by Randy J. Ferrance, DC, MD, FAAP, SFHM
Let me say this first: I love being a hospitalist. I entered medical school as a primary care poster child, but from the first time I stepped onto the wards, I knew that was where I belonged. The acuity, the excitement, the gratification of admitting a patient who is nearly dead – or sometimes actually is dead – and then pulling off something akin to a medical miracle? There is nothing else like that, as far as I’m concerned.
Thirteen years ago when I left residency for a job at a small rural hospital, I was sure I would never do anything else. Ten years ago, five, even three… I don’t think I would have said anything that I’m about to say. I was among the first to apply for Fellow status with SHM, and rapidly thereafter I applied for Senior Fellow status. I’ve been published in the Journal of Hospital Medicine. Twice. Granted, my submissions were partially fictionalized stories in Hand-offs, which doesn’t even exist anymore, but still, I’m indexed and the JHM and I are forever linked in PubMed.
I came to medicine a bit late, as a second career physician. I was 31 when I started med school, and my kids were already toddlers. Now I’m on the downhill side of 50, the kids are gone off to start their lives, and my wife is home but not quite alone, since her parents live with us – leaving the nest not quite as empty, perhaps, as we’d wish. And while the work I do is still exciting and engaging and every bit as gratifying as it was the day I finished residency, the time I spend doing it, and away from my wife, is starting to wear on me.
I still work in a small, rural hospital, where I am privileged to do my own critical care, but where we have single doc coverage, averaging the typical 7-on-7-off but with flexible scheduling so it can be anywhere from 4 to 10 on and then 4 to 10 off, 12 hour shifts, alternating days nights, half of all weekends, half of all holidays. No PTO. I started to look and see what was out there and I found, among other things, that my own health system has a position available for a doc in its PACE program (Program for All-Inclusive Care for the Elderly), which is essentially 8-5, weekdays, no weekends, no holidays, and, get this, 6 weeks of paid time off. When I did the math – because I really was that curious – despite the fact that it’s a $30k a year pay cut? It would actually be a $6/hour raise.
So I have to admit I’m considering it, along with about two dozen other offers that I received within twenty-four hours of posting my CV on a physician jobs website. Do any of those jobs give me the same feeling that being a hospitalist does? The same feeling that I’ve always imagined AFib with RVR gives patients? A sense of urgency and excitement and nervousness? No, not really. But the lifestyle sure does sound nice.
Life is often about compromises. My wife has compromised for thirteen years so I could enjoy practicing the kind of medicine that I love. I’ve compromised on family time so I could enjoy the medicine I’ve loved. Now, it may well be time for me to compromise on the medicine so that I can have some family time, and maybe even concentrate on my own health, rather than that of a long stream of patients who often seemed to care less about their health than I did.
The days of physicians finishing training and hanging out a shingle, working themselves to death in solo practice are essentially over. Now physicians tend to be wholly owned subsidiaries of the Medical Industrial Complex. We pull paychecks, we get 401(k)’s, we get benefits, we earn sick time, some of us even get to use it. Many of our colleagues get to live lives much like our friends in corporate America, working forty hour weeks, enjoying weekends off, taking four to six weeks of paid vacation each year… Yet most hospitalists work 7-on/7-off twelve hour shifts, twenty six weeks per year, which would be the equivalent of working forty-two hours each week year round. With no paid time off. Ever.
Why have we decided that’s its perfectly acceptable to have such a brutal lifestyle in hospital medicine? Would any of us recommend that to any of our patients?
Or am I the only one that finds it so brutal? In all honesty, I don’t remember it being so hard 13 years ago. But now, flipping days and nights is getting harder. And the 7 off just isn’t quite the same when the first day or two is spent recovering, and another 1, 2 or 3 of the “off” days is spent in-house performing administrative tasks, or attending meetings, or conducting chart review, or being lectured on how to improve our Press-Ganey scores.
I’ve always felt it was poor leadership to point out a problem without offering potential solutions. The problem is, I don’t have any. I’ve spent years trying to devise them, but small hospitals come with small budgets. Increasing staffing enough to give the hospitalists a decent lifestyle just isn’t cost-effective, despite the fact that on an hourly basis, we are paid less than just about everyone else on staff. As it is, on the night shift, we already underperform on an RVU to salary basis.
So there’s the problem, SHM. I would like to think that we more “seasoned” hospitalists still have a role within hospital medicine – which I guess is why so many of our luminaries have transitioned into administration. But there are only so many positions behind the glass doors of the C-suite, and only so many of us are suited for that sort of work to begin with.
What of the rest of us? Is there a place under this big tent for the experience and talent accumulated within us older, tired folks who just can’t tolerate – or just aren’t willing to tolerate – the defacto agreed upon (or was it imposed?) lifestyle anymore? I am hoping that as our specialty ages, SHM can direct some attention to looking at schedule optimization. A lot of time and energy has been invested into resident work hour restrictions, but attendings… attendings have no protections whatsoever. Are we really doing what is best for ourselves? For our patients? For our families? Shouldn’t they count in the equation as well?
If we are going to lecture our patients about healthy lifestyle and striving for a work/life balance, shouldn’t we first take our own advice?
NOTE from SHM: If you’re interested in discussing this topic with other hospitalists and you’re a member of SHM, we invite you to join in the discussion on HMX by clicking here.
Randy J Ferrance, DC, MD, FAAP, SFHM is Medical Director of the hospitalist service at Riverside Tappahannock Hospital, a 47 bed rural hospital in Virginia’s Northern Neck region. He also serves as the Medical Director for Hospital Based Quality, and as the Medical Director for Home Health and Hospice. He attended the Indiana University of Pennsylvania for undergraduate studies without bothering with completing an undergraduate degree, obtained a doctorate in chiropractic from Life Chiropractic College in Marietta, Georgia and practiced as a chiropractor for seven years before attending the Medical College of Virginia at Virginia Commonwealth University for his MD. So, yes, he has two doctorates and no bachelor’s degree. He completed a combined residency in internal medicine and pediatrics at MCV/VCU and is now board certified in internal medicine, pediatrics and hospice and palliative medicine.
In his alleged spare time he steals moments with his wife, restores classic cars, revels in medical history, and continues to pound away at his novel.