FOR HOSPITALISTS working seven-on/seven-off, it’s an all too familiar feeling: being swamped on your first day back on service.
“It’s when you feel you’re the least efficient,” says Raymond Kiser, MD, medical director of the hospitalist program at Columbus Regional Hospital in Columbus, Ind. “Teams try to create a good handoff, but the reality is that you just have to learn your new patients. So your first day is really time-intensive.”
That makes, Dr. Kiser adds, the choice of which day of the week to come back on service a high-stakes decision. When your group starts its seven-day stretch can affect patients’ length of stay and doctors’ ability to discharge efficiently. Just as importantly, it sets up a weekly rhythm that can either promote or sabotage work-life balance in an already tough schedule.
“Patients were basically staying an extra day because of our comfort level.”
~ Raymond Kiser, MD
Columbus Regional Hospital
“Our mantra is ‘Schedule is king,’ ” says Gina Puglisi, MD, regional medical director of hospital medicine for the Northeast Operating Unit of Envision Physician Services. “We find that it’s really not about the most money, the least amount of work or finding the perfect group, because that doesn’t exist. Schedule takes priority, and a good one is what people really want.”
Safeguarding Monday discharges
Last year, the 17-providers in Dr. Kiser’s group decided to change their switch day from Monday to Tuesday. Their rationale was the same as many groups that steer clear of switching hospitalist teams on a Monday: That’s the day you need to discharge patients held over the weekend, and doctors just meeting patients for the first time often don’t feel comfortable discharging them.
“Monday morning discharges were at a lower level than we thought they should be,” Dr. Kiser says to explain why his group moved away from Monday. “Mondays should be one of our highest discharge days, and that absolutely wasn’t panning out. Patients were basically staying an extra day because of our comfort level.”
With Tuesday now the switch day, “discharges on Monday are being done by doctors who’ve been with these patients since the previous week. Those physicians serve as a bridge of knowledge for everything that went on over the weekend.”
Another bonus of a Tuesday switch: If they’re off, doctors can take advantage of the three-day weekends—like Labor and Memorial Days—that always fall on a Monday. When he started hearing grumbling this summer from some group members who wanted to change back to Monday, Dr. Kiser surveyed the group. “The majority wants to keep switching on Tuesday.”
Dr. Puglisi says that all the Envision groups in the Northeast (and there are about 20) have likewise made Tuesday their switch day. That’s because they looked at their hospital data and realized that Mondays—along with being the day to “clean up” patients held over the weekend— had the highest number of admissions.
“We feel the switch day should be the day after the one that has the most admissions.”
~ Gina Puglisi, MD
Envision Physician Services
“We feel the switch day should be the day after the one that has the most admissions,” she says. “We think that’s the best time to bring in a new practitioner.”
Further, with Mondays being such a heavy load for the doctors working them, “we wanted that to be their last day of service. According to Dr. Puglisi, the hospitalists in her groups did consider switching on Wednesdays instead.
But “you’re splitting two weeks in half,” she points out. “Plus, we felt that Tuesday through Monday was more consistent with the ‘usual’ week the rest of the world works.”
But the IN Compass Health hospitalist group at Morton Plant Hospital in Clearwater, Fla., has switched on Wednesdays for more than 10 years, says Jordan Messler, MD. Now a part-timer with the group, Dr. Messler worked there full time for many years, including as the group’s director.
He agrees that Mondays are “notoriously busy.” But if Mondays are for clean-up, he maintains that much of that is still going on on Tuesdays.
“Tuesday is when a lot of discharges tend to happen,” he says. “Wednesday may be a low point in terms of having the lowest census during the week, so that struck us as the easiest day to make the switch.”
When your midweek is the weekend
Another advantage to starting Wednesday, Dr. Messler points out: Your midweek is actually the weekend, “so that’s a bit of a lull. I always felt that, psychologically, that reprieve made the seven-day stretch feel more doable.” It also helps doctors gear up for the busy Monday and Tuesday they’ll have at the end of their week.
That’s likewise been hospitalists’ experience at Baylor Scott & White Medical Center-Temple in Temple, Texas. In January 2017, they decided to dump their Friday switch day—which they’d held onto for years to match the switch days of subspecialists—in favor of Wednesday, says Tresa McNeal, MD, division director, inpatient medicine.
“Wednesday may be a low point in terms of having the lowest census during the week, so that struck us as the easiest day to make the switch.”
~ Jordan Messler, MD
Morton Plant Hospital
And changing to a Wednesday start day produced this unanticipated benefit: “By not coming on service on Friday, doctors felt more mentally free to enjoy their weekend evenings, even though they worked Saturday and Sunday,” says Dr. McNeal. “They were more familiar with their patients and more efficient getting their documentation done.”
That adds up to “a bit of a mental break on weekend evenings to be with families. In Texas, Friday night football is really a thing.”With that change, the hospitalists shaved about a half day off their length of stay, although Dr. McNeal is quick to point out that many other factors (including beefed-up resources on the weekends, like diagnostic imaging) likely played a role. Also, by not starting on Fridays, “we improved our number of discharges on weekends.”
But what about beach rentals that run from Sunday to Saturday, or school vacations that last all week? Doesn’t breaking the week in half interfere? That’s the advantage of working in a larger program, Dr. Messler counters, who notes that the group at Morton Plant has 20-plus MDs as well as nurse practitioners. (Dr. McNeal’s group in Texas is even larger, with 50 physicians.)
“If you’re doing seven-on/seven-off with only six physicians, you end up not having much flexibility,” Dr. Messler says. But with a larger group, “people are always willing to switch around.”
“Never” switch days
Envision’s Dr. Puglisi points out that Thursday and Friday are (like Monday, in her groups’ opinion) “never” switch days. Doctors can’t be struggling to learn a new panel of patients on the same days they need to tee up Friday discharges or transfers.
“It’s great to have a buffer of a couple of days both before and after the weekend.”
~ Rachel Hawker, MD
Gundersen Health System
“On Thursdays, we start identifying the patients who can go home or to facilities either Friday or Saturday,” she says. “It’s really a heavy lift to turn over a patient who needs a high degree of care coordination when you’re new to the service.”
But the hospitalist group at Gundersen Health System in La Crosse, Wis., has been switching on Thursdays since at least 2002, the year she started, says hospitalist Rachel Hawker, MD, associate program director of the internal medicine residency program.
Choosing Thursday was pretty much a process of elimination, Dr. Hawker explains. In her 350-bed teaching hospital, residents change rotations on Monday, the hospitalist PAs switch on Tuesdays and many of the subspecialists change on Wednesdays. Because the hospitalists who start on Thursday can rely on the residents and PAs being there from earlier in the week, “we have good continuity,” says Dr. Hawker. “Not being able to process discharges on Friday has never been an issue.”
Plus, switching on Thursdays is a boon for those doctors who maintain both an inpatient and a clinic practice, she points out. “They have a built-in four-day weekend before they have to go back to clinic the next week.”
And she really enjoys having Thursday through Wednesday off. Flights are “way less expensive” on Thursday than if you travel Friday or Saturday. In addition, “it’s great to have a buffer of a couple of days both before and after the weekend. I never have to set foot in a grocery store on a Friday, Saturday or Sunday.”
Missing a Monday switch
Kevin Conrad, MD, a hospitalist with Ochsner Medical Center in New Orleans, points out that his group changed its switch day from Monday to Tuesday about 10 years ago. By making that change, he says the group “probably” reduced its length of stay, although many other hospital initiatives put in place targeted length of stay as well.
“At this point in my career, I want more nonclinical.”
~ Kevin Conrad, MD
Ochsner Medical Center
But despite that advantage, Dr. Conrad misses switching service on Monday. He found that starting his week on a Monday worked better in terms of accommodating meetings for the nonclinical roles he wants to take on.
That consideration, he adds, “definitely breaks along demographic lines. Most new hires aren’t tied into administrative responsibilities—but at this point in my career, I want more nonclinical.” Now a 20-year hospital medicine veteran, “I knew early on that I need to do a significant amount of other things besides seeing patients for this job to be sustainable.”
That’s included being Ochsner’s medical director of community affairs, a position that took him not only out of the hospital but sometimes out of the city. Without a colleague working the opposite week who wants to share nonclinical responsibilities, he’s left coming in during his weeks off. (See “How to make seven-on/seven-off work.“)
“If I’m going to do these activities on my time off, they have to be enjoyable,” Dr. Conrad says. “The work has to be a passion, or it won’t recharge my batteries.”
How to make seven-on/seven-off work
HOW SUSTAINABLE is seven-on/seven-off? Raymond Kiser, MD, the hospitalist medical director at Columbus Regional Hospital in Columbus, Ind., says that some members of his group have talked about doing shorter blocks of, say, five-on/five-off.
That’s not surprising, “given the acuity of care we’re dealing with, which really takes its toll on providers,” says Dr. Kiser. For now, “seven-on/seven-off still feels correct, but I don’t know that it always will.”
Rachel Hawker, MD, who has worked seven-on/ seven-off since 2002 at Wisconsin’s Gundersen Health System, believes the schedule is OK long-term—as long as you have an administration willing to provide resources so volumes don’t get overwhelming.
“We let the administration know once we get to a number of patients we can’t safely handle,” Dr. Hawker says. At a specific census figure, the group’s jeopardy system is triggered so another physician is called in. That happens regularly during winters.
“I really see the need for the systole-diastole schedule.”
~ Tresa McNeal, MD
Baylor Scott & White Medical Center-Temple
The hospitalist group also recently added a consult-only team, which “relieved a huge amount of the patient load,” she notes. “Seven-on/seven-off is doable as long as your number of hours and patients aren’t unmanageable.”
Tresa McNeal, MD, division director, inpatient medicine, at Baylor Scott & White Medical Center-Temple in Temple, Texas, agrees. Along with her colleagues in her 50-member group, “I really see the need for the systole-diastole schedule,” she says. The doctors like the continuity of working seven days, which allows them “to discharge very efficiently.” In fact, about one-quarter of her group has literally doubled down on seven-on/ seven-off, opting to do 14-on/14-off instead.
“Some people prefer it,” Dr. McNeal notes. “They have to take check-out on a group of patients only once a month instead of learning a brand new patient panel twice.”
But teams are capped at 15 patients a day, with this caveat: “As much as 50% of the time, we’re at 16, because we’ve agreed as a group that we’d rather have everyone see one extra patient than call in another person,” she says.
That, however, is a hard limit. “Even adding three patients beyond 15 is a significant degree of complexity,” she says. Another mitigating factor: The group is primarily rounders, with parallel shifts for admitters.
“That makes seven-on/seven-off a bit more feasible than in smaller groups where physicians have to share admissions.”
Dr. McNeal herself works only 25% of her time clinically, maintaining a Monday-through-Friday schedule to accommodate all the weekday meetings she needs to attend. Jordan Messler, MD, says he advocated for just that schedule when he was medical director of the IN Compass Health hospitalist program with Morton Plant Hospital in Clearwater, Fla. He believes that group leaders who work seven-on/seven-off have a hard time engaging with their hospitals and are forced to come in for meetings on their days off.
“Being there Monday through Friday with less of a patient load allows you to participate more in improvement and better define what your group can accomplish,” he says. While “it doesn’t suit everybody to be involved with the hospital, it certainly does for the medical director and for others.”
Dr. Messler points out that he now has a Monday-through-Friday schedule. That’s because he took another position, that of executive director, quality initiatives, for Glytec, a company that produces software for diabetes management, and he now works as a hospitalist only part time. While being able to work only weekdays wasn’t his sole reason for taking the new job, it certainly was a draw.
And although his hospitalist group didn’t extend that schedule to him while he was director, he notes that his successor now works Monday through Friday.
“The better option is always more options,” says Dr. Messler. “Larger groups that can extend that schedule to doctors in leadership and substantial quality improvement should.”
Published in the October 2019 issue of Today’s Hospitalist.