AT HOSPITAL MEDICINE 16

SAN DIEGO (FRONTLINE MEDICAL NEWS) The time has come to do away with the 12-hours-a-day, “7-on, 7-off” schedules followed by nearly all hospitalist groups, according to Dr. Robert Wachter, professor of medicine at the University of California, San Francisco, and father of the hospitalist movement.

To institutionalize such a schedule so broadly in the specialty’s earliest years “was a mistake, a well-meaning, understandable mistake … [but now] it feels like a real error that probably needs to be rethought,” Dr. Wachter said in his closing address at the Society of Hospital Medicine’s annual conference. The model is “fine for a 35-year-old,” he said, “but not so doable for a 55-year-old.”

In a follow-up phone interview, Dr. Wachter explained he’s increasingly hearing “tales of burnout from hospitalists” who are not as young as they used to be. And while burnout is a problem plaguing several medical specialties, “when you drill down and try to understand the source, it sounds like [hospitalists] are running for the entire day for 12 hours, and doing it 7 days a week. I don’t know many 50-year-olds who can do that” in a building where patients are on many floors, he said, noting that hospitalized patients are sicker and more complex.

Dr. Wachter said the hospitalist model is now used by between 70% and 90% of the nation’s hospitals, which given the number of recruiting advertisements in journals, are having a hard time filling hospitalist positions. That’s despite the growing number in the specialty, now counted at about 52,000.

The demand may be due to the fact that many hospitalists are leaving clinical work after 15-20 years, a trend less true with other medical specialties, Dr. Wachter said. “I’m hearing 50-year-old hospitalists say, ‘I need to leave; I can’t do this clinical work anymore. I’m going to be a consultant or a chief medical officer,” or take another administrative or consulting opportunity.

“You don’t want people to feel like they have to find something else if they’re really good doctors,” he said, as it would mean “throwing all that experience and training out the window” in midcareer.

When asked if hospitalists make more errors or put patient safety at risk on the 6th or 7th day of a schedule, Dr. Wachter referred to a study that revealed that when hospitalists get more than 15 patients on a census, costs and lengths of stay go up. “No one knew [before that study] whether 15 was the right number, and I think the same is true here,” he said. Dr. Wachter urged researchers to “study alternative models to see whether we can come up with one that is more sustainable,” and also to conduct appropriate studies with other models to see if error rates are different.

Dr. Wachter said during the phone interview that, as the hospitalist movement was beginning 20 years ago, the 7/7 model was derived from one used by the closest medical specialty to the hospitalist practice, emergency medicine. ED physicians adopted a model closer to 10- to 12-hour shifts every other day, 15 shifts a month.

Because continuity of care was the hospitalists’ goal, that schedule wouldn’t work, Dr. Wachter said. But 7 days of 12-hour shifts would, alternating through the 52 weeks of a year.

In addition, the 7/7 schedule was appealing to young hospitalists entering practice after residency. “Because wow, what a great thing! I work 12 hours a day, 7 days, and then I have a whole week off. What could be better for a younger doctor?” Dr. Wachter said. “But while there may be some 60-year-olds keeping to this schedule and things are fine, I don’t believe this is a viable schedule for a 60-year-old.”

Dr. John Nelson, the cofounder of the Society of Hospital Medicine and a hospital consultant in Bellevue, Wash., said he and Dr. Wachter agreed on this issue.

To a young doctor, the 7/7 schedule “sounds sweet,” but they don’t realize that “you have to shut your life down altogether for a week. What other job requires you to do that? It’s unreasonable,” Dr. Nelson said. The 7/7 schedule “does not promote career longevity,” he added.

Increasingly, Dr. Nelson said “countless” hospitalists tell him: “My 6th or 7th day in a row of work, I’m not really much on top of my game. I’m often less willing to sit and talk with a family as long.” The other issue, he said, is that as doctors get older, they find it difficult to fill their entire 7 days off productively.

So what’s the solution? Dr. Wachter and Dr. Nelson said they aren’t sure. But Dr. Nelson said the holy grail, which is maximizing the number of days off, should be changed. “Pursuit of the maximum number of days off is backfiring, failing to see the big picture,” he said. Rather hospitalists should work more days, but fewer hours.

“Most of us will be happier tending to work more days rather than fewer,” Dr. Nelson said. “You’ll get out to your kids’ soccer game at 4 o’clock in the afternoon, things like that. And you won’t drive into work with a knot in your stomach wondering how you’re going to survive 12 brutal hours.”

ehospitalistnews@frontlinemedcom.com

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