Practice Economics

Flexibility Is King


Michael Radzienda, MD, FHM, once worked in a hospitalist program in which physicians were scheduled 30 days straight on clinical duty and 30 days off clinical duty. Although it sounds harsh by today’s standards, that job was so satisfying, he says, the schedule never felt like a burden. Conversely, he’s seen hospitalists work five days on and five days off, and the job was treacherous.

His point: Work schedules are just one influential piece of the job satisfaction pie.

“Satisfaction has more to do with work relationships and opportunities for growth,” says Dr. Radzienda, chief of hospital medicine and director of hospital medicine service at Medical College of Wisconsin/Froedtert Memorial Lutheran General Hospital in Milwaukee.

Shift-based staffing has become the norm, as more than 70% of hospitalist groups use a shift-based staffing model, according to the State of Hospital Medicine: 2010 Report Based on 2009 Data.1 That figure is up 40% from SHM’s 2005-2006 survey. Conversely, the number of HM groups employing call-based and hybrid (some shift, some call) coverage is declining—2.8% of groups employ call-based schedules, and 26.9% use a hybrid schedule. Those figures have dropped significantly from the 2005-2006 report, from 25% and 35%, respectively.

If you are going to make HM a career, you’ll need time to be with your family and pursue other interests, Dr. Radzienda says. As HM groups turn to more shift-based models, in which hospitalists work a set number of predetermined shifts and have no call responsibility, the challenge is setting a schedule that balances productivity and quality time off.

Maximizing the number of days off is not the holy grail. If you choose to shut your life down on days that you work, that is going to be toxic.—John Nelson, MD, FACP, MHM, director of hospitalist practice, Overlake Hospital, Bellevue, Wash., SHM co-founder

Fixed = Inflexible

The most popular way to schedule is through blocks of five days on/five days off (5/5) or seven days on/seven days off (7/7), in which hospitalists work 12 or 14 hours at a time, says Troy Ahlstrom, MD, FHM, a member of SHM’s Practice Analysis Committee and CFO of Hospitalists of Northern Michigan, a hospitalist-owned and -managed group based in Traverse City, Mich. Many HM groups employ this model because it’s easy to schedule and is attractive to residents who want a fixed schedule. But from a career satisfaction standpoint, the 5/5 and 7/7 schedule models present their own issues.

Fairness is the first potential pitfall. If all of the physicians in a group work the same schedule, they all have to log the same number of shifts and receive the same compensation. This leaves little to no wiggle room for hospitalists who want to make more money by picking up more shifts or those who want to work fewer shifts, Dr. Ahlstrom says. “People have different income goals,” he adds.

Second, physicians have to see the same number of patients throughout the day. This doesn’t take into consideration the reality that some hospitalists naturally work faster than others, thereby forcing the slower-paced doctors to keep up with an imposed patient load. “Invariably, no matter what you do, people are different,” Dr. Ahlstrom says.

Another consideration is that when physicians are working 12 to 14 hours a day, essentially they have no time for activities other than work and sleep, which doesn’t match the realities of life. Inevitably, things in personal lives crop up, which leads to swapping shifts that the group scheduler doesn’t know about or overloading the scheduler with shift-change requests, Dr. Ahlstrom explains.

Additionally, 7/7 schedules and their ilk squeeze a year’s worth of work into a compressed time frame, which can lead to intense stress and burnout, says John Nelson, MD, FACP, MHM, director of the hospitalist practice at Overlake Hospital in Bellevue, Wash., SHM co-founder, and practice management columnist for The Hospitalist. “Maximizing the number of days off is not the holy grail,” he says. “If you choose to shut your life down on days that you work, that is going to be toxic.”

Flexibility Equates to Fairness

Dr. Nelson has long advocated a flexible shift schedule that accommodates individual preferences by giving physicians in the group autonomy in deciding how much or how little they want to work. While the group as a whole has to get all the work done, the flexibility comes from one physician taking more shifts as another takes less.

Dr. Radzienda tries to create teams within his group by pairing hospitalists with similar scheduling preferences. For example, he might have a pair working 5/5 and another working 14/14. “Up front, it takes a lot of work, but once you template it out, it becomes a good strategy,” he says.

He also strives to build robust backup plans and jeopardy models (see “Surge Protection,” September 2010, p. 43) into the schedule for short-notice callouts, as you never know when a hospitalist will need to miss a day or two because of illness or a family emergency. “Psychologically, it helps to know that you don’t have to be a hero if you’re ill or emotionally strained,” Dr. Radzienda says.

Dr. Ahlstrom agrees that a flex-schedule strategy has a positive impact on hospitalists’ career satisfaction and longevity. He suggests hospitalists be allowed to specify how many patients they want to see and be compensated according to their workload through built-in bonuses for physicians who work more. Dr. Nelson suggests paying hospitalists per relative value unit (RVU) of work. “I think hospitalists would like it and find it liberating to be paid on production,” he says.

An added bonus to flexible work hours and patient load, according to Dr. Ahlstrom, is that pay difference “will lead to a far more collegial atmosphere, because physicians know they are getting compensated fairly for the amount of work done.”

Another advantage of a flexible schedule is hospitalists knowing they have the option of ramping up or scaling back the number of shifts they work, Dr. Ahlstrom says—for example, a physician who wants to reduce shifts in order to coach his daughter’s softball team or have Friday nights off to watch her son play high school football.

“You prevent burnout by allowing people to change their work schedule depending on what’s going on in their life,” Dr. Ahlstrom says. TH

Lisa Ryan is a freelance writer based in New Jersey.

Schedules and Small Hospitalist Groups

Schedules for HM groups of four or fewer FTE hospitalists largely depend on whether a group is going to provide in-hospital night coverage, Dr. Radzienda says. If a group doesn’t staff nights, it might make sense for hospitalists to cover calls from home on a rotating basis, he says. However, he advises group leaders to at least have a plan in place for spikes in patient volume, as contingency planning helps mitigate the negative effects that night call has on physicians.

“There are ways a group can incrementally step up prior to adopting a full-time, 24/7 coverage model,” Dr. Radzienda says.

Smaller groups can schedule hospitalists for daytime coverage and employ a nonphysician provider, referring physician, or specialty doctors to cover nights. Another option is to adopt a hybrid schedule, in which hospitalists take call some nights (when volume is high) and provide in-hospital coverage on other nights. About 32% of HM groups use on-call coverage or a combination of on-site and on-call coverage at night, according to the State of Hospital Medicine: 2010 Report Based on 2009 Data.

When a group expands to provide 24/7, in-hospital coverage, many hire nocturnists, or they share the load by rotating night coverage, Dr. Radzienda says.

“It takes some sophisticated data analysis to determine the best model to use,” Dr. Radzienda says. “A group needs to understand what the admitting patterns are, what the nursing models are, what the ER staffing models are.”

Flexible schedules in which physicians specify how many days a year they want to work and how many patients they want to see can work in smaller groups, Dr. Ahlstrom says.

However, it requires the group to find people outside the practice to fill shifts when needed. “We typically try to rub elbows with all of the local, office-based doctors,” he says, adding the best candidates are PCPs who relish the opportunity to earn a little extra or might want to maintain their inpatient exposure and skills. “We're happy to fit them in as long as they do a great job with patients and families.”—LR

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