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How should we define a full-time equivalent?

December 2007

Any one who manages a hospitalist program is painfully familiar with recruiting challenges. It is certainly a “buyer’s market,” given the acute shortage of hospitalists, particularly experienced ones. And with more and more hospitals buying into the hospital medicine concept, the current number of hospitalists is set to increase to 50,000 or more by 2020.

With a growing number of internal medicine graduates pursuing fellowships, it means that the market is set to get even tighter. For our program, we have had to look at family medicine residents as well as midlevel practitioners to augment our ranks and have had only positive experiences with both. (I’m saving the topic of how best to harness the strengths of midlevels for another blog entry.)

Now here is what has me perplexed. Looking at all the ads for hospitalists, there does not seem to be one consistent definition of what constitutes a full-time equivalent for a hospitalist. That definition of an FTE cannot be divorced from call schedule and staffing issues, current supply-and-demand dynamics, and fair market value.

From the “buyer’s” or job seeker’s perspective, we all want a job with adequate time off, good benefits, and a supportive and stable work environment. From an employer’s perspective, the top concern is ensuring that employees are productive and, at the very least, revenue neutral.

The most popular schedule seems to be seven-days on/seven-off, which was, in fact, one of the factors that attracted me to being a hospitalist. Granted, working seven days in row, minimum 12 hours each day, in a pressure-cooker environment, is no walk in the park. Seven days off sure serve as a perpetual light at the end of the tunnel during any given work week. Throughout my career, I have been able to spend quality time with my family during those seven days off.

Reading some of the articles published in Today’s Hospitalist and elsewhere, I know there are valid criticisms of the seven-on/seven-off model. Those criticisms range from the model not allowing enough flexibility and providing zippo life during work weeks to requiring too much hospital subsidy to sustain it.

But from my non-scientific survey of colleagues, hospitalists favor this model over most others. Most medical employment contracts are based on a 40-hour work week, which translates into 2,080 hours per year. A seven-on/seven-off model with 12 hour shifts equals 2,182 hours.

Is that the de facto definition of a full-time equivalent in hospital medicine? One of the largest employers of hospitalists has defined an FTE as 15 shifts a month. I have come across ads for hospitalist jobs that even add vacation time on to the seven-on/seven-off schedule, which begs the question: How much time off is enough?

And would it even be useful to come up with a standard definition of a hospitalist FTE? From the point of view of someone who’s recruiting hospitalists, I think that such a definition might provide a level playing field for everyone in terms of hiring. But will subsidies for hospitalists increase as the market gets tighter anyway–and will new recruits demand better deals?

Then there’s another issue that seems to get lost in the debate over recruiting incentives and lifestyle. One of my favorite industries to compare medicine to is the airline industry. That field is light years ahead of us in terms of standardization and safety procedures and policies.

Airlines have strict guidelines on how many hours a pilot can fly in any given stretch before fatigue seeps in and dulls the brain. Given that we as hospitalists labor under grueling conditions with direct responsibility for human lives, are there studies out there that can help us define an FTE in terms of patient safety and physician fatigue, rather then in just pure dollars?

Some one pass me the antacid!