The Future of Hospitalist Staffing
The Standard Hospitalist Scheduling Can Be Improved—Helping to Reduce Burnout and Improve Patient Care
Greetings! This month, we announced a major new hospitalist partner in Oklahoma, Hillcrest HealthCare System: eight new sites totaling 180,000 patients annually. As this means we are now in full on recruiting mode for 70 clinicians and a system medical director, a lot of what I’ll write about in this issue relates to hospitalist staffing and scheduling models (no surprise there).
But first: this is undoubtedly a huge win for our company, and a huge congratulations goes to our team at Core. Growing organically like this is validating on a number of levels. First, it shows you do not have to scale into a gigantic national group in order to earn large partnerships with health systems.
I’ve been writing about this theme in one way or another since I started this newsletter (See There is no one size fits all and The promises and failures of consolidation), but the overall point is that there is room in this environment for a nimble company like ours to combine the capability of a big EM & hospitalist group with the service and buy-in of a smaller physicians group.
There are a couple reasons why that’s the case. One is the rise of telemedicine, which allows hospitals, health systems, and groups to make more efficient use of their clinical workforce no matter their size.
In other words, telemedicine helps solve a big staffing challenge that previously only gigantic national groups could solve. You don’t need to have “national scope” anymore to pull in physicians from other locations to come fill shifts at a difficult-to-staff site, because telemedicine technology can potentially give every company national scope.
But telemedicine alone isn’t a panacea. Most hospitalist groups know that the standard hospitalist schedules aren’t perfect—but change is hard, and figuring out how to improve the staffing models will require a combination of strategies. How will we approach this on the ground in Oklahoma? Read on!
Not that many groups do HM well
I’m an ER physician by training, and I come from the ER world, so of course my view of hospitalist medicine is inherently shaped by my experience in the EM market. One thing I can say for sure is that most of the big emergency medicine companies tend to think of HM as an add-on to their core business. They might dispute that characterization, but if we’re honest we have to acknowledge that there are a lot of EM groups out there who decided to add on hospitalist medicine, rather than think about how to do HM well as its own stand-alone thing.
One reason for this is that hospital medicine is still pretty new. It didn’t even exist when I started my career. Now, there are hospitalists in just about every hospital in the country. If you’re an internist or a family practitioner, becoming a hospitalist is very attractive because it’s shift work, and you don’t need to run your own office.
Second, a good hospitalist group must thread the needle between what the hospital wants and needs and what the hospitalist physicians themselves want and need, and figure out how to make all of those things better at the same time. There is no silver bullet here, but there is an optimal way to do it where you get clinician satisfaction, hospital satisfaction, and all the stakeholders pointed in the direction of a better patient experience and patient satisfaction.
There are a lot of moving parts and levers to pull in order to do this. But for now, I want to focus on what could be considered the elephant in the hospital: the standard hospital medicine schedule.
The reasons for seven on, seven off, 12-hour shifts
The historic schedule is for hospitalists to work seven days on, 12 hours a day, and then get seven days off. That schedule is (at least initially) really appealing for a lot of physicians: it means they get half their days off! The schedule also makes sense for continuity of care, allowing hospitalists to both admit and see a majority of their patients through until discharge. The more continuity you have in scheduling, the easier it is to implement a successful geographic rounding program. All these things are a big part of why the 7 on, 7 off schedule has proven so resilient.
Yet, despite the obvious benefits for physicians, the hospital, and patients, almost from the beginning, the seven on, seven off schedule has come in for criticism. Here’s a piece from 2013 debating the pros and cons of the schedule, published by SHM’s The Hospitalist. Among the pros of the model:
- It’s simple and easy to understand
- It “eliminates bulky schedules that require calls for nights/weekends”
- It gives 26 weeks of “vacation” a year
But, the piece also noted a bevy of cons:
- It’s expensive to staff this way
- It’s very rigid: switching shifts or making changes is difficult
- Doctors become overworked anyway
- Work/life balance is not what the physicians had hoped: “invariably, (physicians) have some kind of family gathering, a family outing, a child program, or a vacation that falls on the week they’re actually scheduled to work.”
To this, I would add that I would hate to be the patient being taken care of by a physician on hour eleven on the last day of a doctor’s seven on, seven off shift. Not that hospitalists aren’t always striving for excellence in patient care, but it would be hard for anyone to maintain that level of commitment.
By 2016, you start to see a lot of stories about how the 7 on, 7 off schedule needs to be changed. “We got it wrong with 7 on, 7 off,” wrote Marcia Frellick in Medscape. “Time to scrap 7 on, 7 off,” wrote Cheryl Clark in MDedge, and so on. Today, the burnout problem has only gotten worse. And COVID has added fuel to the fire, such that we have more and more nurses and doctors quitting medicine altogether.
Fitting the schedule to the admissions
One thing emergency medicine has been doing reasonably well for a long time is creating schedules which try to provide the most coverage when the most people are expected to come into the ER. Yet the seven on, seven off schedule for hospitalists, which usually has doctors working 7am to 7pm, doesn’t really take the reality of admissions into account.
While it’s true every hospital is different, and there is no one size fits all solution, it is still pretty typical to have the number of patients coming into the ED peak in the mid-afternoon. The hospital admissions from the ER tend to come in somewhere between 3pm and 11pm. But this means a big surge of admissions coming in just as most of the hospitalists are going home for the day. This leaves a night doctor getting an overwhelming number of admissions, not being able to keep up, patients having to wait, ERs getting overcrowded, and so on. There are a range of knock-on effects, none of them good.
We think there is a better way to do this. Plus, financial pressures increasingly demand it. Improving the standard hospitalist staffing model will require several strategies in combination:
1. Leveraging telemedicine
Aside from COVID, the other biggest healthcare story of the past 18 months has undoubtedly been the rise of telemedicine, and one of its biggest use cases is to make more efficient use of a reduced clinical workforce. As nurses and doctors had to stay home to self-isolate, remote monitoring technology helped fewer nurses look after more hospitalized COVID patients, to name just one example. Telemedicine has also helped scarce critical care specialists support hospitals around the country as surges hit different states at different times.
Telemedicine has also entered the hospitalist space in a strong way, notably with helping with coverage on nights and weekends. The great thing about telemedicine used to support a hospitalist program is that a system can use its own hospitalists to support multiple sites. Doctors who live and work in the community can take turns providing cross-coverage and supplemental coverage during surges—and perhaps begin to relieve some of the burnout caused by relentless 12-hour shift scheduling.
2. Shorter shifts and fewer consecutive shifts
Leaving your home and family at 6 or 6:30am for a 7am shift and not getting back until after dinner may feel sustainable early in a hospitalist’s career, but eventually the 12-hour shifts take their toll. One doctor, writing in The Hospitalist, called this way of working a “systole-diastole lifestyle, with no activities other than work during the week on (e.g., no trips to the gym, dinners out with family, etc.) and an effort to move all of these into the week off.” One thing I think is clear is that we need to reduce the length of these shifts, trading slightly more days for fewer working hours during each one.
Similarly, we should look for ways to reduce the number of consecutive shifts hospitalists work, at least occasionally, though it’s important to balance this with maintaining continuity of care.
3. Quality APP support
Another long-term trend that hospitalist groups should embrace is integrating quality APP support. Getting talented NPs and PAs involved in care coordination and other areas can help relieve the burden of low-value work and give the group more flexibility with scheduling overall.
The Future of Hospitalist Staffing
What these strategies will look like in practice, on the ground, is still to be determined—as I said, there is no one size fits all solution. A big part of the work of spinning up a new group of sites is to listen to and learn from the doctors who are already there. We want to know what the current situation is and what can be done better.
That said, part of the model in Oklahoma will be to have a local telemedicine-enabled clinical support center staffed by a physician with APP support. This clinical support center will provide cross-coverage and work with each of the sites to help manage nights, including admissions and transfers. We will likely also staff some of the local post-acute facilities so the clinical support center will also help to improve communication between the hospitals and those facilities, and to make decisions about whether to treat in place or transfer.
The end goal of course is better patient care. But leveraging the above strategies should also help reduce burnout (also good for patient care!), and finally fix the problems with the historic way we’ve been doing hospitalist scheduling. The goal is to give hospitalists more support, provide greater flexibility, and certainly to make more efficient use of clinical resources.
Core is recruiting
As I wrote above, taking over these contracts is a big step for Core—it would be for any group.
To staff these facilities, Core will be hiring approximately 70 clinicians and recruiting for a system director. We also have several non-clinical positions we are actively recruiting for. If you or someone you know are interested, please contact Wins Mathew at wmathew@localhost.