A Work in Progress

The Hospitalist. 2006 October;2006(10):

October 1, 2006 | The Hospitalist

Scheduling: Every Program’s Mt. Everest

Because of the hospitalist program’s size and longevity, physicians have experimented extensively with scheduling. As do many groups, it started with seven 12-hour days on/seven days off blocks, which proved dissatisfying both personally and professionally.

“We experimented with scheduling to find what was sustainable for physicians and provided patient continuity,” says Dr. Fraser. “We’ve found that six eight-hour days in a row of rounding works best.”

Scheduling has evolved to the point that hospitalists provide the following to meet the hospitalist’s, the group’s, and the hospital’s needs: a dedicated triage physician 24/7 to handle calls from all sources of patient flow, two hospitalists on site at all times, eight-hour rounding days, and call physicians who admit and cross-cover after 4 p.m. Average daily census (ADC) is 10-12, plus one or two admissions. While that appears low, if CPMG hospitalists worked 12-hour shifts, their ADC would be 13-16, consistent with national norms.

“Dropping to eight-hour, as opposed to 12-hour, days keeps the job sustainable and helps doctors avoid burnout,” says Dr. Fraser. “However, we work more days per month, an average of 20-22.”

Overall, the scheduling strategy is working. “The majority of physicians who started over a decade ago remain, including many mid-life hospitalists in their 40s and 50s,” she adds. Physicians, rather than administrators, handle scheduling. Dr. Fraser has found that physicians can accept that third triage shift in a month (or an extra night shift when they’re short-handed) when another physician is filling the slots.

AMI Clinical Outcomes and Physician Perception

To move medicine from cottage industry to science requires research, such as the following Permanente study. Lead researcher David Magid, MD, MPH, of Kaiser Permanente’s Denver Clinical Research Unit assessed the relationship between age and the quality of medical care provided to patients presenting with acute myocardial infarction (AMI) at emergency rooms.

In a two-year retrospective study of 2,216 patients presenting with AMI, Permanente researchers correlated administration of provision of aspirin, beta-blockers, and reperfusion therapy with patients’ age. Overall, 80.5% of patients received aspirin, 60.3% got beta-blockers, and 77.8% were given reperfusion therapy. After adjusting for demographics and clinical factors, 15% fewer older patients received aspirin therapy, 23% fewer got beta-blockers, and only 70% fewer received perfusion. The authors concluded that older patients presenting to the ED with AMI received lower quality medical care than younger patients.—MP

Other Features

All CPMG hospitalists can participate in St. Joseph’s residency program as “teaching attendings” for one month. From them, residents learn to co-manage care and participate in interdisciplinary rounds with nurses and social workers. Physicians note that residents make a hospitalist’s life smoother.

“At Good Sam, we do all our own procedures, unlike St. Joe’s, where they have residents. With our patient volumes, there’s little breathing room, especially when we have to cover non-Kaiser patients,” says Dr. Thom. Eventually, residents will rotate through Good Samaritan as well as St. Joseph.

One of the advantages of working in a brand-new hospital like Good Samaritan is establishing systems from scratch. That includes the new hospital’s electronic medical record (EMR), which is integrated with CPMG’s outpatient EMR. “We set up our own systems, complete with order sets and protocols,” explains Dr. Thom. “Considering that 90% of our patients are CPMG members, this gives us a high level of integration, clinically and electronically.”

Challenges Ahead

Despite CPMG’s size and stellar track record, challenges remain. Dr. Fraser identifies them as salaries that rank last within the group, making recruiting difficult; a hard time providing adequate back-up if a physician is unexpectedly absent; adjustments to fluctuations in patient census; time pressures of hospital committee work; and identification of an optimal scheduling model that fosters continuity of care yet provides a sustainable work life.