The Hospitalist-Patient Conundrum

John Nelson, MD, FACP

Hospitalist-patient continuity is primarily a function of the number of consecutive days worked by a hospitalist, but the way new referrals are distributed can also affect continuity. This month, I will discuss both.

For my first few years as a hospitalist in the late 1980s and early 1990s, my one partner and I generally worked a schedule of 21 days on and seven days off. While I wouldn’t recommend that anyone try that today, it wasn’t as bad as you might think, because our patient volumes weren’t terribly high and, on about a third of the worked days, I was done shortly after lunch.

While working that schedule, I became aware of its benefit to hospitalist-patient continuity. I can remember many patients with hospital stays of more than two weeks whom I saw every day myself. As you might imagine, my partner and I talked periodically about working fewer than 21 days at a stretch and handing a service over to one another more frequently. But we were concerned that this would make us inefficient because more of our worked days would involve getting to know a new list of patients. In effect, we’d work more hours without an increase in income or patient volume.

While still working the 21-day schedule, I came to know another practice and was stunned that these doctors had taken essentially the opposite approach to scheduling. They worked 24-hour shifts on site and never worked more than one shift at a time. (If your shifts are 24-hours long, you probably can’t or shouldn’t work more than one at a time.) This schedule meant that a patient would see a different hospitalist each day. I couldn’t believe that either the patients or the hospitalists would think this was a reasonable thing to do, but the doctors were convinced it worked well. Later I learned that this group had been started by an emergency medicine practice, and it seems they had made the mistake of inserting an emergency department (ED) physician schedule into a hospitalist practice—and 24-hour shifts for ED doctors were more common then than now.

While the number of consecutive days of work is the most important variable in determining continuity, the way a group distributes new referrals can also have an impact.

So, early in my career, the first two schedules I became acquainted with sat on opposite ends of a continuum that has since been filled in by many other options. Both the practice I was part of and the 24-hour-shift practice abandoned their original schedules within a few years and moved on to other alternatives. In fact, I have since worked nearly every schedule you can imagine, including the seven-on/seven-off schedule, which I think is a suboptimal choice for most groups. (See August 2006 “Career Management,” p. 9.) With each variation in my work schedule, I’ve thought a lot about its effect on continuity.

Leave a Reply

Your email address will not be published. Required fields are marked *