Published in the June 2007 issue of Today’s Hospitalist.
With children soon to be out of school, and flu and pneumonia season still months away, visions of beachside retreats and bike trips through Europe are dancing in many physicians’ heads. That applies even to some hospitalists who work seven-on/seven-off schedules and have 26 weeks a year of unscheduled time.
Giving physicians an actual vacation “as opposed to unscheduled time “appears to be a growing trend among hospitalist programs. As recruiters work to find an edge to differentiate their program, vacation time and vacation accrual are becoming perks that hospitalists, who are known for their interest in lifestyle, are seeking.
“Time off is a big reason why I became a hospitalist,” says Jose Gude, MD, a nocturnist at Swedish Medical Center in Seattle. “I like the block time off, and when that’s disturbed, it just about kills me.”
But the reality is that for many groups, vacations of more than one week are often out of the question. Some programs object on philosophical grounds, saying that extended vacations are simply too disruptive to patient care and practice revenue.
More groups, however, simply find themselves too short-staffed to give their physicians extended time off. Even when colleagues are willing to pitch in to help each other take that time, scheduling those vacations over the long run can be a logistical nightmare.
When it comes to solving what’s been called the “vacation conundrum” for hospitalists, size counts. That’s because through their sheer size, larger groups often have built-in vacation coverage.
For example, HealthCare Partners Medical Group in Southern California, a multispecialty group that employs 60 hospitalists at 11 hospitals, gives physicians 200 hours of paid time off every year. That number jumps to 240 hours per year after physicians have been employed for four years.
Tyler Jung, MD, medical director of the group’s hospitalist program, says that in some instances, physicians have been able to take as long as a month off at a time. “In our biggest programs,” he explains, “we have a per diem group that we can flex up if a couple of hospitalists are out on their paid time off.”
He says that usually, however, paid time off is already factored into the physicians’ schedule. “Our size helps.”
At some of the country’s larger hospitalist management companies, critical mass allows companies to keep internal locums physicians on staff. These physicians can be used to fill in as a “vacationist” for full-time physicians.
And because IPC-The Hospitalist Company, with 100-plus practices, tends to have multiple practices concentrated in specific markets, its hospitalists can sometimes get vacation relief by having a hospitalist from one practice cover another. The replacement physician is then paid internally as a moonlighter.
Working around seven-on/seven-off
But while size brings flexibility, even medium-size groups are being over-extended and take a case-by-case approach to requests for time off. Dr. Gude, who is one of a 26-physician group that covers three hospitals, recently ran into just that situation when he asked to take a week off in conjunction with a three-week trip to Japan.
The trip is part of an exchange program that Dr. Gude’s medical center has with a hospital outside of Tokyo. Instead of being able to tack on another week there of vacation, Dr. Gude may have to head back to cover his night shift, even though the program administration is working hard to accommodate his request for the time off.
“We’re a bit short-staffed,” he says, adding that one of Swedish’s nocturnists will be relocating around the same time. Complicating the situation, two physicians starting right out of residency this summer may not yet be fully up to speed.
“If you have a larger group, it’s easier to have people do extra shifts,” Dr. Gude explains. “But with more physicians, the complexity of the schedule goes up exponentially.”
Dr. Gude’s practice offers physicians a week of paid vacation, which he says is possible to take if requested months in advance. Hospitalists also occasionally receive two weeks off in a row as part of their regular schedule. But the group’s more typical schedule “a seven-on/seven off pattern for the day-time physicians, with some variations “can make it hard to take more than a week off for much of the year.
Because physicians would be hard-pressed to work two weeks in a row of 12-hour shifts without getting badly burned out, Dr. Gude says, one solution is to tack three more days onto one week’s shift and four days onto another.
“You have to plan almost a month of making up that week, by breaking it up,” he points out. At the same time, when you ask colleagues to swap shifts to accommodate that workaround, “they may or may not be able or willing to do that at that time, for whatever reason,” he adds. “That can make it logistically difficult.”
Chronic staffing shortfalls
Those difficulties are even more pronounced for most hospitalist programs, which do not have the luxury of size or full staffing. A case in point is Columbia Park Medical Group in Fridley, Minn., which has a seven-physician hospitalist program at Unity Hospital.
Paul Kettler, MD, the group’s director, says that a combination of a seven-on/seven-off schedule and short-staffing makes it difficult for physicians to take off 10 days in a row, even if everyone pitches in and picks up shifts. And while he notes that one physician was able to swing a two-week period away recently, it was very tough.
“To get the two weeks would disrupt the whole schedule, and you’d need to work with several physicians just to make it work,” Dr. Kettler explains. While the group, which provides 24/7 coverage, continues to rely on moonlighters for night coverage, “the funds aren’t there” to hire moonlighters for vacation coverage.
“Our group has not been able to easily give a 14-day vacation, and we’ve lost some good people because of it,” Dr. Kettler points out. One recruit, who wanted to spend two to three weeks traveling in Europe, ended up going to a larger, hospital-owned group that could accommodate those plans.
“We weren’t able to guarantee it,” says Dr. Kettler, “and you hate to set a precedent where you’d provide it to someone and not to everyone else.”
So how do smaller groups accommodate requests for time off, particularly bigger blocks of vacation time? While having the right number of physicians is key, some groups say they’ve found an answer in their scheduling system.
Eric Rice, MD, medical director of the hospitalist program at Methodist Hospital in Omaha, Neb., says the physicians in his group don’t technically have vacation time separate from their scheduled time off.
But he says that rarely poses a problem because of the group’s staggered, rotating schedule that covers an eight-week cycle.
“In that eight-week cycle, everybody has a mandatory 11 days off in a row,” Dr. Rice explains. With enough advance planning, physicians in the group who in the past have wanted to go to India or Australia have been able to line up shifts in two concurrent cycles to take two-11 day blocks off back to back, giving them at least three weeks for an international trek.
It’s an example, says Tamara Doehner, MD, who is one of the Methodist hospitalists, of reverse vacation scheduling: You pick the shift cycle that makes your vacation possible. Do the other doctors in the group ever have to pick up extra shifts? While the group can call on two part-time physicians to work an extra shift or two if someone needs time off outside of the rotating schedule, the time that physicians take off as “vacation” is already built in as unscheduled time.
“We’re never short staffed because someone takes time off,” Dr. Doehner says.
And do physicians who string together those time-off cycles get burned out from coming back to work weeks in a row? “That’s the whole genius of the system,” says Dr. Rice, who credits Brian Bossard, MD, who directs the medical hospitalist program at BryanLGH Medical Center in Lincoln, Neb., for helping him design the staggered schedule. “Each eight-week cycle also builds in short breaks of two and five days, so physicians aren’t working continuously.”
A matter of money
At Hospitalist Medicine Physicians of Albany County, a Hospitalists Management Group (HMG) practice in Albany, N.Y., the four full-time doctors also have a staggered schedule, working different blocks of five to seven days broken by a varying number of days off. (The group provides 24/7 coverage.)
While that staggered schedule helps accommodate vacations, so does the group’s new compensation plan. John Krisa, MD, the group’s director, says the group’s previous plan relied on a base salary plus a productivity component, in return for a set number of shifts each month.
“If people worked two or three less shifts in the month they were off, they would have to make those up, which was a hassle for scheduling and accounting,” Dr. Krisa says.
About a year ago, the group decided to switch instead to a compensation model that basically pays physicians an hourly rate, while retaining the productivity component.
“People can make up time when they come back, or they may not want to,” he says. Physicians can opt to earn less the month they are out, money that will go instead to full-time hospitalists who decide to pick up extra hours or to the group’s stable of regular moonlighters, who already help cover nights and weekends.
As an HMG practice, the physicians in Dr. Krisa’s group have an equity stake in local profitability, with physicians closely following their profit and loss statements. But they also, he points out, routinely opt to spend money “potentially at the expense of reduced profitability “on moonlighters to take a reasonable amount of time off.
“It’s a balancing act,” Dr. Krisa says. “It’s your money or your life.”
A 24-week work year?
For Dr. Kettler’s group in Minnesota, switching to a staggered schedule isn’t really an option. That’s because more recruits want a seven-on/seven-off schedule, even if it presents some difficulties in taking off longer blocks of time.
“The schedule is very good for patient care, but it’s a bit difficult as far as physicians getting time away,” says Dr. Kettler. While Columbia Park has been recruiting only full-time physicians, he says the group is now considering hiring some part-time doctors, with the idea of more shift flexibility in mind.
But even with a full complement of physicians, Dr. Kettler points out, the logistical issues of planning for two or more weeks of vacation with seven-on/seven-off scheduling will remain. The solution may be, he says, building two more weeks of vacation into the schedule, so physicians would be in effect working a 24-week schedule every year, rather than a 26-week one.
Finding financial support for such a work year would be tough, Dr. Kettler admits. But “we may need that extra block of time,” he says. “Saying that you can’t have more than seven or 10 days off at a time won’t work very well as a recruitment tool.”
Phyllis Maguire is Executive Editor of Today’s Hospitalist.
Long vacations: Bad for business or good for morale?
When it comes to taking three or four weeks off from a hospitalist practice, Adam Singer, MD, chief executive officer of IPC-The Hospitalist Group, makes no bones about it: Longer vacations, he says, are bad for both practices and physicians.
“They have a tremendously negative impact,” Dr. Singer says, ticking off the list of downsides. Groups often have to pay tens of thousands of dollars for locums help, on top of paying vacationing physicians. In IPC’s model, where each of the 100-plus groups operates as a private practice, that expense affects every physician’s income.
Prolonged time off also affects referral streams, Dr. Singer says, proving frustrating to referring physicians who don’t know who to call or who aren’t familiar with the physician (or physicians) filling in. Short staffing raises the stress level of the other physicians, who often have to pull more shifts to cover. And prolonged vacations can lead to burnout during the rest of the year for physicians taking the time off, because they have no more vacation time left on the clock.
Still, IPC groups sometimes approve requests for longer vacations, Dr. Singer says, after taking several factors in mind. “The team makes decisions based on acuity of illness, patient volume and financial impact,” he says.
Physicians can also opt to take some time off without pay, which at least relieves some of the financial burden to the practice. At the same time, Dr. Singer makes clear, some IPC practices “because of the costs involved to the group “just say no.
“Prolonged periods of time off are very detrimental to a properly running practice,” he says. “In my opinion, they should be reserved for a truly special circumstance.”
Yet other practices have a different culture and set of expectations. That’s the case at Inland Hospitalist Medical Group Inc., a private practice based in Riverside, Calif. According to administrator Ernest Barrio, one of the group’s six physicians is of Colombian descent, while two are of Indian descent, and one has family that hails from both India and Egypt.
While a physician who wants to take three weeks off has to give at least four months’ notice to the group’s board of directors, “the board is very accommodating when a physician needs to travel out of the country to visit family or friends,” Mr. Barrio says. “More likely than not, the board will approve.”
Inland’s physicians are used to covering more shifts for each other in such circumstances, he says. The fact that the group “which covers three hospitals “has a hybrid call- and shift-based schedule gives them more flexibility. And Mr. Barrio says he can call on a locums physician who is local, which at least keeps the cost of that coverage down.
Still, Mr. Barrio points out, a request for three weeks off isn’t necessarily a done deal. Instead, getting that much time off is usually reserved for international travel and for emergencies. “It’s not,” he says, “carte blanche.”