Seven on/seven off: Readers respond

Readers respond to a recent opinion piece on seven on/seven off scheduling.

I must take issue with the Perspectives piece “The scourge of seven on/seven off, “ by Edward Ma, ACP Member (ACP Hospitalist, May 2011). The scenario Dr. Ma describes is more indicative of how not to do this schedule—which doesn't mean it shouldn't be done. I started a community hospital-based hospitalist program in 2003, and we have maintained some form of seven on/seven off ever since inception, with great success. In eight years, our staffing turnover has been limited to one physician. Our quality, morale and camaraderie would be the envy of any program.

Dr. Ma and I understand the benefits of continuity, which we both give homage to via block scheduling. To address burnout, we no longer have 12-hour shifts—all shifts are 10 hours, staggered from 6:00 a.m. to 8:00 p.m., with 10-hour nocturnist shifts. As such, everyone either has some time at home in the morning or gets off work reasonably early. We've found that seven-day blocks allow for excellent continuity, but everyone feels ready for a break after day seven—and gets one. As the director of a small program, I am essentially a full-time hospitalist, and I would never write a schedule I couldn't follow myself.


Dr. Ma suggests that seven on/seven off docs are less engaged in non-clinical activities. But where is the evidence? Our docs are active members of the community in their “off” time and have shown ample energy for quality initiatives, committee work, and passions such as palliative care (not to mention travelling, fishing, and other Northwest pursuits). I would counter that weekends are overrated when compared to having so many weekdays free with your family on a regular basis.

It's been said that the “bean counters” aren't always happy with seven on/seven off, but my administration has been very supportive of our program. As a clinician, spouse and parent, I can testify that it works.

Tom Rafalski, MD, Albany, Ore.

It has been a long time since I was as perplexed and astonished to read a published point of view in an ACP publication as I was when I read “The scourge of seven on/seven off “ (ACP Hospitalist, May 2011). When I was governor of ACP's Kentucky chapter between 1998 and 2002 and the concept of the hospitalist was gaining traction, I had real concerns and expressed them. This piece confirms my concerns.

Medicine is rapidly devolving into employed shift work, where the “quality of life” of the employed physician has become the paramount issue in the profession. Yet medicine was never meant to be a simple or non-time-consuming profession. It was meant to be a lifelong passion, defined by a commitment to others—including a time commitment that necessarily exceeds those of forty-hours-per-week-and-no-weekends jobs. I can only imagine what Osler or Harrison might think of this article, which sounds a lot like whining to me.

I wish the author, and others who might be sympathetic to his view, would realize he is compensated at a far higher rate than others working a forty-hour week, and that many would give anything to be in his position. Even in his proposed new model, his eight to nine weeks of vacation time is unheard of for non-physicians, and certainly to the bulk of independent practitioners. Whether or not sick human beings are best cared for by those “watching the clock,” instead of those who have known them both in and out of the hospital for years, is a whole separate issue for another time.

Joseph G. Weigel, FACP, Somerset, Ky.

Editor's note: The following is Dr. Ma's response to the above letters.

Dr. Weigel comments poignantly about how quality-of-life issues have become a significant factor in the practice of medicine, suggesting this may be in conflict with one's commitment to the field. While it's true there has been a shift in values and priorities with a younger generation of physicians, this does not indicate any less dedication to our profession, our patients, and our community, if we recognize that quality of care is impacted by quality of life.

In specialties that require 24/7 in-house coverage such as hospital medicine, emergency medicine, and anesthesia, the issue of staffing models is important. Unlike other fields, where phone calls can be answered from home and most care can be deferred to another day, we need to be available in a timely manner. This necessitates some form of shift-work staffing. A “watching the clock” mentality is crucial for hospitalists to prioritize care when, at any given moment in the day, they may be faced with three critically ill patients, two admissions, four discharges, and a rapid response.

My suggestion to change our traditional seven on/seven off model is less about working too many or too few hours, and more about providing better quality care in a smarter fashion. While many hospitalist practices like Dr. Rafalski's have successfully implemented this model, it requires a conscientious effort to do so.

Edward Ma, ACP Member, Glen Mills, Pa.