Interview with Dr. Robert Craven
This week's episode is a replay of the second most popular episode since the podcast was launched discussing a great hospital job: utilization management physician advisor. It was first posted in January of 2022 and featured Dr. Robert Craven.
Dr. Craven went to medical school at the University of Tennessee College of Medicine, in Memphis, Tennessee. Then he completed his internship and residency in internal medicine at Carolinas Medical Center (now Atrium Health), in Charlotte, North Carolina. He works in the role of
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He serves on the executive council of the physician advisor special interest group (SIG) for the Society of Hospital Medicine. He still works clinically as a hospitalist two to three shifts a month and also does medicolegal consulting. Rob currently resides in Murrells Inlet, South Carolina, with his wife and two daughters.
Unexpected Opportunity
He had no intention of working as a physician advisor. However, a previous employer contacted him unexpectedly and offered him the position when it decided to expand its UM Program.
Today he tells us what his job entails, why he thinks this a great hospital job, and how you can land a similar position.
A Great Hospital Job: Utilization Management Physician Advisor
Rob explained the details of his job as a physician advisor. It is somewhat unique that he is working remotely for a large system, with occasional opportunities to go on-site if needed.
The job is more flexible than a full-time hospitalist position, and it accommodates his efforts to spend more time with his family. It is intellectually stimulating. And in this job, he provides value to his employer, its physicians, and patients.
Summary
After working nine years as a full-time hospitalist, Dr. Robert Craven finds that his role as utilization management physician advisor is intellectually stimulating and fulfilling. He works remotely from home on most days. And he still works a few clinical shifts each month, which enables him to maintain clinical skills and relate better to his physician colleagues.
NOTE: Look below for a transcript of today's episode.
Links for Today's Episode:
- Connect with Dr. Rob Craven on LinkedIn
- Dr. Robert Craven's email address: cravenmedical@email.com
- American College of Physicians Advisors
- Society of Hospital Medicine
- How to Go from UM Physician Advisor to Revenue Cycle CMO with Dr. Ralph Wuebker – 069
- Meet the Modern Physician Advisor – Interview with Dr. Timothy Owolabi – 012
- How to Find a Top Remote Nonclinical Career – 188
- NewScr!pt – the BEST place to find mentors and experts to advance your career
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Transcription PNC Podcast Episode 230
Why Utilization Management Physician Advisor Is a Great Hospital Job
John: Hello, Dr. Robert Craven.
Dr. Robert Craven: Hi, thanks for having me.
John: I'm just glad to talk to physicians but number one, I've wanted to talk to more hospitalists. I came from a background in family medicine, but I was a hospital administrator. And so, I worked with lots of hospitalists, particularly in those last 10 years or so after that whole specialty became a thing. I like to see what hospitalists are up to and how they transition into leadership positions and management positions. So, that's why I'm really excited to talk to you today, Rob.
Dr. Robert Craven: Excellent.
John: We'd like to hear a little background at the beginning, so you can give us a nutshell description of where you went to school and why you chose being a hospitalist and how that career went, and then just finish up with what you're actually doing today.
Dr. Robert Craven: Excellent. Well, I grew up in Tennessee and grew up really outside of Chattanooga. I went to undergrad at UT Chattanooga and then medical school at the University of Tennessee, in Memphis. I finished there in 2008 and then matched and did my residency in internal medicine in Charlotte, North Carolina, with what is now called Atrium Health. Back then we called it Carolina's Medical Center. I felt like I got excellent training there.
Initially, my plan was to go into pulmonary and critical care, but while I was there, that was right around the time that hospital medicine was becoming a big thing. And the temptation just to come on out and practice and have a week on - week off lifestyle was great. And I got offered an excellent job right out of training in Charlotte. I really liked the inpatient side of medicine. I liked the acuity of it. I liked the flexibility of it. I liked the schedule, the week on - week off schedule. At that point in time, I was still single. I didn't have any children. So, it was really a great lifestyle for me coming out of training in Charlotte.
I worked for about five years for a system in Charlotte and really enjoyed that, and really loved hospital medicine. Got married, settled down, started having children. And that's when my wife and I wanted to get a little bit closer to family because neither of us was from that area. And her parents live in Murrells Inlet, South Carolina, which is where we live now. Around early 2016, we started migrating closer to the coast of South Carolina. And I took a hospitalist position, with the system I currently work for and worked there for about four years.
This was in a small town and while I loved working for that employer, we just didn't really like the town. We wanted to be closer to my wife's parents and didn't really fully adapt to the small-town life in South Carolina. So, about 2019, we decided to move further to the beach. I made the decision to join another group, out this way and that was right before the COVID pandemic hit. And things didn't really pan out that well in that group, as we might talk about more later. But while I was there, the system I had previously worked for reached out to me and said, "We have this opening available as a physician advisor and we know you and you know us and the team you'd be working with, you're very familiar with."
They approached me to see if I would be interested and with everything going on and with the COVID pandemic, it seemed like too good of an opportunity to pass up. Even though I previously would never have told you, I was interested in doing physician advisor work. I interviewed for the job and ended up getting the job. And it has allowed me to work for the system that I work for now, and previously had excellent experience with. But yet I still live where I do now with my family, close to my in-laws, and enjoy the coastal life of South Carolina. Now, I've been doing that for about a year now. I transitioned in December of 2020. A little over a year ago, I made the transition to the nonclinical world and it hasn't been perfect, but it's been great. And I have no regrets.
John: Well, let me see, let me jump in here. One question I have is, are you doing any clinical work currently, even if it's just once a week or a month or anything?
Dr. Robert Craven: I do. The job I'm in is technically 100% admin, which I'm trying to work out to where it's more like 80% admin, 20% clinical. But the way it stands right now, I'm doing an average of two to three shifts a month as a hospitalist. Just more so for my own benefit to make sure I continue to have a foot in the game and continue to have clinical relevance in what I do.
And typically, what I'll do is do a Friday, Saturday, Sunday stretch, and I work throughout the system. So, it's opened me up to get exposed to some of the smaller hospitals in the system I work for. And that's been refreshing and fun to meet new people and work in a bit of a different environment. But typically, I'll do a Friday, Saturday, Sunday stretch. And then back to my administrative role Monday morning.
John: Okay. As I was following that timeline, there was some relocation in there somewhere. The Friday, Saturday, Sunday, is that something that's at a distance? Is it fairly close to where you live? Do you just stay on-site when you're doing those weekends, how does that work?
Dr. Robert Craven: It varies. There are some weekends where I work locally and I just come home every night, and then there are some weekends where I might be two, two and a half hours away. In those situations, I'll stay in a hotel for the weekend.
John: Okay. Let me ask you this about the whole situation as a physician advisor. As a hospitalist, I'm assuming you had interaction with people that were doing that role or could be nursing they were doing the UM and case management. Was this something that you were very familiar with when they asked you? Was it something you had to get up to speed on? How did that work?
Dr. Robert Craven: I was familiar with the very basics of it. I was practicing there before they had a physician advisor and back then, if there was a denial that requires a peer to peer, the attending hospitalist would handle that peer to peer. And maybe I did a couple a month back then. It wasn't that frequent, but it was enough to understand the process. But I'll tell you what really led me to it was that the denial team that I work with, I probably knew 80% of them from my time as a hospitalist there. It largely is comprised of one nurse that is their denials coordinator, their chief physician advisor, who was there before me, who I knew and worked with because he was a former hospitalist and now myself. It's really the three of us. And then the administrative leadership over that, I also knew fairly well with my previous work.
Knowing them and them knowing me, I think led to a lot of that. They knew that I would fit well with the team. They knew my work ethic and they also wanted a bit more of a presence towards the beach because they had facilities out here, and I was able to fill that void as well. It worked out well for them and it's worked out great for me.
John: I want to get into what the day-to-day activities of your job entail. And you can tell us what you like, what you don't like. But one of the first parts of that, is this something that you do pretty much as a remote physician advisor? Do you do any on-site? How does that work out?
Dr. Robert Craven: Most of what I do is remote. I do have an office nearby. It's about 30 minutes from where I live. I might spend one or two afternoons in that office. The rest of the time I'm working from home. I typically commute to our main campus, which is about an hour and a half away, and usually spend a day there a week. Just to keep up to speed with everything that's going on, make sure that I'm seeing the other people in the department, make sure I'm seeing the other physician.
I do think there's value in being seen and having conversations at lunchtime in the doctor's lounge. You'll get different opinions about that. There are some physician advisors that work entirely remote and they'll tell you there's no value at all to being on campus, and then you'll meet others that say that you should never be remote. You should always be on campus. And I like having a bit of a balance. But my schedule is very loose and I get to dictate a lot of it, which I like. I can coordinate with my family if there are certain days that week where I really need to be home, then I'll adjust my schedules to accommodate that and make sure that I'm not working a clinical shift or planning on commuting to a different campus.
John: Now, when we talk about UM and physician advisors on the podcast, a lot of times we're talking to someone who's working for an insurance company or I guess I would say a middle man. Someone who's on the outside trying to get things authorized or that kind of thing. And I only bring it up because sometimes they tell me, "Well, any physician can do that work working for an insurance company. It's basically knowing the protocols, knowing the criteria takes about anywhere from six to 12 weeks to learn it." Okay. So that's cool. I mean, pretty much any physician can do that. I just want to know what your on-ramp was? What was your learning curve at the beginning, and what would you tell others to expect if they're going particularly into a full-time physician advisor role?
Dr. Robert Craven: Right. It is a bit of a learning curve. I think certain specialties adapt to it quicker than others. And I'll say that in this role, I've dealt with medical directors with different insurance companies from a whole host of backgrounds, from OB-GYN to surgery, to ophthalmology. It's possible for anyone of any background to do this. But I think if you're in a specialty that is not so inpatient centered, hospital-based, that sort of thing, I think it's going to be a bit more of a learning curve for you. The people that tend to make the transition easier, and are more common to make this transition, usually come from hospital mass and emergency mass and intensivists that sort of thing. But there's not a whole lot of educational resources out there for this type of work.
The American College of Physician Advisors exists and they're excellent. I don't represent them in our conversation today. I'll say that I'm a member, anyone can join. And they have a lot of video tutorials on their website that are excellent. A lot of explanations on their website, and resources.
There's a lot of self-learning that you can do if it's something you're interested in, but most systems will have some sort of process for bringing you up to speed, with either a third party or some sort of educational program that they have. The system I work for used a third party to educate both me and the physician advisor that I was joining. He went through the same education that I got a few years before. And then when I was onboarding, he went through it again, just to have that extra benefit.
But the training I went through, the actual online training that I went through with this third party was about two days. And then there was a lot of kind of apprenticeship type training with the chief physician advisor, just learning their workflow, which was a big part of it, just how my system in general handles denials.
But then also learning the ins and outs of the two-midnight rule and CMS rules and regulations and the various commercial insurers and how they operate, all those things. Like most things in medicine, you learn by doing. And so, the first peer to peer I would do, he would be in the room with me. He would review the case as well, and give me some pointers. I would make that phone call, put it on speakerphone so he can hear everything that's being said.
And the first ones often didn't go well. And then afterwards, he would be able to teach me and say, well, you really should have emphasized this point or that point. It was very much a learning-by-doing environment.
But I would say, after two or three months, I was pretty comfortable. The first month I spent a lot of time on-site, on our main campus just to have that constant resource of the other physician advisor, someone to bounce things off of. But as time has progressed, I've gotten more independent. Whereas now rarely do I bounce something off of him. Usually, if we're communicating about a case, it's because it's something highly unusual and not because I'm looking for his advice or feedback.
John: Excellent. Now that gives us a good picture of how to work into it. You know the environment. You know what it means to be in the hospital and the different types of admissions and observation and so forth and inpatient-outpatient. It's then learning the language, the jargon they use, and then the criteria that they use, I would imagine.
So, what is your day-to-day now? I know it's probably hard to put it in simple one, two, three, these are the three or four things I do. But what would you say if someone were to ask you that question? What is it you'd spend most of your time doing? Is it something that takes a lot of planning? Is it laid out for you? How does that work?
Dr. Robert Craven: Sure. The past two weeks have been a bit abnormal because my kids are out of school. And when you're working from home and your kids are out of school, it can be a bit challenging. But on an average day as a hospitalist, I was not that involved in my kid's day-to-day routine, but now I am because my day starts later.
So typically, my wife and I will get up around the same time, to help get the kids ready for school. We have a carpool with our neighborhood. Sometimes I drive, sometimes other people drive. But I'm very involved in getting them ready in the morning, getting them off to school. And then now I go to the gym in the morning or try to, after they're ready for school.
John: Nice.
Dr. Robert Craven: I do about 30 minutes of cardio or other exercises. And then I come home, get ready for work. And usually, I'm sitting at my desk, logged in to our system by about 9:00, 9:30 in the morning. I'll be on and off the computer until 4:00 or 5:00 PM, usually. Technically until 5:00, but some days things wrap up a little earlier, our denials coordinator will tell us, look, there's nothing else in the queue. And then, you know you can leave early.
And an interesting thing about physician advisors is it's such a new thing, every system uses them a little differently. My experience as a physician advisor could be very different from another physician advisor in a bigger system, a smaller system, a different area of the country.
But the way it works with our group, the bulk of what we do is review denials, it's what we call denial management. There are multiple cues that I'm following online in our computer system. And one of them is where any denial from an insurer that comes through our system, it will get reviewed by our denials coordinator. She will do a little brief summary as to why it got denied and any specifics about the case. And then it gets put in this queue.
And then myself and four of the other physician advisors, we just work through that as we can and sign up for these denials, claiming it as our own, labeling that we're going to be the one to review it. And when we review it, this is where you get a lot of deviation from one system to another. The way we do it is, we actually will write a report usually about half a page or a one-page report summarizing the case and also stating if we feel like it is really inpatient appropriate, or if we don't and why.
And then we file that report in a couple of different places, both in our electronic healthcare record and on our hospital's systems drive on their internet. So that way, if we were to get audited, if an insurer were to audit us and want to see our review process, we have it very well documented that we thoroughly reviewed it. And we felt like it was inpatient for the following reasons. And sometimes we'll reference CMS guidelines or other criteria like MCG or Interpol, but a lot of times we're re-reviewing it at a bit of a higher level than those things. That's one cue that we're managing.
There's another one full of what we call short stays. And those are discharges within the system that were put in as inpatient but discharged from the hospital before crossing the second midnight. And so, that queue fills up a little slower, but there's usually two or three of those a day that we review, and determine, is this something that was inpatient appropriate that we should release the inpatient bill? Or should we self-deny that and just bill it as observation to try to minimize the risk of us getting audited on the back end? And so, that's a process that we do as well. We also write a report. Usually, there's communication with the attending that we feel if they were placed in the wrong status, we will communicate with them, that they did so, and why we thought that was an error, that sort of thing.
And then there's the third queue and the final queue is secondary reviews or concurrent reviews where a case manager in a hospital is having trouble getting a patient to meet inpatient criteria that the physician put in inpatient. And they'll want us to review that and see if it needs to be downgraded to observation, or if we think inpatient is appropriate. And oftentimes that requires a conversation with that attending.
We're kind of managing these three different queues all at one time. And an average day between the two of us, we might generate 15 to 20 reports a piece. A busy day I'd say is 30 to 40 total between the two of us. But it's not uncommon for us to generate 15 reports a piece for that day.
John: Okay. Now, I probably know just enough to become a little bit dangerous, but I'm going to ask you some questions just because I hear these things come up and because my daughter is a social worker who did UM for a long time and was managing inpatient discharges. You don't have a whole lot of let's say mental health issue denials or admissions or behavioral health units. Those seem to be a little different from the typical medical I would think.
Dr. Robert Craven: They are, but they still, we do have behavioral health hospital. And so, we still deal with that. It is rare, but it does still come up.
John: Okay. And then when you were saying, and this is probably in the weeds, but in terms of inpatient, are you talking about the initial admission, like on day one that they are inpatient as opposed to out? Or let's say each additional day where the insurer might be saying, no, they should have a three-day length of stay and now they're on day four, we're going to deny it?
Dr. Robert Craven: It varies. Both. It's all based on the contractual agreement that your system has with the insurer. Some of them will give you a lump sum for a DRG for the whole hospital stay. And whether you have them there for two days or seven days, they don't really care. They're giving you the same amount and then others will have a per diem component.
And that's where having some negotiation skills can be a benefit because you might end up having a peer-to-peer discussion with that insurer. And they're saying we're not going to pay for the last five days and you're trying to negotiate. You'd like them to pay for all of it, but you end up compromising, and at the end of the conversation, they're not paying for the last two days. It ends up still being a win for the system.
It really goes down to what contractual agreement you have with the insurer, and that is another complexity of all of this because all of them vary and are different.
John: Is there a way that you have that information in front of you when you're having these conversations? Or is it something the nurse relays to you or do you have to look it up?
Dr. Robert Craven: Some systems that have been doing this a while often will have some sort of Excel sheet or Flowsheet where they can glance at it and see the specifics of each insurer and what their agreement is. We don't have that yet. We're working on that, but a lot of it I've learned just by trial and error. And you'll learn from talking with the different medical directors of these insurance companies, because sometimes they'll have the contract in front of them and they can say, "Yeah, we have a per diem component with you all." And then you just learn by repetition, which insurers have a per diem component and which do not. But ideally, I should have a spreadsheet with all that right on it so that I can glance at it for reference.
John: Interesting. Yeah. That makes sense. It's unfortunate that things are so complex that you actually have to create an entire system to deal with it, but that's the way it's been for quite a while.
Dr. Robert Craven: That's right.
John: Tell me more about the things that you like because I think I got the idea that you probably like being more involved with your kids. You like having the flexibility of starting a little later in the day. What are the things you like with what you're doing now?
Dr. Robert Craven: I think I was doing some case review before I made this transition. I was doing some medical malpractice reviews. I was doing and still do some standard of care review for the State Medical Board. I've done disability appeals before. I don't really care to go back to that, but it was something I dabbled in briefly.
I've always enjoyed case reviews. And I think that's critical for this kind of work because it's the bulk of what you do. You're just reviewing it for different details. Instead of reviewing a case to look for a deviation of standard of care or causation of harm, that sort of thing, you're reviewing a case to see can I make an argument for inpatient status with this particular insurer?
But the principles of reviewing a case and how to do it efficiently, I think carry over from one aspect of that to another. That I enjoy. I enjoy the flexibility as we had touched on earlier. I did some traveling over the summer and didn't take any PTO because mostly what I was traveling for was occurring in the evening. So, I would just work in my hotel room during the day. I had excellent internet and cell service and I didn't even have to take PTO. With this kind of work, as long as your employer's okay with it, you can be extremely mobile and even go on vacation, let your family enjoy it, while you're working out of the hotel room.
John: Anything you don't like about it?
Dr. Robert Craven: I think there's a bit of a lack of connection sometimes. On the campus I used to work at full time, I know most of those people. So, if I have an issue and I call one of those physicians, more than likely they remember me, we had a good relationship. But if I'm having to deal with a physician at a campus that I haven't worked at, I feel like there's a disconnect there.
And especially as a physician advisor, which is a fairly new thing, the doctors that don't know me are a bit uncertain of what it is I'm doing. Am I really on their side or am I not? You get a little bit of hesitation from some doctors when they hear what you do. Some of them view this as selling out and becoming a suit, becoming an administrator. But I still very much feel every day that I'm really fighting for the patient, advocating for the patient, and trying to get their insurer to pay for the care that they needed.
John: Yeah. I hear that from some physicians that are thinking about doing it and not sure they want to be seen as an adversary in some ways. But to me, the most successful UM physician advisors have been more looking at it as "I'm just trying to educate the physician so they can document what needs to be documented and put the patient in the right setting in the first place rather than have to go and fight the insurance company later." That's definitely a trend.
Dr. Robert Craven: Right. And it's so much easier if you can get the patient in the right status on the front end, in a controlled environment, in the hospital where you can explain things to them, what it means to be an observation. It's so much easier on the front end than on the back end where maybe they're already home and now they're getting a letter saying, "By the way, your copay is going to be higher and you've got to pay for all these meds that you got in the hospital that you initially thought your insurance was going to pay for, but the doctor puts you in the wrong status. And therefore, now this all comes back to you." That can be a huge dissatisfier for the patient. Hospitals have a lot more control over it and the optics of it, if you're doing it in real-time while the patient is there.
John: Right. Yeah. That makes sense. If somebody you knew came to you and said, "I've been practicing for a few years and it's okay, but it's not as fulfilling as I thought it was going to be. I need to get a little more freedom, a little more flexibility in my life. And I think I'd like to do what you're doing." But as far as you can tell that person has not done anything to really learn about it or get the necessary skills. What would be the things you might advise that mentee to try or to do, to get some of the skills that would position them to potentially move into a part-time or full-time position?
Dr. Robert Craven: Right. That's an excellent question. And I get asked that a lot on different social media forums where people are talking about this kind of work. What I usually tell people is every hospital has to have a process of some sort for this kind of work. And usually, they're overburdened and they would like more help.
I usually tell people to figure out what the process is at your hospital. Do they have a physician advisor? Do they outsource that? Do they have a committee of docs who take turns? There's a number of different ways that a hospital or a system can do this. And try to see if you can participate. Even if it's half a day, every other week. That's still some experience that you previously wouldn't have had. And a lot of times I think systems would be open to that.
Another thing is, like I mentioned, the American College of Physician Advisors. They're an excellent resource. You could become a member there and they have some excellent online content and resources, including several books that they or other people have written that are very well written and informative about this kind of work.
I will say as I read one of these books prior to taking the job. Reading these types of texts before you've actually done the work is kind of like reading Harrison's Internal Medicine before doing an internal medicine residency. The context of it and how it all applies to real-world scenarios is a bit lost on you when you're just reading the book cold.
However, I do think it was helpful for me, but having those books as a reference afterwards to go back and look up certain chapters, certain things have been invaluable. And there's going to be growing content, educational content online for people interested in this kind of work.
I know the Society of Hospital Medicine. I'm a member of the Society of Hospital Medicine but I don't speak for them. They have a special interest group in physician advisors, which I'm a member of, and they are working to develop some educational curriculum, not just for hospitalists, but really for anyone that is interested in learning about the physician advisor world, maybe to get them more interested in it and eventually, to train them into how to become a full-time physician advisor. They already have excellent educational content, but they're talking about adding more specifically for those interested in the physician advisor world.
John: That's very useful. I hadn't heard that. So that would be good to know. And it would seem like you said, you mentioned hospitalists and ER docs in there, but hospitalists probably make up a decent percentage of physician advisors. Something you mentioned earlier really struck the chord with me as an awesome way to get your feet wet in a way is to do other types of chart reviews.
Dr. Robert Craven: Correct.
John: If you're doing peer reviews and you're doing let's say quality reviews in the hospital setting, or like you said, for State Medical Society or something like that, or medical, I guess it would be the licensing board more than a medical society. Those are great ways to say, "Okay, not only do I know how to look through a chart, discern what I need to discern, but I like doing it." If you sit down and do that and look at that page and go, "This is boring as hell. I can't do it" that would weed you out.
Dr. Robert Craven: Right. Yeah. And that's an excellent point. Because if you can't sit in front of a computer all day, you're probably not going to be happy doing this. Just like I would make a horrible radiologist because I wouldn't want to sit in a dark room and look at pictures all day. That's part of it too.
But the other thing too is if sometimes I get bored in my home office, I get my laptop and I go out on the porch or the deck or I go somewhere remote where I'm not going to violate HIPAA, but I know I'm going to have nicer scenery and solid Wi-Fi. There are ways that you can mix it up a bit, but at the end of the day, the majority of your day is reviewing cases.
I should probably point out, there are some misconceptions out there that even I had about what it's like to be a physician advisor. I had thought that, and I hear this from a lot of people who are considering it as well, that there's a lot of arguing. People will say, "Well, I would probably enjoy it, but I just don't like arguing with people." I really don't argue that much at all.
The other common misconception is that the physicians who are working for the insurance company have completely sold their soul and they have gone to the dark side and they are evil people that we should have nothing to do with. And that's not true either, because what I've found, we deal with the same medical directors over and over again, you end up developing a relationship with them.
There are a couple of them that I talk with almost on a daily basis. And you learn about your children. You learn about families. You learn about where they live. It becomes very collegial and really there's not much arguing. You build a case for why you feel the patient should be inpatient. You present that case and usually, they'll agree with you. And if they don't, they'll give you a reason why they don't. And often it's "Look, I'm sorry, but per our protocol, we have to have X, Y, and Z, and you don't have, Y. You just have X and Z." Even they are often apologetic about it. But they're just doing their job. And then instead of arguing, you just kick it to the next level of appeal. Getting all fired up about it and yelling and stomping your feet, I have found doesn't bring any benefit. And developing more of a collegial relationship with these physicians on the other side, I think has a lot more benefit in the long run.
To go back to the two misconceptions, you don't argue a lot at all. I think maybe I've had two argumentative conversations with a physician in a peer-to-peer over the last year. And as a hospitalist full-time I feel like I was having argumentative conversations all the time just to get various consultants to help you out or whatever.
I feel like in that regard, it's a lot less stressful. You realize that the docs on the other side of the phone are much like yourself who maybe didn't have the opportunity to work for a non-profit healthcare system, but the only opportunity they had was for a large national commercial insurance company. I've learned to appreciate the people on the other side of the phone as well in this whole process. Some of them are probably listening to this podcast.
John: No, it's true. And it's true in life in general, even just working on a medical staff. Some people just like to be oppositional, it's part of their personality. But most people want to just get along, help the patients, move people through the system and move on to the next case.
Dr. Robert Craven: Right.
John: All right. I think we're about out of time, really, probably going over a little bit, but that's okay. The last question I have for you is what advice you have for physicians, my listeners in particular, who many of them are burned out or they're frustrated, COVID has had an impact on their lives and they're just getting a little frustrated and looking for different options. Any general advice for people that are getting a little burned out and don't know what to do?
Dr. Robert Craven: A couple of things. First and foremost, I would tell people to keep an open mind, because sometimes the way a job is described can sound really boring and unfulfilling. And then when you actually do it, you actually really enjoy it.
I would've said that about physician advisor work. If you had asked me two or three years ago, would I ever see myself doing that? I would've told you "Absolutely not. It sounds completely boring." So, keep an open mind. I would tell people to try to dabble in different things. Healthcare informatics is a really big thing and there's a lot of people that are transitioning over to become consultants for EHR companies or chief medical informatics officers.
So, dabbling in that can be a benefit. I dabbled some in that and realized it's okay, but it's not something I would want to make my career out of. I ended up not going down that road. Dabbling in administration and asking to become an assistant director of your group or in charge of scheduling or whatever, and see if you like more of the administrative side. I've done some of that and felt like the more I was responsible for other physicians' behavior, the more frustrated I became. So, I felt like that was not really good for me. And there are all sorts of side gigs out there. People starting up concierge practices, medical spas, doing expert witness work. You're not really going to know what you like, what you're good at, unless you try some of it, and talk to people who are doing it. I would definitely tell people to keep an open mind.
Another thing, especially if you're looking at making the jump into more of an administrative role within your system or another system is to always remember, people are always looking at you as a physician and critiquing how you handle stress and how you interact with nurses, how you interact with case managers.
I probably would not have been selected for this job if the case managers that I'd worked with had a bad opinion of me, if I had been volatile or temperamental. Same with the nursing staff. If a physician came to me that I know is temperamental or blows up at medical staff meetings, and they're thinking about transitioning into administration, I'd probably tell them they need to either reconsider that or admit that they might need to have some anger management counseling and work on their demeanor.
Especially if you've worked there for a while, people have already felt you out and decided if you're someone that would be able to fit into the culture there as an administrator or not. That's one of the benefits of working in a system before transitioning to administration. And it's one of the negatives. If you've been there for a number of years and haven't made a good impression on people then trying to get into a position like that is going to be more challenging.
John: Yeah. I think you can try and transfer, let's say, the way an OR works with the surgeon at the head of that team to management and administration, but usually, it's a little different. We usually look at it more as a servant leader when we're talking about actual management and leadership in a more corporate setting as opposed to more of a militaristic approach sometimes in the OR, or surgical center. But it's not that big of a transition if you look at it differently. Those are good bits of advice.
I want to thank you for going into so much detail here in what it means to be a physician advisor in a hospital setting, but in a remote position primarily. I don't think it's unique, but it's a little different. We either think of them and like you said, in a single hospital, they're going to be on site. And if they're working for an insurance company, it's a whole different thing. So, this has been very interesting.
Dr. Robert Craven: Excellent. Well, thank you so much. And I should just clarify that everything that I've mentioned in the podcast are my own thoughts and opinions, and don't reflect my current or previous employers or Society of Hospital Medicine or the American College of Physician Advisors.
John: All right. We appreciate that. But I think it's been very insightful and useful. With that, Rob, I will say goodbye, and I hope to talk to you again down the road sometime.
Dr. Robert Craven: Absolutely. Thank you so much.
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Transcription PNC Podcast Episode 230
Why Utilization Management Physician Advisor Is a Great Hospital Job
John: Hello, Dr. Robert Craven.
Dr. Robert Craven: Hi, thanks for having me.
John: I'm just glad to talk to physicians but number one, I've wanted to talk to more hospitalists. I came from a background in family medicine, but I was a hospital administrator. And so, I worked with lots of hospitalists, particularly in those last 10 years or so after that whole specialty became a thing. I like to see what hospitalists are up to and how they transition into leadership positions and management positions. So, that's why I'm really excited to talk to you today, Rob.
Dr. Robert Craven: Excellent.
John: We'd like to hear a little background at the beginning, so you can give us a nutshell description of where you went to school and why you chose being a hospitalist and how that career went, and then just finish up with what you're actually doing today.
Dr. Robert Craven: Excellent. Well, I grew up in Tennessee and grew up really outside of Chattanooga. I went to undergrad at UT Chattanooga and then medical school at the University of Tennessee, in Memphis. I finished there in 2008 and then matched and did my residency in internal medicine in Charlotte, North Carolina, with what is now called Atrium Health. Back then we called it Carolina's Medical Center. I felt like I got excellent training there.
Initially, my plan was to go into pulmonary and critical care, but while I was there, that was right around the time that hospital medicine was becoming a big thing. And the temptation just to come on out and practice and have a week on - week off lifestyle was great. And I got offered an excellent job right out of training in Charlotte. I really liked the inpatient side of medicine. I liked the acuity of it. I liked the flexibility of it. I liked the schedule, the week on - week off schedule. At that point in time, I was still single. I didn't have any children. So, it was really a great lifestyle for me coming out of training in Charlotte.
I worked for about five years for a system in Charlotte and really enjoyed that, and really loved hospital medicine. Got married, settled down, started having children. And that's when my wife and I wanted to get a little bit closer to family because neither of us was from that area. And her parents live in Murrells Inlet, South Carolina, which is where we live now. Around early 2016, we started migrating closer to the coast of South Carolina. And I took a hospitalist position, with the system I currently work for and worked there for about four years.
This was in a small town and while I loved working for that employer, we just didn't really like the town. We wanted to be closer to my wife's parents and didn't really fully adapt to the small-town life in South Carolina. So, about 2019, we decided to move further to the beach. I made the decision to join another group, out this way and that was right before the COVID pandemic hit. And things didn't really pan out that well in that group, as we might talk about more later. But while I was there, the system I had previously worked for reached out to me and said, "We have this opening available as a physician advisor and we know you and you know us and the team you'd be working with, you're very familiar with."
They approached me to see if I would be interested and with everything going on and with the COVID pandemic, it seemed like too good of an opportunity to pass up. Even though I previously would never have told you, I was interested in doing physician advisor work. I interviewed for the job and ended up getting the job. And it has allowed me to work for the system that I work for now, and previously had excellent experience with. But yet I still live where I do now with my family, close to my in-laws, and enjoy the coastal life of South Carolina. Now, I've been doing that for about a year now. I transitioned in December of 2020. A little over a year ago, I made the transition to the nonclinical world and it hasn't been perfect, but it's been great. And I have no regrets.
John: Well, let me see, let me jump in here. One question I have is, are you doing any clinical work currently, even if it's just once a week or a month or anything?
Dr. Robert Craven: I do. The job I'm in is technically 100% admin, which I'm trying to work out to where it's more like 80% admin, 20% clinical. But the way it stands right now, I'm doing an average of two to three shifts a month as a hospitalist. Just more so for my own benefit to make sure I continue to have a foot in the game and continue to have clinical relevance in what I do.
And typically, what I'll do is do a Friday, Saturday, Sunday stretch, and I work throughout the system. So, it's opened me up to get exposed to some of the smaller hospitals in the system I work for. And that's been refreshing and fun to meet new people and work in a bit of a different environment. But typically, I'll do a Friday, Saturday, Sunday stretch. And then back to my administrative role Monday morning.
John: Okay. As I was following that timeline, there was some relocation in there somewhere. The Friday, Saturday, Sunday, is that something that's at a distance? Is it fairly close to where you live? Do you just stay on-site when you're doing those weekends, how does that work?
Dr. Robert Craven: It varies. There are some weekends where I work locally and I just come home every night, and then there are some weekends where I might be two, two and a half hours away. In those situations, I'll stay in a hotel for the weekend.
John: Okay. Let me ask you this about the whole situation as a physician advisor. As a hospitalist, I'm assuming you had interaction with people that were doing that role or could be nursing they were doing the UM and case management. Was this something that you were very familiar with when they asked you? Was it something you had to get up to speed on? How did that work?
Dr. Robert Craven: I was familiar with the very basics of it. I was practicing there before they had a physician advisor and back then, if there was a denial that requires a peer to peer, the attending hospitalist would handle that peer to peer. And maybe I did a couple a month back then. It wasn't that frequent, but it was enough to understand the process. But I'll tell you what really led me to it was that the denial team that I work with, I probably knew 80% of them from my time as a hospitalist there. It largely is comprised of one nurse that is their denials coordinator, their chief physician advisor, who was there before me, who I knew and worked with because he was a former hospitalist and now myself. It's really the three of us. And then the administrative leadership over that, I also knew fairly well with my previous work.
Knowing them and them knowing me, I think led to a lot of that. They knew that I would fit well with the team. They knew my work ethic and they also wanted a bit more of a presence towards the beach because they had facilities out here, and I was able to fill that void as well. It worked out well for them and it's worked out great for me.
John: I want to get into what the day-to-day activities of your job entail. And you can tell us what you like, what you don't like. But one of the first parts of that, is this something that you do pretty much as a remote physician advisor? Do you do any on-site? How does that work out?
Dr. Robert Craven: Most of what I do is remote. I do have an office nearby. It's about 30 minutes from where I live. I might spend one or two afternoons in that office. The rest of the time I'm working from home. I typically commute to our main campus, which is about an hour and a half away, and usually spend a day there a week. Just to keep up to speed with everything that's going on, make sure that I'm seeing the other people in the department, make sure I'm seeing the other physician.
I do think there's value in being seen and having conversations at lunchtime in the doctor's lounge. You'll get different opinions about that. There are some physician advisors that work entirely remote and they'll tell you there's no value at all to being on campus, and then you'll meet others that say that you should never be remote. You should always be on campus. And I like having a bit of a balance. But my schedule is very loose and I get to dictate a lot of it, which I like. I can coordinate with my family if there are certain days that week where I really need to be home, then I'll adjust my schedules to accommodate that and make sure that I'm not working a clinical shift or planning on commuting to a different campus.
John: Now, when we talk about UM and physician advisors on the podcast, a lot of times we're talking to someone who's working for an insurance company or I guess I would say a middle man. Someone who's on the outside trying to get things authorized or that kind of thing. And I only bring it up because sometimes they tell me, "Well, any physician can do that work working for an insurance company. It's basically knowing the protocols, knowing the criteria takes about anywhere from six to 12 weeks to learn it." Okay. So that's cool. I mean, pretty much any physician can do that. I just want to know what your on-ramp was? What was your learning curve at the beginning, and what would you tell others to expect if they're going particularly into a full-time physician advisor role?
Dr. Robert Craven: Right. It is a bit of a learning curve. I think certain specialties adapt to it quicker than others. And I'll say that in this role, I've dealt with medical directors with different insurance companies from a whole host of backgrounds, from OB-GYN to surgery, to ophthalmology. It's possible for anyone of any background to do this. But I think if you're in a specialty that is not so inpatient centered, hospital-based, that sort of thing, I think it's going to be a bit more of a learning curve for you. The people that tend to make the transition easier, and are more common to make this transition, usually come from hospital mass and emergency mass and intensivists that sort of thing. But there's not a whole lot of educational resources out there for this type of work.
The American College of Physician Advisors exists and they're excellent. I don't represent them in our conversation today. I'll say that I'm a member, anyone can join. And they have a lot of video tutorials on their website that are excellent. A lot of explanations on their website, and resources.
There's a lot of self-learning that you can do if it's something you're interested in, but most systems will have some sort of process for bringing you up to speed, with either a third party or some sort of educational program that they have. The system I work for used a third party to educate both me and the physician advisor that I was joining. He went through the same education that I got a few years before. And then when I was onboarding, he went through it again, just to have that extra benefit.
But the training I went through, the actual online training that I went through with this third party was about two days. And then there was a lot of kind of apprenticeship type training with the chief physician advisor, just learning their workflow, which was a big part of it, just how my system in general handles denials.
But then also learning the ins and outs of the two-midnight rule and CMS rules and regulations and the various commercial insurers and how they operate, all those things. Like most things in medicine, you learn by doing. And so, the first peer to peer I would do, he would be in the room with me. He would review the case as well, and give me some pointers. I would make that phone call, put it on speakerphone so he can hear everything that's being said.
And the first ones often didn't go well. And then afterwards, he would be able to teach me and say, well, you really should have emphasized this point or that point. It was very much a learning-by-doing environment.
But I would say, after two or three months, I was pretty comfortable. The first month I spent a lot of time on-site, on our main campus just to have that constant resource of the other physician advisor, someone to bounce things off of. But as time has progressed, I've gotten more independent. Whereas now rarely do I bounce something off of him. Usually, if we're communicating about a case, it's because it's something highly unusual and not because I'm looking for his advice or feedback.
John: Excellent. Now that gives us a good picture of how to work into it. You know the environment. You know what it means to be in the hospital and the different types of admissions and observation and so forth and inpatient-outpatient. It's then learning the language, the jargon they use, and then the criteria that they use, I would imagine.
So, what is your day-to-day now? I know it's probably hard to put it in simple one, two, three, these are the three or four things I do. But what would you say if someone were to ask you that question? What is it you'd spend most of your time doing? Is it something that takes a lot of planning? Is it laid out for you? How does that work?
Dr. Robert Craven: Sure. The past two weeks have been a bit abnormal because my kids are out of school. And when you're working from home and your kids are out of school, it can be a bit challenging. But on an average day as a hospitalist, I was not that involved in my kid's day-to-day routine, but now I am because my day starts later.
So typically, my wife and I will get up around the same time, to help get the kids ready for school. We have a carpool with our neighborhood. Sometimes I drive, sometimes other people drive. But I'm very involved in getting them ready in the morning, getting them off to school. And then now I go to the gym in the morning or try to, after they're ready for school.
John: Nice.
Dr. Robert Craven: I do about 30 minutes of cardio or other exercises. And then I come home, get ready for work. And usually, I'm sitting at my desk, logged in to our system by about 9:00, 9:30 in the morning. I'll be on and off the computer until 4:00 or 5:00 PM, usually. Technically until 5:00, but some days things wrap up a little earlier, our denials coordinator will tell us, look, there's nothing else in the queue. And then, you know you can leave early.
And an interesting thing about physician advisors is it's such a new thing, every system uses them a little differently. My experience as a physician advisor could be very different from another physician advisor in a bigger system, a smaller system, a different area of the country.
But the way it works with our group, the bulk of what we do is review denials, it's what we call denial management. There are multiple cues that I'm following online in our computer system. And one of them is where any denial from an insurer that comes through our system, it will get reviewed by our denials coordinator. She will do a little brief summary as to why it got denied and any specifics about the case. And then it gets put in this queue.
And then myself and four of the other physician advisors, we just work through that as we can and sign up for these denials, claiming it as our own, labeling that we're going to be the one to review it. And when we review it, this is where you get a lot of deviation from one system to another. The way we do it is, we actually will write a report usually about half a page or a one-page report summarizing the case and also stating if we feel like it is really inpatient appropriate, or if we don't and why.
And then we file that report in a couple of different places, both in our electronic healthcare record and on our hospital's systems drive on their internet. So that way, if we were to get audited, if an insurer were to audit us and want to see our review process, we have it very well documented that we thoroughly reviewed it. And we felt like it was inpatient for the following reasons. And sometimes we'll reference CMS guidelines or other criteria like MCG or Interpol, but a lot of times we're re-reviewing it at a bit of a higher level than those things. That's one cue that we're managing.
There's another one full of what we call short stays. And those are discharges within the system that were put in as inpatient but discharged from the hospital before crossing the second midnight. And so, that queue fills up a little slower, but there's usually two or three of those a day that we review, and determine, is this something that was inpatient appropriate that we should release the inpatient bill? Or should we self-deny that and just bill it as observation to try to minimize the risk of us getting audited on the back end? And so, that's a process that we do as well. We also write a report. Usually, there's communication with the attending that we feel if they were placed in the wrong status, we will communicate with them, that they did so, and why we thought that was an error, that sort of thing.
And then there's the third queue and the final queue is secondary reviews or concurrent reviews where a case manager in a hospital is having trouble getting a patient to meet inpatient criteria that the physician put in inpatient. And they'll want us to review that and see if it needs to be downgraded to observation, or if we think inpatient is appropriate. And oftentimes that requires a conversation with that attending.
We're kind of managing these three different queues all at one time. And an average day between the two of us, we might generate 15 to 20 reports a piece. A busy day I'd say is 30 to 40 total between the two of us. But it's not uncommon for us to generate 15 reports a piece for that day.
John: Okay. Now, I probably know just enough to become a little bit dangerous, but I'm going to ask you some questions just because I hear these things come up and because my daughter is a social worker who did UM for a long time and was managing inpatient discharges. You don't have a whole lot of let's say mental health issue denials or admissions or behavioral health units. Those seem to be a little different from the typical medical I would think.
Dr. Robert Craven: They are, but they still, we do have behavioral health hospital. And so, we still deal with that. It is rare, but it does still come up.
John: Okay. And then when you were saying, and this is probably in the weeds, but in terms of inpatient, are you talking about the initial admission, like on day one that they are inpatient as opposed to out? Or let's say each additional day where the insurer might be saying, no, they should have a three-day length of stay and now they're on day four, we're going to deny it?
Dr. Robert Craven: It varies. Both. It's all based on the contractual agreement that your system has with the insurer. Some of them will give you a lump sum for a DRG for the whole hospital stay. And whether you have them there for two days or seven days, they don't really care. They're giving you the same amount and then others will have a per diem component.
And that's where having some negotiation skills can be a benefit because you might end up having a peer-to-peer discussion with that insurer. And they're saying we're not going to pay for the last five days and you're trying to negotiate. You'd like them to pay for all of it, but you end up compromising, and at the end of the conversation, they're not paying for the last two days. It ends up still being a win for the system.
It really goes down to what contractual agreement you have with the insurer, and that is another complexity of all of this because all of them vary and are different.
John: Is there a way that you have that information in front of you when you're having these conversations? Or is it something the nurse relays to you or do you have to look it up?
Dr. Robert Craven: Some systems that have been doing this a while often will have some sort of Excel sheet or Flowsheet where they can glance at it and see the specifics of each insurer and what their agreement is. We don't have that yet. We're working on that, but a lot of it I've learned just by trial and error. And you'll learn from talking with the different medical directors of these insurance companies, because sometimes they'll have the contract in front of them and they can say, "Yeah, we have a per diem component with you all." And then you just learn by repetition, which insurers have a per diem component and which do not. But ideally, I should have a spreadsheet with all that right on it so that I can glance at it for reference.
John: Interesting. Yeah. That makes sense. It's unfortunate that things are so complex that you actually have to create an entire system to deal with it, but that's the way it's been for quite a while.
Dr. Robert Craven: That's right.
John: Tell me more about the things that you like because I think I got the idea that you probably like being more involved with your kids. You like having the flexibility of starting a little later in the day. What are the things you like with what you're doing now?
Dr. Robert Craven: I think I was doing some case review before I made this transition. I was doing some medical malpractice reviews. I was doing and still do some standard of care review for the State Medical Board. I've done disability appeals before. I don't really care to go back to that, but it was something I dabbled in briefly.
I've always enjoyed case reviews. And I think that's critical for this kind of work because it's the bulk of what you do. You're just reviewing it for different details. Instead of reviewing a case to look for a deviation of standard of care or causation of harm, that sort of thing, you're reviewing a case to see can I make an argument for inpatient status with this particular insurer?
But the principles of reviewing a case and how to do it efficiently, I think carry over from one aspect of that to another. That I enjoy. I enjoy the flexibility as we had touched on earlier. I did some traveling over the summer and didn't take any PTO because mostly what I was traveling for was occurring in the evening. So, I would just work in my hotel room during the day. I had excellent internet and cell service and I didn't even have to take PTO. With this kind of work, as long as your employer's okay with it, you can be extremely mobile and even go on vacation, let your family enjoy it, while you're working out of the hotel room.
John: Anything you don't like about it?
Dr. Robert Craven: I think there's a bit of a lack of connection sometimes. On the campus I used to work at full time, I know most of those people. So, if I have an issue and I call one of those physicians, more than likely they remember me, we had a good relationship. But if I'm having to deal with a physician at a campus that I haven't worked at, I feel like there's a disconnect there.
And especially as a physician advisor, which is a fairly new thing, the doctors that don't know me are a bit uncertain of what it is I'm doing. Am I really on their side or am I not? You get a little bit of hesitation from some doctors when they hear what you do. Some of them view this as selling out and becoming a suit, becoming an administrator. But I still very much feel every day that I'm really fighting for the patient, advocating for the patient, and trying to get their insurer to pay for the care that they needed.
John: Yeah. I hear that from some physicians that are thinking about doing it and not sure they want to be seen as an adversary in some ways. But to me, the most successful UM physician advisors have been more looking at it as "I'm just trying to educate the physician so they can document what needs to be documented and put the patient in the right setting in the first place rather than have to go and fight the insurance company later." That's definitely a trend.
Dr. Robert Craven: Right. And it's so much easier if you can get the patient in the right status on the front end, in a controlled environment, in the hospital where you can explain things to them, what it means to be an observation. It's so much easier on the front end than on the back end where maybe they're already home and now they're getting a letter saying, "By the way, your copay is going to be higher and you've got to pay for all these meds that you got in the hospital that you initially thought your insurance was going to pay for, but the doctor puts you in the wrong status. And therefore, now this all comes back to you." That can be a huge dissatisfier for the patient. Hospitals have a lot more control over it and the optics of it, if you're doing it in real-time while the patient is there.
John: Right. Yeah. That makes sense. If somebody you knew came to you and said, "I've been practicing for a few years and it's okay, but it's not as fulfilling as I thought it was going to be. I need to get a little more freedom, a little more flexibility in my life. And I think I'd like to do what you're doing." But as far as you can tell that person has not done anything to really learn about it or get the necessary skills. What would be the things you might advise that mentee to try or to do, to get some of the skills that would position them to potentially move into a part-time or full-time position?
Dr. Robert Craven: Right. That's an excellent question. And I get asked that a lot on different social media forums where people are talking about this kind of work. What I usually tell people is every hospital has to have a process of some sort for this kind of work. And usually, they're overburdened and they would like more help.
I usually tell people to figure out what the process is at your hospital. Do they have a physician advisor? Do they outsource that? Do they have a committee of docs who take turns? There's a number of different ways that a hospital or a system can do this. And try to see if you can participate. Even if it's half a day, every other week. That's still some experience that you previously wouldn't have had. And a lot of times I think systems would be open to that.
Another thing is, like I mentioned, the American College of Physician Advisors. They're an excellent resource. You could become a member there and they have some excellent online content and resources, including several books that they or other people have written that are very well written and informative about this kind of work.
I will say as I read one of these books prior to taking the job. Reading these types of texts before you've actually done the work is kind of like reading Harrison's Internal Medicine before doing an internal medicine residency. The context of it and how it all applies to real-world scenarios is a bit lost on you when you're just reading the book cold.
However, I do think it was helpful for me, but having those books as a reference afterwards to go back and look up certain chapters, certain things have been invaluable. And there's going to be growing content, educational content online for people interested in this kind of work.
I know the Society of Hospital Medicine. I'm a member of the Society of Hospital Medicine but I don't speak for them. They have a special interest group in physician advisors, which I'm a member of, and they are working to develop some educational curriculum, not just for hospitalists, but really for anyone that is interested in learning about the physician advisor world, maybe to get them more interested in it and eventually, to train them into how to become a full-time physician advisor. They already have excellent educational content, but they're talking about adding more specifically for those interested in the physician advisor world.
John: That's very useful. I hadn't heard that. So that would be good to know. And it would seem like you said, you mentioned hospitalists and ER docs in there, but hospitalists probably make up a decent percentage of physician advisors. Something you mentioned earlier really struck the chord with me as an awesome way to get your feet wet in a way is to do other types of chart reviews.
Dr. Robert Craven: Correct.
John: If you're doing peer reviews and you're doing let's say quality reviews in the hospital setting, or like you said, for State Medical Society or something like that, or medical, I guess it would be the licensing board more than a medical society. Those are great ways to say, "Okay, not only do I know how to look through a chart, discern what I need to discern, but I like doing it." If you sit down and do that and look at that page and go, "This is boring as hell. I can't do it" that would weed you out.
Dr. Robert Craven: Right. Yeah. And that's an excellent point. Because if you can't sit in front of a computer all day, you're probably not going to be happy doing this. Just like I would make a horrible radiologist because I wouldn't want to sit in a dark room and look at pictures all day. That's part of it too.
But the other thing too is if sometimes I get bored in my home office, I get my laptop and I go out on the porch or the deck or I go somewhere remote where I'm not going to violate HIPAA, but I know I'm going to have nicer scenery and solid Wi-Fi. There are ways that you can mix it up a bit, but at the end of the day, the majority of your day is reviewing cases.
I should probably point out, there are some misconceptions out there that even I had about what it's like to be a physician advisor. I had thought that, and I hear this from a lot of people who are considering it as well, that there's a lot of arguing. People will say, "Well, I would probably enjoy it, but I just don't like arguing with people." I really don't argue that much at all.
The other common misconception is that the physicians who are working for the insurance company have completely sold their soul and they have gone to the dark side and they are evil people that we should have nothing to do with. And that's not true either, because what I've found, we deal with the same medical directors over and over again, you end up developing a relationship with them.
There are a couple of them that I talk with almost on a daily basis. And you learn about your children. You learn about families. You learn about where they live. It becomes very collegial and really there's not much arguing. You build a case for why you feel the patient should be inpatient. You present that case and usually, they'll agree with you. And if they don't, they'll give you a reason why they don't. And often it's "Look, I'm sorry, but per our protocol, we have to have X, Y, and Z, and you don't have, Y. You just have X and Z." Even they are often apologetic about it. But they're just doing their job. And then instead of arguing, you just kick it to the next level of appeal. Getting all fired up about it and yelling and stomping your feet, I have found doesn't bring any benefit. And developing more of a collegial relationship with these physicians on the other side, I think has a lot more benefit in the long run.
To go back to the two misconceptions, you don't argue a lot at all. I think maybe I've had two argumentative conversations with a physician in a peer-to-peer over the last year. And as a hospitalist full-time I feel like I was having argumentative conversations all the time just to get various consultants to help you out or whatever.
I feel like in that regard, it's a lot less stressful. You realize that the docs on the other side of the phone are much like yourself who maybe didn't have the opportunity to work for a non-profit healthcare system, but the only opportunity they had was for a large national commercial insurance company. I've learned to appreciate the people on the other side of the phone as well in this whole process. Some of them are probably listening to this podcast.
John: No, it's true. And it's true in life in general, even just working on a medical staff. Some people just like to be oppositional, it's part of their personality. But most people want to just get along, help the patients, move people through the system and move on to the next case.
Dr. Robert Craven: Right.
John: All right. I think we're about out of time, really, probably going over a little bit, but that's okay. The last question I have for you is what advice you have for physicians, my listeners in particular, who many of them are burned out or they're frustrated, COVID has had an impact on their lives and they're just getting a little frustrated and looking for different options. Any general advice for people that are getting a little burned out and don't know what to do?
Dr. Robert Craven: A couple of things. First and foremost, I would tell people to keep an open mind, because sometimes the way a job is described can sound really boring and unfulfilling. And then when you actually do it, you actually really enjoy it.
I would've said that about physician advisor work. If you had asked me two or three years ago, would I ever see myself doing that? I would've told you "Absolutely not. It sounds completely boring." So, keep an open mind. I would tell people to try to dabble in different things. Healthcare informatics is a really big thing and there's a lot of people that are transitioning over to become consultants for EHR companies or chief medical informatics officers.
So, dabbling in that can be a benefit. I dabbled some in that and realized it's okay, but it's not something I would want to make my career out of. I ended up not going down that road. Dabbling in administration and asking to become an assistant director of your group or in charge of scheduling or whatever, and see if you like more of the administrative side. I've done some of that and felt like the more I was responsible for other physicians' behavior, the more frustrated I became. So, I felt like that was not really good for me. And there are all sorts of side gigs out there. People starting up concierge practices, medical spas, doing expert witness work. You're not really going to know what you like, what you're good at, unless you try some of it, and talk to people who are doing it. I would definitely tell people to keep an open mind.
Another thing, especially if you're looking at making the jump into more of an administrative role within your system or another system is to always remember, people are always looking at you as a physician and critiquing how you handle stress and how you interact with nurses, how you interact with case managers.
I probably would not have been selected for this job if the case managers that I'd worked with had a bad opinion of me, if I had been volatile or temperamental. Same with the nursing staff. If a physician came to me that I know is temperamental or blows up at medical staff meetings, and they're thinking about transitioning into administration, I'd probably tell them they need to either reconsider that or admit that they might need to have some anger management counseling and work on their demeanor.
Especially if you've worked there for a while, people have already felt you out and decided if you're someone that would be able to fit into the culture there as an administrator or not. That's one of the benefits of working in a system before transitioning to administration. And it's one of the negatives. If you've been there for a number of years and haven't made a good impression on people then trying to get into a position like that is going to be more challenging.
John: Yeah. I think you can try and transfer, let's say, the way an OR works with the surgeon at the head of that team to management and administration, but usually, it's a little different. We usually look at it more as a servant leader when we're talking about actual management and leadership in a more corporate setting as opposed to more of a militaristic approach sometimes in the OR, or surgical center. But it's not that big of a transition if you look at it differently. Those are good bits of advice.
I want to thank you for going into so much detail here in what it means to be a physician advisor in a hospital setting, but in a remote position primarily. I don't think it's unique, but it's a little different. We either think of them and like you said, in a single hospital, they're going to be on site. And if they're working for an insurance company, it's a whole different thing. So, this has been very interesting.
Dr. Robert Craven: Excellent. Well, thank you so much. And I should just clarify that everything that I've mentioned in the podcast are my own thoughts and opinions, and don't reflect my current or previous employers or Society of Hospital Medicine or the American College of Physician Advisors.
John: All right. We appreciate that. But I think it's been very insightful and useful. With that, Rob, I will say goodbye, and I hope to talk to you again down the road sometime.
Dr. Robert Craven: Absolutely. Thank you so much.
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