7-on/7-off Is Growing, but Will We Be Asked to Peel It back?

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The new SHM/MGMA State of Hospital Medicine (SOHM) report has just been released and as always it is full of interesting nuggets about the way hospital medicine is practiced these days in our country. One fact/trend caught my eye. The number of 7-on/7-off scheduled programs is climbing. In the past two years, we have seen a rise from 41.9% in 2012 to now 53.8% of programs are working their schedule this way.

I personally have always been a fan of win-win solutions and 7-on/7-off to me has been the mother of win-win solutions in hospital medicine. It’s a win for many doctors (but not all) in allowing blocks of time off to either focus on personal pursuits, or to manage your quality/safety/educational side of your job at your own pace and schedule. It’s a win for hospitals because it guarantees a steady presence of invested doctors ready to care for patients or improve on systems. And it always has seemed like a win for patients and families who got to have more continuity with their core hospital provider.

In my hospital, I see the impact of other specialty services that still have Monday through Friday coverage and then weekend coverage by a different provider, sometimes even a different one on Saturday and a different one on Sunday! Things get dropped; the weekend doc is typically covering double the patients and is in survival mode just trying to keep all the balls in the air. True decision-making and care progression only happens when they are pushed either by hospitalists, patients and families, or simply changes in condition.

We were so convinced of the benefits of hospitalist continuity, that our original schedule back in 1997 was 14-on/14-off. This worked fine in our not-as-busy-as-we-thought-we-were early days; however, events and times changed. Resident work hours retreated, finances tightened, efficiencies improved all with the net result that our days became much more intense. People were starting to experience feelings of burnout trying to maintain those intense days for 14 in a row, so we organically, one request at a time, backed it up to 7 in a row, as had become very common, still feeling that continuity, while not as good as with 14, was still better than weekend coverage models. This was all predicated on gut feelings and local observations. We talked about trying to study this but never did.

In July of this year, Turner, et al out of Northwestern University in Chicago published a study in the Journal of General Internal Medicine looking at The Impact of Hospitalist Discontinuity on Hospital Cost, Readmissions, and Patient Satisfaction. This study looked at 18, 375 hospitalizations all on staff-only 7-on/7-off Monday to Sunday services. No residents or students were harmed in the making of this study. Good. Keep it clean for now.

They used a couple of different statistical measures of continuity that either quantified the number of different providers that wrote notes during a hospital stay (Number of Physicians Index) or looked at the preponderance of care by one provider (Usual Provider of Continuity Index). What they found was a slight increase in costs with less continuity, and interestingly a borderline statistical significance of fewer readmissions with less continuity. Patient satisfaction seemed to drop with less continuity but this part of the study may have been underpowered to achieve significance. Go figure! OK, so the costs and patient satisfaction numbers fit conventional wisdom, but what about the readmission being worse with more continuity? A hypothesis is floated that having more fresh eyes on the case may allow for new approaches and a better outcome that results in less readmits. Sounds good to me.

I love that somebody finally looked at this continuity thing and I always like when a study makes you think. This one certainly has enough contrasting points in it to support whatever bias you already had. Mostly it points the way to more needed studies.

These patients were all on staff 7-on/7-off services. What about residents? Maybe they are the bridge in continuity as attending hospitalists rotate on/off/on, or maybe they just add to the number of providers and discontinuity? What about outpatient-like schedules, Monday through Friday with weekend coverage? What about David Meltzer’s Comprehensive Care Physician (CCP) model?

Does continuity only matter for part of the hospitalization? Does it matter if there is an admitting physician (night or day) and afterwards the rest of the care is managed by a daily management team? Does it matter if there is a discharging physician who hasn’t managed the daily care?

It boggles the mind how we are almost twenty years into this grand experiment and we don’t have answers to these questions. Again, glad to see this and a few other studies starting to broach our information gap.

Already, in spite of the growth of 7-on/7-off scheduling, we are starting to feel the financial pinch and limitations that this schedule can bring. The costs to staff a service of 7/7 are 2 FTE’s for a year. The same service built Monday through Friday with weekend/holiday coverage can be had for approximately 1.4-1.6 FTE’s. John Nelson has long argued for different models (Here and here) that move away from the stressful systole and diastole life of 7-on/7-off. R. Jeffrey Taylor, president and COO at IPC The Hospitalist Company, was advocating in the October issue of The Hospitalist that from a cost and comp standpoint, avoiding 7-on/7-off is better for his physician’s pocketbooks.

Hospitals are starting to feel the financial squeeze for a number of reasons, the Affordable Care Act, tightening governmental budgets, continued rise in costs, and as our number 1 benefactors, they will start looking ever more closely at the payments they are making to hospitalists. They may very well start to ask the question that if I am funding each hospitalist FTE to the tune of $137,600 (new SOHM data), would my dollar go farther if those hospitalists moved to a more traditional schedule? Can I staff 4 services for the price of 3? We need the studies and we need to make the case as to why that is bad math.

I still strongly believe the 7-on/7-off schedule is the right one in most situations and provides the most benefit to the system with better familiarity, less repetition of costs and better satisfaction, but we need to, as we always have needed to, show our value on an individual programmatic level, develop more studies that elucidate and illuminate the mysteries and benefits of systolic scheduling, and show why hospitalist continuity is key to our success.

Burke Kealey

Burke Kealey, MD, SFHM is the Senior Medical Director for Hospital Specialties at HealthPartners Medical Group in Bloomington, Minnesota. Dr. Kealey began his career as a hospitalist in 1995 and has worked in medical leadership since 2000. In 2003 he was awarded SHM’s Award for Clinical Excellence. He has Chaired SHM’s Practice Analysis Committee and helped produce several of SHM’s Compensation and Productivity surveys. Dr. Kealey is a past president of SHM’s board of directors and has served as secretary and treasurer in past terms.

Dr. Kealey has a strong interest in ensuring that hospital medicine practices are effectively managed with a strong focus on the triple aim of affordability, great experience, and best health for our patients.

Raised in Texas, Dr. Kealey received his undergraduate degree from Texas A&M University, his medical degree from the University of Texas at Houston, and then moved north for Internal Medicine training at the University of Minnesota Hospitals and Clinics. While in chief residency he met his lovely wife Samantha, a Minnesota native and current Emergency Medicine physician. Together, they have 4 children.

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