Growing up, I had always associated shift work with blue-collar jobs – typically those jobs that didn’t require a degree or graduate education. Not that there’s anything wrong with those jobs (a lot of them are vital public services), but I never expected to one day be working in a job where I would see myself as a “shift worker,” or worse still one where I “clocked in and clocked out” at the start and finish of the day. Graduating from medical school and beginning a career in medicine, I surely had started a noble profession—a calling—where I was as far away from this as possible; in a position where I would receive autonomy and a certain degree of freedom. Now several years into a career in hospital medicine, I sometimes feel surprised at where my chosen specialty has found itself. I’m also surprised by how some of my peers view their own work schedules.
Having worked in a handful of different hospital medicine programs and heard feedback from friends and colleagues across the country, I’ve certainly noticed two distinct types of program evolving. The first is one where the attending physician is expected to work for any given day, has their list of patients and gets to work on them. Let’s call this the traditional model. There will likely be a number of new patients each day and admissions coming in through the ED. The doctor knows their pager responsibilities but isn’t necessarily thinking in terms of a set finish time. On a good day, they may be done earlier, on others end up finishing late.
The second type of program is one where hours are more strictly enforced, usually by a misguided—and even micromanaging—administration. Misguided because it’s a useless metric to focus on and doesn’t bear any relationship to either quality or productivity. It’s in this type of program that I’ve also noticed doctors often all too willing to allow themselves to think in terms of “shifts.” Usually it’s the bigger and more academically affiliated programs where this is catching on, and always ones where hospital doctors are employed directly by the hospital as opposed to a separate smaller private group.
So what’s the problem with that? Well, there are many. First, as soon as we get to a point where shifts and hours are viewed as set in stone, we get into a situation where we are only one small step away from “clocking in and clocking out” with your name badge, similar to what a lot of nurses and even other hospital workers do. It’s the next logical step (my answer to people who ask what’s wrong with doctors doing it if nurses do it is that nurses shouldn’t need to do it either).
Sadly, I’ve already heard of programs where administration has even been registering what time doctors arrive to the minute with an administrator standing outside the office writing down when doctors first walk in (I don’t know what history brought that particular program to that point, but it just seems like an incredibly inappropriate and demeaning way to treat doctors). Indeed, most doctors would probably rightly run away fast from such an environment. Situations like this aren’t just the fault of administrators either. Could we also be to blame for weak leadership on our part that has allowed this to happen—and wouldn’t be tolerated by any other specialties? If hospital physicians permit themselves to become shift workers, that’s how other colleagues will view you too.
The second problem with shift work in hospital medicine regards the nature of the job itself. It’s simply impossible to know exactly what time you’ll finish on most days. You don’t know when an emergent or complicated situation will present itself or when you will face a higher than usual patient census. On these days you may well need to stay a little longer, which is the duty and expectation for a physician. If we are stuck in a mentality of needing to finish at an exact time, this will invariably evoke a very negative feeling on days that last longer than expected.
Finally, apart from the one single exception of ED doctors, the shift mentality also separates us from all other specialties in the hospital. There’s even a case to be made that it lowers the prestige of our great specialty. The argument that hospital medicine exists because doctors want to work shifts is a hollow one. As is the theory that this is an inevitable consequence of being employed directly by hospitals. I’ve personally never liked it when nurses have asked me, “What time does your shift finish?” Sorry, but I’m a doctor and don’t work shifts (they would never ask a cardiologist or surgeon the same question). I leave my pager on till late anyway and request to be called on any issues regarding my patients. I want to be told if something goes wrong with any patient that I may have seen just a few hours earlier. I’m also happy to talk to patients’ families over the telephone in the evenings if I haven’t managed to communicate an important message during the day.
Without getting into the completely separate debate about how hospital medicine doctors should be compensated i.e. hourly pay, daily rate, RVUs—shifts should not be in our vocabulary. Going back to Emergency Room physicians for a moment (or even an “Admitter” role for a hospital doctor), these are the only types of jobs that can perhaps be viewed in terms of a set start and finish time. If we want to define our work pattern, talking about “work days” with defined pager responsibilities is a better descriptive term to use. Like other high-ranking professionals, we have our workday, put our heads down and get to work. Beyond knowing when we have a colleague to cross-cover us, we cannot know precisely when our day in the hospital will be over.
So hospital medicine doctors, keep in mind the connotations if you’ve become a “shift worker.”. It comes with a lot of negative strings attached.