Home On the Wards New hospitalists and the “parent trap”

New hospitalists and the “parent trap”

How to persuade physicians to take a more flexible view of schedules

December 2010
Family biking

Published in the December 2010 issue of Today’s Hospitalist

You’re interviewing a hospitalist candidate who seems to have everything you’re looking for. The visit goes just fine “until you bring out your call schedule.

“I don’t know,” says Dr. Hotstuff. “Evenings with my family are really important to me, and those afternoon and night shifts’ ”

It used to be easy to find doctors willing to work nights. Many male doctors were married to stay-at-home moms, and women physicians were extremely creative about finding nannies, making rounds with preschoolers and racing home from night shifts to get youngsters off to school.

But fortunately, the days when residents did their training by pulling 36-hour shifts are behind us, and federal work-hour limits have meant that teaching hospitals now make other arrangements to ensure 24-hour patient coverage. A hospitalist group that expects its members to make rounds on Tuesday, admit all that night and then round again on Wednesday will have trouble recruiting new members “and retaining old ones.

You’ve worked out rotating shifts, hired moonlighters and freed up as many weekends as you can. But the doctor you’re interviewing has preschoolers with a set bedtime routine or an elderly parent to watch over and is clearly doubtful about doing more than daytime rounds. How do you convince him “or her “that taking other shifts can work for both of you?

Making expectations more realistic
As someone who’s been there, I think combining medicine and family can be more of a plus than many of us realize at first.

Patients who spend their days arguing with just about everyone may thaw considerably at the sight of your preschooler in a frilly dress and cowboy boots. And I found that nurses rarely mind watching over a five-year old who’s sitting with a coloring book while you check in on a couple of patients.

If you have to make a hurried trip back to work, sometimes seeing you in your Valentine Day school-party get-up will make patients think of you as more than another white-coated authority figure. And even difficult phone calls may turn friendlier when someone hears baby noises in the background.

But back to the job interview. If a hospitalist is coming from a teaching hospital, he may think that the admitting doctor needs to be onsite for the whole shift. Residents usually do just that, passing the less-busy hours studying, because they’re expected to see new admits immediately.

But if your ED is competently staffed and you can trust the doctors who send patients from their offices, this is usually not necessary. You can phone in orders, answer questions from nurses and contact consultants from anywhere your phone works. And you can do the H&P up to several hours later.

Tell your new recruit that 24-hour availability for admissions and consults does not have to mean a 24-hour presence in the hospital. Nurses can and do handle disasters, especially if the hospital has a rapid response team. And when you’re coordinating a move to the ICU or treating panic lab values, your phone calls to the surgeon or critical care consultant are often more crucial than your physical presence.

Give examples. One of my partners used to start night shifts at 6 p.m. but she didn’t leave home until she had at least two admissions, so she had time for the family dinner. Doctors with kids can break away from daytime rounds to pick up preschoolers at noon or get a teenager to a rehearsal. And weekend rounds don’t have to start at 7 a.m. or prevent a quick run to a soccer game or the grocery store.

Your big advantage: flexibility
Some parent-track doctors fail to realize that afternoon and night shifts can actually improve their ability to handle tasks on the home front. Having their mornings free means time for school field trips and dental appointments (for themselves as well as the kids), while teenagers who learn to get dinner ready on their own will better handle living independently a few years from now.

Show willingness to offer other options, like a “leave-at-midnight” schedule. Admissions drop off in the early morning hours anyway and can be seen by somebody who slept at home.

A “cap” on admissions in busy shifts isn’t a concession to weakness; it prevents errors made by a tired doctor or one who is in a rush to get to the next patient. Having moonlighters for nights and weekends not only decompresses the schedule for regular group members, but it may be an option that a doctor who’s dubious about full-time work may want to consider.

Having a mix of lifestyles can also help. Parents of school-age children may find it easier to work Friday night when there’s no homework to supervise, making it possible for other colleagues to attend religious services. A physician whose elderly parent’s caregiver has weekends off may have less trouble taking shifts during the week. Even someone who can’t handle more than a few shifts a month may come up with ideas that make the schedule more workable for everybody.

Both old and new members of the group need to realize that the schedule will periodically need major surgery as you acquire new partners or get more referrals from colleagues. The two-shift model may have to change to three, a family illness or transfer may convert a full-timer to a moonlighter, and even docs with stay-at-home spouses may have to cut back their hours for health reasons.

It’s important that you all sit down together to discuss changes and get input and suggestions from everybody involved. The newest group members, because of their fresh perspective, may come up with ideas that solve problems for everybody.

Live better electronically
Face-to-face handoffs are great but consume a lot of time. HIPAA-compliant e-mail and phone calls allow you to exchange just as much information, and a doctor who has to pick up someone from day care can leave on time.

Most hospital EMR systems allow you to access the hospital database from home and protect confidential information at the same time. A doctor whose kids are eating breakfast can get a head start on the day by checking labs and even accessing other doctors’ dictation; add a smartphone and you can do it anywhere. That’s not to say that working out schedules for parents of young children (or caregivers for elderly parents) is easy. Here are some tips:

  • Plan early. Given sufficient notice, your partners may be able to take shifts they would otherwise avoid. If the schedule is set up a few weeks in advance, everyone has time to make back-up arrangements, warn spouses not to leave town or reschedule plans.
  • Constantly be on the lookout for moonlighters, particularly among other hospital staff members. Yes, they’re expensive, but so is training a replacement for a full-timer who loved the productivity pay but found the pace too tiring. And the eager young nephrologist who helps with weekend rounds or non-renal admissions will be quicker to come when you consult him for other patients.
  • Let the ED know how you work, especially if you take “no-doc” patients, so they don’t hand you five new patients at 11 p.m. You can start the H&P before the labs are all back and check the labs later.
  • Avoid the “suck-it-up” mentality. When a day is unusually busy or patients come in at the end of a shift, it’s better to have part of the work done by a doctor who just came on shift than by one who is tired, irritable or in a hurry to leave. The doctor(s) who take up the extra work will know that their backs will be covered when they’re in the same situation.
  • Stay in touch with each other. Group meetings have to cover consultant problems, OR schedules and the hospital formulary. But spending some social time with your colleagues helps tremendously when it comes to making everyone aware of each other’s scheduling needs.

If you know that Dr. A’s son is having school problems or Dr. B’s mother is having a heart cath, their requests for trading shifts won’t come as a surprise. And your hospitalists will feel far better about their place in the group if they don’t feel that they have to sneak around to take care of their families.

Stella Fitzgibbons, MD, is married to an engineer and began covering nights in the hospital when her kids were 5, 3 and 1. She has taken infants to hospital staff meetings, raced home from night call to make breakfast and assisted an illegal alien through Ronald Reagan’s amnesty process so she could hire her as a nanny. Since becoming a full-time hospitalist when her oldest child started college, she has been through uncounted variations in call schedules.

Making medicine and parenting work for you?

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