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24/7, shift work and vacation time

November 2007

Hospitalist medicine seems to be evolving into a 24/7 in-house specialty with shift-work type schedules. Much like ER doctors, we are figuratively “punching the clock,” and it wouldn’t surprise me if soon hospitalists did so literally on their way in and out of the hospital.

Because our care of patients–unlike those of our colleagues in the ER–requires continuity, we tend to work in blocks. My guess is that the most common model is seven-on/seven-off, the one that I am most familiar with. But I have heard of various combinations, some sane (five-on/five-off), some not so much (10-on/four-off).

“On” is usually 12 hours, but many variations exist as well, with shifts usually not less than 8 hours and, one would hope, never more than 12. The programs where I have worked always used 12-hour shifts. However, because there were usually three day-shift hospitalists, we always allowed one person to go home early and one to come in late, to create a more flexible, livable schedule.

So, how do we define a full-time shift-worker hospitalist? The number 2,080 may be a good starting point because those are the number of hours that accrue working a seven-on/seven-off schedule for 26 weeks a year. That number also corresponds well with SHM national data on hours worked in a shift-work system. As I see it, anyone who works much more than 2,200 hours will face inevitable burn-out, while working less than 1,900 hours a year will make it tough to pay the program’s bills.

Getting back to our ER friends: How is it that their specialty evolved to the point that 1,900 hours a year qualifies as full-time (at least according to the two ER directors with whom I recently spoke), while ours logs an additional 100 hours or more each year? In my opinion, it is because ER physicians have demanded vacation time, whereas shift-work hospitalists have not.

It seems that the majority of employers with seven-on/seven-off programs consider “off” time to be “vacation time.” When any of us, for example, is gone for three weeks, we may come back and find that 21 straight days of work await.

Hospitalists of the world unite! I’m being somewhat flip here, but I do believe that we need to consider what will keep us happy as hospitalists. We have made significant salary gains over the last five years but–and excuse me for evoking Psych 101 here–money over and above what we need to cover the basics does not always buy happiness. On the other hand, I’m sure there is a study out there proving that time with family, friends and the dog leads to better overall well-being.

I just finished a budget for my new program at Virtua Memorial Hospital. In the budget, each FTE hospitalist is considered a 1.09 employee. This means that if I hire five hospitalists, I will need a budget to pay for 5.5 hospitalists to cover the 160 hours of yearly paid time off (a week off being 80 hours) and the 40 hours of CME.

This paid time off can be worked by part-time hospitalists or FTE hospitalists, particularly those who are younger and looking to pick up extra shifts on their off days. For the older guys, like myself, having vacation time built into the schedule gives me hope that I will be able to retire as a hospitalist in my golden years, not burned out by the time I hit my first midlife crisis at age 40.