Dear Dr. Hospitalist:
Our group is considering hiring another nocturnist. This may reduce the number of shifts that hospitalists will be able to work per month—we have some who work 20 or more shifts per month. While the vast majority of hospitalists would welcome a nocturnist in order to decrease the number of night shifts required, some who work a lot of shifts are concerned that their income will be affected since there won’t necessarily be any day shifts available to compensate for the decrease in night shifts.
I am wondering if there is a maximum number of shifts per month that a hospitalist should not exceed. We work 12-hour shifts. In other words, is there a tipping point when too many shifts starts to negatively impact the quality of work, increase length of stay, decrease patient satisfaction, and lead to physician burnout? Are there any studies or data to look at this question?
Your feedback is very much appreciated.
–Donna Ting, MD, MPH
Dr. Hospitalist responds:
Although many jobs (i.e. air-traffic controllers, truck drivers) use hours worked as a gauge of operator fatigue, physicians traditionally have not used these criteria to judge one’s ability to be effective. That being said, we all know of occasions when we were physically and/or mentally exhausted and not performing at our best.
Multiple studies have shown that physicians tend to work an average of 60 hours a week. Of course, this does not take into consideration the typical hospitalist, who still tends to work 12-hour shifts on a seven-on/seven-off schedule, although there is a trend away from this type of block scheduling. A recent study also showed that physicians in practice less than five years were more likely to work hours in agreement with the 2003 Accreditation Council for Graduate Medical Education (ACGME) duty-hour regulations for physicians in training. The authors speculated that this was due to this group having trained under the new ACGME guidelines and being of Generation X, whose members tend to favor more work-life balance than their predecessors.
Several studies have examined physician work hours in relationship to fatigue and patient safety. Volp et al examined two large studies and found no change in mortality among Medicare patients for the first two years after implementation of the ACGME duty-hour regulations. However, they did find that mortality decreased for four common medical conditions in a VA hospital. Fletcher et al performed a systematic review and found no conclusive evidence that the decreased resident work hours had any affect on patient safety.
This is what I would have expected: inconclusive data. Most studies of this type are surveys, which have well-known limitations. Each of us has our own individual stamina, tolerance for fatigue, and desire for work-life balance. We intuitively know that most individuals are not at their best when tired or stressed, but to capture the true effect of these variables on patient satisfaction, morbidity, mortality, and other clinical metrics will be very difficult.
There are several ways I would approach a group that is contemplating another nocturnist. Because most hospitalists don’t want to work nights, the group members who feel their moonlighting income would be affected should commit to covering a certain portion or all of the available nights. If only some of the nights are covered, then you can hire a part-time nocturnist.
This is easier than you might imagine, as my very large hospitalist group has four nocturnists and none work a full FTE. I think three to four extra shifts a month are reasonable on a routine basis. We have, however, allowed physicians who wanted to have a month off to work seven extra days the months before and after to get their desired time off. We would not allow that to occur on a regular basis.
Ultimately, your group has to decide its own tolerance for fatigue and burnout, and have some mechanism to monitor the quality of work. After all, we owe it to our patients to not place their safety in jeopardy.
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