Dr. Nelson advises reducing the daily workload by spreading the work over 210 to 220 days annually. While that doesn’t afford the luxury of seven consecutive days off, it allows the doctors to titrate their work out over more days so that the average day will be less busy. He also advises flexibility in starting and stopping times for individual shifts, allowing HMGs to adjust to changes in patient volume and workload. Scheduling elasticity lets doctors adapt to a day’s ebbs and flows, perhaps taking a lunch hour or driving a child to soccer practice. That may mean early evening hospital time to finish up, but variety keeps life interesting.
About patient volume (another scheduling headache) Dr. Nelson says that capping individual physician workloads makes sense because overwhelmed physicians tend to make mistakes. But capping a practice’s volume looks unprofessional and can limit a group’s earnings. Several HMGs we profiled disagree with Dr. Nelson. (See below.) Most didn’t actually cap patient volume, but instead restricted the number of physicians transferring inpatients to the HMG, adding more referral sources only as patient volume stabilized or new hospitalists came on board to handle growing volume.
Some of the best-functioning HMGs we encountered have lured well-known office-based doctors ready for a change. Eager to shed a practice’s financial and administrative burden, as well as regular office hours, these physicians relish the chance to return to hospital work—their first career love. They also remember what it’s like to have to work Thanksgiving, Christmas, and New Year’s, and the more generous among them volunteer for those shifts so that younger hospitalists can spend holidays with their families.
Awards for Struggling through Scheduling Issues
Data on where the average HMG stands on scheduling are important, but every successful group has physician leaders who craft schedules based on a broad and subtle understanding of their medical communities. They factor in whether the areas surrounding their hospitals are stable, growing, or shrinking; the patient mix they’re likely to see; their hospital’s corporate culture and those of the referring office practices. For recruiting, they think about whether their location offers an attractive lifestyle or how they can sweeten the pot if it doesn’t. If they’re at an academic medical center, they’ll have a lower average daily census (ADC) and different expectations about productivity than if they’re a private HMG at a community hospital. Chemistry, meaning whether or not a new hospitalist who looks great on paper and interviews well will gel with the group or upset the apple cart, is a tantalizing unknown.
So here’s our list of HMGs that wrestled successfully with their scheduling challenges:
The “Are We Good, or What? Award” goes to Health Partners of Minneapolis, Minn. These hospitalists have won numerous SHM awards for clinical excellence, reflecting their high standards and competence. The 25 physicians and two nurse practitioners can choose between two block schedules: seven days on/seven days off or 14 days on/14 days off. They also work two night shifts a month—6 p.m. to 8 a.m.—backing up residents. Key to avoiding burnout on this schedule is geographical deployment. Hospitalists work only in one or two units, rather than covering the entire seven-floor hospital.
The “Go Gators Award” goes to Sage Alachua General Hospital of Gainesville, Fla. Whenever possible, these hospitalists attend the home football games of their beloved Florida Gators, 2007 Bowl Championship Series winners. This reflects their strong ties to the University of Florida Medical School—also Dr. Nelson’s alma mater—and the many physicians who come from or settle in the Gainesville area. The group started with three hospitalists on a seven on/seven off schedule, backed up by a nocturnist who quit due to the heavy volume of night admissions. They now have nine hospitalists—all family practice physicians—working a seven/seven schedule. Each one covers Monday through Thursday night call every nine weeks, with residents handling Friday through Sunday. An internist who retired from his office practice works Monday through Friday mornings and occasionally covers holiday shifts for his younger colleagues.