Published in the November 2003 issue of Today’s Hospitalist
From 24-hour in-house service to beeper coverage, Andrew McDonagh, MD, has seen it all when it comes to hospitalist scheduling. As president of Professional Internal Medicine Services, a hospitalist practice that staffs hospitals and clinics in the Milwaukee area, Dr. McDonagh has experience with virtually every type of scheduling model.
Because his company covers a wide range of hospitals, Dr. McDonagh has found that no one type of schedule fits all needs. As a result, he has customized hospitalist scheduling to respond to factors like cost and the impact on both hospitals and on patients.
Dr. McDonagh clearly prefers, however, one type of hospitalist scheduling. “While it may not fit in all situations,” he says, “I think that a 24-hour hospitalist schedule offers the greatest benefits to patients and the hospital.”
That view lands Dr. McDonagh squarely in the center of the debate over the need for 24-hour presence by hospitalists. Because a fundamental goal of hospitalist programs is to provide timely and consistent inpatient care, many experts argue that a successful hospitalist program must provide 24-hour service, with an inpatient physician working around the clock. Some like Dr. McDonagh even suggest that the level of patient care suffers under any other schedule.
Not everyone agrees. As skeptics of the 24-hour model are quick to point out, no studies have demonstrated how around-the-clock coverage improves patient outcomes. They also say that much of the anecdotal evidence put forward to support the model is contradictory.
Perhaps even more importantly, those same skeptics point out that the costs of full-time coverage are high, and not just in terms of physician salaries. They argue that the 24-hour model has the potential to burn out physicians, which can cripple a program “and actually raise the overall costs of inpatient care.
“Scheduling is one of the most difficult issues that any hospitalist group faces,” says Ronald Greeno, MD, chief medical officer of Cogent Healthcare Inc., a national inpatient care management and hospitalist company. “If you are running a 24-hour schedule, the challenge is to develop a palatable and sustainable work schedule with a reasonable patient workload.”
For some hospitalist programs, 24-hour coverage isn’t an issue. The patient census at many nonurban hospitals may simply be too low to support overnight hospitalists.
At some of these hospitals, staff physicians like ER doctors can handle the occasional overnight admission, patient issues or codes. And in academic hospitals, residents and interns cover overnight needs. “Our group does not staff at night because as a teaching hospital, we can rely heavily on residents,” says Corinne Taylor, MD, a pediatric hospitalist at Children’s Healthcare of Atlanta who works for a faculty practice employed by Emory University. “While most community hospitals do not have access to housestaff, their need for overnight care is probably so low that it may be difficult to justify the cost of having a hospitalist there overnight.”
While the costs of 24-hour coverage can be daunting to hospital administrators, particularly those who are trying to keep expenses in check, supporters of the model say that having a hospitalist available to admit and treat patients all the time can offset any additional costs.
At many community hospitals, for example, patients who arrive through the emergency room or who have a physician with admitting privileges at the hospital are not actually admitted until their physician or a staff physician arrives the next day. Delays in admission–as well as delays in treatment for admitted patients who experience problems–can dramatically increase length of stay and ratchet up the overall cost of treating patients. By being available to immediately treat and admit patients–even a relatively small number–hospitalists working in a 24hour program can reduce patient-care costs enough to offset their additional expenses.
“When you look at the cost savings that can be generated by a hospitalist,” says Dr. McDonagh, “having a hospitalist on a 24-hour schedule can be justified, even in small community hospitals.”
Not everyone, however, is convinced that a 24-hour schedule is always the right approach. Martin Buser, partner at Hospitalist Management Resources LLC, a Del Mar, Calif.-based company that provides management and consulting services to hospitalist programs nationwide, said that when evaluating the benefits of an overnight hospitalist program, facilities like small community hospitals must carefully consider all the ramifications of such an approach.
He said that if patient volume is low, for example, the potential cost savings may simply not cover the program’s costs. “Our experience has been that few hospitalist programs at community hospitals are willing to stay with a 24-hour schedule,” he says. “Those that have tried it find that the benefits rarely justify the cost.”
Cost is not the only consideration. As Mr. Buser pointed out, “Small hospitals run the risk of putting too high a burden on a relatively small group of doctors, which could lead to high turnover.”
Some hospitalists worry that a 24-hour schedule will fatigue physicians to the point of burnout. With the intensity of the activity and patient load, they say, asking physicians to rotate through overnight shifts puts too great a burden on hospitalists “and their families.
“In the past, we lost a number of partners to burnout,” says Dr. Taylor from Children’s in Atlanta. “The physicians had a tendency to stay at the hospital well beyond the end of their shifts. That generated a lot of spousal discontent, and our physicians were easily lured away.”
Some hospitalist programs say they have found ways to lessen the impact of providing 24-hour coverage on their physicians. To balance the rigors of aroundthe-clock service, these programs make sure that their hospitalists have real time off in the schedule. During those hours, the physicians do not carry a beeper, do rounds, or engage in any work-related activities.
“We have a hospital where the schedule includes one rotation of 24 straight hours balanced by days off during which the physician is not expected to perform any duties,” says Dr. McDonagh. “That is one of our most popular assignments, and our doctors prefer it to beeper coverage. Many of our physicians ask to be assigned to that hospital because the undisturbed time off is so important to them.”
Lack of data
The issue of patient care frequently emerges as a focal point in the debate over 24-hour hospitalist coverage. The problem is that there have been no good studies to support either side.
Supporters like Dr. McDonagh say the model allows hospitalists to provide superior care by being able to respond quickly to patient needs, admit patients without delay and address the whole range of clinical care at a time when there would not be another physician immediately available.
“We have had patients go into cardio-pulmonary arrest or have other lifethreatening events,” he explains, “and our hospitalists are there in minutes to treat them. It seems perfectly clear to me that this is better than the alternative of waiting for someone like an ER doctor, especially one not at all familiar with the patient.”
While numerous studies have shown that hospitalist programs improve patient care through measures like length of stay and mortality rates, researchers have never differentiated between 24-hour programs and models that use call or beeper coverage.
As David Meltzer, MD, PhD, an associate professor in the departments of medicine and economics and the Harris Graduate School of Public Policy at the University of Chicago, and director of its hospitalist program, points out, most of these studies were conducted at academic centers where residents and interns provided most of the overnight care. Looking back, he says, most research has so far examined what might be considered a hybrid model, falling somewhere between 24-hour hospitalist coverage and beeper call.
While researchers have yet to hone in on the impact of 24-hour hospitalist coverage, they have noticed one trend: There appears to be a relationship between the experience of the hospitalists and the quality of care, one that quickly brings the discussion back to issues of physician burnout and retention.
“The experience level of the hospitalist seems to be critical to the quality of care,” says Dr. Meltzer. “Scheduling issues that cause experienced hospitalists to leave a program can indirectly impact the quality of care.”
The worry isn’t just that 24-hour coverage may cause physicians to leave a program. Some take that argument a step further and say that embracing the model will make recruiting top-notch physicians “one key to a successful program–more difficult.
“We feel that by being less shift-like in our scheduling,” says Dr. Taylor, “we can attract and retain the type of team-oriented and intellectually curious doctor that practicing in a teaching hospital demands.”
Whether because of deliberate planning or the result of circumstances, most hospitalist programs do not maintain a 24-hour presence at the hospitals they serve. While precise numbers are not available, Dr. Greeno estimates that perhaps fewer than 20 percent of hospitalist services and programs provide 24hour in-house service.
The Brigham and Women’s/Faulkner hospitalist service in Boston does not schedule overnight hospitalists because the academic hospital network relies on its residency program to provide on-site care during nights and weekends. But it has also chosen to avoid overnight scheduling to keep its experienced hospitalists satisfied and working with the practice.
“We have been cognizant of the potential of physician burnout from the beginning, as well as the need for quality patient care,” says Sylvia McKean, MD, medical director of the hospitalist service at the Brigham. “While scheduling remains a challenge for us, we have initiated improvements in the quality of care and teaching at both hospitals without chronically overloading our physician staff by expanding our full-time equivalents.”
Mark Thoelke, MD, clinical director of the hospitalist program at Barnes-Jewish Hospital in St. Louis, echoes that approach. While a separate service provides 24-hour coverage, Dr. Thoelke is still very careful about scheduling his hospitalists. He said that losing an experienced hospitalist to burnout would have as great an impact on the quality of care as any other factor.
“Initially, our physicians were spending a lot of time at the hospital,” says Dr. Thoelke. “While this offered excellent continuity of care, this benefit was more than outweighed by problems such as infrequency of weekends off. Now we are more flexible with our scheduling. Our physicians are happier, and we have not noticed any impact on patient care.”
With so many factors to consider and so many variables at each hospital, many hospitalists say there is no definitive answer to the question about whether to use a 24-hour schedule.
“Every situation is unique, and the medical director must be constantly reviewing both the needs of the hospital and the needs of the physicians,” says Dr. Thoelke. “Greater demands on the time of the hospitalist must be balanced by either monetary or job satisfaction-related rewards to physicians. If a medical director does not sufficiently address the needs of the hospitalist, there will be problems with burnout.”
Michael Krivda is a freelance writer specializing in health and technology. He is located in Perkasie, Pa.