Practice Economics

A New Schedule Could Be Better for Your Hospitalist Group


 

Present “hospitalist” in a word association exercise to a wide range of healthcare personnel in clinical and administrative roles, and many would instantly respond with “seven-on/seven-off schedule.”

Some numbers from SHM’s 2014 State of Hospital Medicine report:

  • 53.8%: Portion of hospitalist groups using a seven-on/seven-off schedule.
  • 182: Median number of shifts worked annually by a full-time hospitalist (standard contract hours, does not include “extra” shifts).
  • 65%: Portion of groups having day shifts that are 12.0–13.9 hours in length.

These numbers suggest to me that, at least outside of academia, the standard hospitalist is working 12-hour shifts on a seven-on/seven-off schedule. And that mirrors my experience working on-site with hundreds of hospitalist groups across the country.

In other words, the hospitalist marketplace has spoken unambiguously regarding the favored work schedule. In some ways, it is a defining feature of hospitalist practice. In the same way that a defining characteristic of Millennials is devotion to social media and that air travel is associated with cramped seats, this work schedule is a defining characteristic for hospitalists.

Schedule Benefits? Many …

There is a reason for its popularity: It is simple to understand and operationalize, it provides for good hospitalist-patient continuity, and having every other week off is often cited as a principle reason for becoming a hospitalist (in many cases, it might only take a clerk or administrator a few hours to create a group’s work schedule for a whole year). Many hospitalist groups have followed this schedule for a decade or longer, and while they might have periodically discussed moving to an entirely different model, most have stuck with what they know.

I’m convinced this schedule will be around for many years to come.

Not Ideal in All Respects

Despite this schedule’s popularity, I regularly talk with hospitalists who say it has become very stressful and monotonous. They say they would really like to change to something else but feel stuck by the complexity of alternative models and the difficulty achieving consensus within the group regarding what model offers enough advantages—and acceptable costs—to be worth it.

They cite as shortcomings of the seven-on/seven-off schedule:

  • It can be a Herculean task to alter the schedule to arrange a day or two off during the regularly scheduled week. They often give up on the effort, and over time, this can lead to some resentment toward their work.
  • There is a tendency to adopt a systole-diastole lifestyle, with no activities other than work during the week on (e.g., no trips to the gym, dinners out with family, etc.) and an effort to move all of these into the week off. They’ll say, “What other profession requires one to shut down their personal life for seven days every other week?”
  • It can be difficult to reliably use the seven days off productively. Sometimes it might be better to return to work after only two to four days off if at other times it were easy to arrange more than seven consecutive days off.
  • The “switch day” can be difficult for the hospital. Such schedules nearly always are arranged so that all the doctors conclude seven days of work on the same day and are replaced by others the following day. Every hospitalist patient (typically more than half of all patients in the hospital) gets a new doctor on the same day, and the whole hospital runs less efficiently as a result.

Change Your Schedule?

Who am I kidding? Few groups, probably none to be precise, are likely to change their schedule as a result of reading this column. But I’m among what seems to be a small contingent who believe alternative schedules can work. Whether your group decides to pursue a different model should be entirely up to its members, but it is worthwhile to periodically discuss the costs and benefits of your current schedule as well as what other options might be practical. In most cases the discussion will conclude without any significant change, but discussing it periodically might turn up worthwhile small adjustments.

But if your group is ready to make a meaningful change away from a rigid seven-on/seven-off schedule, the first step could be to vary the number of days off. No longer would all in the group switch on the same day; only one doctor would switch at a time (unless there are more than seven day shifts), and that could occur on any day of the week.

To illustrate, let’s say you’re in a group with four day shifts. For this week, Dr. Plant might start Monday after four days off, Dr. Bonham has had 11 days off and starts Tuesday, Dr. Page starts Friday after nine days off, and Dr. Jones starts Saturday after six days off. Each will work seven consecutive day shifts, and the number of off days will vary depending on their own wishes and the needs of the group. This is much more complicated to schedule, but varying the switch day and number of days off between weeks can be good for work-life balance.

Some will quickly identify difficulties, such as how to get the kids’ nanny to match a varying work schedule like this. I know many hospitalists who have done this successfully and are glad they did, but I’m sure there are also many for whom changing to a schedule like this might require moving from their current terrific childcare arrangements to a new one, something that they (justifiably) are unwilling to do.

And if your group successfully moves to a seven-on/X-off schedule (i.e., varied number of days off), you could next think about varying the number of consecutive days worked. Maybe it could range from no fewer than five or six (to preserve reasonable continuity) to as many as 10 or 11 as long as you have the stamina.

I don’t have research proving this would be a better schedule. But my own career, and the experiences of a number of others I’ve spoken with, is enough to convince me it’s worth considering. TH


Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at john.nelson@nelsonflores.com.

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