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Time to waste

March 2010

Perhaps the only reason I have time to write this blog and you have time to read it is because neither of us works very hard. Well, that may not be entirely true for you, but collectively, it’s clear that we don’t work as much as we used to.

Between 1992 and 2007, the number of hours that physicians self-report working dropped 12%, according to a JAMA article last month. We peaked out at about 56 hours a week in the early 1990s and now poop out at the end of this decade at fewer than 51 hours a week.

That may not sound like much of a drop. But when the AMA calculated the effect of 5.7% fewer hours being worked by the roughly 630,000 physicians practicing in 2007, the loss equaled approximately 36,000 physicians. Coincidence or chance: 36,000 doctors is almost exactly the number of hospitalists thought to be currently working.

Which brings us to the timeless chicken-or-egg question: Did hospitalists beget lifestyle changes, or did lifestyle changes beget hospitalists? I tend to go mostly with the latter, but I bet the former is true as well.

While many factors fueled the development of our specialty, most fit into the financial category, the quality category or both. But make no mistake about it: Once veteran physicians smelled the good life–or at least what was on the stove at home most nights–the days of endless hours were over.

Two other trends came into play. First, more physicians became either outright employees or virtual employees. I define “virtual employees” as doctors who are so bogged down in paperwork or insurer regulations that they no longer feel they have any autonomy over the practice they technically own. Point being, people are not going to work as hard, no matter how many incentives are stuffed into their contract, if they don’t own the practice.

Then there are the residents who saw an even bigger drop in work hours during the same timeframe. Residents come out of training working an average of 56 hours a week. Take that first job and ramp up those hours? I don’t think so.

But while I believe the desire for a better lifestyle fueled the hospitalist movement, the nature of our jobs also reinforced limited hours. For example, our most popular schedule is the shift-work model, seven-on/seven-off. This averages out to roughly a 42 hour week. Nothing cuts down on hours worked more than when physicians start to literally punch the clock. Look at ER doctors, who define full time as less than 40 hours per week. And of course, the hospitalist model had a direct effect on limiting the hours worked by primary care. No longer shackled to the hospital, outpatient doctors can now work 9-5, no nights, no weekends.

What does all this mean? Certainly, as the JAMA article suggests, it has far-reaching effects on a predicted physician shortage, especially if meaningful health care reform opens up more access to preventive care for the uninsured. And reform or no, cuts in reimbursement for some physicians seem inevitable. Even more physicians who aren’t going to make as much will jump off the treadmill and not work as hard.

No doubt, physicians will continue to be respected. But the concept of the physician as a tireless worker may be about to be put to bed. People may no longer choose lifestyle specialties like dermatology and ophthalmology once they get into medical school; instead, they’ll choose to become a doctor in the first place because they believe it affords a good lifestyle. Needless to say, this is a radical departure from days of old.

And no doubt too, hospital medicine will continue to be both the chicken and the egg in the evolution of fewer clinical hours worked. So fret not, even though you just wasted five minutes of your time reading this: You still have an additional 4 hours and 55 minutes to squander compared to if you were practicing 15 years ago.