By Sowmya Kanikkannan, MD, FACP, SFHM
My earliest memories of medicine take me back to dinner table conversations with my mother, who is a physician. She would share with us her daily stories, telling us about patients she took care of in her clinics and in the hospital. As an internist, she often found herself traveling between many locations. I grew up knowing this to be medicine. As I have progressed in my career as a hospitalist, I have seen how physicians’ practice has evolved and changed in many ways. Some of us stick to the inpatient world, some of us the outpatient, and many still partake in the ‘traditional’ model my mother practiced in. Throughout all of these scenarios, I see one commonality. Most of us see our patients day after day in a continuous fashion for the length of time that we work; we have a degree of continuity.
Recently I have been hearing more and more discussions in the C-suite about ”reactive scheduling” models for hospitalists. And it should come as no surprise to you then that I find this concerning.
Reactive scheduling suggests a system akin to that used by many nursing practices throughout the country. The model functions by way of supply and demand. Practitioners are scheduled, canceled or asked to work overtime based on the hospital-wide census and a need for manpower on a day-to-day basis. My nursing colleagues tell me stories of waiting for ”the call” to hear if they will be working or not, and sometimes coming in to work only to be sent home early later in the day. To me, it seems a bit chaotic.
I can easily see the allure of applying this model to hospital medicine. Census can shift dramatically; one day the patient volume is exceptionally high with many admissions, but several days and many discharges later, it’s very low. Wouldn’t it be great if you could cancel shifts for docs you didn’t need? Or call more in when things are busy? While it might make financial sense on the surface, this type of model creates a slippery slope that could harm physician morale, patient care, and the overall function of any given hospital system.
Let’s start with physician morale. Most physicians enter the medical profession knowing they will make sacrifices to succeed as a doctor. This creates a mindset that makes it the right thing to do to put in extra hours to ensure a patient is well taken care of. Our days by their very nature are fluid and dependent on the needs of our patients. We also like to (when possible) provide complete care for our patients, seeing them through the entirety of their hospital stay, helping them get better. Reactive scheduling undermines this mindset and dampens our level of commitment. For example, if a doc’s shift could be canceled, he or she may be less inclined to put in that extra effort to tee things up for the next day. Additionally, continuity of care suffers. It becomes difficult to make thoughtful medical decisions, especially if you are covering shifts in a spotty fashion. Where do you get a chance to see the big picture? And with a constantly shifting census, will you even be seeing the same patients?
I re-emphasize here continuity of care. Besides just affecting our medical thought process, it more importantly impacts patient care. This is why most hospitalist practices are a 7-on/7-off model. A full week of work allows for the majority of one’s patients to be managed by a single practitioner. That person is aware of everything that happens to the patient, makes consistent medical decisions, and is better equipped to see the big picture. Furthermore, hand-offs decrease, and with that, so do medical errors. All of these things are positive for patients. From an institutional perspective, continuity is a wonderful thing. HCAHPS scores go up, length of stay goes down, and patients move through the system more efficiently and are better cared for. Reactive scheduling would kill continuity, eliminating all of the efficiency we’ve provided for our hospitals over the many years.
While a great financial argument can be made to staff physicians based on census, the benefits do not outweigh the true cost to the health system. It would create an environment where hospitalists are dissatisfied and disassociated from their job. It does not engage practitioners to commit to providing high-quality, efficient, ‘big-picture’ medicine. It would likely reflect poorly on patient outcomes and the metrics we currently look at to ensure that we are practicing well. It will definitely increase hand-offs, worsen medical errors, and negatively affect care.
Patients like familiarity and to see the same doctor day after day. While they certainly need work, our current hospital medicine models do provide for this. Let’s continue to provide our patients with the best possible care, and stop trying to beat the supply/demand curve.
Sowmya Kanikkannan, MD, FACP, SFHM is Hospitalist Medical Director and Assistant Professor of Medicine at Rowan University School of Osteopathic Medicine where she directs a multi-site academic hospitalist practice. She serves on the national SHM Leadership Committee and as Team Hospitalist for The Hospitalist. She is very active at the regional level in both SHM and ACP, organizing events for Hospitalists in the region to network, improve their knowledge of hospital medicine and build effective practices. In addition to practice management, her interests include quality improvement, patient engagement, and hospital medicine education.
Outside the hospital, Dr. Kanikkannan likes staying active and keeping fit. She enjoys creative writing, traveling, music and spending time with family. She lives in the City of Brotherly Love with her husband.
Follow her on twitter @skanikkannan