Categories
Inpatient Practice

It’s Time To Rethink Hospitalist Work Schedules

No two hospitals have exactly the same approach to scheduling hospitalists. Early in the era of hospitalists, a 7-day on, 7-day off work schedule was most common, with hospitalists working a total of about 15 shifts per month, each of which was 12-hours. Schedulers liked this because it was simple. But the 7-on, 7-off work schedule can lead to physician burnout. So, what is the ideal schedule?

The best schedule is the one that results in optimal patient outcomes plus optimal physician job satisfaction, tempered with fiscal responsibility.

Summary Points:

  • The traditional 7-day on, 7-day off model is not always the best model
  • A successful scheduling model aligns the priorities of the hospital with the priorities of the hospitalists
  • Scheduling flexibility is crucial
  • Hospitalists’ schedule priorities change with age, experience, and family needs

Optimizing patient outcomes

Although many hospitalist variables can affect patient outcomes, two of the most important are inpatient continuity and inpatient workload. Inpatient continuity refers to how consistently a single physician manages a patient during that patient’s hospital stay. This generally equates to how many days a hospitalist works in a row. Inpatient workload refers to the number of patients a hospitalist manages per shift.

Inpatient Continuity 

In a 2020 study from JAMA Internal Medicine, the clinical outcomes of 114,777 patients were studied from 229 hospitals in Texas. 25% of the patients had low hospitalist continuity during their hospitalization, defined as hospitalists working 0 – 30% of their total working days with shifts of ≥ 7 days in a row. 25% of the patients had high hospitalist continuity during their hospitalization, defined as hospitalists working 67 – 100% of their total working days with shifts of ≥ 7 days in a row. The high continuity cohort had a lower average 30-day mortality rate, lower readmission rate, higher rate of discharge to home, and lower 30-day post-discharge costs. The authors’ overall conclusion was that “…patients receiving care from hospitalists who usually work several days in a row experience better outcomes and lower costs…”.

In many ways, these results are not surprising. Patient hand-offs are frequently sources inadequate communication. For hospitalists, there are 2 kinds of handoffs: (1) those that occur between the day shifts and night shift hospitalists and (2) those that occur between two sequential day shifts. The information impacting continuity of care is primarily in the second type of handoff whereas day-night shift handoffs are limited to new problems occurring with a patient during the night shift and with new nighttime admissions. The Joint Commission has identified hand-offs as major source of medical errors. More consecutive days on-duty equates to fewer handoffs.

I have only rarely worked shifts as a hospitalist. However, I have attended innumerable times on our hospital’s general internal medicine resident teaching services and on our medical intensive care unit service. On the first day of service, I would spend the bulk of my time just getting to know the patients’ histories and active medical problems. I never knew the patients who I picked up as well as those that I admitted and performed the initial history and physical exam myself. And I often kept those picked-up patients in the hospital longer so I could be sure that I had addressed all of their medical issues. Moreover, I would generally work longer hours on those first days of service because for me, every patient on the service was a new patient that required more time to become familiar with.

Patient satisfaction can also improve if inpatients see the same doctor every day. All too often, inpatients do not even know who their attending physician is. If the hospitalist caring for a patient changes every one or two days, then there is no opportunity to build a doctor-patient relationship and inpatient satisfaction scores will suffer.

Inpatient Workload 

When a hospitalist has to take care of too many patients, bad things happen. But what constitutes too many patients? There is not a single number because workload involves both the number of patients encounters per day and the complexity of the patient encounters. Taking care of 18 inpatients per day at one hospital may be easier than taking care of 12 inpatients per day at another hospital.

In a previous post, I discussed 19 variables that impact the ideal number of patients that a hospitalist should see per day. Those include:

      • Case mix index
      • Residents versus no residents
      • Admitting service versus consultative service
      • Presence or absence of advance practice providers
      • ICU versus general ward patients
      • Day shift versus night shift
      • Observation status versus regular inpatient status
      • Ease of documentation
      • Shared electronic medical record with primary care physicians
      • Non-clinical duties
      • Shift duration (hours)
      • Hospitalist experience
      • Patient geographical location within the hospital
      • Average length of stay
      • Inpatient census variability
      • RVU productivity
      • Quality of case management
      • Local hospitalist employment market
      • Patient demographics

A good rule of thumb is to start with a target inpatient census of 15 patients per hospitalist and then work up or down depending on your hospital’s unique mix of these 19 variables. So, if you have a very robust case management department, increase the number to 17 per day. Of if your hospitalists are mostly new residency program graduates, then drop the number down to 13.

Optimizing hospitalist job satisfaction

Physician burnout is real and when it comes to burnout, nothing is more combustable than an unhappy doctor. But a schedule that makes one hospitalist happy may make another hospitalist unhappy. At the risk of over-generalization, the age of the hospitalists can affect their schedule preferences:

  • The 30-year old hospitalist. Young hospitalists are fresh out of residency where they had been working 60-80 hours per week with 1-month service blocks and 4 days off per month. They are used to working long hours and working many days in a row. For these hospitalists, a 7-day on, 7-day off schedule with 12-hour shifts can seem like career heaven. From their vantage point, they have a vacation every other week. They have been doing night block rotations for the past 3 years and still owe a lot on their medical school loans so they do not object to doing night shifts, as long as they get paid a shift differential. They will likely need maternity and paternity leave.
  • The 40-year old hospitalist. They now have 10 years of hospitalist experience and with that experience, they have become very efficient. They can take care of more patients per day and still finish their daily work sooner than the 30-year old hospitalist. They begin feeling resentful when they are sitting around in the physician lounge at 4:00 pm reading the newspaper and waiting for their shift to end while their kids are playing in a little league game that they are missing. They want to be able to schedule their shifts around their family’s calendar.
  • The 50-year old hospitalist. With 20 years of hospital medicine behind them, they are highly efficient. They began working as hospitalists in the very beginning of the hospitalist movement and now are valuable as mentors for younger hospitalists. They feel that they have put in their time and do not want to do overnight shifts. They are taking on administrative roles in exchange for doing fewer shifts. Working 7 days in a row is increasingly tedious. They would often prefer to do more shifts per year in exchange for the shifts being shorter.
  • The 60-year old hospitalist. There are very few of these now but as the current hospitalists continue to age, they will be increasingly common in the future. They are close to retirement and are less interested in making major career changes at this point in their lives. Their children are now grown so as empty-nesters, they do not have the priority of getting home early or having weekends free. But they prefer lower acuity patients.

The main point is that different hospitalists have different priorities. Some hospitalist groups will develop their own work schedule culture and then hire new hospitalists who share those same priorities. These groups can have a fairly standardized schedule and keep everyone happy. Other hospitalist groups will have a more heterogenous set of hospitalist priorities and forcing hospitalists into shift schedules that do not match their priorities will result in unhappy hospitalists and a high turn-over rate. The bottom line is that it is essential that you know what your own hospitalists’ priorities are.

Fiscal responsibility

Hospitalists are expensive. The average hospitalist total compensation varies considerably by region and by who is doing the salary survey but the national average is about $290,000 for salary, bonuses, and incentives. If you add in other benefits (malpractice insurance, retirement, disability insurance, health insurance) as well as the cost of recruiting a new hospitalist (at least $30,000 in direct costs alone), the number rises considerably. It is virtually impossible for hospitalists to cover their entire costs from professional revenue alone and almost all hospitalists require hospital subsidization. This subsidy will vary from hospital to hospital but $200,000 per hospitalist is typical.

Because of the magnitude of this expense, hospital CEOs want value from their hospitalists. That means hitting the sweet spot of the hospitalists seeing as many patients per day while at the same time keeping the per-patient costs as low as possible and at the same time keeping the patient outcomes has high as possible and at the same time keeping hospitalist turnover as low as possible.

The relationship between these variables is complex. For example, the amount of subsidy that the hospital has to pay per hospitalist compared to the number of patients seen per day by the hospitalist is fairly linear (red line above). The more patients a hospitalist sees per day, the more professional revenue the hospitalist generates and therefore the less subsidy the hospital has to provide. On the other hand, the relationship between hospitalist case load and patient outcomes is exponential instead of linear (blue line above). Once a critical number of patients per day is exceeded, patient outcomes worsen and per patient hospital expenses increase. Having a hospitalist take care of one patient per day would result in the best outcomes but would be prohibitively expensive. On the other hand, having a hospitalist take care of 25 patients per day would cost the hospital very little in hospitalist subsidy but would result in devastatingly poor patient outcomes, longer length of stay, and frequent hospitalist turnover.

So, what is the best schedule?

By now, it should be clear that there is no one single best hospitalist schedule. The best schedule at any given hospital will depend on the unique needs of that hospital and the priorities of the individual hospitalists. But the underlying theme of scheduling success is flexibility. To understand how to incorporate flexibility into your hospitalists’ schedule, it is first necessary to understand the circadian rhythm of the hospitalist’s workday. A typical day would look something like this:

7 AM to 8 AM – chart review

8 AM to 10 AM – morning work rounds

10 AM to 11 AM – interdisciplinary rounds

11 AM to 1 PM – discharges

1 PM to 3 PM – write daily notes

3 PM to 6 PM – new admission work-ups

6 PM to 7 PM – chart review

7 PM to 12 midnight – evening admissions

12 midnight to 7 AM – emergency calls

In terms of the amount of work, hospitalists are generally busy from early morning to mid afternoon, have a lull until early evening when admissions start to increase, then have a bigger lull after midnight. Each hospital will have slightly different hospitalist needs by time of the day so it is important that you track your admissions by time of the day in order to optimize hospitalist schedules. A typical hospital’s requirements are as seen below:

There are several tactics that you can take to achieve the goals of optimizing hospitalist satisfaction and optimizing patient outcomes while being fiscally prudent:

  1. Know what your hospitalists want. Knowing what is valued by each party is the key to any successful negotiation. Survey your hospitalists to find out what their scheduling priorities are. Because those priorities will change as a hospitalist gets older and as their family life changes, get in the habit of re-assessing their individual priorities annually.
  2. Know your hospital’s hourly hospitalist needs. This  will require you to learn how long it takes the hospitalists to do work rounds, interdisciplinary rounds, and daily charting. You will need to know what time of day your patients are typically discharged and what your average admissions are by hour of the day.
  3. Incentivize continuity. Because it takes a hospitalist less time to care for a group of patients the more continuous days that hospitalist works, use that to your mutual advantages. For example, when working a 7-on and 7-off schedule, consider making the first 3 days of the 7-day block 12-hour shifts, the next 3 days of the block 10-hour shifts, and the last day of the block an 8-hour shift. Let the hospitalists take home calls from the nurses until the night shift hospitalist arrives.
  4. But you don’t need continuity at night. The night shift hospitalists are there for new admissions and patient care emergencies. They are not necessary for the regular continuity of care and it is not essential that they do consecutive days on-duty.
  5. Consider an observation unit. By definition, observation patients spend less than 2 midnights in the hospital. Their care is often more protocoled and with their short hospital stays, it is less necessary for daily continuity. Hospitalists covering observation units do not need to adhere to a consecutive 7-day on schedule to ensure optimal outcomes.
  6. Align shift duration with workload. If you find that the hospitalists are often done with their work at 3:00 PM, then create an option for them to leave the hospital at 3:00 but to carry their pager for nursing calls and do their evening chart review later from home. This may require designating one or more hospitalists to have the “long shift” to cover admissions and patient emergencies until the night shift hospitalist arrives.
  7. Use resident teaching services strategically. Residents learn the most when they do their own admissions and then follow those patients that they admitted. So, consider having the teaching services take the bulk of new admissions in the mornings and early afternoons. That frees up the hospitalists to get their daily rounds completed and get their discharges out earlier in the day so that they can then take admissions in the evening and night.
  8. Flexibility, flexibility, flexibility. If you ask hospitalists what the one thing is that they would like in their schedule, it is flexibility. Maybe they want a particular day off for their spouse’s birthday. Maybe they want to be able to get home in time to pick up their kids from school. Maybe they are planning a 2-week international vacation and want to do a 14-day work block to accrue 14 consecutive days off. A schedule that is too rigid will lead to dissatisfaction. Preserve the ability of the hospitalists to switch shifts for days off on short notice. Create a short shift/long shift schedule so the 40-year old hospitalists can pick-up their children from grade school. This may require some scheduling creativity, for example, requiring a hospitalist to do one long shift for every short shift, requiring an extra shift per month for every 2 short shifts, or paying less for a short shift than for a long shift.
  9. Be woman-friendly. Do not penalize maternity leave by requiring new mothers to make up the shifts that they were off during maternity leave. Once you know that one of your hospitalists will be out on maternity leave, if you won’t be able to cover her shifts internally then start looking for a locum tenens hospitalist for those months. New mothers may prefer doing more shorter shifts instead of fewer 12-hour shifts. Or they may want to come back part-time. Breast feeding hospitalists need extra time during the day to pump so be sure that there is backup coverage and/or give them fewer patients per shift. The majority of medical students are now women; in order to be competitive for the best hospitalists in the future, your hospital must be accommodating for pregnancy and new mothers.
  10. Consider a swing shift. In most hospitals, the majority of hospitalist admissions come from the emergency department. The number of ER admissions tends to be low in the early morning hours, shortly after midnight. The number of admissions starts to rise in late morning and then peaks in the evening. Having an extra hospitalist or advance practice provider to help with admissions between 5:00 PM and 11:00 PM can improve patient throughput. Alternatively, have the swing shift start 3:00 PM to cover both admissions and emergency calls on short-shift hospitalist’s inpatients.
  11. Schedule holidays intelligently. Be equitable when assigning holidays. A policy of assigning the youngest hospitalists all of the major holidays can breed disgruntlement if those are the only hospitalists with young children at home. Don’t assign your Jewish hospitalist to be on-duty during Rosh Hashanah and Yom Kippur.  Don’t assign your Muslim hospitalist to be on-duty during Eid al-Fitr and Eid al-Adha. Don’t assign your Christian hospitalist to be on-duty on Christmas and Easter. Different people prioritize New Year’s Day, MLK Day, Memorial Day, and Thanksgiving differently so create a preference list each year allowing hospitalists to choose which of those holidays they want to be off-duty.
  12. Consider an advance practice provider. If your hospitalists strongly prefer fewer consecutive days on-duty, then an APP can bridge the continuity gap. A nurse practitioner or physician assistant who works on the same nursing unit Monday through Friday every week can allow for the improved outcomes that continuity brings. The APP results in the supervising hospitalist being able to cover more inpatients by freeing the hospitalist up from time-consuming data collection, note writing, and paperwork. Having a consistent APP permits the hospitalists to do fewer consecutive work days.
  13. Align incentives. The hospital is going to have to subsidize the hospitalists so use the subsidization as an opportunity to align what the hospital wants (optimal patient outcomes and low inpatient costs) with hospitalist bonuses and incentives. With respect to the hospitalist schedule, an example could be bonusing based on the number of times the day shift hospitalists do 7 consecutive days on-duty each year.
  14. Be willing to change. Just because you had a 7-on, 7-off schedule last year does not mean that you must have a 7-on, 7-off schedule next year. Don’t be committed to one schedule simply because that is the way that you have always done things. If 7 consecutive days on is too much, try 6. If 7 consecutive days off is too little, try 8. If your hospitalists are consistently done with their work at 4:00 PM, then change to 8-hour day shifts with a reduced staff 4-hour evening shift before the 12-hour night shift.

For many years, our hospital had two hospitalist groups – a private group that did mostly 7 days on, 7 days off with shifts that were 12 hours each and an academic group that did more shifts per year per hospitalist but many of the shifts were shorter than 12 hours. The two groups attracted different types of physicians with different priorities. The physicians in both groups were equally happy and the patient outcomes were similar. The lesson was that you do not have to do the same thing for everybody in order to achieve the same level of success.

May 19, 2022

By James Allen, MD

I am a Professor Emeritus of Internal Medicine at the Ohio State University and former Medical Director of Ohio State University East Hospital