Wachter: We Got It Wrong With 7 On, 7 Off Work Schedules

Marcia Frellick

March 15, 2016

SAN DIEGO — The wisdom of scheduling hospitalists 7 days on and 7 days off has been challenged by hospitalist groups nationwide. That challenge was given high-level validation when Bob Wachter, MD, widely known as the father of the field, weighed in.

"It was a mistake," he said to great applause during the closing plenary here at the Society of Hospital Medicine 2016 Annual Meeting. Dr Wachter, professor and interim chair of the Department of Medicine at the University of California, San Francisco, along with Lee Goldman, MD, coined the word "hospitalist" in 1996 (N Engl J Med. 1996;335:514-517).

He explained the initial thinking behind the schedule to the crowd that gathered to hear him speak.

"When we looked at analogies to see what hospital medicine was like, the closest fit we could come up with was emergency medicine," he said. Doctors in the emergency department were working 10- to 12-hour shifts about 3 days a week.

Dr Bob Wachter

"In emergency-room medicine, a Monday, Wednesday, Friday schedule is just fine. In hospital medicine, it's a disaster," he said. The alternative was to "work as many days in a row as you possibly can, because we want to maximize patient continuity, until about the day that you want to kill yourself, and then subtract one."

At the time the schedule was designed, nearly every hospitalist was 30 to 40 years old. But the demographics have changed, Dr Wachter pointed out.

"I believe the 7-day-on, 7-day-off schedule is the schedule you would create for a 30-year-old finishing residency taking his or her first job," he said, although he acknowledged he has no data to back this up.

 
I don't believe this is a viable schedule for a 60-year-old.
 

"I don't believe this is a viable schedule for a 60-year-old," he said.

After Dr Wachter's presentation, attendees were buzzing about the work model, said Melissa Mattison, MD, chief of the hospital medicine unit at Massachusetts General Hospital in Boston, and program coordinator for the conference.

"It's up to every group to figure it out," she said, "but it's nice to see that people very high up in leadership are acknowledging that it is probably not the best way to schedule things."

Embracing Value-Based Care

Dr Wachter encouraged his colleagues to lead the change.

"The overarching principle of value-driven and patient-centered care has been our legacy, and I think that needs to continue to be where our focus is," he said.

"What's odd is not that we're being pressured to improve value, what's odd is that it's new," he pointed out. "Of course, that's what we should have been figuring out for the last 50 years, but we had a different payment system."

The two biggest transformations in the past 2 decades have been the switch to value-based care and the switch from paper to digital, said Dr Wachter. The latter has the most potential to transform healthcare.

It hasn't happened yet, he said, because the tools and the use of them are in the rudimentary stage. But it's coming.

"I can tell you no one in the hotel industry saw Airbnb coming. I can tell you no one in the taxi business saw Uber coming. If you think digitization is going to leave healthcare alone, you're wrong," he told the audience. "We are an enormous target. Silicon Valley has woken up to the possibilities and they are just waiting to disrupt healthcare."

Hospitalists might be somewhat insulated from the disruption at first because it likely will start with ambulatory care, telemedicine, and personal monitoring devices, said Dr Wachter, but eventually it will transform all of medicine.

 
Silicon Valley has woken up to the possibilities and they are just waiting to disrupt healthcare
 

"We need to be in the middle of that," he said. Hospitalists need to make sure that they have enough representatives in the realm of information technology to make the connection with clinical care.

"I was pleased to see that we had a section in this conference on health information technology. It has to be a bigger deal," he added. "It has turned out to be a crucial part of the healthcare world."

Burnout was another theme of the meeting.

Significantly more physicians reported burnout in 2014 than in 2011, according to a recent survey (Mayo Clin Proc. 2015;90:1600-1613). And doctors in the emergency department had the highest rate of burnout in the United States.

The structure of the shifts in the emergency department likely has something to do with that, Dr Wachter pointed out. He reminded the audience that the basis of the hospitalist model is the emergency department.

The Right Number of Patients

A factor in burnout can be patient load. The historic thinking that the right patient census is 15 also needs another look, Dr Wachter noted.

That number came from an early survey of about 12 hospitalists who were asked their average daily census, but there were no data to support it, he explained. The problem is that if there are no data, hospital management might think you can handle a few more, and then a few more after that, he said.

"That's exactly what happened in primary care," he reported. There were no data to support the length of a visit for patients with comorbidities, so the length of each patient visit dwindled to less than 15 minutes, "making it undoable."

Hospitalists need to produce data to show that the number in the patient census has a direct effect on quality of care, Dr Wachter said.

A Call to Action

The conference was the best attended to date and, despite the talk of burnout and increasing requirements, "there was a really positive energy," said Dr Mattison.

"There are challenges, but we're up to the challenges and we'll meet the need," she said.

Hospitalists now have a call to action, said Leonard Feldman, MD, associate professor of medicine at the Johns Hopkins University School of Medicine in Baltimore.

"We can make a difference by calling our elected officials, by taking ownership of the opiate epidemic, and by playing a key role in prevention, both in and out of the hospital," he said.

Dr Wachter reports serving as a director, officer, partner, employee, adviser, consultant, or trustee for PatientSafe Solutions, CRISI, EarlySense, QPID, Amino.com, IPC Healthcare, and the American Board of Internal Medicine Foundation; being an investor in Smart Patients; writing books, textbooks, and blogs for Lippincott, Williams & Wilkins, McGraw-Hill, and John Wiley & Sons; and editing patient-safety websites for the US Agency for Healthcare Research and Quality. Dr Mattison and Dr Feldman have disclosed no relevant financial relationships.

Society of Hospital Medicine 2016 Annual Meeting. Presented March 10, 2016.

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