The scourge of seven on/seven off

How many soccer games have you missed because of your work schedule? How often has your spouse had to eat dinner without you?.

Hospitalists are all too familiar with the seven days on and seven days off staffing model, usually consisting of 12-hour shifts. According to the Medical Group Management Association/Society of Hospital Medicine's (MGMA/SHM) 2010 survey of hospitalists, 73% of practices use a shift-based model, and the majority of these are likely seven on/seven off schedules. Despite its popularity, however, it may be time to reconsider this model and ponder the negative impact it has had on our sustainability and effectiveness as hospitalists.

The illusion of free time

At first glance, the seven on/seven off model sounds great. Who wouldn't want to work just half the year? In reality though, hospitalists are laboring so much more than is apparent. Those 26 weeks of work include 26 weekends. In contrast, most of my non-hospitalist physician friends have no more than 13 call weekends per year. Granted, they may cover call for the whole weekend, day and night, whereas a hospitalist typically can sign out to an evening doctor. But the intensity of care we provide is at a much higher level than that of our consultant colleagues.

Edward Ma ACP Member
Edward Ma, ACP Member

Weekends are especially precious to most of us. I personally view a 12-hour-per-day of work as tantamount to a 40-hour week of weekdays. With seven on/seven off, you are working at least 26 weeks of weekdays (possibly more, since the Monday to Friday stretch usually comprises 60 hours), and another 26 “weeks” worth of weekends. Altogether, this is substantially more than just “half the year,” from a quality-of-life standpoint.

Most non-medical professionals work 240 days per year (48 weeks) and no weekends. In comparison, seven on/seven off hospitalists work 180 days, 52 of which are weekend days—double to quadruple the number of weekend days of our physician colleagues in other specialties.

The impact on personal life

When my first son was born, I only saw him every other week for his first seven months (after which I left my seven on/seven off practice). I departed for work at 6:30 a.m., while he was still snoozing away, and returned at 8 p.m., when he was already asleep. How many of your kids' soccer games have you missed because of your work schedule? How often has your spouse had to eat dinner without you? How many outings with your friends have you skipped because the remaining functional brain cells you had after work could only muster the neural capacity to blankly stare at a TV screen, especially by day four? My hospitalist friends in seven on/seven off groups have all shared these same experiences.

The impact on professional life

The schedule has significant consequences at work for hospitalists, as well. We are using only half our workforce on any given week and essentially performing 240 days' worth of work in 180 days. We shouldn't subject ourselves to this any more than we would a one week on/three weeks off schedule, where a quarter of the work force would work in a given week, and each hospitalist would see 40 daily encounters instead of the usual 20. This type of model only serves to fuel the burnout of hospitalists that has become so prevalent in recent years.

Hospitalists should be the backbone of quality and process improvement projects in any hospital. Yet with the seven on/seven off model, they are too busy to attend meetings and participate in committee work during the workweek, and too burnt out to come in during their off weeks. Hospitalists are left without a voice at the table, and then subsequently complain about the policies and protocols thrust upon them by administration.

Frequently, we hospitalists find ourselves rushing with patients and their family members because we have so many other acutely ill patients (and their family members) on our list to tend to. Some follow-up patients don't get seen until 5 p.m. or later, at which point one's role as a hospitalist is no more effective than an outpatient physician coming in to round after office hours. Because we often spend so little time with these patients, clinical care is sloppy, patients are unhappy, and unnecessary tests and consults are ordered.

Primary care physicians frequently complain that they do not receive calls from hospitalists when their complicated patients are discharged. But hospitalists hit the ground running at 7 a.m. and are often working non-stop for an entire 12 hours. The few opportunities to call the PCPs are at the start of our workday, at which time their offices are still closed, and at the end of our day, when their offices are long shuttered. Additionally, when a PCP tries to contact a hospitalist about a discharged patient, there is a good chance the hospitalist has rotated off service.

A proposed solution

The most successful hospitalist practices I have seen implement a more balanced work schedule. They have shorter shifts (10 hours or eight hours, typically) and work more often than “half a year.”

The staffing model emulates the traditional outpatient model, with physicians working Monday thru Friday for most weeks of the year. This enhances communication with PCPs and optimizes transitions of care. At times, these hospitalists work stretches longer than seven days, but fatigue is less of an issue because they have reasonable work days with sensible patient loads. Overall, this shorter-day, greater-frequency model lessens hospitalist fatigue, improves patient care, and increases involvement with hospital administrative work.

In our practice, we average eight hours of work a day on weekdays, with some days being six hours and some days 10 hours. (To maximize continuity of care on the shorter days, we make sure we're still accessible even if we're not in the hospital.) In a three-week period, we will work a 12-day stretch (Monday thru Friday, weekend, and another Monday thru Friday) alternating with a five-day stretch (Monday thru Friday). While we don't have 26 weeks “off,” we still have ample vacation time (eight to nine weeks). Despite the possibility of a slightly higher weekend census compared to seven on/seven off hospitalists, we are able to work more efficiently because we're not as tired from the previous days' work and we know a good portion (usually 50%) of the patients already.

The majority of hospitalists I know are in practices with the seven on/seven off model, and most dislike it. Yet there is a great inertia, lack of will, and downright resistance to changing the model because it is simple, predictable and offers a convenient lifestyle for a small percentage of people (usually young and single). Creating an eight-hour, Monday through Friday scheduling model requires a bit more thought and energy, but I can personally attest that this alternative schedule changes the hospitalist's personal and professional life for the better, while improving the practice of hospital medicine at the same time.