Published in the March 2007 issue of Today’s Hospitalist
In the four years since it was founded, the hospitalist program at Methodist Hospital in Omaha, Neb., has followed a fairly typical evolution in how it schedules physicians.
Starting with three physicians, Eric Rice, MD, the group’s medical director, and his colleagues worked a call-based schedule, with one physician on call for 24 hours as “the hospitalist of the day,” Dr. Rice says. “With lower patient volumes, that was the only model that was economically viable.”
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As the daily census ballooned above 80 patients, however, the program made the switch last summer to 24/7 coverage with shift-based scheduling. After having worked shifts for less than a year, Dr. Rice says that neither he nor his colleagues would ever go back.
“Most physicians are willing to do the seven-on schedule because they can anticipate exactly their weekends on.”
~ Stacy Goldsholl, MD, TeamHealth
“The shift-based schedule gives you some back-up, and you know who your ‘go-to’ person is if you need help,” he says. Another big benefit of working shifts, he adds, is that admissions are taken care of more quickly, which has made a big difference in length of stay for COPD patients.
Dr. Rice is not alone in his enthusiasm for shift-based scheduling. According to the most recent data from the Society of Hospital Medicine (SHM), the percentage of hospitalist programs that use call-only scheduling fell 11% “from 36% to 25% of all programs ” in two years.
By comparison, the number of programs using hybrid schedules that mix call-only and shift-based scheduling grew 8%, to 35% of hospitalist groups. And 40% of hospitalist groups now report using only shift-based scheduling, up 2% from two years before.
As more programs incorporate physician shifts into their schedules, veteran hospitalists and practice management experts debate what type of shifts work best for physician recruitment, work/life balance and patient care. While block scheduling may be emerging as the industry favorite, some experts point to alternative types of scheduling that programs should consider.
At the same time, critics of shift-based scheduling worry that the model may put hospitalists on a collision course with economic realities “and that shift-based scheduling, for many programs, may be too expensive to maintain long-term.
Today’s Hospitalist spoke with several hospitalist leaders about their scheduling preferences and the factors that programs should keep in mind when choosing a scheduling model.
The rise of shift-based schedules
Hospitalist Stacy Goldsholl, MD, is president of the hospital medicine division for TeamHealth, which works with more than 400 hospitalists in 17 states. She counts herself as one of a growing number of hospitalists who prefer shift-based scheduling.
“Hybrid schedules have merit when your program is growing,” points out Dr. Goldsholl. “But overall, shift-based tends to be my favorite.”
Further, she prefers block scheduling, in blocks of either five on/five off or seven on/seven off. The advantage? The predictability that allows physicians to plan a reasonable lifestyle.
“Most physicians are willing to do the seven-on schedule because they can anticipate exactly their weekends on,” Dr. Goldsholl says. Having set start and stop shift times, she says, confers the same advantage.
As proof of physicians’ strong preference for block scheduling with set shifts, she points to a perennial challenge for hospitalist programs: recruiting.
“From my own experience, these are definitely the easiest programs to recruit for,” says Dr. Goldsholl. Further, she says, the work/ life balance possible with block schedules improves physician retention, pointing to TeamHealth’s hospitalist retention rate of 95% as proof.
An alternative to set shift times
John Nelson, MD, the director of the hospitalist program at Overlake Hospital in Bellevue, Wash., readily acknowledges the advantages of set start and stop times for day shifts.
But he worries that some groups don’t spend time considering the pros and cons of their current schedule and the possibility of other alternatives. And he argues that set shifts have one major failing: “It’s not a good way to match manpower to workload.”
Standard 12-hour shifts, explains Dr. Nelson, who also works as a national practice consultant, will sometimes leave programs with too many physicians in the afternoon when the hospitalist service typically slows down. (Such schedules may also leave programs with too few physicians in the evening, when ED admissions heat up.)
Dr. Goldsholl counters that she doesn’t see any disadvantage to having a little downtime in the afternoon. “That allows you to revisit a patient or have a family conference that you didn’t have time for earlier,” she says. It also allows hospitalists to boost the capacity of their program by, for instance, fielding a consult on a surgical admission in the emergency department.
But Dr. Nelson points out that while you may not have much to do in the afternoon for half of the days you work, you’ll invariably have too much to do during the other half. That makes it hard to meet what Dr. Nelson calls the single biggest challenge that programs need to address through scheduling: handling unpredictable changes in patient volume day to day.
Another option: staggered, flexible shifts
One alternative to consider, says Dr. Nelson, is a schedule that provides for “dramatically different amounts of physician manpower every day.” That doesn’t necessarily mean varying the number of doctors who come in, but it does mean varying the number of hours each doctor works, depending on what’s required.
Take the example of a group with four day physicians each working a 12-hour shift, for a fixed manpower total of 48 hours for that day. On many days, that fixed total could be a mismatch “either too many hours or too few “for actual needs.
One solution is staggered shifts where physicians, on a rotating basis, alternate the number of hours they are scheduled to work, with some working more hours than average and some working less.
Physicians working staggered shifts, Dr. Nelson says, should have the flexibility to take off early on slow days, as long as they stay available by pager until the end of the workday. That flexibility, however, comes with a flip side: On days when they’re extra busy, physicians know they need to stay later.
“There is a cost of not being able to say exactly when I’m leaving the hospital today, but I think it’s worth it,” says Dr. Nelson. “When the workload is unexpectedly high, if all four of the doctors working in our practice stay an extra two hours, we just created eight hours of unscheduled physician manpower, and we didn’t have to call in somebody to do it.”
But don’t schedules with set shifts, particularly those that last 12 hours, build in coverage for unpredictably high workloads? They do, he says “but at the cost of making physicians stay in the hospital when they don’t have much to do.
“Add up all those hours of somebody staying around ‘just in case,’ ” he says. “Those costs can be high.”
More days, less burnout?
One problem with seven-on/seven-off schedules, Dr. Nelson adds, is that programs are effectively compressing a year’s worth of work into 26 weeks. Because these workweeks are so intense, he explains, physicians tend to increasingly segregate their work and personal lives, which may actually increase the risk of burnout.
He prefers a shift schedule that has physicians working more consecutive days, as many as eight or 12 in a row. “People hear 12 days and say, ‘No way,’ ” Dr. Nelson says. “But they’re thinking of 12 12-hour days.”
By varying shift lengths and introducing shorter days, he explains, physicians can comfortably stretch out the hours they now pack into 12-hour shifts over more days, doing the same amount of work at a less grueling pace “a plus for career longevity.
Working more days, he adds, also addresses a critical challenge for hospital medicine: patient continuity.
“The best way to ensure good continuity is for the day hospitalists to work as many consecutive days as is reasonable,” says Dr. Nelson.
The private practice model
As chief executive officer of IPC-The Hospitalist Company, which has more than 100 practices nationwide, Adam Singer, MD, has worked with just about every type of scheduling model under the sun. And while he says his company is too big to rely on one scheduling model, some work better than others.
Some large IPC practices, for example, provide 24/7 coverage by having physicians work seven-on/seven-off 12-hour shifts. “I don’t like it,” says Dr. Singer of hospital medicine’s most popular schedule, “but sometimes it’s the right choice.”
Hospitalist services that have a daily census of 100-plus patients, he says, need 24/7 shifts because of their critical mass. According to Dr. Singer, however, shift-based models for practices that don’t have that patient volume are the wrong scheduling choice. Instead, he prefers a schedule that emulates the private practice model, with some call coverage.
“The only thing that has lasted in health care is the small private practice,” Dr. Singer explains. “That was here before managed care and during managed care, and it’s here now.”
What Dr. Singer calls IPC’s “ideal practice” employs five physicians treating between 60 and 70 patients a day. Those physicians work Monday through Friday, with a rotating call schedule supplemented by a nocturnist who manages one-half of the nights.
Physicians typically work no more than 12 days in a row for a total of between 21 and 23 days a month. Like Dr. Nelson, Dr. Singer touts the patient continuity that such a schedule helps maintain.
But he is even more blunt about what he sees as the financial shortfall of a seven-on/seven-off schedule. Because that schedule builds in so much time off, Dr. Singer says that physicians who work those schedules effectively work only about 70% of the hours of a full-time equivalent (FTE), compared to what IPC physicians work. That leaves programs scrambling with a hole in their workforce.
To bridge that financial shortage, he says, many programs that want to maintain block shifts must rely on financial support from hospitals, a dependency he feels doesn’t bode well for the sustainability of programs. (Programs can offer 24/7 coverage without hospital funding, says Dr. Singer, only with a daily census of 100-plus patients.)
“You have now made yourself a servant of the facility,” he says. “You are constantly under the gun to justify your existence, and any single penny downturn in hospital subsidy means that the practice is getting ready to implode.”
He also believes that employing a scheduling model that depends on greater physician staffing is a poor choice for a field where physicians are in such short supply.
“When you work a seven-on/seven-off shift,” Dr. Singer says, “you require more doctors to see the same volume of patients, and there are just not enough human beings or dollars in the system to pay for that.” Because of that bottom line reality, he adds, it is a “virtual impossibility” that the industry, which has “apparently 15,000 open jobs,” will move completely to a shift model.
“A buyer’s market”
When it comes to hospital support for hospitalist programs, TeamHealth’s Dr. Goldsholl says she sees that support in a different light. Instead of potentially making programs more vulnerable, she says, hospital funding could be “insurance for program sustainability and stability.”
And as far as characterizing seven on/seven off as less than an FTE, Dr. Goldsholl points out that hospital medicine has yet to define an FTE or set annualized work expectations. (TeamHealth has defined an FTE as working 15 12-hour shifts a month, she says.) As the specialty gathers more data on how work expectations “and what schedules best meet them “affect program sustainability and physician turnover, “that will define us,” she says, “in a way that emergency medicine has been able to define itself.”
In the meantime, various scheduling models, including those with set shifts and those that mirror private practice, “probably self-select for the physicians who work best in that particular model,” says Dr. Goldsholl.
She also points out that the “buyer’s market for hospitalists” will continue to drive scheduling choices. With more programs offering shift-based schedules, she says, “hospitalists don’t have to join a group where they take call every third night. There are just too many alternatives.”
Phyllis Maguire is Executive Editor of Today’s Hospitalist.
Making the case for staggered shifts
While block schedules and set shifts are increasingly popular among hospitalist programs, veteran hospitalist John Nelson, MD, urges physicians to consider alternatives.
Dr. Nelson, who directs the hospitalist program at Overlake Hospital in Bellevue, Wash., touts potential benefits of working more days a year, but fewer hours on each of those days. To make such a schedule work, he suggests staggering shift lengths and giving physicians the flexibility to leave early on slow days.
To illustrate, he offers the following example of a four-day rotation using four daytime physicians. They each need to be available pager at 7 a.m., but they can decide for themselves exactly when they will come to work as long as they start in time to complete discharges early in the day. Each physician could work one of the following shifts, which are all slightly different:
- Day 1: Physicians working this shift would have a long day and stay in the hospital until the night doctor arrives. They would also stay later on busy days. They would accept one-half of the new referrals to the practice over the course of the day.
- Day 2: These physicians would round on patients already under their care and not take on new daytime referrals unless it is unusually busy. They would typically work much less than 12 hours.
- Day 3: The physicians working this shift would accept one-half of the practice’s new daytime referrals until an hour or two before the night doctor arrives. They would be free to go home when “caught up.”
- Day 4: These physicians would round on the patients already under their care and not take on new daytime referrals unless it is unusually busy.
Under this system, all day physicians would assume care of one-quarter of the patients admitted by the nocturnist the previous night. The exception? If the “day 4” physician is rotating off the next day, then he or she would not take over care for any of the previous night’s admissions.
All day physicians would keep their pager on until a specified time in the evening. For a patient needing bedside attention after one of the day physicians has left, which Dr. Nelson says is relatively unusual, that physician can return to the hospital to handle the issue or ask a “day 1” colleague still on duty to see the patient.
Matching physician manpower to patient demand
Hospitalist John Nelson, MD, who directs the hospitalist program at Overlake Hospital in Bellevue, Wash., and works as a national practice consultant, offers these rules of thumb for coping with what he claims is the biggest challenge programs must meet with scheduling: dealing with day-to-day variations in patient volume and care:
- Intentionally staff for more than your average volume. “That means that each doctor may have to work more days annually,” he points out, “but is less often unreasonably busy.”
- Have physicians share “extra” work during busy times to avoid activating a jeopardy system or sticking a colleague with a pager during his or her time off.
- Have doctors anticipate working longer days during busy months.
- Match compensation to productivity. “That encourages doctors to see very busy times as economically rewarding,” Dr. Nelson says.