How to Find the Best Hospitalist Schedule

Jennifer Fink

Disclosures

May 04, 2017

Just over half of all hospitalists work a 7-on/7-off schedule, and nearly two thirds work 12- to 14-hour days, according to the 2016 State of Hospital Medicine Report by the Society of Hospital Medicine.[1] But is that schedule the best?

Answering that question is trickier than it may seem at first glance because sometimes what's best for patients conflicts directly with what's best for doctors.

"When you think about scheduling, you have to consider two parameters: continuity and physician lifestyle," says John Nelson, MD, a hospital medicine consultant. "There is hardly anything more important that trying to ensure very good continuity between patient and hospitalist over the course of their stay. The other domain to think about is whether the schedule supports a reasonable physician lifestyle. Is it something that you can do for a career of 30 years or more?"

The traditional 7-on/7-off schedule has long been embraced by young physicians just out of residency; after all, regularly getting a week off after working just 7 days seems practically luxurious to many new hospitalists. But a schedule that seems ideal in one's younger years may not seem so ideal a few decades later.

"The 7-on/7-off model tended to work really well for people with no family obligations," says Andrew White, MD, a member of the Society of Hospital Medicine's Practice Analysis Committee. "Now, as the field has gained experience and we have more senior hospitalists in groups, we have both older physicians and physicians with more family obligations who find the 7-on/7-off schedule much more difficult to manage than they did in their early 30s."

Of course, no schedule will make everyone happy. "Any schedule you pick is a set of compromises," Dr Nelson says. "There is no perfect solution."

Understanding the advantages and disadvantage of different hospitalist schedules can help you choose a schedule that best meets your needs.

7-On/7-Off

Easy to create and easy to understand, a 7-on/7-off schedule is exactly what it sounds like: Hospitalists work 7 days in a row and then have 7 days off. Repeat again and again.

Advantages. This schedule strikes a pretty good balance between patient continuity and physician time off. It's a cinch to create, too. "If I have to sit down and schedule a large group of doctors, I can make a year's schedule in an hour," Dr Nelson says.

Disadvantages. "It's a very systole/diastole way to live your life," Dr Nelson says. Hospitalists on a 7-on/7-off schedule tend to do little besides work on their days on. "You don't do laundry, you don't invite friends over to watch a video, and if your kid has a soccer game, you're either not going to go or you're going to see it as a huge burden," he says. And all too often, days off are frittered away rather than used productively.

Make it work for you. One way to ease the burden of a typical 7-on/7-off schedule is to allow physicians to go home when they're done with their work for the day, rather than forcing them to stay at least 12 hours. "We all have different work habits and efficiency," Dr Nelson says. "Start when you need to start, do a good job, and get patients seen in a reasonable amount of time."

Make it a point to plan some social events during your work week, even if it's just dinner out with a friend or another family. And try to schedule something fun for your days off.

Flexible Scheduling

Flexible schedules vary from practice to practice, but all have one thing in common: They're built to accommodate the preferences of group members. In Dr Nelson's practice, "the first thing that goes on the calendar is your social plans," he says. Physicians block out the dates and times they'd like off; work shifts are then filled in according to predetermined rules. The hospital medicine practice run by Romil Chadha, MD, for instance, includes two married couples. The spouses in each couple prefer to work the same schedule and have the same days off, says Dr Chadha, who is scheduling committee chair in hospital medicine at University of Kentucky Healthcare.

Advantages. Increased physician satisfaction and retention. "If you can help people do the things outside of work that are meaningful to them, it will keep them around longer," Dr White says.

Disadvantages. Creating a flexible schedule can be a logistical nightmare because there are so many variables to consider. Also, you may end up working consecutive weekends.

Make it work for you. Use scheduling software. Such software is not cheap and takes plenty of time to set up; after all, your group needs to develop the rules that the software will use to create the schedule. But those who have invested the money and effort say that it's well worth it. Dr Chadha's group uses a program called Lightning Bolt to create a flexible schedule for their nearly 60 physicians.

CICLE (Creating Incentives and Continuity Leading to Efficiency)

Created by a group of hospitalists at Johns Hopkins in 2009, the CICLE schedule was designed to maximize continuity.[2] It's informally known as "slam and dwindle" because during a physician's first day on duty, he or she takes only new patients, up to a cap of 12. (If the cap isn't met during the day, any patients admitted during the night will be added to that physician's load until the cap is met.) The next 3 days are dedicated to managing the care of and discharging those patients.

Advantages. Most patients have the same physician for their entire length of stay. In fact, a 2012 study published in Mayo Clinic Proceedings found that the odds of having a single hospitalist for an entire hospitalization nearly doubled with CICLE. Costs and length of stay decreased too.[2]

Disadvantages. "This required a lot of ingenuity and buy-in from the group," Dr White notes. "It requires a lot of culture change."

Make it work for you. If your group is interested in trying CICLE or a variation of CICLE, commit to spending significant time researching and discussing the benefits of greater continuity of care. CICLE worked at Johns Hopkins because the hospitalists themselves designed the schedule to reflect their belief that patient continuity is best for patients and physicians.

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