Home Blog The (hospitalist) cycle of life: Week on!

The (hospitalist) cycle of life: Week on!

September 2008

There are probably as many permutations and combinations in hospitalist schedules as there are hospitalist programs. One of the most common and popular is week-on/week-off. Quite a few freshly minted residents/internists are lured to the field of hospital medicine by this seven-on/seven-off schedule–though, truth be told, more specifically the seven-off part. Having lived this schedule for the last eight years, I admit I’m partial to it. It has allowed me to spend a substantial amount of time with my friends and family.

Here is a snapshot of how I view my work week, which starts Tuesday and ends the following Monday. Sure enough, after battling the Monday evening blues, the new work week looms ahead. Blech!! One drawback of not showing up for work for seven days is getting your body and mind ready for non-stop action for the next seven. A must-do for Monday evenings: hitting the sack early. Because I’ve slept later than usual most mornings during my week off, that’s a big change. Getting my game face on is the order of the day.

I show up Tuesday morning, energized and ready to go. Pick up a list of patients, which invariably is like a “box of chocolates”–ya never know what ya gonna get! Like Forrest Gump, I am ready to run. No matter how good the sign-out is, the first day often packs plenty of surprises. It could be the unexpected discharge, or a new relative showing up and requesting a full assessment of an invariably complex case, or a rock stable medical situation that turns sour.

The fact that you do not know your patients makes these situations even more challenging. Tuesday is also the day where I am reading as much as possible, scanning and scouring pages and pages of documents: histories and physicals, progress notes, labs, radiology reports and consultations. It is also a day of introductions. Just as my patients are new to me, I am a new physician for them, an unknown entity, trying to establish a bond. I often don’t realize how tiring the first day is until I get home. It is like going from 0 to 60 mph in five seconds and staying there for the whole day.

Wednesday and Thursday: I am beginning to get know my patients–a bit. The patients are now certainly mine. On Tuesday, I am performing in the wake of the outgoing hospitalist, but from Wednesday on, that wake is entirely mine. This growing sense of ownership brings with it a more tangible sense of responsibility.

The reading cornucopia continues, grasping at elusive facts, and tying together varied medical problems and test results into a cohesive diagnosis. These are the days when I make a concerted attempt to contact relatives and reach out to specialists for clarifications. I also become much more aware of social issues, family dynamics and the personality quirks of my patients.

On the personal front, my body is getting used to being in work mode. I get home bone tired, and most nights, I am off to sleep as soon as my head hits the pillow. Having a good six-to-seven hours of sleep is imperative to function with all cylinders firing. There is no substitute to a good night’s rest.

Ahh, Friday!! Even though I am not off on Saturday and Sunday, on Friday I can see the light at the end of the tunnel. Once this day is over, the major part of the work week is passed, and I am over the hump!

Typically, Fridays come with a little more activity than usual to prepare for the reduced availability of certain services over the weekend. Medicine is a 24/7 business, and theoretically there should no difference in level of care on any given day. But having worked at quite a few hospitals and systems, trust me, weekends and major holidays are always different. It is like moving from a full service hotel into a youth hostel!

So Friday could involve getting that IR procedure done, the one that it would be next to impossible to get the IR doc to do over the weekends. Or Friday involves teeing up patients for discharge over the weekend, with extra meetings or conversations with patients, family members and case managers. Friday is also the day when I truly feel that I know my patients. I have a grasp of the nuances of their care and a bond that facilitates a higher level of communication. Coming home on Friday, I also have a different feeling: relief mixed with worries and concerns about patients’ medical problems that perpetually stack up, the ones that are hard not to think about while driving home or even when waking up the next morning.

The weekend is usually quieter, with fewer pages for sure. I can sense my colleagues relaxing, breaking out into smiles more often, and we even get a chance to have lunch together. We usually start preparing for Monday usually over the weekend, doing the bulk of it on Sunday. This involves setting up discharges, laying the groundwork for procedures that will be done on Monday.

On a personal level, the constant demands of the work week are starting to sink into the bones, but typically my body is now adjusted to the higher metabolic rate and a sensation akin to a “runner’s high” creeps in. With it comes a conviction that I could work another full week in a row. Delusional, you say? I agree.

Monday!!! Yup, it is my real Friday. I can sense freedom, my mind is trying to sneak a peek into coming week off and I am so happy when I show up for work in the morning.

This happiness is short lived. As soon as I hit the ground running on Monday, no matter how calm and controlled my service was over the past few days, there is just something about Mondays: the level of activity ratchets up quite a few notches. I have tried to analyze this phenomenon and have come to the conclusion that it is all the energy from people who are rested and energized from the weekend break that just fuels the Monday buzz. To this, add the extra steps that most hospitalists go through trying to leave a tidy, well-managed service for the incoming hospitalist, and Monday becomes a very long day indeed.

The week that seemed daunting on Tuesday, unending on Thursday and quite burdensome on Monday has, as always, gone by quite fast. What am I going to do tomorrow? Hmmm………

Many people, including John Nelson, MD, a practicing hospitalist who also consults for hospital medicine groups, have criticized this schedule, characterizing it as “systolic/diastolic” and saying doctors have to put too much of their life on hold during their week on.

This is a valid criticism. Some weeks on, I hardly get to interact with my family at all, although there are rare occasions when I’m able to get home on time and even take part in social endeavors, depending on the boom/bust cycle of patients’ clinical and social issues.

But for me, the week off makes up for the week spent at the hospital. Is it an ideal schedule? Probably not. Is it right for everyone? I don’t know.

I do think that we need to design a study to compare hospitalist teams that have opted for the week-on/week-off with those who have a more traditional schedule of five-days on/two-off, with stretched weekend coverage.

I’d really like to see that comparison from both provider and patient perspectives to see which is a better fit in terms of well-being and system performance.