Surviving seven on/seven off

Love it or loathe it, the seven days on/seven days off schedule is gaining traction among hospitalist programs. Experts discuss its pluses and pitfalls and share some strategies for success.


Love it or loathe it, the seven days on/seven days off schedule is gaining traction among hospitalist programs.

“The market is voting,” said John Nelson, FACP, medical director of the hospitalist practice at Overlake Hospital in Bellevue, Wash. “Seven on/seven off is clearly the most popular scheduling model. It's not necessarily a bad choice, but I think many groups don't take the time to think about the implications of the schedule, its costs and benefits, before adopting it.”

Pluses and pitfalls

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When it's based on 12-hour shifts, the seven on/seven off schedule allows even a small practice to provide 24/7 coverage.

“It also provides for good continuity between patient and hospitalist,” Dr. Nelson said. “There are fewer occasions when you're handing patients off to another hospitalist, which is inefficient and probably has adverse patient outcomes.”

For individual hospitalists, one of the main benefits of the schedule is predictability. They can know up to a year in advance if they'll be working on a particular day, Dr. Nelson pointed out.

The prospect of having every other week off holds particular appeal for young hospitalists recruited from residency programs, according to Richard Rohr, FACP, director of hospitalist programs for the Guthrie Healthcare System in Sayre, Pa. “For residents coming out of training, the idea that you're going to work 80 hours every other week instead of every week, and get a big salary for it, looks like heaven,” Dr. Rohr said.

They rapidly discover the disadvantages, however. “Once you get into it you realize that your ‘on’ week is a week you don't have time to do anything else. Go to work, come home, go to bed, and then get up and go to work again. And it's exhausting to work 12 hours straight, particularly in a job when you're walking around all day. If the hospitalist starts at 7 a.m., do you really want to be the patient rounded on at 6:45 p.m.?” he said.

Many hospitalists spend the first few days of the “off” week recovering from the stress of the work week, then scramble to fit family activities, errands and exercise into the remaining days, Dr. Nelson said.

“When I was on this schedule, I'd tend to sit around and do nothing the first day, because it seems like you have this vast amount of time,” he said. “Then on the last day off, I'd mope because I knew I would have to shut my life down for seven days.”

Strategies for success

Both short- and long-term planning are essential to making the seven on/seven off schedule work. “That means the day before your ‘on’ week starts, get your groceries and everything else you're going to need for that week,” Dr. Rohr said. “Then you have more time to rest after work.”

To avoid missing key events such as family weddings and professional meetings, Dr. Nelson suggested taking a calendar and crossing out the on-duty weeks for the entire year.

“Try to schedule your social plans and travel well in advance, realizing that you're going to miss some school plays and outings,” he said. “If you plan ahead several months, and find that an out-of-town conference is going to fall during your week on, you can try to arrange a switch with someone. But realize that in order to do that, you and the person you switch with may need to work 10 days in a row.”

Switches may also be required to schedule around major holidays. Some hospitalist programs, for example, will move things around to make sure the same team doesn't work Thanksgiving and Christmas.

For hospitalists whose seven-on involves 12-hour shifts, maintaining energy and focus is critical for patient care. To combat fatigue, Mark V. Williams, FACP, chief of the division of hospital medicine at Northwestern Memorial Hospital in Chicago, scheduled a “bridging” shift starting in the late afternoon to handle admissions from the emergency department.

“During our busy times, it's critical to have evening physician help so that our hospitalists don't end up working past 7 p.m. day after day,” he said. Depending on volume and patient needs, some hospitalists may be able to leave before the end of their shifts, Dr. Williams said, adding that the size of Northwestern's hospitalist group—more than 50 FTEs—enables that flexibility.

For physicians in smaller programs who must consistently work the full shift, Dr. Rohr advised against depending on a time-honored tactic: caffeine. “It's very long-lasting, and it may prevent you from getting to sleep. That just compounds the problem,” he said.

Who's best suited?

A hospitalist's age and life circumstances can have a direct bearing on whether he or she thrives on the seven on/seven off schedule or merely survives it.

“I think older physicians find this to be more wearing,” said Dr. Rohr. “I'm in my 50s and doing it, but I'm not happy about it. I'm hoping to get the program big enough so I can move to a different model in a year or two.”

But certain hospitalists view the schedule as their best option, Dr. Nelson said.

“Hospitalists who live an hour or two away, which is fairly common, often move into the hospital or rent a crash pad during their week on. And if your passion in life requires you to have many days off in a row—I heard of one West Coast group who loved to surf in Hawaii—then you probably have to have that kind of schedule.”