Published in the November 2015 issue of Today’s Hospitalist
A FEW YEARS AGO, Chad Friel, DO, was already thinking of moving his group toward a formal scheduling system to address holiday coverage when the topic quickly moved to the front burner.
“The issue came to a head when one of our hospitalists said, ‘I am getting both Thanksgiving and Christmas off this year, and I’m not changing my schedule,’ ” recalls Dr. Friel, director of the hospital medicine program at Self Regional Healthcare in Greenwood, S.C. “I realized at that point that I had a problem we had to address as a group.”
Dr. Friel, who at the time was relatively new to the group, got the hospitalists together to discuss the issue. Ironically, it was the hospitalist who had both holidays off who proposed the solution the group later adopted: having the hospitalists break their seven-on/seven-off block cycle between Thanksgiving and Christmas by working an additional half week on top of their full week. (Then, instead of being off seven days, doctors take off a week and a half.) That way, no one ends up working both Thanksgiving and Christmas.
“If I’d done this top down, no one would have been happy.”
“That was the hospitalists’ choice, and that’s what we went with, even though doctors end up working a 10or 11-day stretch,” Dr. Friel says. “They think this is better than getting stuck in a cycle of working both major holidays several years in a row.”
The group’s 18 FTE hospitalists can make trades among themselves to break up long blocks, as long as they let the practice lead know about switches.
“This solution seems to have stopped the complaining,” Dr. Friel says. “Since we established the standard, I haven’t heard a single word. I try to leave decisions up to the group, and I think that’s helped.”
Sound Physicians, which operates 190 hospitalist programs with more than 2,100 hospitalists, has taken a similar approach to holiday scheduling. Across most programs, the hospitalists, who generally work seven-on/seven-off schedules, are assured that in most cases they’ll only have to work either Thanksgiving or Christmas, even if that wreaks temporary havoc with the schedule.
“Sometimes, we have to adjust the number of consecutive days worked so hospitalists don’t cover both holidays,” says Robert Zipper, MD, Sound Physicians’ regional chief medical officer for the Evergreen region. Hospitalists are allowed to trade among themselves, which helps because hospitalists may have different preferences for particular holidays. Practice sites all maintain local control of their schedule.
Dr. Zipper points out that it’s not difficult to cover “minor” holidays like Memorial Day, Labor Day and the Fourth of July. “Most hospitalists just expect that they’ll have to work many of these lesser holidays over the year because it goes with the field,” Dr. Zipper says. “I don’t really hear many concerns about those.”
And to head off problems and major squabbles that might jeopardize coverage around major holidays, Sound Physicians encourages programs to publish the holiday schedule up to six months in advance. That can be difficult in hospital medicine, he points out, when temporary doctors are helping support a site.
“We try to publish the schedule by July at the latest, because we recognize that people want to make plans and that a lot of our hospitalists have family outside the areas where they work,” says Dr. Zipper. “I think groups should try to plan schedules early enough to accommodate the people who want to travel, or else it becomes more of an urgent issue as you get closer to the holidays.”
While Sound Physicians’ system works fairly well, hospitalists working in understaffed programs might have to work both Thanksgiving and Christmas. Dr. Zipper says that it can be very difficult to find locum tenens doctors willing to work holidays, so the “double-duty” situation is sometimes unavoidable.
“Most of our hospitalists accept that working holidays comes with the ‘always open’ nature of hospital medicine,” he explains, “and that it might not be possible to always be mathematically fair.”
Letting hospitalists sort it out
At Virtua in southern New Jersey, perceived unfairness about holiday coverage was such a problem three years ago that the group’s then-new director, Christopher Pomrink, DO, tackled the issue as a high-priority “fix” that needed to be addressed.
“We have 60-plus hospitalists who work seven-on/seven-off and service three hospitals, so the schedule is a challenge,” says Dr. Pomrink. “It becomes even more difficult around the holidays.”
Some doctors were very frustrated, he recalls, when they expected a certain holiday off one year because they had worked it the previous year. “Some hospitalists kept having to work the same holidays every year because of how the calendar worked out, and they thought it was unfair,” Dr. Pomrink says. “And it was.”
He decided that all hospitalists would work one of the “majors” (Thanksgiving or Christmas) each year, then work the other one the next year. Beyond that, he asked the hospitalists themselves to come up with a solution, appointing two lead hospitalists at each campus to undertake the task.
“They went through weeks of discussions, trying to come up with every possible solution,” he says. “But when they came back, their answer was, ‘Leave it the way it is; we’ll figure it out on our own.’ And coincidentally, all three groups came up with the same solution: They’d make the switches among themselves. I think that if I’d done this top down, no one would have been happy.”
Two years into the new arrangement, the “sort-it-out-ourselves” approach has been surprisingly successful, Dr. Pomrink reports. There’s enough collegiality in the group that when he gave members complete autonomy to figure out a solution, he says, “They came up with something fair and equitable. I still expected more turmoil, but frankly, it hasn’t happened.”
At Aurora Healthcare in Milwaukee, Wis., hospitalists are expected to share holiday coverage, but there’s no formal mechanism to divide that coverage any differently than any other period. The hospitalists work primarily seven-on/seven-off schedules, and if individual hospitalists end up with the short end of the stick in a given year, they can even out that burden by swapping some shifts with colleagues.
“I actually think that seven-on/seven-off schedules make it easier to cover holidays, if you’re allowed to swap if you need to,” says Rupesh Prasad, MD, a hospitalist with the 10-physician group at Aurora Sinai Medical Center. “That works here because our group is collegial and our dynamics are very good.”
The hospitalists and the group’s supervisor work out the swaps to ensure coverage. And if there’s an issue with two hospitalists who need the same holiday off, the group’s manager tries to bring in a physician from another program, Dr. Prasad explains. (Aurora has approximately 120 hospitalists system-wide.)
Continuity of care is a driving factor in what ultimately gets worked out, because hospitalists focus on working at least four days consecutively. Holidays are no exception, Dr. Prasad notes. “Any switching we do has to observe that policy,” he says. He adds that this also helps with patient satisfaction.
Both Drs. Prasad and Pomrink note that their respective groups’ cultural diversity “both have a substantial number of hospitalists who are foreign-born “actually helps with holiday scheduling.
“Some of our hospitalists don’t celebrate holidays like Christmas, and they’d rather have another holiday off, depending on where they’re from,” Dr. Prasad says. “That’s made holiday scheduling a little easier for us than for some groups.”
Dr. Pomrink says the Virtua group’s diversity is a boon for the same reason. “The diverse preferences for cultural, ethnic or religious observances really lend to having something like this work, with the hospitalists doing the swaps themselves,” he says. “But it’s still a challenge for our physicians around the holidays because so many have children who are out of school during this time.”
A lottery system
While many groups attempt the simplest possible solution to make holiday coverage reasonably fair, some opt for a more complicated approach to absolutely ensure equitable coverage. The hospitalist practice at Middlesex Hospital in Middletown, Conn., fits that bill.
The group has a fairly complicated schedule anyway because it uses both five-on/five-off blocks and traditional Monday-through-Friday staffing for its 26 FTE hospitalists. It also has a corps of swing-shift hospitalists and “weekendists.”
“Our hospitalist schedule is not fun to look at,” explains Middlesex’s practice manager Alessandra Cornelio, MPH. But it becomes even more complicated when it comes to holidays.
Middlesex pulls major holidays from its basic schedule and operates a designated lottery system to allocate coverage. The top four lottery “winners” get their first choice for a week of summer vacation, while the last four get their preferred major holiday (Thanksgiving, Christmas and New Year’s, and a second consecutive day) off that year.
“Most people get their first holiday off, and only two or three get only their second or third choice “but then they’re moved up the list the following year,” explains Linda Godfrey, DO, a senior hospitalist who directs the hospital’s perioperative program and who spearheaded the lottery system’s development. The group tries to have each hospitalist work only one of the major holidays, but if there are gaps in the schedule, Dr. Godfrey notes, they’re filled through the lottery system.
The lottery that Dr. Godfrey devised is loosely modeled on the one used by the hospital’s ED group. That local provenance improved buy-in.
“It helped that the ED physicians were doing something similar, and that the person who spent the most time developing this is a hospitalist,” says Rachel Lovins, MD, Middlesex’s section chief of hospital medicine. “The lottery doesn’t make everyone happy all of the time, but it’s fair and that’s what people care about.”
But one drawback: Hospitalists may have to work several years to benefit from the system and that can irk some newcomers. “It could be a problem for staff who are with us for a short time,” Dr. Lovins admits, “but as we’re definitely looking for people who want to stay with us for many years, I think it works out in the end.”
Bonnie Darves is a freelance health care writer based in Seattle.
ONE OF THE KEYS to making a holiday schedule work is to clearly document and communicate expectations and details as far in advance as possible.
At Virtua in Southern New Jersey, for example, hospitalist director Christopher Pomrink, DO, says he brings up holiday coverage during interviews. “Honestly, I think it helps to set these expectations when you hire your hospitalists,” he says. “I also go over the holiday schedule and coverage requirements during orientation.”
Most sources concurred that online intranet-published schedules, supported with e-mail alerts to all hospitalists when important changes occur, are the gold standard and an effective way to avoid having a hospitalist not show up on a key holiday.
And for groups that allow hospitalists to trade holiday shifts, the consensus is that a third party “a program leader or practice administrator “should always be in the loop.
“You can’t be too loose about the schedule itself or about trades,” says Robert Zipper, MD, regional chief medical officer for the Evergreen region of Sound Physicians. “You should have a process in place where you are tracking schedule changes and swaps in the same way and making sure that all parties in a swap agree in writing and that the medical director is copied. Hospitalist medical directors make the mistake of not requiring that documentation.”
In the same vein, Dr. Zipper thinks it’s important to track hospitalists’ holiday coverage over time to make sure individual perceptions match reality. He recalls one hospitalist who insisted that he’d worked every Christmas and Thanksgiving for four years running, and wanted a break. In fact, he had actually worked only half of those holidays.
“When I showed him that he had worked exactly 50% of them, that was pretty much the end of the discussion,” says Dr. Zipper. “If you want to reduce the squabbling about holiday coverage, the most important thing is data, data, data.”