Volume, Value, and Thinking outside the Box

By  |  July 23, 2014 | 

Solving the increasing demands within busy hospitalist practices while maintaining high levels of quality will need a touch of creative scheduling.

by Dr. Sowmya Kanikkannan MD, FACP, SFHM

When I began my job search at the end of residency, I was looking for a career that’s fast-paced, system-oriented focus on a shift schedule. Hospital medicine was at the top of my list because it has all of this, and it also afforded me the opportunity to travel, which is one of my passions. During my weeks on, I was rewarded for working hard with thankful patients and vibrant residents who were eager to learn. During my weeks off, I traveled the world; exploring the Pyramids in Cairo, swimming with sea turtles in the Galapagos Islands and visiting my cousins in Rio de Janeiro. As amazing as these experiences were, I began to notice that during my weeks on, I had very little time for family and friends. The intensity of working seven days straight coupled with the changing nature and growing inpatient responsibilities of hospital medicine became more palpable over time. In short, I think that both the job and I were beginning to mature.

Hospital medicine is definitely growing up. These, our ‘teenage years,’ are full of responsibility, new direction, and expanding roles. It is an exciting time, but it will be a period that forces us to reflect, adapt and perhaps completely overhaul our current model of hospitalist practice. In my eight years of HM practice, I’ve seen our focus expand from executing simple goals (e.g. reducing length of stay) to figuring out how to impact almost every measurable inpatient metric! It is amazing how invaluable we have become to our hospitals, and that tells me that our field has a very bright future. In the short term, however, those responsibilities present a challenge for individual hospitalist groups — especially when there are limited resources.

Finding successful solutions for the ever-expanding roles of our groups is a big focus for hospitalist thought leaders. SHM’s Leadership Committee has long encouraged creative thinking to answer our most pressing questions, and many of us are in the field trying to figure out how to support our institutions and nurture our hospitalists simultaneously.

In many discussions with other hospitalist leaders, one controversial question always seems to surface: when the volume goes up, how do you continue to spend time on achieving the many goals set forth for the group? How do your provide the coverage without over-burdening your docs? Can you maintain quality in that scenario? The very same question was most recently raised by Dr. Robert Zipper at our last Leadership Committee meeting, which got me thinking. Usually, the quick answer always seems to be to hire more physicians. More docs should equal more productivity. But that isn’t always financially possible, especially in small groups with even smaller budgets. What can they do to tackle this increasingly frequent puzzle?

It is worthwhile at this point to revisit a recent post by Dr. Bob Wachter (http://community.the-hospitalist.org/2014/04/14/hospitalist-potpourri/). Here he calls attention to a recent study (http://onlinelibrary.wiley.com/doi/10.1002/jhm.2146/abstract) that shows burnout among hospitalists rivaling that of primary care physicians. In addition, he notes an increasing number of hospitalists moving into leadership and administrative roles. As he points out, “…a 45-year old hospitalist doing 12 hour shifts of 7 days on, 7 days off is going to begin feeling it in his or her bones. While the movement to leadership and administrative roles is fantastic, it should also make us ask whether the jobs we’ve created are truly sustainable.”

The popular hospitalist model has physicians working 7 days on, 7 days off for a 12-hr shift. While the merit of this model is obvious, the perils may not be apparent immediately. Years ago, when length of stay (LOS) was our main goal, this might have been the most appropriate model for our field. With the advent of value based purchasing, more work is both expected and crunched into our twelve hour days. This has lead to exhausting “weeks on” with one’s week off spent recovering. It’s not a surprise that studies would find increasing burnout among hospitalists; and when our docs burn out, the group’s productivity suffers.

I wouldn’t be the first to suggest that we should revise current scheduling models as the key step in reducing burnout and making our jobs more sustainable. However, I believe that taking a creative approach and creating a variation of 7-on-7-off model presents a more sustainable solution. To take a cue from our colleagues in other specialties– a model where our shifts are shorter but we work a few more days during the month (getting guaranteed time and weekends off) might be a better fit for the changing nature of the field. A few more but shorter shifts would yield a greater number of docs working on any given day. They can see more patients, evenly divide work, and “get it done” faster and more efficiently — all things that improve quality in the hospital. You would see less burnout and more provider satisfaction in the long run. Changes of this sort might better support multi-site programs where manpower often shifts based on the census. Staggering shifts would still allow for 24/7 coverage as requested by our hospitals. The addition of PAs and NPs into a system like this would continue to be invaluable. Most importantly, it could be cost neutral.

I know that this is a hard sell in an environment where we have embraced our weeks off. I have to admit that when I graduated from residency, the 7-on-7-off model truly appealed to me. As a travel nut, this was the ideal schedule for me back in 2006. The model was simple and uncomplicated. However, as our field grows and matures, we need to grow and change with it to be successful. The trick is to do this in such a way that doesn’t compromise our ability to excel in what we do while simultaneously maintaining a balance between work and life.

I think it’s time to get creative. Don’t you agree?


Kanikkannan_SowmyaSowmya 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


  1. Brian Wolfe July 24, 2014 at 11:12 pm - Reply

    Great to read about your multiple leadership positions! Sounds exciting and busy. I really enjoyed your article and agree that I feel it in my bones a lot more than I did a decade ago. However, one of the problems that shorter shifts create is additional hand offs. We have crated a swing service that allows for improved lifestyle by minimizing the dreaded 12.5-13 hour day that we both shared back on the 5th floor CDU. However, there is no question that there there is a significant voltage drop with a handoff around 4:30-5 followed by a second one at 7. This has really challenged our ability to provide high quality care in the late afternoon and evening which I think of as one of the most vulnerable times of the day to be admitted or to have an urgent issue arise. How have you guys tackled this problem?

  2. Sowmya Kanikkannan July 27, 2014 at 11:02 am - Reply

    Great to hear from you, Brian! You raise a great question. I think that most programs find it a challenge to optimize their patient handoffs overall and especially during the busy evening hours. Given that frequent handoffs are inherent to our field since we work shifts, implementing an electronic sign out system (i.e. Wardmanger etc.) might ensure a more standard and safer patient handoff. Sicker patients can be signed out with a face to face interaction during the evening hours.

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