The Great Scheduling Divide

[Arcan57]

As referenced in the EM - Job vs. Lifestyle thread, there is a fundamental tension that exists for most EM groups. Everyone wants a good circadian cycle but everyone also wants to have significant flexibility in requesting days off. Unfortunately, these goals are almost always mutually exclusive FOR THE AVERAGE DOC IN A GROUP (directors or PT/locums need not read further). There are pro's and con's to both approaches, but our field is so heavily weighted towards days off that I don't think people consciously realize what they're giving up in exchange.

1) Circardian : progressing in a step-wise fashion forward with adequate time off to reset in between cycles.
Pros - being well-rested. This is something that's undervalued due to the relative youth of our specialty. Most of us probably used to be able to stay out partying for the duration of an overnight shift, but I cannot recall the last time I was out past 1am that wasn't work related.
Cons: difficult/impossible to execute without broad buy-in from docs in terms of schedule requests. Difficult to maintain circadian discipline during days off due to other responsibilities. Inability to participate in mid/high frequency fixed time/day events due to pattern of shifts. Also, some people are significantly more wrecked by strings of nights than random individual nights.

2) Days off: prioritizing your non-work commitments over quality of work life
Pros - given a large enough group/shifts needing covered is usually easy to schedule. Maximizes ability to commit to non-work events, especially those with fixed times/days.
Cons - Variable consistency in terms of respect of circadian rhythm. Easier to abuse system unless there are tight rules regarding number of shifts and night/weekend/holiday coverage (PROTIP: at least in Tangier, judicious use of "need night prior off" combined with a high single digit number of requested days off allowed can let you basically dictate what nights you work).

And finally the biggest effect of choosing to go with route #2 is that it represents a fundamentally different approach to working in EM than the circadian route. As Birdstrike has pointed out, what we do is intense and regardless of scheduling philosophy is difficult to do for more than 3-4 shifts/week averaged over months/years. By prioritizing days off, we try and maintain this polite fiction that when you're done with your shift you're off the clock and completely available for any other responsibilities. How many EM docs have over 50% of their family's childcare responsibilities? How many are running side businesses? How many travel like they're a teenager with a trust fund?

These extracurriculars come at a cost and it's a cost that's harder to pay as we get older. There are certainly things in my life that I couldn't do and have a decent sleep schedule but it's tough to look at the mass exodus of what should be mid-career (8-12 yrs) docs to free-standings or side-gigs and not think we've gotten the balance wrong.

---

Members don't see this ad.

 

[ewokka]

Is it too late for me to withdraw from the match? Hahah I'm kidding. Interesting perspective. I think all students wanting to go into EM should understand this. I witnessed this first hand with my mother who is a practicing ED doc.

Generic response --> there is no perfect speciality. It all depends on what you want/need/will put up with.

 

[Hair Police]

I've done the circadian rhythm and I didn't find it that restful. It was disruptive to everything else I wanted to do.

I also find that doing 12s overnight is easier than 8s, so maybe it's just me.

 

[Daiphon]

I think *both* approaches are right, and don't need to be mutually exclusive.

Put a different way, I work pretty much all nights by choice; with the choice being able to call the ball & dictate my schedule - this allows me to prioritize my days off & not miss much.

Plus, on the occasion when I have to work a day or swing, it gets done with appropriate circadian influence because of my nights - e.g. preferential treatment.

I think the bigger issue, unfortunately, is that EP's will always miss out on *something* - but having a strategy ab initio is essential.

-d

 

[Birdstrike]

On that note, there's no end to the physician-, and particularly BC/BE ED physician-shortage, in sight:

"A report issued in March 2015 by the Association of American Medical Colleges concluded that the “demand for physicians continues to grow faster than supply, leading to a projected shortfall of between 46,100 and 90,400 physicians by 2025.”

http://content.medjobnetwork.com/2015/03/09/new-physician-compensation-trend/


“It’s a buyer’s market for emergency medicine physicians..."

http://www.mephealth.com/the-shift/...et-shortage-creates-new-challenges-em-groups/


"Emergency medicine, most in demand specialty: 3 jobs per candidate"

http://www.practicelink.com/magazin...ong-the-most-in-demand-physician-specialties/



Good news-That bodes well for EP job security and higher demand should have a positive effect on salary.

Bad news-There could be increasing pressure to work over your "redline" regardless of scheduling model, since current staffing models target patient wait times, not physician hours totals as physicians themselves see appropriate (ie, staffing must be increased to meet patient volume at fixed wait-time goals, and therefore physician staffing must be increased beyond max hours requested due to shortage).

Good news-If you leverage that demand for your services you can use it to get higher pay in areas where shortages are most severe.

Know reality. Manage it well.

 

[Hercules]

I've done the circadian rhythm and I didn't find it that restful. It was disruptive to everything else I wanted to do.

I also find that doing 12s overnight is easier than 8s, so maybe it's just me.

I've had a colleague who felt the same with their circadian schedule. I guess it depends on what rests/rejuvenates you. I'm part of a group that has a request driven approach to scheduling and it works for us.

As for your 12s being easier than 8s I'll have to chock that up to insanity. I've worked 12s and 8s and 8s win every time even at the expense of having more shifts to cover per month.

 

[Arcan57]

I've done the circadian rhythm and I didn't find it that restful. It was disruptive to everything else I wanted to do.

I also find that doing 12s overnight is easier than 8s, so maybe it's just me.

I wonder if you committed to keeping a circadian schedule and treated the time you have to spend sleeping as part of your shift if it would have been more restful. That being said I have no idea how I would do that in my own life.

In terms of overnights, I find that absolute length of shift is far less important than what the ED volume is doing in the hours before you end. A 12hr shift where the volume hasn't started picking up yet isn't bad. A 10hr shift (haven't worked 8s since residency) where 8 check in in the last two hours can be brutal. Especially since there are always one or two that seem like quick in and out but when you take the history you realize they're actually ticking time bombs.

 

[deleted6669]

I've done the circadian rhythm and I didn't find it that restful. It was disruptive to everything else I wanted to do.

I also find that doing 12s overnight is easier than 8s, so maybe it's just me.

I agree with this. 12s are easier than 8s and all nights is easier than block of days/block of swings/block of nights/repeat.
I do all 12 hr nights at my primary job, which also allows for fewer days worked/mo vs many of my colleagues who like the 8 and 9 hr days and swings.

 

[two guys]

It's nice to see this discussed. I've worked 8s, 10s, 12's, 100hrs/month and 200hrs/month. Extremes of any of these can still feel rough. It does depend on volume, shop culture and how the shifts are scheduled.

I think the OP is talking specifically to the last one, how the shifts are scheduled. To me, it seems the most important and most ignored of the other factors (shift length, hours and shift distribution). I can work 160hrs/month and feel about the same as 140 if I'm scheduled well. Everybody has a different balance. For me the nightmare month would be working every other day flipping back days to nights. I want to work 2-4 shifts in a row and have them be either the same shift or a slight circadian.

Ideal month 140 hrs:
6a-4p, 8a-6p, 8a-6p, 11a-9p, then off for a few days
then
5p-3a, 9p-6a, 9p-6a, 9p-6a then off for a few days
then
3p-1a, 3p-1a, 5p-3a, 5p-3a, then off a few days
then
6a4p, 11a-9p then done

Nightmare month 140 hrs
6a-4p, 9p-6a off 24 hrs, 8a-6p, 5p-3a then off a few days
then
8a-6p then off a day then 9p-6a then off a few days
then
3p-1a then off a day then 11a-9p then off a few days
then
9p-6a then off a few days
then
6a-4p, 5p-3a then off a few days
then
3p-1a off a day, 3p-1a off a day, 11a-9p

They're both 140 hrs, have no long string of shifts or nights, and technically the same number of days off but there is a vast difference in my quality time with schedule #2. I guess this is "shift efficiency". I could work 12's are even an extra 2 shifts if my shifts were more efficient.

 

[The White Coat Investor]

Any month with 140 hours is a nightmare month by definition in my book. Whenever I see someone working that much I think to myself, "What, he can't live on $3-400K?" I'm at 120 and very seriously considering going to less than 100 in the next year or two.

 

[Hercules]

Any month with 140 hours is a nightmare month by definition in my book. Whenever I see someone working that much I think to myself, "What, he can't live on $3-400K?" I'm at 120 and very seriously considering going to less than 100 in the next year or two.

Agree completely. Full time in our group is 12 shifts and ~105 hrs/month. We're all pretty happy.

 

[Birdstrike]

Agree completely. Full time in our group is 12 shifts and ~105 hrs/month. We're all pretty happy.

I spent way too many years at a place that routinely required you to work 140-190 hr per month, depending on volume and staffing, or more accurately lack thereof, while the mantra "we're just a couple docs from being fully staffed" was repeated ad infinitum. Just as soon as you'd get a couple people signed up during the recruiting cycle, a 2 or 3 more would quit due to burnout and volume would bump up a few percent. The pay was not even very good, but the location was. Don't make this same mistake.

 

[two guys]

Lets try and think beyond just hours/month. It's simplistic and doesn't really capture whats happening to us with different schedules. No one's promoting 140hrs /month here. I work well less than that (although I have worked much more). I used it for my example because it seems much more common than 120 in my area and I thought it would illustrate my point about schedule efficiency better. The hours matter, but 120 can still be brutal if scheduled poorly or 130 can feel like a cakewalk if scheduled well.

Go tell a stranger that you work 100-140 hrs/month and they think that sounds awesome (and it usually is). They think you're talking about 9-5 Monday to Thursday. Compare that to working 30 minutes every 2.5 hours straight for 28 days without a break. Its the same hours but a much different lifestyle.

 

[Arcan57]

I spent way too many years at a place that routinely required you to work 140-190 hr per month, depending on volume and staffing, or more accurately lack thereof, while the mantra "we're just a couple docs from being fully staffed" was repeated ad infinitum. Just as soon as you'd get a couple people signed up during the recruiting cycle, a 2 or 3 more would quit due to burnout and volume would bump up a few percent. The pay was not even very good, but the location was. Don't make this same mistake.

This is so true it's not even funny.

 

[The White Coat Investor]

Lets try and think beyond just hours/month. It's simplistic and doesn't really capture whats happening to us with different schedules. No one's promoting 140hrs /month here. I work well less than that (although I have worked much more). I used it for my example because it seems much more common than 120 in my area and I thought it would illustrate my point about schedule efficiency better. The hours matter, but 120 can still be brutal if scheduled poorly or 130 can feel like a cakewalk if scheduled well.

Go tell a stranger that you work 100-140 hrs/month and they think that sounds awesome (and it usually is). They think you're talking about 9-5 Monday to Thursday. Compare that to working 30 minutes every 2.5 hours straight for 28 days without a break. Its the same hours but a much different lifestyle.

I agree with you but I'm one of those guys that wants the days off that I want off, even if my schedule sucks. I routinely make 5-10 requests a month, so of course my schedule sucks most of the time. Most of the group is the same way, but very few of us actually work all the shifts like I do. The day guys just don't care if it's a couple of day shifts than a couple of evening shifts then a few days off before a couple more day shifts. There just isn't that much sleep disruption when you're never working after midnight.

 

[jendc08]

I want to work at whitecoats ed!

 

[Old_Mil]

You know, there's probably some way to come up with a formula that will objectively allow you to rank an Emergency Medicine practice. It will be hard to fit things like "scheduling" into the mix; our group right now has a scheduler and a couple of others who like days off in a row so those of us who stick around town often find ourselves in the unpleasant situation of 9 or more shifts crammed into two weeks.

But you could take my:

Annual Volume / (365 x Daily Coverage Hours) = Patients Per Hour ... leave it at that if you're interested in pace, or then divide Hourly Rate / PPH to get dollars per patient as well.

 

[Birdstrike]

I want to work at whitecoats ed!

Lol. Me too. With a nationwide BC/BE EP shortage, overstaffed or fully-staffed EDs like his are and likely will remain the exception to the norm, which is: The chronically understaffed ED.

 

[deleted77919]

…

 

[Hercules]

A bump to discuss scheduling...

I find this by far the most painful part of my current practice. My group definitely prioritizes days off and we all end up with wacky (crappy) schedules.

We do not have a limit on the number of schedule requests. I feel this leads us to a tragedy of the commons problem whereby everyone can improve their schedule by making more requests at the expense of making everyone else's schedule worse.

Do your groups have a limit on the number of schedule requests you can make per month?

You absolutely have to have a group agreed upon limit to scheduling requests. Otherwise you are simply penalizing the people who don't make requests. It makes the whole groups schedule revolve around a few doctors who make a ridiculous number of requests. You can make that limit an annual or a monthly one (or a combination of the two).

We have 8 docs, work 14 8 hr shifts per month and we have a limit of 8 high priority requests per month (we use shiftadmin and it breaks it out into high priority, medium, and low). You can decide as a group what value you place on high vs med vs low vs crazy circadian rhythm.


Sent from my iPhone using SDN mobile