Published in the January 2017 issue of Today’s Hospitalist
NOW THAT HIS MANY YEARS as a program director are behind him, hospitalist Thomas McIlraith, MD, is very much looking forward to resuming his all-time favorite schedule: working 14 days in a row.
Dr. McIlraith, who works with Mercy Medical Group in Sacramento, has listened to the leaders of the field decry seven-on/seven-off as a major mistake, one that threatens the sustainability of the field. Still, he’s perfectly comfortable literally doubling down, taking what’s typically cast as a soul-killing slog of seven days and making it 14.
Why? For many reasons, Dr. McIlraith says, but primarily because of continuity: “I feel I’m a better doctor when I’ve had a longer period of time with my patients.”
“The last day of a block is not the problem for me. Day 1 is the problem.”
~ Thomas McIlraith, MD,
Mercy Medical Group
But perhaps just as importantly, there’s the fact that he hates day 1, that hectic first day back on service, and he’s determined to subject himself to only one day 1 a month, not two.
“The last day of a block is not the problem for me,” Dr. McIlraith explains. “Day 1 is the problem. You’ve got all these patients, and you have to figure out what’s going on and develop relationships with them all, and that is really hard when you’re a stranger walking in.”
Most physicians don’t take such a radical approach to minimizing the hassle of their first day back on service. But many people agree that their care on day 1 tends to be less efficient and more stressful.
Given that the majority of hospitalists work one particular schedule—55% of full-time hospitalists who treat adults report working seven-day blocks, according to 2016 Today’s Hospitalist Compensation & Career Survey results—it stands to reason that hospitalist groups would have chosen one day a week as the standard day 1.
But that’s definitely not the case. Doctors have many ideas about which day of the week works best for that service transition, and why. And hospitalists around the country are employing different strategies to minimize the stress of their day 1.
Which day is best?
Now a nocturnist in Austin, Texas, Sandeep Pangarkar, MD, has had six hospitalist jobs over the past 15 years. In his first position, he and his colleagues—most also young and single—decided to switch services on Wednesday.
“We were all traveling,” Dr. Pangarkar recalls, “and Wednesdays had the best airfares.”
In his current job with Hospital Internists of Austin, Dr. Pangarkar works seven-on/seven-off in nine-hour shifts, Monday through Sunday. Group members who work days choose the traditional Monday-through-Friday schedule, rotating weekend coverage.
But looking back on the many schedules he’s worked with former groups, Dr. Pangarkar believes it makes the most sense to switch services on Tuesday or Wednesday (for reasons besides airfares). He also thinks Fridays and Mondays are the worst.
“Switch days have to accommodate physicians’ lives, not discharges.”
“Those are the two busiest days for discharges,” he notes. “Fridays are when most people go home after surgery or you’re trying to get them out before the weekend.” Monday is when you discharge patients who didn’t get out on Friday or transfer patients to a SNF or nursing home. Those institutions historically haven’t accepted patients on weekends, although that’s changing.
“When you discharge patients you don’t know, even with a good chart and a good colleague, you have problems with readmissions,” says Dr. Pangarkar. Most hospitalists, he adds, feel it takes at least a day to get to know the patients they’re picking up.
“So doctors tend to say, ‘Maybe we should just watch them one more day,’ and they drag their feet discharging unless it’s a simple pneumonia or chest pain,” he says. By switching midweek, on the other hand, physicians get a “cleaner” panel with few discharges their first day back. Based only on his own experience, Dr. Pangarkar believes transitioning midweek can improve a group’s average length of stay by at least 0.25 days.
Dr. McIlraith agrees and says that his group’s internal data show that discharge rates drop significantly on switch days. That’s another reason he likes to work long blocks.
“When there’s a handoff, length of stay goes up,” he says. “There’s always reworking you have to do when you accept a handoff, so that’s less efficient care for your group.”
Should switch days be staggered?
To avoid discharge-heavy days, Dr. McIlraith’s group has switched services on Tuesday. That has the added benefit, he says, of giving doctors an extra day after the weekend before they come back to work.
(Dr. Pangarkar points out that having Tuesday be your switch day can be tricky for scheduling vacations. That’s because you need to find someone to work your last day—Monday—if you want to start your vacation at the beginning of the week to match the schedule of your spouse or children.)
While Dr. McIlraith and his colleagues used to universally switch on Tuesdays, some group members now start their service on Saturday. “Saturdays, there’s less case management to worry about,” Dr. McIlraith points out. “It’s a more mellow day to start than in the middle of the week when everything else is up and running.”
That raises the question: Is it better to have your whole group switch on the same day if everyone works the same number of days, or is it better to stagger those day 1s? Kimberly Bell, MD, divisional director of hospital medicine for the CHI Franciscan Inpatient Team in Tacoma, Wash., oversees 100 providers in hospitalist programs across five hospitals.
One of those hospitals is critical access, and the hospitalists there don’t work a standard seven-on/ seven-off schedule, Dr. Bell says. But the clinicians in the other programs all work seven-on/seven-off, and they all switch services on Tuesday.
Dr. Bell admits it can be “very difficult in a large facility when you have 15 people who all change the same day.” Not only do the total number of discharges that day go down, she points out, but “the time of discharge is usually delayed.”
She believes that staggering switch days is “a very good idea,” and one of her practices is considering it. But the challenge with staggered days in a multisite system, she explains, is “having to coordinate providers moving from one site to another.”
While clinicians are typically assigned to only one practice, “we do have backup where you could be asked to go to a different site,” Dr. Bell says. “And sometimes, people pick up additional shifts at different sites.”
In a former practice, Dr. Bell says she spread out the group’s first day back on service across Tuesday, Wednesday and Thursday.
That works very well, she points out, if you have a stable team. “If you have open shifts you’re trying to fill with locums or per diems, that gets more challenging because you’re really obligated around their availability.”
At Meriter Hospital in Madison, Wis., Jeremy Jaskunas, MD, medical director and division chief of hospital medicine, says his group of 28 hospitalists has opted for flexible scheduling. While some doctors work seven consecutive days and others work only four, the majority work five-day blocks.
As a result, switch days are naturally staggered throughout the week, “which we see as a good thing,” says Dr. Jaskunas. Staggered shift days mitigate the inefficiency of doctors coming on service and having to get up to speed. The program makes one exception: Hospitalists aren’t allowed to start their scheduled blocks on Mondays.
“Any other day of the week,” he says, “is fair game.” He starts his own four-day clinical blocks on Fridays.
Colleen McCoy, MD, the hospitalist medical director at Williamsport Regional Medical Center in Williamsport, Pa., which is part of the Susquehanna Health System, has heard all the arguments about the downsides of making Mondays hospitalists’ first day back at work.
Still, all the hospitalists in her group switch on one day, and that day is Monday.
“Switch days have to accommodate physicians’ lives, not discharges,” says Dr. McCoy. Doctors have to build a life outside the hospital with spouses and partners who, mainly, live a Monday-Friday schedule, she explains. “Push childcare availability into that mix, which is also Monday through Friday, and that really locks doctors into that schedule too.”
While physicians can adjust to switching services on other days of the week, “the stress of that life on physicians is my main concern over the long haul,” Dr. McCoy points out. And losing doctors due to an unsustainable transition day “is something only urban programs can afford. They already have enough hospitalists to go around.”
Smoothing out the transition
Dr. McCoy also notes that her hospital uses a selected nursing-home network that accepts patients over the weekend, so those patients aren’t still waiting on Monday to be discharged.
And “half our group works a schedule including 14-day runs,” she says, “so out of seven rounding MDs, one is continuing from the previous week.” That person becomes the lead hospitalist on Mondays, “because it is not their first day, which is typically the hardest.”
In Wisconsin, Dr. Jaskunas tries to tamp down the learning curve on the patients he’s taking over by looking through their records the night before. “That way,” he says, “I have some familiarity with them.”
Too, doctors coming on service often start with an admitting shift. “That allows them to admit a good portion of the patients they’ll be seeing day 1 of their rounding block,” he points out.
Doctors going off rounding blocks also often end with a day or two of admissions.
“The physician handing off his or her patients to me on Friday may actually still be in the building doing admissions,” says Dr. Jaskunas. That allows him to “run the list” with that doctor, who’s also available to help with discharges if admissions are quiet. And while rounders in the group take some admissions during the day, doctors on their first day back on service are exempt from doing admissions until 3 p.m., giving them more time to get to know their new patients.
Dr. Bell points out that while the physicians in her groups start service on Tuesdays, the case managers who are part of multidisciplinary rounds at several sites start Mondays. And in one program, hospitalists are being paired with advanced practice clinicians, who also begin their blocks of shifts on Monday.
“When new doctors come in Tuesday, the APCs already know a lot about the patients,” she says. “They can say, ‘This is what we’re thinking.’ ” In addition, doctors handing off patients are encouraged to spend a half hour on the phone with incoming physicians either the night before the service switch or the morning of.
In York, Pa., William “Tex” Landis, MD, the medical director of Wellspan Hospitalists, thinks it would be a good idea to actually schedule a half-day overlap between incoming and outgoing physicians.
Such a 7.5-on/6.5-off schedule would facilitate handoffs and discharges, particularly of longer-stay, more complex patients. That would be an improvement over a “last-day handover that often results in a lot of stress for new providers,” Dr. Landis says. His group of about 100 clinicians covers four acute care hospitals and one surgical/rehab specialty hospital.
He’s perfectly aware, however, that most doctors— many of whom commute a considerable distance, now that taking call is a thing of the past—aren’t interested in driving back on what’s technically their first day off. (See “The pros and cons of seven-on/ seven-off.“)
But because he spends so much time in the hospital as an administrator, he’s able to achieve that overlap himself.
That’s because at York Hospital where he practices, hospitalists lead interdisciplinary bedside rounds in the morning, Monday through Friday. “If I’m going to pick up new patients on Saturday,” says Dr. Landis, “I’ll participate in those rounds on Friday.”
That way, he points out, the outgoing physician can introduce him to the patients he’ll be taking on. Plus, “I’ll have a face-to-face and a shared mental model of what’s happening with that patient. When I see her tomorrow, I’ll know what she looked like today.”
Phyllis Maguire is Executive Editor of Today’s Hospitalist.
By day 14, Dr. McIlraith says, “I’m definitely getting tired. But what I can’t stand is three- or four-day blocks because that’s hardly enough time to get to know the patients.”
While he’s heard all the talk about how long blocks lead to burnout, he flips that argument around. “The more say you have over your schedule,” he notes, “the better your schedule can mitigate burnout.”
“After 14 consecutive days, you cannot work more shifts until you’ve had at least two days off.”
~ Kimberly Bell, MD,
CHI Franciscan Inpatient Team
He’s not the only physician in his group pulling two-week shifts. And while such long blocks are an exception, many of his colleagues like working 10 or 11 days straight.
But at Meriter Hospital in Madison, Wis., that’s unheard of. According to hospital medicine division chief Jeremy Jaskunas, MD, the group doesn’t need any official policy about working long stretches—because no one in the group has ever expressed any interest in them.
The CHI Franciscan Inpatient Team in Tacoma, Wash., however, has put just such a policy in place.
“We’ve stepped in to say that after 14 consecutive days, you cannot work more shifts until you’ve had at least two days off,” says Kimberly Bell, MD, divisional director of hospital medicine. The issue has cropped up particularly among the group’s nocturnists, who work only 19 weeks a year. Several have wanted to pull, say, three weeks straight and then take extended periods off, particularly for international travel.
Some group members have been able to take a month off at a stretch, says Dr. Bell. But “we really discourage long periods of time on and off.”
In Pennsylvania, Wellspan Hospitalists has no official cap on the number of consecutive shifts that hospitalists can work. For one thing, “people’s tolerance is quite different from one physician to another,” says medical director William “Tex” Landis, MD.
For another, some group members—who all work seven-on/seven-off—want to moonlight. While they’re encouraged to do their moonlighting internally, some work in competing hospital systems.
But the group does have one policy in place to help guard against people working too much for their own good. “Doctors have to receive annual approval,” Dr. Landis points out, “to do moonlighting.”
The pros and cons of seven-on/seven-off
YOU CAN’T REALLY CONSIDER switch days without also looking at schedules. And probably no other debate in hospital medicine generates as much heat as the pros and cons of seven-on/seven-off.
For the CHI Franciscan Inpatient Team in Tacoma, Wash., the hospitalists embrace seven-on/seven-off wholeheartedly. “I think there would be a mutiny if we moved away from it,” says Kimberly Bell, MD, the divisional director of hospital medicine.
But William “Tex” Landis, MD, the medical director of Wellspan Hospitalists in York, Pa., says he had to be “dragged kicking and screaming” into adopting seven-on/seven-off several years ago. That remains the standard schedule in his group of about 100 providers across five hospitals.
The reasons that forced his hand are familiar: The group was leaning too heavily on program leaders to cover all the weekends, and it was otherwise impossible to recruit young physicians.
Along with giving doctors a full week off, Dr. Landis notes that seven-on/seven-off has this further advantage: Physicians now have many more options as to where they can live. When he started practicing 30 years ago, he lived five minutes from the hospital, which was the only way he could handle being called back twice a night.
But very few hospitalists now take call, and many doctors in his group commute a half hour or more each way, with one physician driving in from New Jersey. Given those commutes, doctors aren’t interested in what Dr. Landis believes was a saner physician schedule: working more days a year, but having shorter shifts.
“When you’re not living close to the hospital, it changes your willingness to come in for half days, short shifts and meetings,” he says. It also changes the dynamics around service signouts.
His group used to switch services on Friday, and “we would actually overstaff on Friday,” he says. “That made it easier because you could slow your pace and get to know your patients. I didn’t have to discharge patients who’d been in the hospital for 13 days on the day I met them, which is not ideal.”
While hospitalists “have jettisoned some old practices that weren’t necessarily great, we’ve gotten rid of some good features too,” Dr. Landis says, counting shorter shifts that allow for better coverage around service changes on that list. “I hope our seven-on/seven-off block schedule turns out to be a transition phase that gets us from the past to a better future.”