Published in the January 2007 issue of Today’s Hospitalist.
It’s one of hospital medicine’s most hotly debated topics: Which type of work schedule provides the best patient care while preserving a reasonable lifestyle for physicians?
Some hospital medicine leaders claim that shift-only schedules-where hospitalists work a set number of predetermined shifts, without any additional call demands-is the way to go, as long as programs have reached the critical mass to have enough physicians to fill those shifts. Proponents of this model say the big advantage is a predictable work/life balance for physicians, which translates into easier recruitment for programs.
Other experts, however, disagree. They claim that shift-only schedules tend to cram too many hours into too few days, which may pose a bigger risk of burnout. And staffing shifts, they say-as opposed to also relying on some type of call schedule-costs too much in terms of physician salaries and benefits, threatening the long-term financial viability of hospital medicine.
No matter where your group weighs in on the scheduling debate, the fact is that practices are bringing a great deal of thought and creativity to the way they structure hospitalist schedules. That’s important because the scheduling models
that hospitalist groups use have a serious impact on their workforce.
Here’s a look at what the latest data say about hospitalist scheduling systems and what kinds of trends are being seen in the marketplace.
Call-only schedules declining?
While the data on hospitalist schedules are complex, one clear trend emerges: Call-only schedules appear to be on the wane among hospitalist groups.
The Society of Hospital Medicine (SHM), which releases survey data on hospitalist groups every two years, found in its 2005-06 report that call-only scheduling was the model of choice among 25% of responding groups. That’s a drop of 11% from 2003-04, when 36% of hospitalist groups said they used a call-only scheduling model.
Compare today’s use of call-only schedules to the early days of hospital medicine, and the contrast is even greater. In 1997, for example, the first year for which survey data were available, more than 60% of responding hospitalist groups used call-only scheduling.
The rise of shift-based schedules
What model is replacing the traditional call system? The clear winner is shift-based scheduling, which is being used by 40% of groups. But 35% of hospitalist groups said they use a hybrid schedule that contains features of both shift-based and call-based models.
Here’s a snapshot of what types of groups are using the various scheduling models:
Overall, 40% of hospitalist groups reported using shift-only coverage schedules. The model appears to be most popular among groups where physicians are employed by hospitals.
Sixty percent of the hospitalist groups that reported using shift-only schedules were employed by a hospital, and shift-based scheduling also appears to be more popular in the Western and Eastern regions of the country.
However, only 18% of those who reported using the model were groups working at for-profit hospitals. Only 20% were multi-state hospitalist groups or management companies, and 24% were academic medical centers.
While the overall use of call-only schedules was 25%, here is a breakdown of groups that reported using call-only schedules: 53% were at academic institutions, 41% were multi-state hospitalist groups or management companies, and 40% worked at for-profit hospitals.
Among those reporting call-only schedules, only 19% were hospitals that had fewer than 200 beds, 15% were hospital employee groups, and only 8% were hospitalist groups affiliated with government hospitals.
- Hybrid schedules.
Hybrid schedules are making big gains and are now used by 35% of hospitalist groups overall.
According to the data, hybrid schedules appeared most popular among hospitalist groups working at government hospitals, academic medical centers and for-profit hospitals. Less likely to use hybrid models were groups employed by hospitals and local hospitalist-only groups.
With night coverage becoming increasingly common in hospitalist groups-51% reported that they provide on-site coverage at night-an important issue for individual physicians is how groups are covering night shifts. Here’s a look at how groups said they are providing on-site coverage in the 2005-06 SHM survey:
- Physician hospitalist: 95%
- Contracted physician, such as a moonlighter: 24%
- Physician non-hospitalist, such as a resident or fellow in training: 11%
- Physician assistant: 5%
- Nurse practitioner: 3%
By contrast to on-site coverage, 41% of hospitalist groups reported using on-call hospitalists from home for night coverage. Those groups tended to be multi-state hospitalist or management companies, while only 26% were groups of hospital employees.
Among those reporting the use of nurse practitioners or physician assistants for night coverage, academic medical centers led the pack with 18%. Using extenders for night coverage also appeared to be linked to program maturity. According to SHM data, 15% of hospitalist groups that reported using extenders for night coverage were more than five years old, as opposed to younger
Interestingly, only 8% of groups reported offering no night coverage at all. This group was led by hospitalist groups affiliated with for-profit hospitals. Pediatric hospitalist groups, by comparison, were the least likely to not cover nights.
Who’s using moonlighters?
Moonlighters can resolve many scheduling problems related to a shortage of new hospitalist recruits. They are being used to staff evening swing shifts and cover weekends to make full-time hospitalists’ schedules more manageable.
While 24% of hospitalist groups overall reporting using moonlighters, the 2005-06 SHM data also gave details on what types of groups are-and aren’t-using these physicians.
Of the 24% using them, moonlighters appeared to be particularly popular among hospitalist groups at academic medical centers, where they are used by 46% of respondents, and in groups in the Eastern region, where they are used by 39% of respondents.
Among the groups using moonlighters, there were fewer multistate hospitalist groups or management companies (14%), fewer hospitalist groups that treated both adults and children (13%), and fewer groups in the Southern region (13%).
How scheduling models translate into hours worked
How do scheduling models translate into hours worked? These 2005-06 Society of Hospital Medicine data broke down mean annual schedule hours as follows:
- Shift-only: 2,020 hours (187 shifts, with 10.8 hours per shift)
- Call-only: 2,621 hours (150 days on call, with 15.7 hours per day on call)
- Hybrid: 1,833 shift hours (206 shifts, each 8.9 hours) and 1,139 call hours (82 days on call, 12.8 hours per day)