing levels result in higher individual physician census, which has been associated with longer length of stay and lower efficiency of work.19,20 As a result, there is a clinical imperative to ensure that staffing of hospital medicine programs is sufficient to meet clinical workload demands and patient volumes, and that all shifts are adequately and consistently covered to achieve that goal.
Inadequate staffing levels also result in higher individual workloads. Work overload has been associated with higher burnout rates and greater intention to leave practice for a range of health care workers during the COVID-19 pandemic.21 Prior studies have suggested that high rates of physician staffing turnover result in significant recruitment costs to their organizations.22,23 As such, it is important for hospitalist physician leaders to retain their existing staff, as well as recruit new members to their programs.24 Given the impact of COVID-19 on frontline physician burnout levels,25 organizations must develop strategies to empower hospitalist physician leaders to address staffing shortfalls before it is too late.
A bigger challenge that was identified in the survey, and further explored in interviews, revolved around the importance of developing relations with various key stakeholders (particularly the regional health authorities that are responsible for the delivery of services). Historically, relations between hospitalist physicians and health authorities in BC have been characterized by periods of stability punctuated by episodes of strife and mutual distrust, mainly revolving around difficult contract negotiations.26,27 Given that health authorities fund and operate hospitalist services, the quality of relations between health authority administrators and hospitalist physicians can have a direct impact on work satisfaction and burnout among frontline providers. It can also affect the ability of hospitalist physician leaders to fulfill their responsibilities as they sit in a potentially uncomfortable position that straddles the divide between the two sides.
Although more than half the physician leaders in our survey identified relations with health authorities as an area of challenge, a more nuanced picture emerged during the interviews. The degree of challenge varied based on the level of bureaucracy in the health authority: hospitalist leaders described generally effective and collaborative relations with their health authority counterparts locally, but progressive erosion of the quality of the working relationship with higher levels of authority. Lack of access to health system leaders at the provincial level (e.g., the ministry of health, which ultimately oversees and operates the health authorities as its service delivery agencies) may explain the headline-making staffing challenges for some hospitalist programs in recent months.28,29
In this context, leadership training that focuses on developing skills and competencies around establishing and improving relations can be very important for hospitalist leaders. Such training could allow them to adopt strategies that would improve collaboration with their hospital administration counterparts locally and identify an approach to reach out to higher levels of health care leadership in a highly bureaucratic management system. In fact, a number of interviewees in our study highlighted leadership training for that purpose.
The LEADS in a caring environment capability framework30 has been widely adopted in Canada as the basis for various leadership training programs for physicians and other health care leaders. It emphasizes the importance of building and managing relations, with a number of domains focusing on various aspects of relationship development (engagement, developing coalitions, and spreading changes).31,32 It has also been shown to effectively address the capabilities required by health care leaders to address overarching challenges, such as the COVID-19 pandemic response.33 Leadership development programs based on the LEADS framework can address the competency requirements of hospitalist physician leaders in addressing the challenges we uncovered in our evaluation study.
To our surprise, a large percentage of hospitalist physician leaders in our sample lacked formal leadership training. Only 46% of those who identified as physician leaders had participated in leadership training. This was confirmed during the interviews, when only two of the 11 leaders interviewed had received formal training to enhance their leadership skills. Many interviewees indicated that such leadership opportunities were available to them, but they could not find the time away from clinical work to participate in such programs. Hospitalist physician leaders undertake leadership training for a variety of reasons: improving communication and interpersonal skills, enhancing negotiation skills, refining goals and strategic thinking, and improving self-development.34 However, lack of protected time and increasing clinical responsibilities can prevent many from taking such training.
Our evaluation of hospitalist physician leaders in BC during the COVID-19 pandemic has uncovered a number of operational challenges, particularly related to staffing shortfalls. In addition, it highlights the importance of relations between hospitalists and health care administrators in the BC context and the impact of the pandemic response on these relations. Lack of formal leadership training remains a notable issue. Health care organizations, such as health authorities in BC, should invest in their hospitalist leaders by more than simply offering training programs, but also facilitating their participation through compensation for lost clinical time. They should also support engagement in leadership training, not only by the individuals in formal leadership roles, but also for those who are informally considered to be influential or have the potential to assume leadership positions in the future.
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I wish to acknowledge the Section of Hospital Medicine, Doctors of BC, for providing funding for the evaluation project. I also thank Ms. Elayne McIvor for conducting the evaluation on behalf of the section as an external evaluation specialist. She was engaged by the section to conduct this evaluation study and received payment for her work.
Vandad Yousefi, MD, is interim head of the Department of Family and Community Practice, Vancouver Acute, Vancouver Coastal Health.
Ethics approval — This evaluation project was conducted by the professional medical association as an evaluation project of its membership, which is deemed exempt from the need for ethics approval in BC.
Availability of data and materials — The data that support the findings of this study were used under license for the current study, and so are not publicly available. However, data are available from the author on reasonable request and with permission of Doctors of BC’s Section of Hospital Medicine.
Competing interests — VY is the CEO and cofounder of Hospitalist Consulting Solutions, Inc., a health care management consultancy. He is also on the executive of the Section of Hospital Medicine of Doctors of BC. He did not receive any payment for his involvement in this project.
Funding — This project was supported by Doctors of BC’s Section of Hospital Medicine, which provided a grant to hire a professional evaluator to conduct the project. The section was involved in the design and administration of the evaluation study of its membership.
Informed consent — All survey and interview participants provided informed consent before participating in the evaluation study.
Correspondence to: email@example.com
This article has been peer reviewed.