Managing Your Practice

Whether your hospitalist group has five or 500 practitioners, you and your partners might be thinking about whether you want—or need—to enter into a merger or acquisition in the near future. For some hospitalist groups, mergers and acquisitions could be part of a growth strategy designed to increase geographic footprint, market penetration, or bargaining power. These types of transactions will allow larger groups to increase their competitiveness by being able to leverage investments in such items as information technology upgrades across a larger base of business.

For others, a desire to retire or an inability to either afford or justify certain capital investments needed to remain competitive might be leading some players to consider selling their hospitalist groups. Moreover, changes in the healthcare industry, coupled with the anticipation of tax increases, could factor into decisions to sell practices in the relatively near term.

While each transaction is unique, most tend to follow a similar process, incorporating a number of relatively standard phases that must be undertaken in order to complete a transaction. The transaction process typically takes between three and nine months, although preparations are often best begun in advance of the actual deal process.

Preliminary Matters

For hospitalist group owners and executives considering selling their practice, a number of preliminary matters should be addressed in preparation for a sale. First, potential sellers should carefully consider whether they really wish to enter into the sale process. The sale process is lengthy, time-consuming, and costly, and it is often stressful and demanding on the practice’s management. Thus, potential sellers should not undertake the process unless they are serious about selling and have a realistic expectation of what they will receive as the purchase price.

As part of the preparation, sellers should begin by assembling an experienced transaction team. Typically, the team includes key members of the practice’s management, as well as experienced healthcare mergers and acquisitions attorneys and accountants. These experienced professionals can be of great assistance in making sure that a transaction is executed on a timely basis and under terms appropriate for the specific transaction.

Another prudent step is undertaking a tax analysis to determine the implications of the sale on both the selling practice and its individual owners. This analysis should be performed as far in advance of a proposed transaction as possible, in order to allow time for adjustments to be made (if necessary) to limit the tax implications in advance of the sale. Sellers also will want to use this preparatory phase to make sure that the practice’s books and records are in good order in preparation for the buyer’s due diligence review, as well as to address any issues in order to make the practice more attractive to potential buyers. Some sellers might want to have an investment banker or other qualified professional provide a valuation appraisal of the practice to provide a realistic purchase price.

Finding a Buyer

As a seller begins the process to find a buyer, the seller must first consider the approach that it wants to take. Some larger groups are sold through auction-like processes in which a number of bidders are contacted and invited to participate. The advantage of this type of process is that it typically drives prices higher by introducing competition into the bidding process. On the other hand, this type of process has certain disadvantages, such as a longer time frame and increased risk of a breach of confidentiality.

For some sellers, a more targeted approach, with limited participants, might be more desirable. If a fair purchase price can be obtained without involving multiple potential buyers, the process can be completed faster and with less risk to the ongoing business operations.

The process of finding a buyer typically requires the seller to provide potential buyers with confidential information regarding the business so the interested parties can evaluate whether the selling group is even of interest and the amount that they will be willing to pay. However, the selling practice should only provide this confidential information after potential buyers have signed nondisclosure agreements.

Ultimately, the process will lead to the submission of specific proposals from interested parties. Typically, this results in the seller and the selected buyer entering into a letter of intent, a statement of key terms for the proposed transaction. Letters of intent are largely not binding and are subject to the satisfaction of conditions, such as the negotiation of definitive written agreements. Typically, in this phase of the process, the basic structure of the transaction, the purchase price, and the manner of payment are determined.

Due Diligence

In almost all sale transactions, the buyer will conduct a review and investigation of the seller’s business. The purpose of this review is to confirm the information previously provided by the seller and to allow the buyer to gain a thorough understanding of the business to determine whether it is truly willing to buy the business on the terms identified in the letter of intent. The buyer will want to confirm that it is not going to inherit any unexpected liabilities or problems, such as healthcare regulatory issues or lawsuits. To comply with the information requests from the buyer as it conducts its due diligence review, the seller will be required to assemble many documents and voluminous amounts of financial and other information. The burden of providing this information to the buyer will be substantial and could distract management from their day-to-day duties of running the practice.

Upon completion of the due diligence process, the buyer will either confirm that it is willing to move forward with the transaction “as is,” or, if the due diligence review reveals troubling information, the buyer can either demand changes to the transaction (such as a reduction of the purchase price) or be unwilling to proceed with the transaction altogether.

Negotiating Definitive Agreements

The parties will need to negotiate and agree on certain definitive written agreements, which will govern the transaction. First and foremost, this will include a purchase agreement, such as a stock purchase agreement or an asset purchase agreement. In addition, there may also be various ancillary agreements, such as noncompetition agreements between the buyer and the owners of the selling practice and new employment agreements for the sellers.

Typically, the negotiation of definitive agreements proceeds in parallel with the buyer’s due diligence review.

Closing

At the closing, both sides will sign numerous documents, including those necessary to transfer ownership of the purchased group to the buyer, as well as all ancillary agreements and other documents needed for the transaction. Once signatures have been obtained and exchanged between the parties, the transfer of title will occur and the buyer will tender the purchase price.

Post-Closing

Although the vast majority of the work associated with the transaction will terminate upon the completion of the closing, certain aspects of the sale will require some attention after the closing. For example, there may be purchase price adjustments based upon the final balance sheet or net working capital position of the seller’s business as of the closing date. Typically, these adjustments are addressed in the months following the closing. Also, if any indemnification claims are brought, the parties will need to address those claims and reach a resolution.

Merger and acquisition transactions are complex, time-consuming matters that require a great deal of effort on the part of all parties involved. An orderly process is essential for both buyers and sellers. Sellers will want to take steps to make sure that the transaction is completed in a timely manner while minimizing risk to the ongoing business operations. At the same time, buyers will want to make sure that the value that they are receiving from the seller’s business is commensurate with the purchase price and that the buyer’s goals for entering into the sale will truly be met post-closing.

Steven M. Harris, Esq., is a nationally recognized healthcare attorney and a member of the law firm McDonald Hopkins LLC in Chicago. Write to him at [email protected].

Whether your hospitalist group has five or 500 practitioners, you and your partners might be thinking about whether you want—or need—to enter into a merger or acquisition in the near future. For some hospitalist groups, mergers and acquisitions could be part of a growth strategy designed to increase geographic footprint, market penetration, or bargaining power. These types of transactions will allow larger groups to increase their competitiveness by being able to leverage investments in such items as information technology upgrades across a larger base of business.

For others, a desire to retire or an inability to either afford or justify certain capital investments needed to remain competitive might be leading some players to consider selling their hospitalist groups. Moreover, changes in the healthcare industry, coupled with the anticipation of tax increases, could factor into decisions to sell practices in the relatively near term.

While each transaction is unique, most tend to follow a similar process, incorporating a number of relatively standard phases that must be undertaken in order to complete a transaction. The transaction process typically takes between three and nine months, although preparations are often best begun in advance of the actual deal process.

Preliminary Matters

For hospitalist group owners and executives considering selling their practice, a number of preliminary matters should be addressed in preparation for a sale. First, potential sellers should carefully consider whether they really wish to enter into the sale process. The sale process is lengthy, time-consuming, and costly, and it is often stressful and demanding on the practice’s management. Thus, potential sellers should not undertake the process unless they are serious about selling and have a realistic expectation of what they will receive as the purchase price.

As part of the preparation, sellers should begin by assembling an experienced transaction team. Typically, the team includes key members of the practice’s management, as well as experienced healthcare mergers and acquisitions attorneys and accountants. These experienced professionals can be of great assistance in making sure that a transaction is executed on a timely basis and under terms appropriate for the specific transaction.

Another prudent step is undertaking a tax analysis to determine the implications of the sale on both the selling practice and its individual owners. This analysis should be performed as far in advance of a proposed transaction as possible, in order to allow time for adjustments to be made (if necessary) to limit the tax implications in advance of the sale. Sellers also will want to use this preparatory phase to make sure that the practice’s books and records are in good order in preparation for the buyer’s due diligence review, as well as to address any issues in order to make the practice more attractive to potential buyers. Some sellers might want to have an investment banker or other qualified professional provide a valuation appraisal of the practice to provide a realistic purchase price.

Finding a Buyer

As a seller begins the process to find a buyer, the seller must first consider the approach that it wants to take. Some larger groups are sold through auction-like processes in which a number of bidders are contacted and invited to participate. The advantage of this type of process is that it typically drives prices higher by introducing competition into the bidding process. On the other hand, this type of process has certain disadvantages, such as a longer time frame and increased risk of a breach of confidentiality.

For some sellers, a more targeted approach, with limited participants, might be more desirable. If a fair purchase price can be obtained without involving multiple potential buyers, the process can be completed faster and with less risk to the ongoing business operations.

The process of finding a buyer typically requires the seller to provide potential buyers with confidential information regarding the business so the interested parties can evaluate whether the selling group is even of interest and the amount that they will be willing to pay. However, the selling practice should only provide this confidential information after potential buyers have signed nondisclosure agreements.

Ultimately, the process will lead to the submission of specific proposals from interested parties. Typically, this results in the seller and the selected buyer entering into a letter of intent, a statement of key terms for the proposed transaction. Letters of intent are largely not binding and are subject to the satisfaction of conditions, such as the negotiation of definitive written agreements. Typically, in this phase of the process, the basic structure of the transaction, the purchase price, and the manner of payment are determined.

Due Diligence

In almost all sale transactions, the buyer will conduct a review and investigation of the seller’s business. The purpose of this review is to confirm the information previously provided by the seller and to allow the buyer to gain a thorough understanding of the business to determine whether it is truly willing to buy the business on the terms identified in the letter of intent. The buyer will want to confirm that it is not going to inherit any unexpected liabilities or problems, such as healthcare regulatory issues or lawsuits. To comply with the information requests from the buyer as it conducts its due diligence review, the seller will be required to assemble many documents and voluminous amounts of financial and other information. The burden of providing this information to the buyer will be substantial and could distract management from their day-to-day duties of running the practice.

Upon completion of the due diligence process, the buyer will either confirm that it is willing to move forward with the transaction “as is,” or, if the due diligence review reveals troubling information, the buyer can either demand changes to the transaction (such as a reduction of the purchase price) or be unwilling to proceed with the transaction altogether.

Negotiating Definitive Agreements

The parties will need to negotiate and agree on certain definitive written agreements, which will govern the transaction. First and foremost, this will include a purchase agreement, such as a stock purchase agreement or an asset purchase agreement. In addition, there may also be various ancillary agreements, such as noncompetition agreements between the buyer and the owners of the selling practice and new employment agreements for the sellers.

Typically, the negotiation of definitive agreements proceeds in parallel with the buyer’s due diligence review.

Closing

At the closing, both sides will sign numerous documents, including those necessary to transfer ownership of the purchased group to the buyer, as well as all ancillary agreements and other documents needed for the transaction. Once signatures have been obtained and exchanged between the parties, the transfer of title will occur and the buyer will tender the purchase price.

Post-Closing

Although the vast majority of the work associated with the transaction will terminate upon the completion of the closing, certain aspects of the sale will require some attention after the closing. For example, there may be purchase price adjustments based upon the final balance sheet or net working capital position of the seller’s business as of the closing date. Typically, these adjustments are addressed in the months following the closing. Also, if any indemnification claims are brought, the parties will need to address those claims and reach a resolution.

Merger and acquisition transactions are complex, time-consuming matters that require a great deal of effort on the part of all parties involved. An orderly process is essential for both buyers and sellers. Sellers will want to take steps to make sure that the transaction is completed in a timely manner while minimizing risk to the ongoing business operations. At the same time, buyers will want to make sure that the value that they are receiving from the seller’s business is commensurate with the purchase price and that the buyer’s goals for entering into the sale will truly be met post-closing.

Steven M. Harris, Esq., is a nationally recognized healthcare attorney and a member of the law firm McDonald Hopkins LLC in Chicago. Write to him at [email protected].

Whether your hospitalist group has five or 500 practitioners, you and your partners might be thinking about whether you want—or need—to enter into a merger or acquisition in the near future. For some hospitalist groups, mergers and acquisitions could be part of a growth strategy designed to increase geographic footprint, market penetration, or bargaining power. These types of transactions will allow larger groups to increase their competitiveness by being able to leverage investments in such items as information technology upgrades across a larger base of business.

For others, a desire to retire or an inability to either afford or justify certain capital investments needed to remain competitive might be leading some players to consider selling their hospitalist groups. Moreover, changes in the healthcare industry, coupled with the anticipation of tax increases, could factor into decisions to sell practices in the relatively near term.

While each transaction is unique, most tend to follow a similar process, incorporating a number of relatively standard phases that must be undertaken in order to complete a transaction. The transaction process typically takes between three and nine months, although preparations are often best begun in advance of the actual deal process.

Preliminary Matters

For hospitalist group owners and executives considering selling their practice, a number of preliminary matters should be addressed in preparation for a sale. First, potential sellers should carefully consider whether they really wish to enter into the sale process. The sale process is lengthy, time-consuming, and costly, and it is often stressful and demanding on the practice’s management. Thus, potential sellers should not undertake the process unless they are serious about selling and have a realistic expectation of what they will receive as the purchase price.

As part of the preparation, sellers should begin by assembling an experienced transaction team. Typically, the team includes key members of the practice’s management, as well as experienced healthcare mergers and acquisitions attorneys and accountants. These experienced professionals can be of great assistance in making sure that a transaction is executed on a timely basis and under terms appropriate for the specific transaction.

Another prudent step is undertaking a tax analysis to determine the implications of the sale on both the selling practice and its individual owners. This analysis should be performed as far in advance of a proposed transaction as possible, in order to allow time for adjustments to be made (if necessary) to limit the tax implications in advance of the sale. Sellers also will want to use this preparatory phase to make sure that the practice’s books and records are in good order in preparation for the buyer’s due diligence review, as well as to address any issues in order to make the practice more attractive to potential buyers. Some sellers might want to have an investment banker or other qualified professional provide a valuation appraisal of the practice to provide a realistic purchase price.

Finding a Buyer

As a seller begins the process to find a buyer, the seller must first consider the approach that it wants to take. Some larger groups are sold through auction-like processes in which a number of bidders are contacted and invited to participate. The advantage of this type of process is that it typically drives prices higher by introducing competition into the bidding process. On the other hand, this type of process has certain disadvantages, such as a longer time frame and increased risk of a breach of confidentiality.

For some sellers, a more targeted approach, with limited participants, might be more desirable. If a fair purchase price can be obtained without involving multiple potential buyers, the process can be completed faster and with less risk to the ongoing business operations.

The process of finding a buyer typically requires the seller to provide potential buyers with confidential information regarding the business so the interested parties can evaluate whether the selling group is even of interest and the amount that they will be willing to pay. However, the selling practice should only provide this confidential information after potential buyers have signed nondisclosure agreements.

Ultimately, the process will lead to the submission of specific proposals from interested parties. Typically, this results in the seller and the selected buyer entering into a letter of intent, a statement of key terms for the proposed transaction. Letters of intent are largely not binding and are subject to the satisfaction of conditions, such as the negotiation of definitive written agreements. Typically, in this phase of the process, the basic structure of the transaction, the purchase price, and the manner of payment are determined.

Due Diligence

In almost all sale transactions, the buyer will conduct a review and investigation of the seller’s business. The purpose of this review is to confirm the information previously provided by the seller and to allow the buyer to gain a thorough understanding of the business to determine whether it is truly willing to buy the business on the terms identified in the letter of intent. The buyer will want to confirm that it is not going to inherit any unexpected liabilities or problems, such as healthcare regulatory issues or lawsuits. To comply with the information requests from the buyer as it conducts its due diligence review, the seller will be required to assemble many documents and voluminous amounts of financial and other information. The burden of providing this information to the buyer will be substantial and could distract management from their day-to-day duties of running the practice.

Upon completion of the due diligence process, the buyer will either confirm that it is willing to move forward with the transaction “as is,” or, if the due diligence review reveals troubling information, the buyer can either demand changes to the transaction (such as a reduction of the purchase price) or be unwilling to proceed with the transaction altogether.

Negotiating Definitive Agreements

The parties will need to negotiate and agree on certain definitive written agreements, which will govern the transaction. First and foremost, this will include a purchase agreement, such as a stock purchase agreement or an asset purchase agreement. In addition, there may also be various ancillary agreements, such as noncompetition agreements between the buyer and the owners of the selling practice and new employment agreements for the sellers.

Typically, the negotiation of definitive agreements proceeds in parallel with the buyer’s due diligence review.

Closing

At the closing, both sides will sign numerous documents, including those necessary to transfer ownership of the purchased group to the buyer, as well as all ancillary agreements and other documents needed for the transaction. Once signatures have been obtained and exchanged between the parties, the transfer of title will occur and the buyer will tender the purchase price.

Post-Closing

Although the vast majority of the work associated with the transaction will terminate upon the completion of the closing, certain aspects of the sale will require some attention after the closing. For example, there may be purchase price adjustments based upon the final balance sheet or net working capital position of the seller’s business as of the closing date. Typically, these adjustments are addressed in the months following the closing. Also, if any indemnification claims are brought, the parties will need to address those claims and reach a resolution.

Merger and acquisition transactions are complex, time-consuming matters that require a great deal of effort on the part of all parties involved. An orderly process is essential for both buyers and sellers. Sellers will want to take steps to make sure that the transaction is completed in a timely manner while minimizing risk to the ongoing business operations. At the same time, buyers will want to make sure that the value that they are receiving from the seller’s business is commensurate with the purchase price and that the buyer’s goals for entering into the sale will truly be met post-closing.

Steven M. Harris, Esq., is a nationally recognized healthcare attorney and a member of the law firm McDonald Hopkins LLC in Chicago. Write to him at [email protected].

Postpartum high BP; mother suffers brain damage

HOSPITALIZED TWICE FOR HYPERTENSION in the month before her child was born, a 41-year-old woman gave birth to a healthy baby by cesarean delivery. The mother was discharged 2 days later with a blood pressure (BP) of 130/90 mm Hg.

Three days later, she went to her ObGyn’s office because she was not feeling well and had extreme swelling. Her BP, taken twice by a nurse, read 170/88 mm Hg, and 168/90 mm Hg, but she was not examined by the ObGyn.

That evening, the patient had difficulty breathing and was taken to the emergency department (ED), where she was intubated. She went into cardiac arrest and suffered permanent brain damage after being without a pulse for 15 minutes. She was in a coma for 45 days. She is unable to walk without assistance, is legally blind, and her hands are so contorted that she cannot feed herself. She suffers from short-term memory loss and has difficulty speaking.

PATIENT’S CLAIM The ObGyn should have examined her when she was at the office. Her hypertension would have been properly treated and injuries avoided. She had classic signs of postpartum cardiomyopathy.

PHYSICIAN’S DEFENSE The patient had not come to the office because she was feeling ill, but to show off her baby and have her BP checked. If he had been advised of the BP readings, he would have examined her.

VERDICT A $5 million Georgia verdict was returned.

Cervical biopsy results improperly reported

A 44-YEAR-OLD WOMAN UNDERWENT a cervical biopsy in July 2007 performed by a pathologist. A few days later, the pathologist contacted the patient and reported that the biopsy revealed invasive cervical cancer that required immediate surgery. Several procedures were performed without any cancer ever being found.

A second opinion was sought, and it was determined that the cancer diagnosis was incorrect; another patient’s pathology had been reported as the patient’s.

PATIENT’S CLAIM The pathologist and hospital were negligent in reporting incorrect results of the cervical biopsy, which resulted in the patient’s physical and emotional injuries, including unnecessary surgical procedures and depression and anxiety.

DEFENDANTS’ DEFENSE The defendants did not oppose the patient’s motion for summary judgment on liability; the issue of damages was contested.

VERDICT The patient received summary judgment on liability. She then discontinued claims against the pathologist, and the matter proceeded on damages against the hospital. A $46,000 New York verdict was returned. Stipulated medical expenses were added to the verdict for a total recovery of $60,979.

Brachial plexus injury: child has significant functional disability

AT 38 6/7 WEEKS’ GESTATION, a 23-year-old woman went to the ED with contractions. She had pregestational diabetes mellitus. Her admitting glucose level was 143 mg/dL, and she had gained 25 lb during pregnancy. Her fundal height was 40 cm, and estimated fetal weight was 4000 g (8 lb 13 oz). A pelvic examination determined that she was 3 to 4 cm dilated, 100% effaced, and at minus-1 station. She was given oxytocin to aid labor. The ObGyn noted that overall fetal heart-rate tracings were reassuring, and that a pediatrician would be present for delivery due to suspected macrosomia. Shoulder dystocia occurred during delivery, but it was resolved in 40 seconds. The mother sustained a second-degree perineal laceration.

At birth, the baby’s left arm was limp. Apgar scores were 5 and 9 at 1 and 5 minutes, respectively. Her birth weight was 10 lb 2 oz. A brachial plexus injury was diagnosed, and she underwent surgery in October 2008. Despite successful nerve grafts at C5 and C6, the child has significant functional disability in the left arm.

PARENTS’ CLAIM A cesarean delivery should have been scheduled when a macrosomic fetus was suspected.

PHYSICIAN’S DEFENSE The case was settled during trial.

VERDICT A $1,475,000 Maryland settlement was reached.

Breech position and umbilical cord prolapse: Was everything done that could be done?

DURING A MOTHER’S 38-WEEK PRENATAL VISIT, ultrasonography showed the baby was in breech position. The midwife offered two options: to schedule an external cephalic version procedure at 38 weeks or a cesarean delivery at 39 weeks. The parents agreed to schedule a cesarean delivery for 8 days later. The day before the scheduled birth, the mother awoke to find the umbilical cord between her legs. An emergency cesarean delivery was performed. The newborn required resuscitation and mechanical ventilation and suffered permanent brain damage attributed to hypoxia from umbilical cord prolapse.

PARENTS’ CLAIM The midwife’s negligence caused the baby’s injuries. Breech presentation put the pregnancy at high-risk. She did not have a physician examine the patient before scheduling a cesarean delivery and did not attempt to rotate the child back to a head-first position. She did not warn the parents about the risks of breech presentation and umbilical cord prolapse.

DEFENDANTS’ DEFENSE The choices given the parents were reasonable. Scheduling a cesarean delivery at 39 weeks was proper. A prolapsed cord is not predictable or preventable.

VERDICT A $12.6 million Pennsylvania verdict was returned against the midwife and the hospital; a confidential high/low agreement was reached.

Extensive adhesions result in bowel injury

A 58-YEAR-OLD WOMAN UNDERWENT exploratory laparotomy in May 2009. There were extensive adhesions, and the gynecologist used blind, blunt dissection to resect a large pelvic mass adhered to the sidewall. He had difficulty removing the specimen because it was too large to fit through the incision. A left salpingo-oophorectomy was also performed.

On the second postoperative day, the patient reported shortness of breath, intermittent chest pain, and had a fever of 103° F. The next day, she was unable to ambulate due to shortness of breath. CT results ruled out deep vein thrombosis or pulmonary embolism but revealed significantly decreased lung volume. She continued to experience shortness of breath and temperature spikes for 3 more days. She was discharged on the seventh postoperative day despite shortness of breath.

Two days later, she experienced severe abdominal pain and shortness of breath at home and returned to the ED by ambulance. A CT scan revealed free pelvic air, ascites, and extensive inflammatory changes, likely due to bowel perforation. She was intubated and airlifted to a regional trauma center. During exploratory surgery, the surgeon aspirated a foul-smelling fluid and identified a perforation at the rectosigmoid junction; a colostomy was created. The patient stayed in intensive care for 5 days, developed renal failure, and was transfused due to acute blood loss. She was hospitalized for 19 days. The colostomy was reversed in October 2009.

PATIENT’S CLAIM The ObGyn was negligent in injuring the bowel during surgery and in not recognizing the bowel injury and treating it in a timely manner.

PHYSICIAN’S DEFENSE The case was settled during the trial.

VERDICT A $600,000 Virginia settlement was reached.

Pregnant woman stabbed: mother and baby die

A 20-YEAR-OLD WOMAN AT 30 WEEKS’ gestation was treated in the ED for a stab wound to the shoulder. The emergency medicine (EM) physician noted internal bleeding and a possible collapsed lung on radiographs, and began efforts to have the woman transferred. One facility declined because of her pregnancy. The patient was in pain and her ability to breathe declined. An airlift was finally arranged, but she suffered cardiac arrest as the helicopter arrived. A cesarean delivery was performed, but both the mother and baby died.

ESTATE’S CLAIM The EM physician was negligent in failing to perform a thoracotomy and arrange for a more timely transfer. The physician didn’t contact a hospital that was only 8 miles away.

DEFENDANTS’ DEFENSE The federal government, which operated the facility, admitted fault.

VERDICT A $7,267,390 Mississippi verdict included $5.45 million in noneconomic damages.

What caused child’s brain damage?

DURING LABOR AND DELIVERY, electronic fetal heart-rate monitoring indicated fetal distress. Meconium-stained fluid was present. The child was born with brain damage. It is unlikely that he will walk independently, talk in full sentences, or be able to perform daily activities independently.

PARENTS’ CLAIM The fetal heart-rate monitor indicated a need for emergency cesarean delivery. The quality and quantity of meconium should have alerted the caregivers to fetal distress and caused them to perform a cesarean delivery.

DEFENDANTS’ DEFENSE Fetal heart-rate strips did not indicate a need for emergency delivery until shortly before the delivery occurred. The underlying cause of the child’s injuries was an infection that spread to the brain and was irreversible.

VERDICT A $1.71 million Massachusetts verdict was returned.

When did bladder injury occur?

AN 84-YEAR-OLD WOMAN suffered recurrent bladder cancer. She underwent a cystoscopy, and then chemotherapy. Several weeks later, she was diagnosed with a bladder perforation became septic, and died.

ESTATE’S CLAIM The bladder was lacerated during cystoscopy; she would have survived if the laceration had been treated in a timely manner.

PHYSICIAN’S DEFENSE Bladder perforation during cystoscopy is a known risk of the procedure. However, the bladder was not perforated during cystoscopy; chemotherapy may have caused the perforation.

VERDICT A Michigan defense verdict was returned.

Fetal tracings poor: Why wasn’t an internal lead used?

AT 32 WEEKS’ GESTATION, a woman’s membranes ruptured, and she was admitted. Her ObGyn planned to induce labor at 34 weeks’ gestation. She experienced contractions on the morning of the scheduled induction. Although fetal heart-rate monitoring was reassuring, the fetus was in a compound position, with the chin leading. Labor progressed rapidly to 6-cm dilation. The fetal heart rate began to show recurrent mild variable decelerations that became increasingly deeper. Although the technical quality of the external monitoring was poor, no internal lead was applied.

After 3 hours, the tracing showed severe variable decelerations. The mother was fully dilated and began to push. The tracings were of poor quality, but interpretable portions showed minimal variability and significant decelerations during contractions. The fetal baseline heart rate became tachycardic. The obstetric nurse and resident continued to note abnormalities, but there is no evidence that they called the attending ObGyn. The fetal baseline heart rate reached 190 bpm with ongoing decelerations associated with contractions. Variability remained minimal to absent. After 2 hours of pushing, meconium-stained fluid was noted. The infant was born 1 hour later. The attending ObGyn was present for the last 30 minutes of labor.

The newborn’s Apgar scores were 1, 5, and 7, at 1, 5, and 10 minutes, respectively. His arterial cord pH was significantly low. MRI of the head showed subdural and intraventricular hemorrhage and evolving, profound hypoxic ischemic injury. At 1 year of age, the child suffers from a seizure disorder, cortical blindness, and severe developmental delays.

PARENTS’ CLAIM The nurse and resident failed to respond to fetal heart-rate abnormalities and failed to insert an internal lead to obtain better quality heart-rate tracings. They did not expedite delivery when fetal distress was evident.

DEFENDANTS’ DEFENSE The case was settled during trial.

VERDICT A $4.2 million Massachusetts settlement was reached.

Hypoxic ischemic encephalopathy

DUE TO PREECLAMPSIA, a woman was admitted to the hospital 5 weeks before her due date. Her condition was monitored for 2 weeks when it was decided to induce labor with oxytocin. After 3 hours in labor, the fetal heart-rate tracing began to show significant decelerations. The baby was born at 37 weeks’ gestation with severe hypoxic ischemic encephalopathy. The child died 2 years later from severe brain damage.

PARENTS’ CLAIM The ObGyns failed to respond to signs of fetal distress by performing an emergency cesarean. The brain images would have been different if a stroke-like event had occurred.

DEFENDANTS’ DEFENSE The fetus experienced an embolic process due to a compressed umbilical cord, resulting in a stroke-like vascular event, which led to the hypoxic ischemic encephalopathy.

VERDICT A $450,000 Wisconsin settlement was reached.

Postpartum high BP; mother suffers brain damage

HOSPITALIZED TWICE FOR HYPERTENSION in the month before her child was born, a 41-year-old woman gave birth to a healthy baby by cesarean delivery. The mother was discharged 2 days later with a blood pressure (BP) of 130/90 mm Hg.

Three days later, she went to her ObGyn’s office because she was not feeling well and had extreme swelling. Her BP, taken twice by a nurse, read 170/88 mm Hg, and 168/90 mm Hg, but she was not examined by the ObGyn.

That evening, the patient had difficulty breathing and was taken to the emergency department (ED), where she was intubated. She went into cardiac arrest and suffered permanent brain damage after being without a pulse for 15 minutes. She was in a coma for 45 days. She is unable to walk without assistance, is legally blind, and her hands are so contorted that she cannot feed herself. She suffers from short-term memory loss and has difficulty speaking.

PATIENT’S CLAIM The ObGyn should have examined her when she was at the office. Her hypertension would have been properly treated and injuries avoided. She had classic signs of postpartum cardiomyopathy.

PHYSICIAN’S DEFENSE The patient had not come to the office because she was feeling ill, but to show off her baby and have her BP checked. If he had been advised of the BP readings, he would have examined her.

VERDICT A $5 million Georgia verdict was returned.

Cervical biopsy results improperly reported

A 44-YEAR-OLD WOMAN UNDERWENT a cervical biopsy in July 2007 performed by a pathologist. A few days later, the pathologist contacted the patient and reported that the biopsy revealed invasive cervical cancer that required immediate surgery. Several procedures were performed without any cancer ever being found.

A second opinion was sought, and it was determined that the cancer diagnosis was incorrect; another patient’s pathology had been reported as the patient’s.

PATIENT’S CLAIM The pathologist and hospital were negligent in reporting incorrect results of the cervical biopsy, which resulted in the patient’s physical and emotional injuries, including unnecessary surgical procedures and depression and anxiety.

DEFENDANTS’ DEFENSE The defendants did not oppose the patient’s motion for summary judgment on liability; the issue of damages was contested.

VERDICT The patient received summary judgment on liability. She then discontinued claims against the pathologist, and the matter proceeded on damages against the hospital. A $46,000 New York verdict was returned. Stipulated medical expenses were added to the verdict for a total recovery of $60,979.

Brachial plexus injury: child has significant functional disability

AT 38 6/7 WEEKS’ GESTATION, a 23-year-old woman went to the ED with contractions. She had pregestational diabetes mellitus. Her admitting glucose level was 143 mg/dL, and she had gained 25 lb during pregnancy. Her fundal height was 40 cm, and estimated fetal weight was 4000 g (8 lb 13 oz). A pelvic examination determined that she was 3 to 4 cm dilated, 100% effaced, and at minus-1 station. She was given oxytocin to aid labor. The ObGyn noted that overall fetal heart-rate tracings were reassuring, and that a pediatrician would be present for delivery due to suspected macrosomia. Shoulder dystocia occurred during delivery, but it was resolved in 40 seconds. The mother sustained a second-degree perineal laceration.

At birth, the baby’s left arm was limp. Apgar scores were 5 and 9 at 1 and 5 minutes, respectively. Her birth weight was 10 lb 2 oz. A brachial plexus injury was diagnosed, and she underwent surgery in October 2008. Despite successful nerve grafts at C5 and C6, the child has significant functional disability in the left arm.

PARENTS’ CLAIM A cesarean delivery should have been scheduled when a macrosomic fetus was suspected.

PHYSICIAN’S DEFENSE The case was settled during trial.

VERDICT A $1,475,000 Maryland settlement was reached.

Breech position and umbilical cord prolapse: Was everything done that could be done?

DURING A MOTHER’S 38-WEEK PRENATAL VISIT, ultrasonography showed the baby was in breech position. The midwife offered two options: to schedule an external cephalic version procedure at 38 weeks or a cesarean delivery at 39 weeks. The parents agreed to schedule a cesarean delivery for 8 days later. The day before the scheduled birth, the mother awoke to find the umbilical cord between her legs. An emergency cesarean delivery was performed. The newborn required resuscitation and mechanical ventilation and suffered permanent brain damage attributed to hypoxia from umbilical cord prolapse.

PARENTS’ CLAIM The midwife’s negligence caused the baby’s injuries. Breech presentation put the pregnancy at high-risk. She did not have a physician examine the patient before scheduling a cesarean delivery and did not attempt to rotate the child back to a head-first position. She did not warn the parents about the risks of breech presentation and umbilical cord prolapse.

DEFENDANTS’ DEFENSE The choices given the parents were reasonable. Scheduling a cesarean delivery at 39 weeks was proper. A prolapsed cord is not predictable or preventable.

VERDICT A $12.6 million Pennsylvania verdict was returned against the midwife and the hospital; a confidential high/low agreement was reached.

Extensive adhesions result in bowel injury

A 58-YEAR-OLD WOMAN UNDERWENT exploratory laparotomy in May 2009. There were extensive adhesions, and the gynecologist used blind, blunt dissection to resect a large pelvic mass adhered to the sidewall. He had difficulty removing the specimen because it was too large to fit through the incision. A left salpingo-oophorectomy was also performed.

On the second postoperative day, the patient reported shortness of breath, intermittent chest pain, and had a fever of 103° F. The next day, she was unable to ambulate due to shortness of breath. CT results ruled out deep vein thrombosis or pulmonary embolism but revealed significantly decreased lung volume. She continued to experience shortness of breath and temperature spikes for 3 more days. She was discharged on the seventh postoperative day despite shortness of breath.

Two days later, she experienced severe abdominal pain and shortness of breath at home and returned to the ED by ambulance. A CT scan revealed free pelvic air, ascites, and extensive inflammatory changes, likely due to bowel perforation. She was intubated and airlifted to a regional trauma center. During exploratory surgery, the surgeon aspirated a foul-smelling fluid and identified a perforation at the rectosigmoid junction; a colostomy was created. The patient stayed in intensive care for 5 days, developed renal failure, and was transfused due to acute blood loss. She was hospitalized for 19 days. The colostomy was reversed in October 2009.

PATIENT’S CLAIM The ObGyn was negligent in injuring the bowel during surgery and in not recognizing the bowel injury and treating it in a timely manner.

PHYSICIAN’S DEFENSE The case was settled during the trial.

VERDICT A $600,000 Virginia settlement was reached.

Pregnant woman stabbed: mother and baby die

A 20-YEAR-OLD WOMAN AT 30 WEEKS’ gestation was treated in the ED for a stab wound to the shoulder. The emergency medicine (EM) physician noted internal bleeding and a possible collapsed lung on radiographs, and began efforts to have the woman transferred. One facility declined because of her pregnancy. The patient was in pain and her ability to breathe declined. An airlift was finally arranged, but she suffered cardiac arrest as the helicopter arrived. A cesarean delivery was performed, but both the mother and baby died.

ESTATE’S CLAIM The EM physician was negligent in failing to perform a thoracotomy and arrange for a more timely transfer. The physician didn’t contact a hospital that was only 8 miles away.

DEFENDANTS’ DEFENSE The federal government, which operated the facility, admitted fault.

VERDICT A $7,267,390 Mississippi verdict included $5.45 million in noneconomic damages.

What caused child’s brain damage?

DURING LABOR AND DELIVERY, electronic fetal heart-rate monitoring indicated fetal distress. Meconium-stained fluid was present. The child was born with brain damage. It is unlikely that he will walk independently, talk in full sentences, or be able to perform daily activities independently.

PARENTS’ CLAIM The fetal heart-rate monitor indicated a need for emergency cesarean delivery. The quality and quantity of meconium should have alerted the caregivers to fetal distress and caused them to perform a cesarean delivery.

DEFENDANTS’ DEFENSE Fetal heart-rate strips did not indicate a need for emergency delivery until shortly before the delivery occurred. The underlying cause of the child’s injuries was an infection that spread to the brain and was irreversible.

VERDICT A $1.71 million Massachusetts verdict was returned.

When did bladder injury occur?

AN 84-YEAR-OLD WOMAN suffered recurrent bladder cancer. She underwent a cystoscopy, and then chemotherapy. Several weeks later, she was diagnosed with a bladder perforation became septic, and died.

ESTATE’S CLAIM The bladder was lacerated during cystoscopy; she would have survived if the laceration had been treated in a timely manner.

PHYSICIAN’S DEFENSE Bladder perforation during cystoscopy is a known risk of the procedure. However, the bladder was not perforated during cystoscopy; chemotherapy may have caused the perforation.

VERDICT A Michigan defense verdict was returned.

Fetal tracings poor: Why wasn’t an internal lead used?

AT 32 WEEKS’ GESTATION, a woman’s membranes ruptured, and she was admitted. Her ObGyn planned to induce labor at 34 weeks’ gestation. She experienced contractions on the morning of the scheduled induction. Although fetal heart-rate monitoring was reassuring, the fetus was in a compound position, with the chin leading. Labor progressed rapidly to 6-cm dilation. The fetal heart rate began to show recurrent mild variable decelerations that became increasingly deeper. Although the technical quality of the external monitoring was poor, no internal lead was applied.

After 3 hours, the tracing showed severe variable decelerations. The mother was fully dilated and began to push. The tracings were of poor quality, but interpretable portions showed minimal variability and significant decelerations during contractions. The fetal baseline heart rate became tachycardic. The obstetric nurse and resident continued to note abnormalities, but there is no evidence that they called the attending ObGyn. The fetal baseline heart rate reached 190 bpm with ongoing decelerations associated with contractions. Variability remained minimal to absent. After 2 hours of pushing, meconium-stained fluid was noted. The infant was born 1 hour later. The attending ObGyn was present for the last 30 minutes of labor.

The newborn’s Apgar scores were 1, 5, and 7, at 1, 5, and 10 minutes, respectively. His arterial cord pH was significantly low. MRI of the head showed subdural and intraventricular hemorrhage and evolving, profound hypoxic ischemic injury. At 1 year of age, the child suffers from a seizure disorder, cortical blindness, and severe developmental delays.

PARENTS’ CLAIM The nurse and resident failed to respond to fetal heart-rate abnormalities and failed to insert an internal lead to obtain better quality heart-rate tracings. They did not expedite delivery when fetal distress was evident.

DEFENDANTS’ DEFENSE The case was settled during trial.

VERDICT A $4.2 million Massachusetts settlement was reached.

Hypoxic ischemic encephalopathy

DUE TO PREECLAMPSIA, a woman was admitted to the hospital 5 weeks before her due date. Her condition was monitored for 2 weeks when it was decided to induce labor with oxytocin. After 3 hours in labor, the fetal heart-rate tracing began to show significant decelerations. The baby was born at 37 weeks’ gestation with severe hypoxic ischemic encephalopathy. The child died 2 years later from severe brain damage.

PARENTS’ CLAIM The ObGyns failed to respond to signs of fetal distress by performing an emergency cesarean. The brain images would have been different if a stroke-like event had occurred.

DEFENDANTS’ DEFENSE The fetus experienced an embolic process due to a compressed umbilical cord, resulting in a stroke-like vascular event, which led to the hypoxic ischemic encephalopathy.

VERDICT A $450,000 Wisconsin settlement was reached.

Postpartum high BP; mother suffers brain damage

HOSPITALIZED TWICE FOR HYPERTENSION in the month before her child was born, a 41-year-old woman gave birth to a healthy baby by cesarean delivery. The mother was discharged 2 days later with a blood pressure (BP) of 130/90 mm Hg.

Three days later, she went to her ObGyn’s office because she was not feeling well and had extreme swelling. Her BP, taken twice by a nurse, read 170/88 mm Hg, and 168/90 mm Hg, but she was not examined by the ObGyn.

That evening, the patient had difficulty breathing and was taken to the emergency department (ED), where she was intubated. She went into cardiac arrest and suffered permanent brain damage after being without a pulse for 15 minutes. She was in a coma for 45 days. She is unable to walk without assistance, is legally blind, and her hands are so contorted that she cannot feed herself. She suffers from short-term memory loss and has difficulty speaking.

PATIENT’S CLAIM The ObGyn should have examined her when she was at the office. Her hypertension would have been properly treated and injuries avoided. She had classic signs of postpartum cardiomyopathy.

PHYSICIAN’S DEFENSE The patient had not come to the office because she was feeling ill, but to show off her baby and have her BP checked. If he had been advised of the BP readings, he would have examined her.

VERDICT A $5 million Georgia verdict was returned.

Cervical biopsy results improperly reported

A 44-YEAR-OLD WOMAN UNDERWENT a cervical biopsy in July 2007 performed by a pathologist. A few days later, the pathologist contacted the patient and reported that the biopsy revealed invasive cervical cancer that required immediate surgery. Several procedures were performed without any cancer ever being found.

A second opinion was sought, and it was determined that the cancer diagnosis was incorrect; another patient’s pathology had been reported as the patient’s.

PATIENT’S CLAIM The pathologist and hospital were negligent in reporting incorrect results of the cervical biopsy, which resulted in the patient’s physical and emotional injuries, including unnecessary surgical procedures and depression and anxiety.

DEFENDANTS’ DEFENSE The defendants did not oppose the patient’s motion for summary judgment on liability; the issue of damages was contested.

VERDICT The patient received summary judgment on liability. She then discontinued claims against the pathologist, and the matter proceeded on damages against the hospital. A $46,000 New York verdict was returned. Stipulated medical expenses were added to the verdict for a total recovery of $60,979.

Brachial plexus injury: child has significant functional disability

AT 38 6/7 WEEKS’ GESTATION, a 23-year-old woman went to the ED with contractions. She had pregestational diabetes mellitus. Her admitting glucose level was 143 mg/dL, and she had gained 25 lb during pregnancy. Her fundal height was 40 cm, and estimated fetal weight was 4000 g (8 lb 13 oz). A pelvic examination determined that she was 3 to 4 cm dilated, 100% effaced, and at minus-1 station. She was given oxytocin to aid labor. The ObGyn noted that overall fetal heart-rate tracings were reassuring, and that a pediatrician would be present for delivery due to suspected macrosomia. Shoulder dystocia occurred during delivery, but it was resolved in 40 seconds. The mother sustained a second-degree perineal laceration.

At birth, the baby’s left arm was limp. Apgar scores were 5 and 9 at 1 and 5 minutes, respectively. Her birth weight was 10 lb 2 oz. A brachial plexus injury was diagnosed, and she underwent surgery in October 2008. Despite successful nerve grafts at C5 and C6, the child has significant functional disability in the left arm.

PARENTS’ CLAIM A cesarean delivery should have been scheduled when a macrosomic fetus was suspected.

PHYSICIAN’S DEFENSE The case was settled during trial.

VERDICT A $1,475,000 Maryland settlement was reached.

Breech position and umbilical cord prolapse: Was everything done that could be done?

DURING A MOTHER’S 38-WEEK PRENATAL VISIT, ultrasonography showed the baby was in breech position. The midwife offered two options: to schedule an external cephalic version procedure at 38 weeks or a cesarean delivery at 39 weeks. The parents agreed to schedule a cesarean delivery for 8 days later. The day before the scheduled birth, the mother awoke to find the umbilical cord between her legs. An emergency cesarean delivery was performed. The newborn required resuscitation and mechanical ventilation and suffered permanent brain damage attributed to hypoxia from umbilical cord prolapse.

PARENTS’ CLAIM The midwife’s negligence caused the baby’s injuries. Breech presentation put the pregnancy at high-risk. She did not have a physician examine the patient before scheduling a cesarean delivery and did not attempt to rotate the child back to a head-first position. She did not warn the parents about the risks of breech presentation and umbilical cord prolapse.

DEFENDANTS’ DEFENSE The choices given the parents were reasonable. Scheduling a cesarean delivery at 39 weeks was proper. A prolapsed cord is not predictable or preventable.

VERDICT A $12.6 million Pennsylvania verdict was returned against the midwife and the hospital; a confidential high/low agreement was reached.

Extensive adhesions result in bowel injury

A 58-YEAR-OLD WOMAN UNDERWENT exploratory laparotomy in May 2009. There were extensive adhesions, and the gynecologist used blind, blunt dissection to resect a large pelvic mass adhered to the sidewall. He had difficulty removing the specimen because it was too large to fit through the incision. A left salpingo-oophorectomy was also performed.

On the second postoperative day, the patient reported shortness of breath, intermittent chest pain, and had a fever of 103° F. The next day, she was unable to ambulate due to shortness of breath. CT results ruled out deep vein thrombosis or pulmonary embolism but revealed significantly decreased lung volume. She continued to experience shortness of breath and temperature spikes for 3 more days. She was discharged on the seventh postoperative day despite shortness of breath.

Two days later, she experienced severe abdominal pain and shortness of breath at home and returned to the ED by ambulance. A CT scan revealed free pelvic air, ascites, and extensive inflammatory changes, likely due to bowel perforation. She was intubated and airlifted to a regional trauma center. During exploratory surgery, the surgeon aspirated a foul-smelling fluid and identified a perforation at the rectosigmoid junction; a colostomy was created. The patient stayed in intensive care for 5 days, developed renal failure, and was transfused due to acute blood loss. She was hospitalized for 19 days. The colostomy was reversed in October 2009.

PATIENT’S CLAIM The ObGyn was negligent in injuring the bowel during surgery and in not recognizing the bowel injury and treating it in a timely manner.

PHYSICIAN’S DEFENSE The case was settled during the trial.

VERDICT A $600,000 Virginia settlement was reached.

Pregnant woman stabbed: mother and baby die

A 20-YEAR-OLD WOMAN AT 30 WEEKS’ gestation was treated in the ED for a stab wound to the shoulder. The emergency medicine (EM) physician noted internal bleeding and a possible collapsed lung on radiographs, and began efforts to have the woman transferred. One facility declined because of her pregnancy. The patient was in pain and her ability to breathe declined. An airlift was finally arranged, but she suffered cardiac arrest as the helicopter arrived. A cesarean delivery was performed, but both the mother and baby died.

ESTATE’S CLAIM The EM physician was negligent in failing to perform a thoracotomy and arrange for a more timely transfer. The physician didn’t contact a hospital that was only 8 miles away.

DEFENDANTS’ DEFENSE The federal government, which operated the facility, admitted fault.

VERDICT A $7,267,390 Mississippi verdict included $5.45 million in noneconomic damages.

What caused child’s brain damage?

DURING LABOR AND DELIVERY, electronic fetal heart-rate monitoring indicated fetal distress. Meconium-stained fluid was present. The child was born with brain damage. It is unlikely that he will walk independently, talk in full sentences, or be able to perform daily activities independently.

PARENTS’ CLAIM The fetal heart-rate monitor indicated a need for emergency cesarean delivery. The quality and quantity of meconium should have alerted the caregivers to fetal distress and caused them to perform a cesarean delivery.

DEFENDANTS’ DEFENSE Fetal heart-rate strips did not indicate a need for emergency delivery until shortly before the delivery occurred. The underlying cause of the child’s injuries was an infection that spread to the brain and was irreversible.

VERDICT A $1.71 million Massachusetts verdict was returned.

When did bladder injury occur?

AN 84-YEAR-OLD WOMAN suffered recurrent bladder cancer. She underwent a cystoscopy, and then chemotherapy. Several weeks later, she was diagnosed with a bladder perforation became septic, and died.

ESTATE’S CLAIM The bladder was lacerated during cystoscopy; she would have survived if the laceration had been treated in a timely manner.

PHYSICIAN’S DEFENSE Bladder perforation during cystoscopy is a known risk of the procedure. However, the bladder was not perforated during cystoscopy; chemotherapy may have caused the perforation.

VERDICT A Michigan defense verdict was returned.

Fetal tracings poor: Why wasn’t an internal lead used?

AT 32 WEEKS’ GESTATION, a woman’s membranes ruptured, and she was admitted. Her ObGyn planned to induce labor at 34 weeks’ gestation. She experienced contractions on the morning of the scheduled induction. Although fetal heart-rate monitoring was reassuring, the fetus was in a compound position, with the chin leading. Labor progressed rapidly to 6-cm dilation. The fetal heart rate began to show recurrent mild variable decelerations that became increasingly deeper. Although the technical quality of the external monitoring was poor, no internal lead was applied.

After 3 hours, the tracing showed severe variable decelerations. The mother was fully dilated and began to push. The tracings were of poor quality, but interpretable portions showed minimal variability and significant decelerations during contractions. The fetal baseline heart rate became tachycardic. The obstetric nurse and resident continued to note abnormalities, but there is no evidence that they called the attending ObGyn. The fetal baseline heart rate reached 190 bpm with ongoing decelerations associated with contractions. Variability remained minimal to absent. After 2 hours of pushing, meconium-stained fluid was noted. The infant was born 1 hour later. The attending ObGyn was present for the last 30 minutes of labor.

The newborn’s Apgar scores were 1, 5, and 7, at 1, 5, and 10 minutes, respectively. His arterial cord pH was significantly low. MRI of the head showed subdural and intraventricular hemorrhage and evolving, profound hypoxic ischemic injury. At 1 year of age, the child suffers from a seizure disorder, cortical blindness, and severe developmental delays.

PARENTS’ CLAIM The nurse and resident failed to respond to fetal heart-rate abnormalities and failed to insert an internal lead to obtain better quality heart-rate tracings. They did not expedite delivery when fetal distress was evident.

DEFENDANTS’ DEFENSE The case was settled during trial.

VERDICT A $4.2 million Massachusetts settlement was reached.

Hypoxic ischemic encephalopathy

DUE TO PREECLAMPSIA, a woman was admitted to the hospital 5 weeks before her due date. Her condition was monitored for 2 weeks when it was decided to induce labor with oxytocin. After 3 hours in labor, the fetal heart-rate tracing began to show significant decelerations. The baby was born at 37 weeks’ gestation with severe hypoxic ischemic encephalopathy. The child died 2 years later from severe brain damage.

PARENTS’ CLAIM The ObGyns failed to respond to signs of fetal distress by performing an emergency cesarean. The brain images would have been different if a stroke-like event had occurred.

DEFENDANTS’ DEFENSE The fetus experienced an embolic process due to a compressed umbilical cord, resulting in a stroke-like vascular event, which led to the hypoxic ischemic encephalopathy.

VERDICT A $450,000 Wisconsin settlement was reached.

Every medical office, even the smallest, should have a time clock, and there are two very good reasons why. The obvious one is for stamping employee time cards. This is essential, even if all your employees are paid weekly or semiweekly rather than by the hour.

In most states, any employee who works more than 40 hours in any given week must be paid overtime wages. Employees know this, and disgruntled ones have been known to file complaints stating that they had worked hundreds of hours of unpaid overtime. This may be completely untrue, but labor boards almost invariably side with employees in such disputes – unless the employer can produce time records to disprove the claim. A time clock is cheap insurance against such headaches.

For hourly wage employees, time records are even more important, obviously because you only want to pay them for the hours they work. If you are paying your part-timers for the number of hours they should be working, without documenting how many hours they actually work, you could be paying for a lot of nonwork. Employees have little incentive to arrive on time or to stay the entire length of their shift, if they know they are being paid for a set number of hours anyway. And they certainly will balk at staying late if they can’t count on being paid for the extra time.

Time clocks also work to the advantage of your employees, since they will be paid for all the time they work. In fact, if any employees object to being asked to punch in every day, point out that they will be assured of payment for fractional time worked past their usual hours – time which until now may have gone unpaid.

The second – possibly more important – reason to have a time clock is to punch in your patients. A time clock is a great tool in the endless struggle to run your practice on time.

As each patient arrives, have your receptionist time-stamp the "encounter form" that goes back with the patient’s chart. As you take each chart off the door and enter the room, one glance at the time stamp will tell you exactly how long that patient has been waiting.

Now you no longer have to guess how far behind you are – and you’ll have an answer for the curmudgeon who walked in 15 minutes ago, but insists he’s been sitting there for 2 hours.

Time/attendance systems range from simple and cheap to complex and expensive. Many of the newer mechanical clocks will automatically calculate time between punches and total work time, and these can be configured for weekly, biweekly, semimonthly or monthly pay periods. Some will automatically deduct meal breaks from the totals. However, remember that you can only exclude meal breaks from compensable time when an employee is completely relieved of work duties for at least 1 uninterrupted half-hour.

If you have a problem with "buddy punching" (employees punching in or out for each other), some clocks are equipped to recognize fingerprints or hand contours.

There are also electronic timing systems, both web-based and in-house, which can be deployed across a local computer network. These systems will print time sheets with employee hours and earnings calculated, and some will even interface with financial software such as QuickBooks and other third party payroll services.

One popular Web-based system is Count Me In, which has the fingerprint option, and also allows you to restrict clocking in or out to those IP addresses that you authorize. The system prevents employees from punching in from home, or a vacation house, or a distant casino. Other examples of cloud-based systems: Time Card Manager, Time Force, and Time America. PHP Timeclock is a free, open-source download – though setting it up on your server will require some technical expertise.

As always, I have no financial interest in any product or service discussed in this column. Whether you go the mechanical or electronic route, make sure that the system you choose has security measures in place to prevent anyone from altering the displayed time at will. You need to be reasonably certain that your time stamps have not been fudged.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J.

Every medical office, even the smallest, should have a time clock, and there are two very good reasons why. The obvious one is for stamping employee time cards. This is essential, even if all your employees are paid weekly or semiweekly rather than by the hour.

In most states, any employee who works more than 40 hours in any given week must be paid overtime wages. Employees know this, and disgruntled ones have been known to file complaints stating that they had worked hundreds of hours of unpaid overtime. This may be completely untrue, but labor boards almost invariably side with employees in such disputes – unless the employer can produce time records to disprove the claim. A time clock is cheap insurance against such headaches.

For hourly wage employees, time records are even more important, obviously because you only want to pay them for the hours they work. If you are paying your part-timers for the number of hours they should be working, without documenting how many hours they actually work, you could be paying for a lot of nonwork. Employees have little incentive to arrive on time or to stay the entire length of their shift, if they know they are being paid for a set number of hours anyway. And they certainly will balk at staying late if they can’t count on being paid for the extra time.

Time clocks also work to the advantage of your employees, since they will be paid for all the time they work. In fact, if any employees object to being asked to punch in every day, point out that they will be assured of payment for fractional time worked past their usual hours – time which until now may have gone unpaid.

The second – possibly more important – reason to have a time clock is to punch in your patients. A time clock is a great tool in the endless struggle to run your practice on time.

As each patient arrives, have your receptionist time-stamp the "encounter form" that goes back with the patient’s chart. As you take each chart off the door and enter the room, one glance at the time stamp will tell you exactly how long that patient has been waiting.

Now you no longer have to guess how far behind you are – and you’ll have an answer for the curmudgeon who walked in 15 minutes ago, but insists he’s been sitting there for 2 hours.

Time/attendance systems range from simple and cheap to complex and expensive. Many of the newer mechanical clocks will automatically calculate time between punches and total work time, and these can be configured for weekly, biweekly, semimonthly or monthly pay periods. Some will automatically deduct meal breaks from the totals. However, remember that you can only exclude meal breaks from compensable time when an employee is completely relieved of work duties for at least 1 uninterrupted half-hour.

If you have a problem with "buddy punching" (employees punching in or out for each other), some clocks are equipped to recognize fingerprints or hand contours.

There are also electronic timing systems, both web-based and in-house, which can be deployed across a local computer network. These systems will print time sheets with employee hours and earnings calculated, and some will even interface with financial software such as QuickBooks and other third party payroll services.

One popular Web-based system is Count Me In, which has the fingerprint option, and also allows you to restrict clocking in or out to those IP addresses that you authorize. The system prevents employees from punching in from home, or a vacation house, or a distant casino. Other examples of cloud-based systems: Time Card Manager, Time Force, and Time America. PHP Timeclock is a free, open-source download – though setting it up on your server will require some technical expertise.

As always, I have no financial interest in any product or service discussed in this column. Whether you go the mechanical or electronic route, make sure that the system you choose has security measures in place to prevent anyone from altering the displayed time at will. You need to be reasonably certain that your time stamps have not been fudged.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J.

Every medical office, even the smallest, should have a time clock, and there are two very good reasons why. The obvious one is for stamping employee time cards. This is essential, even if all your employees are paid weekly or semiweekly rather than by the hour.

In most states, any employee who works more than 40 hours in any given week must be paid overtime wages. Employees know this, and disgruntled ones have been known to file complaints stating that they had worked hundreds of hours of unpaid overtime. This may be completely untrue, but labor boards almost invariably side with employees in such disputes – unless the employer can produce time records to disprove the claim. A time clock is cheap insurance against such headaches.

For hourly wage employees, time records are even more important, obviously because you only want to pay them for the hours they work. If you are paying your part-timers for the number of hours they should be working, without documenting how many hours they actually work, you could be paying for a lot of nonwork. Employees have little incentive to arrive on time or to stay the entire length of their shift, if they know they are being paid for a set number of hours anyway. And they certainly will balk at staying late if they can’t count on being paid for the extra time.

Time clocks also work to the advantage of your employees, since they will be paid for all the time they work. In fact, if any employees object to being asked to punch in every day, point out that they will be assured of payment for fractional time worked past their usual hours – time which until now may have gone unpaid.

The second – possibly more important – reason to have a time clock is to punch in your patients. A time clock is a great tool in the endless struggle to run your practice on time.

As each patient arrives, have your receptionist time-stamp the "encounter form" that goes back with the patient’s chart. As you take each chart off the door and enter the room, one glance at the time stamp will tell you exactly how long that patient has been waiting.

Now you no longer have to guess how far behind you are – and you’ll have an answer for the curmudgeon who walked in 15 minutes ago, but insists he’s been sitting there for 2 hours.

Time/attendance systems range from simple and cheap to complex and expensive. Many of the newer mechanical clocks will automatically calculate time between punches and total work time, and these can be configured for weekly, biweekly, semimonthly or monthly pay periods. Some will automatically deduct meal breaks from the totals. However, remember that you can only exclude meal breaks from compensable time when an employee is completely relieved of work duties for at least 1 uninterrupted half-hour.

If you have a problem with "buddy punching" (employees punching in or out for each other), some clocks are equipped to recognize fingerprints or hand contours.

There are also electronic timing systems, both web-based and in-house, which can be deployed across a local computer network. These systems will print time sheets with employee hours and earnings calculated, and some will even interface with financial software such as QuickBooks and other third party payroll services.

One popular Web-based system is Count Me In, which has the fingerprint option, and also allows you to restrict clocking in or out to those IP addresses that you authorize. The system prevents employees from punching in from home, or a vacation house, or a distant casino. Other examples of cloud-based systems: Time Card Manager, Time Force, and Time America. PHP Timeclock is a free, open-source download – though setting it up on your server will require some technical expertise.

As always, I have no financial interest in any product or service discussed in this column. Whether you go the mechanical or electronic route, make sure that the system you choose has security measures in place to prevent anyone from altering the displayed time at will. You need to be reasonably certain that your time stamps have not been fudged.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J.

For the first time in several years, SHM included questions about employee benefits and paid time off in its 2012 State of Hospital Medicine survey. The median value of benefits per physician FTE reported by HM groups serving adults only was $26,000, according to the 2012 survey. But what a surprise it was when survey respondents in 2007 reported median benefits of $31,900.

I admit to being flummoxed by the decrease. The definition of “benefits” was identical in both surveys. The only difference is that in 2007, SHM collected actual benefit cost for each individual on the individual questionnaire; in 2012, we asked for the average benefits per FTE for the group. One possible explanation is that some respondents simply guessed about the average, because they didn’t have to report data for individual doctors. Of course, it’s also possible that groups are requiring physicians to pay a higher proportion of insurance premiums or are reducing retirement plan contributions due to the weak economy. But in the work I do with hospitalist groups around the country, I rarely see benefit costs below about $35,000.

click for large version

Another interesting finding from the 2012 survey is that 37% of adult medicine groups reported offering paid time off (PTO), down from 54% in 2007. Even among groups using a seven-on/seven-off schedule, the PTO rate was only 44%. Does this represent a survey design or respondent input error, differences in respondent populations, or an actual shift in the prevalence of PTO benefits? I suspect it’s the latter, because the median amount of PTO time awarded has also declined. In 2007, adult HMGs reported a median of 25 PTO days annually. In 2012, the median for those groups offering PTO was 160 hours of PTO, which represents somewhere around 13 to 20 days, depending on shift length.

Why might PTO benefits be declining? I suppose it could be belt-tightening associated with the poor economy. But I think many HM groups simply have found PTO benefits difficult to administer and fraught with unintended consequences. Many groups are so thinly staffed that for someone to take a PTO day, someone else must work extra to cover. Then, when the covering doctor takes PTO, the first doctor must work extra—effectively offsetting the value of PTO. And if a hospitalist takes PTO and also works extra shifts in the same pay period, do these two offset each other? Or does the doctor get paid for both the PTO days and the extra shift days?

For clinicians such as hospitalists, whose work is defined in highly variable, shift-based schedules that include a lot of night and weekend work, it becomes very difficult to determine which of the days not worked were PTO days versus just days the doctor wasn’t scheduled.

Personally, I don’t think it makes much sense for most hospitalists to have PTO. Don’t get me wrong—I think hospitalists should be paid well and have generous amounts of time off in exchange for long, challenging workdays and a disproportionate amount of night and weekend work. But arbitrarily assigning some of the days not worked as PTO while others are just unscheduled days seems unnecessarily complex.

Time will tell if the specialty as a whole agrees with me or not.

Leslie Flores is a principal in Nelson Flores Hospital Medicine Consultants and a member of SHM’s Practice Analysis Committee.

For the first time in several years, SHM included questions about employee benefits and paid time off in its 2012 State of Hospital Medicine survey. The median value of benefits per physician FTE reported by HM groups serving adults only was $26,000, according to the 2012 survey. But what a surprise it was when survey respondents in 2007 reported median benefits of $31,900.

I admit to being flummoxed by the decrease. The definition of “benefits” was identical in both surveys. The only difference is that in 2007, SHM collected actual benefit cost for each individual on the individual questionnaire; in 2012, we asked for the average benefits per FTE for the group. One possible explanation is that some respondents simply guessed about the average, because they didn’t have to report data for individual doctors. Of course, it’s also possible that groups are requiring physicians to pay a higher proportion of insurance premiums or are reducing retirement plan contributions due to the weak economy. But in the work I do with hospitalist groups around the country, I rarely see benefit costs below about $35,000.

click for large version

Another interesting finding from the 2012 survey is that 37% of adult medicine groups reported offering paid time off (PTO), down from 54% in 2007. Even among groups using a seven-on/seven-off schedule, the PTO rate was only 44%. Does this represent a survey design or respondent input error, differences in respondent populations, or an actual shift in the prevalence of PTO benefits? I suspect it’s the latter, because the median amount of PTO time awarded has also declined. In 2007, adult HMGs reported a median of 25 PTO days annually. In 2012, the median for those groups offering PTO was 160 hours of PTO, which represents somewhere around 13 to 20 days, depending on shift length.

Why might PTO benefits be declining? I suppose it could be belt-tightening associated with the poor economy. But I think many HM groups simply have found PTO benefits difficult to administer and fraught with unintended consequences. Many groups are so thinly staffed that for someone to take a PTO day, someone else must work extra to cover. Then, when the covering doctor takes PTO, the first doctor must work extra—effectively offsetting the value of PTO. And if a hospitalist takes PTO and also works extra shifts in the same pay period, do these two offset each other? Or does the doctor get paid for both the PTO days and the extra shift days?

For clinicians such as hospitalists, whose work is defined in highly variable, shift-based schedules that include a lot of night and weekend work, it becomes very difficult to determine which of the days not worked were PTO days versus just days the doctor wasn’t scheduled.

Personally, I don’t think it makes much sense for most hospitalists to have PTO. Don’t get me wrong—I think hospitalists should be paid well and have generous amounts of time off in exchange for long, challenging workdays and a disproportionate amount of night and weekend work. But arbitrarily assigning some of the days not worked as PTO while others are just unscheduled days seems unnecessarily complex.

Time will tell if the specialty as a whole agrees with me or not.

Leslie Flores is a principal in Nelson Flores Hospital Medicine Consultants and a member of SHM’s Practice Analysis Committee.

For the first time in several years, SHM included questions about employee benefits and paid time off in its 2012 State of Hospital Medicine survey. The median value of benefits per physician FTE reported by HM groups serving adults only was $26,000, according to the 2012 survey. But what a surprise it was when survey respondents in 2007 reported median benefits of $31,900.

I admit to being flummoxed by the decrease. The definition of “benefits” was identical in both surveys. The only difference is that in 2007, SHM collected actual benefit cost for each individual on the individual questionnaire; in 2012, we asked for the average benefits per FTE for the group. One possible explanation is that some respondents simply guessed about the average, because they didn’t have to report data for individual doctors. Of course, it’s also possible that groups are requiring physicians to pay a higher proportion of insurance premiums or are reducing retirement plan contributions due to the weak economy. But in the work I do with hospitalist groups around the country, I rarely see benefit costs below about $35,000.

click for large version

Another interesting finding from the 2012 survey is that 37% of adult medicine groups reported offering paid time off (PTO), down from 54% in 2007. Even among groups using a seven-on/seven-off schedule, the PTO rate was only 44%. Does this represent a survey design or respondent input error, differences in respondent populations, or an actual shift in the prevalence of PTO benefits? I suspect it’s the latter, because the median amount of PTO time awarded has also declined. In 2007, adult HMGs reported a median of 25 PTO days annually. In 2012, the median for those groups offering PTO was 160 hours of PTO, which represents somewhere around 13 to 20 days, depending on shift length.

Why might PTO benefits be declining? I suppose it could be belt-tightening associated with the poor economy. But I think many HM groups simply have found PTO benefits difficult to administer and fraught with unintended consequences. Many groups are so thinly staffed that for someone to take a PTO day, someone else must work extra to cover. Then, when the covering doctor takes PTO, the first doctor must work extra—effectively offsetting the value of PTO. And if a hospitalist takes PTO and also works extra shifts in the same pay period, do these two offset each other? Or does the doctor get paid for both the PTO days and the extra shift days?

For clinicians such as hospitalists, whose work is defined in highly variable, shift-based schedules that include a lot of night and weekend work, it becomes very difficult to determine which of the days not worked were PTO days versus just days the doctor wasn’t scheduled.

Personally, I don’t think it makes much sense for most hospitalists to have PTO. Don’t get me wrong—I think hospitalists should be paid well and have generous amounts of time off in exchange for long, challenging workdays and a disproportionate amount of night and weekend work. But arbitrarily assigning some of the days not worked as PTO while others are just unscheduled days seems unnecessarily complex.

Time will tell if the specialty as a whole agrees with me or not.

Leslie Flores is a principal in Nelson Flores Hospital Medicine Consultants and a member of SHM’s Practice Analysis Committee.

Awarded to a hospital by comparing an individual hospital’s performance measure rates during a certain period with all hospitals’ rates during the baseline period.

Awarded to a hospital by comparing an individual hospital’s performance measure rates during a certain period with all hospitals’ rates during the baseline period.

Awarded to a hospital by comparing an individual hospital’s performance measure rates during a certain period with all hospitals’ rates during the baseline period.

Does your team have:

• Eagerness to improve their discharge processes and reduce unnecessary readmissions and avoidable adverse events in the post-discharge period?
• A multidisciplinary team in place capable of working collaboratively to redesign existing care processes?
• A dedicated leader to manage the process of tailoring the BOOST intervention to your site’s needs and implementing BOOST?
• Support of at least one executive sponsor who can meet with the team monthly?
• Access to data support personnel needed to collect baseline and post-implementation data?

Does your team have:

• Eagerness to improve their discharge processes and reduce unnecessary readmissions and avoidable adverse events in the post-discharge period?
• A multidisciplinary team in place capable of working collaboratively to redesign existing care processes?
• A dedicated leader to manage the process of tailoring the BOOST intervention to your site’s needs and implementing BOOST?
• Support of at least one executive sponsor who can meet with the team monthly?
• Access to data support personnel needed to collect baseline and post-implementation data?

Does your team have:

• Eagerness to improve their discharge processes and reduce unnecessary readmissions and avoidable adverse events in the post-discharge period?
• A multidisciplinary team in place capable of working collaboratively to redesign existing care processes?
• A dedicated leader to manage the process of tailoring the BOOST intervention to your site’s needs and implementing BOOST?
• Support of at least one executive sponsor who can meet with the team monthly?
• Access to data support personnel needed to collect baseline and post-implementation data?

After years of juggling more than one career, Kulleni Gebreyes, MD, MBA, had a tough decision to make. "I'm a little bit of a glutton for punishment," she admits with a chuckle. While overseeing quality improvement (QI) for a healthcare foundation, she had negotiated to take off every other Friday and work several ED shifts per month on weekends at two local hospitals.

Then, in January 2012, Dr. Gebreyes began a new full-time position as a director at PricewaterhouseCoopers in McLean, Va. It became too time-consuming and exhausting to treat patients and consult in healthcare industries, says the mother of two children, who are 7 and 4.

Dr. Gebreyes is among a growing number of physicians who, after a number of years, opt to give up clinical medicine for nonclinical roles in healthcare or other industries altogether. "You are ready for transition when the new choice excites and energizes you," she explains, "and not necessarily when your first choice disappoints you."

A career shift offers new opportunities for broadening one's horizons while often striking a better work-life balance. Many clinicians make the transition slowly and wisely, and some take an expected financial hit as they carve out an entrepreneurial and creative path.

"Modern medicine is very difficult. You can burn out if you're not careful," says Dan Hale, MD, FAAP, a pediatric hospitalist in the Floating Hospital for Children at Tufts Medical Center in Boston.

Stepping off the merry-go-round can help you regroup. Fortunately, he adds, hospitalists can exercise more flexibility in scheduling than physicians in different specialties. Some hospitalists prefer to work nights and weekends in order to free up weekdays for other activities. Others decrease their clinical shifts and devote more time to teaching, research, or administration.

For those who decide to leave medicine completely, "hospitalists definitely have people skills day to day in their jobs that are applicable in multiple other careers," says Dr. Hale, a Team Hospitalist member. "Becoming a physician requires so much dedication and hard work, so you will succeed in whatever career you choose."

The Society of Physician Entrepreneurs (www.sopenet.org) is expanding by about 150 to 200 new members each month. Founded in 2008 and officially launched in January 2011, the society has more than 4,700 members globally. The interdisciplinary network includes physicians and innovators in other professions—from law to information technology to product development.

Its purpose is to "bring all the stakeholders together in one virtual space to collaborate," says co-founder and president Arlen Meyers, MD, MBA, professor in the departments of otolaryngology, dentistry, and engineering at the University of Colorado Denver, where he directs the graduate program in bio-innovation and entrepreneurship.

"The opportunities for physician entrepreneurs include working with industry, consulting, creating their own company, and much more," Dr. Meyers says. "As domain experts, physicians are in a unique position to add value to the innovation chain.

I have really enjoyed using all of my medical background and knowledge and applying it toward film. It’s very grounding. It gives you a purpose.

–Maren Grainger-Monsen, MD, filmmaker-in-residence and director of the bioethics and film program, Stanford Center for Biomedical Ethics, Stanford, Calif.

"However, to leave practice and be successful at something nonclinical requires education, experience, and networks," he says. "Doing what you did successfully in your last career won't be a guarantee of success in your next career, so you have to be willing to pay your dues and accept the risk."

The Writer

Deborah Shlian, MD, MBA, a former family medicine physician and managed-care executive in California, has evolved into a medical management consultant and an author of both fiction and nonfiction titles. Dr. Shlian, who now lives in Boca Raton, Fla., had always wanted to write. Her father, an internist, encouraged the pursuit of medicine, so she followed in his footsteps.

Deborah Shlian, MD, MBA

"I wanted to emulate what he did," she says. Over time, she realized that "doctors have a lot of skills that are applicable to other endeavors."

She and her husband, Joel Shlian, MD, MBA, also a former family medicine physician, fully gave up clinical practice about 10 years ago after doing it part time for a decade. The Shlians met as students at the University of Maryland School of Medicine in 1970. Initially, their new business concentrated on physician executive recruitment. As clients requested other services, the Shlians helped identify nonphysician managers as well. Clients included established, as well as start-up health plans, academic institutions, utilization review, and healthcare consulting companies.

Given the accelerated changes in healthcare delivery, earning a graduate education in business is not a quick and easy avenue to another career. "An MBA should never be viewed as the means to 'get out of medical practice,'" Dr. Shlian says in her new book, "Lessons Learned: Stories from Women in Medical Management," released this month by the American College of Physician Executives.

"In fact, I would submit that if you really hate clinical medicine, medical management is not for you," she says. "It can be every bit as demanding and frustrating as clinical practice."

The Entrepreneur

Jeffrey N. Hausfeld, MD, MBA, FACS, completed an MBA program on evenings and weekends. After graduation in 2005, he gave up his 24-year practice of otolaryngology and facial plastic surgery. He continued his education by obtaining a graduate certificate in leadership coaching and organizational development. Then he became involved in the first of several business ventures, capitalizing on his clinical experience.

Jeffrey N. Hausfeld, MD, MBA, FACS

"Doctors don't have a trusted partner to do their debt collections," says Dr. Hausfeld, co-founder and treasurer of the Society of Physician Entrepreneurs. His own negative experiences with debt-collection agencies contributed to his "understanding the obstacles and objections to create this kind of an entity."

You are ready for transition when the new choice excites and energizes you, and not necessarily when your first choice disappoints you.

—Kulleni Gebreyes, MD, MBA, director of healthcare consulting, PricewaterhouseCoopers, McLean, Va.

Hence the emergence of FMS Financial Solutions, based in Greenbelt, Md. "This seemed to be a very natural fit for me," says Dr. Hausfeld, who is the managing director. By collecting money owed to physicians, hospitals, and surgical centers, he has increased the revenues of his business fourfold since 2006. The company has 24 full- and part-time workers.

Meanwhile, his son, Joshua, who joined him in the healthcare MBA program at Johns Hopkins University in Baltimore and now works for an investment banking firm that provides real estate loans for senior housing, introduced Dr. Hausfeld to a group of Midwest-based assisted-living-facility developers. Four years ago, they struck a deal to provide private equity funding and create Memory Care Communities of Illinois, with Dr. Hausfeld serving as president. The 24-hour residential facilities are home to patients with Alzheimer's disease and dementia.

To some degree, he misses practicing medicine, but Dr. Hausfeld is enthusiastic about making a difference in even more people's lives than he did as a physician and surgeon.

"I've done 10,000 ear, nose, and throat operations. If I did 1,000 more, how much would I be changing the world?" Dr. Hausfeld says. Ultimately, "you find a way to leave a bigger footprint."

Deborah Shlian, MD, MBA

His entrepreneurial spirit has led to other consulting roles. For instance, he is trying to help two startup companies—one in the medical device arena, the other in information technology—grow by leaps and bounds.

The Director

Maren Grainger-Monsen, MD, has made her mark as an award-winning physician filmmaker. She is filmmaker-in-residence and director of the bioethics and film program at the Stanford Center for Biomedical Ethics in Palo Alto, Calif. She studied at the London Film School and received her medical training at the University of Washington in Seattle and Stanford University School of Medicine.

"I have really enjoyed using all of my medical background and knowledge and applying it toward film," Dr. Grainger-Monsen says of her position at Stanford, which she has held since 1998. "It's very grounding. It gives you a purpose."

Her one-hour documentary "Rare," which features a family with a very uncommon genetic disease, aired last August on PBS. Another film, "The Revolutionary Optimists," follows a group of aspiring youngsters in the slums of Calcutta, India, who battle poverty and transform their neighborhoods from the inside out. One-hour and 80-minute versions of the film are slated to air on the PBS series "Independent Lens" as part of the Women and Girls Lead Global partnership.

Dr. Grainger-Monsen co-produced and co-directed both films with Nicole Newnham, an independent documentary filmmaker who is in residence at Stanford's bioethics and film program.

As an undergraduate art history major, Dr. Grainger-Monsen became interested in social and ethical issues in medicine. Later, films shown in medical school struck a chord with her. She was amazed at how images could resonate with viewers and trigger animated debate. During the summer between her first and second years of medical school, she was inspired to study film at New York University.

Dr. Grainger-Monsen eventually trained in emergency medicine at Stanford and completed a fellowship in palliative care at Stanford-affiliated Palo Alto Veterans Administration Hospital. For years, she split her career between working in community ER clinics and producing films. Her films are large-scale projects that may take five years or longer to make, and she raises all the funds to bring them to fruition.

"I really do find documentary filmmaking tremendously gratifying," Dr. Grainger-Monsen says of the chance "to talk with all different kinds of people in all different situations and walk in their shoes, with them, for a time. That is what I'm trying to share with the audience."

In creating character-driven documentaries, she aims to spark discussions about important issues in contemporary medicine. "I hope my films can help increase understanding and empathy," she says, "and result in improvements to the delivery of healthcare and reduction of disparities on multiple levels."

Susan Kreimer is a freelance writer in New York.

After years of juggling more than one career, Kulleni Gebreyes, MD, MBA, had a tough decision to make. "I'm a little bit of a glutton for punishment," she admits with a chuckle. While overseeing quality improvement (QI) for a healthcare foundation, she had negotiated to take off every other Friday and work several ED shifts per month on weekends at two local hospitals.

Then, in January 2012, Dr. Gebreyes began a new full-time position as a director at PricewaterhouseCoopers in McLean, Va. It became too time-consuming and exhausting to treat patients and consult in healthcare industries, says the mother of two children, who are 7 and 4.

Dr. Gebreyes is among a growing number of physicians who, after a number of years, opt to give up clinical medicine for nonclinical roles in healthcare or other industries altogether. "You are ready for transition when the new choice excites and energizes you," she explains, "and not necessarily when your first choice disappoints you."

A career shift offers new opportunities for broadening one's horizons while often striking a better work-life balance. Many clinicians make the transition slowly and wisely, and some take an expected financial hit as they carve out an entrepreneurial and creative path.

"Modern medicine is very difficult. You can burn out if you're not careful," says Dan Hale, MD, FAAP, a pediatric hospitalist in the Floating Hospital for Children at Tufts Medical Center in Boston.

Stepping off the merry-go-round can help you regroup. Fortunately, he adds, hospitalists can exercise more flexibility in scheduling than physicians in different specialties. Some hospitalists prefer to work nights and weekends in order to free up weekdays for other activities. Others decrease their clinical shifts and devote more time to teaching, research, or administration.

For those who decide to leave medicine completely, "hospitalists definitely have people skills day to day in their jobs that are applicable in multiple other careers," says Dr. Hale, a Team Hospitalist member. "Becoming a physician requires so much dedication and hard work, so you will succeed in whatever career you choose."

The Society of Physician Entrepreneurs (www.sopenet.org) is expanding by about 150 to 200 new members each month. Founded in 2008 and officially launched in January 2011, the society has more than 4,700 members globally. The interdisciplinary network includes physicians and innovators in other professions—from law to information technology to product development.

Its purpose is to "bring all the stakeholders together in one virtual space to collaborate," says co-founder and president Arlen Meyers, MD, MBA, professor in the departments of otolaryngology, dentistry, and engineering at the University of Colorado Denver, where he directs the graduate program in bio-innovation and entrepreneurship.

"The opportunities for physician entrepreneurs include working with industry, consulting, creating their own company, and much more," Dr. Meyers says. "As domain experts, physicians are in a unique position to add value to the innovation chain.

I have really enjoyed using all of my medical background and knowledge and applying it toward film. It’s very grounding. It gives you a purpose.

–Maren Grainger-Monsen, MD, filmmaker-in-residence and director of the bioethics and film program, Stanford Center for Biomedical Ethics, Stanford, Calif.

"However, to leave practice and be successful at something nonclinical requires education, experience, and networks," he says. "Doing what you did successfully in your last career won't be a guarantee of success in your next career, so you have to be willing to pay your dues and accept the risk."

The Writer

Deborah Shlian, MD, MBA, a former family medicine physician and managed-care executive in California, has evolved into a medical management consultant and an author of both fiction and nonfiction titles. Dr. Shlian, who now lives in Boca Raton, Fla., had always wanted to write. Her father, an internist, encouraged the pursuit of medicine, so she followed in his footsteps.

Deborah Shlian, MD, MBA

"I wanted to emulate what he did," she says. Over time, she realized that "doctors have a lot of skills that are applicable to other endeavors."

She and her husband, Joel Shlian, MD, MBA, also a former family medicine physician, fully gave up clinical practice about 10 years ago after doing it part time for a decade. The Shlians met as students at the University of Maryland School of Medicine in 1970. Initially, their new business concentrated on physician executive recruitment. As clients requested other services, the Shlians helped identify nonphysician managers as well. Clients included established, as well as start-up health plans, academic institutions, utilization review, and healthcare consulting companies.

Given the accelerated changes in healthcare delivery, earning a graduate education in business is not a quick and easy avenue to another career. "An MBA should never be viewed as the means to 'get out of medical practice,'" Dr. Shlian says in her new book, "Lessons Learned: Stories from Women in Medical Management," released this month by the American College of Physician Executives.

"In fact, I would submit that if you really hate clinical medicine, medical management is not for you," she says. "It can be every bit as demanding and frustrating as clinical practice."

The Entrepreneur

Jeffrey N. Hausfeld, MD, MBA, FACS, completed an MBA program on evenings and weekends. After graduation in 2005, he gave up his 24-year practice of otolaryngology and facial plastic surgery. He continued his education by obtaining a graduate certificate in leadership coaching and organizational development. Then he became involved in the first of several business ventures, capitalizing on his clinical experience.

Jeffrey N. Hausfeld, MD, MBA, FACS

"Doctors don't have a trusted partner to do their debt collections," says Dr. Hausfeld, co-founder and treasurer of the Society of Physician Entrepreneurs. His own negative experiences with debt-collection agencies contributed to his "understanding the obstacles and objections to create this kind of an entity."

You are ready for transition when the new choice excites and energizes you, and not necessarily when your first choice disappoints you.

—Kulleni Gebreyes, MD, MBA, director of healthcare consulting, PricewaterhouseCoopers, McLean, Va.

Hence the emergence of FMS Financial Solutions, based in Greenbelt, Md. "This seemed to be a very natural fit for me," says Dr. Hausfeld, who is the managing director. By collecting money owed to physicians, hospitals, and surgical centers, he has increased the revenues of his business fourfold since 2006. The company has 24 full- and part-time workers.

Meanwhile, his son, Joshua, who joined him in the healthcare MBA program at Johns Hopkins University in Baltimore and now works for an investment banking firm that provides real estate loans for senior housing, introduced Dr. Hausfeld to a group of Midwest-based assisted-living-facility developers. Four years ago, they struck a deal to provide private equity funding and create Memory Care Communities of Illinois, with Dr. Hausfeld serving as president. The 24-hour residential facilities are home to patients with Alzheimer's disease and dementia.

To some degree, he misses practicing medicine, but Dr. Hausfeld is enthusiastic about making a difference in even more people's lives than he did as a physician and surgeon.

"I've done 10,000 ear, nose, and throat operations. If I did 1,000 more, how much would I be changing the world?" Dr. Hausfeld says. Ultimately, "you find a way to leave a bigger footprint."

Deborah Shlian, MD, MBA

His entrepreneurial spirit has led to other consulting roles. For instance, he is trying to help two startup companies—one in the medical device arena, the other in information technology—grow by leaps and bounds.

The Director

Maren Grainger-Monsen, MD, has made her mark as an award-winning physician filmmaker. She is filmmaker-in-residence and director of the bioethics and film program at the Stanford Center for Biomedical Ethics in Palo Alto, Calif. She studied at the London Film School and received her medical training at the University of Washington in Seattle and Stanford University School of Medicine.

"I have really enjoyed using all of my medical background and knowledge and applying it toward film," Dr. Grainger-Monsen says of her position at Stanford, which she has held since 1998. "It's very grounding. It gives you a purpose."

Her one-hour documentary "Rare," which features a family with a very uncommon genetic disease, aired last August on PBS. Another film, "The Revolutionary Optimists," follows a group of aspiring youngsters in the slums of Calcutta, India, who battle poverty and transform their neighborhoods from the inside out. One-hour and 80-minute versions of the film are slated to air on the PBS series "Independent Lens" as part of the Women and Girls Lead Global partnership.

Dr. Grainger-Monsen co-produced and co-directed both films with Nicole Newnham, an independent documentary filmmaker who is in residence at Stanford's bioethics and film program.

As an undergraduate art history major, Dr. Grainger-Monsen became interested in social and ethical issues in medicine. Later, films shown in medical school struck a chord with her. She was amazed at how images could resonate with viewers and trigger animated debate. During the summer between her first and second years of medical school, she was inspired to study film at New York University.

Dr. Grainger-Monsen eventually trained in emergency medicine at Stanford and completed a fellowship in palliative care at Stanford-affiliated Palo Alto Veterans Administration Hospital. For years, she split her career between working in community ER clinics and producing films. Her films are large-scale projects that may take five years or longer to make, and she raises all the funds to bring them to fruition.

"I really do find documentary filmmaking tremendously gratifying," Dr. Grainger-Monsen says of the chance "to talk with all different kinds of people in all different situations and walk in their shoes, with them, for a time. That is what I'm trying to share with the audience."

In creating character-driven documentaries, she aims to spark discussions about important issues in contemporary medicine. "I hope my films can help increase understanding and empathy," she says, "and result in improvements to the delivery of healthcare and reduction of disparities on multiple levels."

Susan Kreimer is a freelance writer in New York.

After years of juggling more than one career, Kulleni Gebreyes, MD, MBA, had a tough decision to make. "I'm a little bit of a glutton for punishment," she admits with a chuckle. While overseeing quality improvement (QI) for a healthcare foundation, she had negotiated to take off every other Friday and work several ED shifts per month on weekends at two local hospitals.

Then, in January 2012, Dr. Gebreyes began a new full-time position as a director at PricewaterhouseCoopers in McLean, Va. It became too time-consuming and exhausting to treat patients and consult in healthcare industries, says the mother of two children, who are 7 and 4.

Dr. Gebreyes is among a growing number of physicians who, after a number of years, opt to give up clinical medicine for nonclinical roles in healthcare or other industries altogether. "You are ready for transition when the new choice excites and energizes you," she explains, "and not necessarily when your first choice disappoints you."

A career shift offers new opportunities for broadening one's horizons while often striking a better work-life balance. Many clinicians make the transition slowly and wisely, and some take an expected financial hit as they carve out an entrepreneurial and creative path.

"Modern medicine is very difficult. You can burn out if you're not careful," says Dan Hale, MD, FAAP, a pediatric hospitalist in the Floating Hospital for Children at Tufts Medical Center in Boston.

Stepping off the merry-go-round can help you regroup. Fortunately, he adds, hospitalists can exercise more flexibility in scheduling than physicians in different specialties. Some hospitalists prefer to work nights and weekends in order to free up weekdays for other activities. Others decrease their clinical shifts and devote more time to teaching, research, or administration.

For those who decide to leave medicine completely, "hospitalists definitely have people skills day to day in their jobs that are applicable in multiple other careers," says Dr. Hale, a Team Hospitalist member. "Becoming a physician requires so much dedication and hard work, so you will succeed in whatever career you choose."

The Society of Physician Entrepreneurs (www.sopenet.org) is expanding by about 150 to 200 new members each month. Founded in 2008 and officially launched in January 2011, the society has more than 4,700 members globally. The interdisciplinary network includes physicians and innovators in other professions—from law to information technology to product development.

Its purpose is to "bring all the stakeholders together in one virtual space to collaborate," says co-founder and president Arlen Meyers, MD, MBA, professor in the departments of otolaryngology, dentistry, and engineering at the University of Colorado Denver, where he directs the graduate program in bio-innovation and entrepreneurship.

"The opportunities for physician entrepreneurs include working with industry, consulting, creating their own company, and much more," Dr. Meyers says. "As domain experts, physicians are in a unique position to add value to the innovation chain.

I have really enjoyed using all of my medical background and knowledge and applying it toward film. It’s very grounding. It gives you a purpose.

–Maren Grainger-Monsen, MD, filmmaker-in-residence and director of the bioethics and film program, Stanford Center for Biomedical Ethics, Stanford, Calif.

"However, to leave practice and be successful at something nonclinical requires education, experience, and networks," he says. "Doing what you did successfully in your last career won't be a guarantee of success in your next career, so you have to be willing to pay your dues and accept the risk."

The Writer

Deborah Shlian, MD, MBA, a former family medicine physician and managed-care executive in California, has evolved into a medical management consultant and an author of both fiction and nonfiction titles. Dr. Shlian, who now lives in Boca Raton, Fla., had always wanted to write. Her father, an internist, encouraged the pursuit of medicine, so she followed in his footsteps.

Deborah Shlian, MD, MBA

"I wanted to emulate what he did," she says. Over time, she realized that "doctors have a lot of skills that are applicable to other endeavors."

She and her husband, Joel Shlian, MD, MBA, also a former family medicine physician, fully gave up clinical practice about 10 years ago after doing it part time for a decade. The Shlians met as students at the University of Maryland School of Medicine in 1970. Initially, their new business concentrated on physician executive recruitment. As clients requested other services, the Shlians helped identify nonphysician managers as well. Clients included established, as well as start-up health plans, academic institutions, utilization review, and healthcare consulting companies.

Given the accelerated changes in healthcare delivery, earning a graduate education in business is not a quick and easy avenue to another career. "An MBA should never be viewed as the means to 'get out of medical practice,'" Dr. Shlian says in her new book, "Lessons Learned: Stories from Women in Medical Management," released this month by the American College of Physician Executives.

"In fact, I would submit that if you really hate clinical medicine, medical management is not for you," she says. "It can be every bit as demanding and frustrating as clinical practice."

The Entrepreneur

Jeffrey N. Hausfeld, MD, MBA, FACS, completed an MBA program on evenings and weekends. After graduation in 2005, he gave up his 24-year practice of otolaryngology and facial plastic surgery. He continued his education by obtaining a graduate certificate in leadership coaching and organizational development. Then he became involved in the first of several business ventures, capitalizing on his clinical experience.

Jeffrey N. Hausfeld, MD, MBA, FACS

"Doctors don't have a trusted partner to do their debt collections," says Dr. Hausfeld, co-founder and treasurer of the Society of Physician Entrepreneurs. His own negative experiences with debt-collection agencies contributed to his "understanding the obstacles and objections to create this kind of an entity."

You are ready for transition when the new choice excites and energizes you, and not necessarily when your first choice disappoints you.

—Kulleni Gebreyes, MD, MBA, director of healthcare consulting, PricewaterhouseCoopers, McLean, Va.

Hence the emergence of FMS Financial Solutions, based in Greenbelt, Md. "This seemed to be a very natural fit for me," says Dr. Hausfeld, who is the managing director. By collecting money owed to physicians, hospitals, and surgical centers, he has increased the revenues of his business fourfold since 2006. The company has 24 full- and part-time workers.

Meanwhile, his son, Joshua, who joined him in the healthcare MBA program at Johns Hopkins University in Baltimore and now works for an investment banking firm that provides real estate loans for senior housing, introduced Dr. Hausfeld to a group of Midwest-based assisted-living-facility developers. Four years ago, they struck a deal to provide private equity funding and create Memory Care Communities of Illinois, with Dr. Hausfeld serving as president. The 24-hour residential facilities are home to patients with Alzheimer's disease and dementia.

To some degree, he misses practicing medicine, but Dr. Hausfeld is enthusiastic about making a difference in even more people's lives than he did as a physician and surgeon.

"I've done 10,000 ear, nose, and throat operations. If I did 1,000 more, how much would I be changing the world?" Dr. Hausfeld says. Ultimately, "you find a way to leave a bigger footprint."

Deborah Shlian, MD, MBA

His entrepreneurial spirit has led to other consulting roles. For instance, he is trying to help two startup companies—one in the medical device arena, the other in information technology—grow by leaps and bounds.

The Director

Maren Grainger-Monsen, MD, has made her mark as an award-winning physician filmmaker. She is filmmaker-in-residence and director of the bioethics and film program at the Stanford Center for Biomedical Ethics in Palo Alto, Calif. She studied at the London Film School and received her medical training at the University of Washington in Seattle and Stanford University School of Medicine.

"I have really enjoyed using all of my medical background and knowledge and applying it toward film," Dr. Grainger-Monsen says of her position at Stanford, which she has held since 1998. "It's very grounding. It gives you a purpose."

Her one-hour documentary "Rare," which features a family with a very uncommon genetic disease, aired last August on PBS. Another film, "The Revolutionary Optimists," follows a group of aspiring youngsters in the slums of Calcutta, India, who battle poverty and transform their neighborhoods from the inside out. One-hour and 80-minute versions of the film are slated to air on the PBS series "Independent Lens" as part of the Women and Girls Lead Global partnership.

Dr. Grainger-Monsen co-produced and co-directed both films with Nicole Newnham, an independent documentary filmmaker who is in residence at Stanford's bioethics and film program.

As an undergraduate art history major, Dr. Grainger-Monsen became interested in social and ethical issues in medicine. Later, films shown in medical school struck a chord with her. She was amazed at how images could resonate with viewers and trigger animated debate. During the summer between her first and second years of medical school, she was inspired to study film at New York University.

Dr. Grainger-Monsen eventually trained in emergency medicine at Stanford and completed a fellowship in palliative care at Stanford-affiliated Palo Alto Veterans Administration Hospital. For years, she split her career between working in community ER clinics and producing films. Her films are large-scale projects that may take five years or longer to make, and she raises all the funds to bring them to fruition.

"I really do find documentary filmmaking tremendously gratifying," Dr. Grainger-Monsen says of the chance "to talk with all different kinds of people in all different situations and walk in their shoes, with them, for a time. That is what I'm trying to share with the audience."

In creating character-driven documentaries, she aims to spark discussions about important issues in contemporary medicine. "I hope my films can help increase understanding and empathy," she says, "and result in improvements to the delivery of healthcare and reduction of disparities on multiple levels."

Susan Kreimer is a freelance writer in New York.

Ask supporters and detractors of the seven-on/seven-off schedule their favorite (or least favorite) aspect of the model, and they’ll say the same thing: how it impacts work-life balance.

Heads: “For me, I know that there’s that balance,” says Dr. Houser, who works in Rapid City, S.D. “I know that there are going to be some holidays, some weekends where I’m not going to go to the soccer game or go to the volleyball game or see the choir practice. But the other side of me knows that I will be able to make it up to the kids, if it was something that I missed. I’ll be able to devote that time that I really like to devote to my family when I’m off.”

Tails: “I really believe that [seven-on/seven-off] scheduling is probably more desirable to Generation Y, which tends to have a lot more life quality and life balance as part of their mentality,” says Eshbaugh, the administrator in Traverse City, Mich. “I think the older generation of physicians, especially because they came out of the outpatient world, they were used to working five days a week, every week.”

Ask supporters and detractors of the seven-on/seven-off schedule their favorite (or least favorite) aspect of the model, and they’ll say the same thing: how it impacts work-life balance.

Heads: “For me, I know that there’s that balance,” says Dr. Houser, who works in Rapid City, S.D. “I know that there are going to be some holidays, some weekends where I’m not going to go to the soccer game or go to the volleyball game or see the choir practice. But the other side of me knows that I will be able to make it up to the kids, if it was something that I missed. I’ll be able to devote that time that I really like to devote to my family when I’m off.”

Tails: “I really believe that [seven-on/seven-off] scheduling is probably more desirable to Generation Y, which tends to have a lot more life quality and life balance as part of their mentality,” says Eshbaugh, the administrator in Traverse City, Mich. “I think the older generation of physicians, especially because they came out of the outpatient world, they were used to working five days a week, every week.”

Ask supporters and detractors of the seven-on/seven-off schedule their favorite (or least favorite) aspect of the model, and they’ll say the same thing: how it impacts work-life balance.

Heads: “For me, I know that there’s that balance,” says Dr. Houser, who works in Rapid City, S.D. “I know that there are going to be some holidays, some weekends where I’m not going to go to the soccer game or go to the volleyball game or see the choir practice. But the other side of me knows that I will be able to make it up to the kids, if it was something that I missed. I’ll be able to devote that time that I really like to devote to my family when I’m off.”

Tails: “I really believe that [seven-on/seven-off] scheduling is probably more desirable to Generation Y, which tends to have a lot more life quality and life balance as part of their mentality,” says Eshbaugh, the administrator in Traverse City, Mich. “I think the older generation of physicians, especially because they came out of the outpatient world, they were used to working five days a week, every week.”

We have been doing some education with hospitals over the last three or four years of just doing the math. We often give a dual proposal. This is how much it will cost for seven-on/seven-off; this is how much it will cost with the Monday-through-Friday model. Obviously, the Monday-through-Friday model is a lower cost, but it may take a little bit longer to get it staffed.

—Jeff Taylor, president, chief operating officer, IPC: The Hospitalist Co., North Hollywood, Calif.

Robert Houser, MD, MBA, co-medical director of Rapid City Regional Hospital in Rapid City, S.D., left his primary-care practice a little more than 10 years ago to become a hospitalist. At the time, his new schedule—working seven days in a row, then taking off seven days in a row—struck him as odd. But the idea of being able to throw himself completely and alternately into both his job and his family appealed to him. More than a decade later, he still believes his schedule is a perfect mix of personal and professional time.

Bradley Eshbaugh, MBA, FACMPE, chief administrator of Hospitalists of Northern Michigan (HNM) in Traverse City, Mich., and a SHM Administrators’ Committee member, doesn’t see it that way. His hospitalists tell him the work-a-week, skip-a-week schedule is too inflexible for the work-life balance they crave. Even when newly hired physicians accustomed to the week-on/week-off schedule ask if they can continue it, Eshbaugh says, most quickly realize the flexible-schedule option that HNM utilizes offers them a more balanced approach to time off work.

Dr. Houser

Dr. Eshbaugh

Welcome to the world of seven-on/seven-off scheduling, where detractors and supporters often have the same reasons for their differing viewpoints. Those who favor the model say that its simple-to-implement block approach to scheduling allows physicians to know far in advance when their time off is. That allows clinicians to plan their lives way in advance, a carrot hospitalist groups have used for more than a decade to attract new hires. Those who prefer other scheduling methods say the seven-on/seven-off model’s rigidity leaves little flexibility to deal with the unscheduled inevitabilities of life (sickness, personal time, maternity leave, resignations, etc.) and is not the best construct to match staffing to the busiest admissions periods.

And while everyone agrees that the seven-on/seven-off model is among the most popular, there is as yet no clinical data that show whether its practitioners are more or less likely to provide higher-quality care. So the oft-asked question of whether the schedule is sustainable comes down not to care delivery but financial pressure. Three-quarters of HM groups (HMGs) rely on their host hospitals for financial support, and that support-per-FTE at nonacademic groups serving only adults rose to an median of $140,204 this year, according to SHM’s 2012 State of Hospital Medicine report—a 40% increase over data in the 2010 SHM/MGMA‐ACMPE survey.

“When we started in this business 15 years ago, the average hospital might have three to five hospitalists, maybe a subsidy of $300,000 to $500,000,” says Martin Buser, a partner in Hospitalist Management Resources of Del Mar, Calif. “That same program today is probably running 15 to 20 hospitalists, a subsidy of $3 million-plus. It’s really strongly on the radar screen for administrators to look at, ‘Can I keep affording this, or do I need to find less expensive ways to get the same result?’”

Viewpoints Vary

The origins of the seven-on/seven-off schedule are a bit murky. Some believe it was borrowed from the shift-work model in the ED. Others think it has roots in the nursing ranks. Still others think that in the nascent days of HM, two- and three-physician groups developed the schedule by simply splitting monthly schedules by weeks. Regardless of pedigree, the model has grown to be just about the most common schedule for HMGs serving adults only. The State of Hospital Medicine report reported that 41.9% of adult groups use the seven-on/seven-off schedule, with 41.6% reporting their schedule as “variable” and “other.”

SHM has never queried hospitalists specifically about their schedules before, so no comparative data are available for information. Interestingly, the State of Hospital Medicine report found that hospitalist management companies and private HM groups were less likely to use the seven-on/seven-off schedule than hospital-owned or academic groups.

Jeff Taylor, president and chief operating officer of IPC: The Hospitalist Co., a national physician group practice based in North Hollywood, Calif., says just 10% of his 1,400 providers nationwide uses the seven-on/seven-off construct. He argues the model “is economically inefficient.” For example, he says, take a hospital with a census of around 60 inpatients per day. An HM group that wants to limit daily censuses to about 15 patients would need four doctors to staff that patient load. Using the seven-on/seven-off schedule, the group would need eight dayside hospitalists (not counting nocturnists). In a more traditional staffing model of a five-day workweek and call coverage, a group likely could handle the same workload with five FTE hospitalists, Taylor says.

“We have been doing some education with hospitals over the last three or four years of just doing the math,” he adds. “How many doctors would you need to staff this census? … We often give a dual proposal. This is how much it will cost for seven-on/seven-off; this is how much it will cost with the Monday-through-Friday model. Obviously, the Monday-through-Friday model is a lower cost, but it may take a little bit longer to get it staffed.”

Staffing difficulties—particularly recruitment and retention—are a major driver of the popularity of the seven-on/seven-off schedule, says Gregory Martinek, DO, FHM, medical director of Lexington Hospitalists in Altoona, Pa. He says it’s tough to recruit hospitalists to work in a small town in central Pennsylvania, so offering a schedule those physicians want to work is helpful.

Dr. Martinek

In fact, Dr. Martinek offers his hospitalists an extra week of vacation in addition to the 26 weeks they don’t work. That allows some of his foreign-born physicians to take a three-week break from work, which many use as a chance to return to their birth countries.

“We had trouble recruiting when we had a different model,” Dr. Martinek says. “This has really worked for us. It’s allowed us to recruit.”

Cost Concerns

How do HM group leaders answer C-suite questions about whether the expenses associated with the seven-on/seven-off model are worth it? The short answer is data. Know basic metrics on length of stay, cost of care, etc., before having that conversation. For example, a traditional 40-hour workweek is 2,080 hours per annum (and probably less with vacation time). And while some might think that 26 weeks off a year equates to fewer hours, 26 weeks of 12-hour shifts totals 2,184 hours.

Per Danielsson, MD, medical director of Swedish Hospital Medicine in Seattle, says his group uses a hybrid seven-on/seven-off schedule that has demonstrated that their cost-of-care delivery is consistently $1,000 to $1,500 less per case than other physicians’ cases at Swedish Medical Center—and those other physicians often take care of patients with the same diagnoses.

Our program started with three physicians in 2004 and has grown to over 30 in 2012. There has been such great value brought to our community and our medical staff and our patients, just over and above what the bottom line would show on a monthly operational statement, that we don’t have the bean-counters knocking on our door.

—Kristi Gylten, MBA, director, hospitalist services, Rapid City (S.D.) Regional Hospital, SHM Administrators’ Committee member

“When you have those kinds of numbers, and you’re doing 7,000 admissions per year, the numbers add up quickly,” Dr. Danielsson says.

Kristi Gylten, MBA, director of hospitalist services at Rapid City Regional Hospital and a member of SHM’s Administrators’ Committee, says hospitalist group leaders should urge their administrations to look at more than just financial statements when judging the value of an HM group, particularly in rural areas.

“Our program started with three physicians in 2004 and has grown to over 30 in 2012,” she says. “There has been such great value brought to our community and our medical staff and our patients, just over and above what the bottom line would show on a monthly operational statement, that we don’t have the bean-counters knocking on our door.”

IPC’s Taylor says a complicating factor in moving away from the seven-on/seven-off format is the passion physicians have for their schedules. Or, to use his words: “You make major changes to schedules at great peril.”

John Frehse, managing partner of Core Practice, a Chicago consultancy that designs and implements labor strategies for shift-work operations, says that managers and administrators looking to change schedules often shy away from the upheaval.

“This emotional and potentially disruptive environment is something that makes them say, ‘We’re getting away with it now, so let’s not change it. Why rock the boat?’” Frehse explains. “They should be saying, ‘What is the methodology to get this out of here and put in something that’s financially responsible for the organization?’”

Practice Concerns

Ten years ago, Dr. Houser found the seven-on/seven-off schedule “a little bit unusual.” Now, his workweek of seven 10-hour days in a row seems natural. Even so, he understands those who voice concerns about hospitalized patients who would not be happy to know their hospitalist was on his 60th, 70th, or 80th hour of work that week.

“The physician’s side of me stays in a mode where I know I have to be a resource to the patient and I have to be a resource to my colleagues, and so I don’t think terms of being mentally drained,” he says. “Whether I’m starting or finishing, I just want to be as fresh as I can to approach those problems and mentally stay in the game that way. If I start thinking about being fatigued or tired, I feel like I won’t be able to provide the type of care that I can for that patient.”

Some groups using the seven-on/seven-off model allow physicians to leave the hospital at slow times while requiring they be on call. That allows hospitalists to recharge a bit midweek while ensuring that there is enough staff to provide coverage. Dr. Martinek says there’s no need to “hold them in the hospital if there is no work to do.” Daytime hospitalists also split admission to lighten the workload, he says.

Taylor says another practical concern for hospitalists working the seven-on/seven-off schedule is how engaged they can be with their institutions, particularly when they aren’t there half the year for committee meetings, staff gatherings—even water cooler conversation.

“I just have difficulty understanding how if half your workforce is gone every other week, how that group of doctors can become as integrated and ingrained and as part of the fabric of that facility as people who are there every week,” he says. “There are people who disagree with me on that, obviously.”

Richard Quinn is a freelance writer in New Jersey.

We have been doing some education with hospitals over the last three or four years of just doing the math. We often give a dual proposal. This is how much it will cost for seven-on/seven-off; this is how much it will cost with the Monday-through-Friday model. Obviously, the Monday-through-Friday model is a lower cost, but it may take a little bit longer to get it staffed.

—Jeff Taylor, president, chief operating officer, IPC: The Hospitalist Co., North Hollywood, Calif.

Robert Houser, MD, MBA, co-medical director of Rapid City Regional Hospital in Rapid City, S.D., left his primary-care practice a little more than 10 years ago to become a hospitalist. At the time, his new schedule—working seven days in a row, then taking off seven days in a row—struck him as odd. But the idea of being able to throw himself completely and alternately into both his job and his family appealed to him. More than a decade later, he still believes his schedule is a perfect mix of personal and professional time.

Bradley Eshbaugh, MBA, FACMPE, chief administrator of Hospitalists of Northern Michigan (HNM) in Traverse City, Mich., and a SHM Administrators’ Committee member, doesn’t see it that way. His hospitalists tell him the work-a-week, skip-a-week schedule is too inflexible for the work-life balance they crave. Even when newly hired physicians accustomed to the week-on/week-off schedule ask if they can continue it, Eshbaugh says, most quickly realize the flexible-schedule option that HNM utilizes offers them a more balanced approach to time off work.

Dr. Houser

Dr. Eshbaugh

Welcome to the world of seven-on/seven-off scheduling, where detractors and supporters often have the same reasons for their differing viewpoints. Those who favor the model say that its simple-to-implement block approach to scheduling allows physicians to know far in advance when their time off is. That allows clinicians to plan their lives way in advance, a carrot hospitalist groups have used for more than a decade to attract new hires. Those who prefer other scheduling methods say the seven-on/seven-off model’s rigidity leaves little flexibility to deal with the unscheduled inevitabilities of life (sickness, personal time, maternity leave, resignations, etc.) and is not the best construct to match staffing to the busiest admissions periods.

And while everyone agrees that the seven-on/seven-off model is among the most popular, there is as yet no clinical data that show whether its practitioners are more or less likely to provide higher-quality care. So the oft-asked question of whether the schedule is sustainable comes down not to care delivery but financial pressure. Three-quarters of HM groups (HMGs) rely on their host hospitals for financial support, and that support-per-FTE at nonacademic groups serving only adults rose to an median of $140,204 this year, according to SHM’s 2012 State of Hospital Medicine report—a 40% increase over data in the 2010 SHM/MGMA‐ACMPE survey.

“When we started in this business 15 years ago, the average hospital might have three to five hospitalists, maybe a subsidy of $300,000 to $500,000,” says Martin Buser, a partner in Hospitalist Management Resources of Del Mar, Calif. “That same program today is probably running 15 to 20 hospitalists, a subsidy of $3 million-plus. It’s really strongly on the radar screen for administrators to look at, ‘Can I keep affording this, or do I need to find less expensive ways to get the same result?’”

Viewpoints Vary

The origins of the seven-on/seven-off schedule are a bit murky. Some believe it was borrowed from the shift-work model in the ED. Others think it has roots in the nursing ranks. Still others think that in the nascent days of HM, two- and three-physician groups developed the schedule by simply splitting monthly schedules by weeks. Regardless of pedigree, the model has grown to be just about the most common schedule for HMGs serving adults only. The State of Hospital Medicine report reported that 41.9% of adult groups use the seven-on/seven-off schedule, with 41.6% reporting their schedule as “variable” and “other.”

SHM has never queried hospitalists specifically about their schedules before, so no comparative data are available for information. Interestingly, the State of Hospital Medicine report found that hospitalist management companies and private HM groups were less likely to use the seven-on/seven-off schedule than hospital-owned or academic groups.

Jeff Taylor, president and chief operating officer of IPC: The Hospitalist Co., a national physician group practice based in North Hollywood, Calif., says just 10% of his 1,400 providers nationwide uses the seven-on/seven-off construct. He argues the model “is economically inefficient.” For example, he says, take a hospital with a census of around 60 inpatients per day. An HM group that wants to limit daily censuses to about 15 patients would need four doctors to staff that patient load. Using the seven-on/seven-off schedule, the group would need eight dayside hospitalists (not counting nocturnists). In a more traditional staffing model of a five-day workweek and call coverage, a group likely could handle the same workload with five FTE hospitalists, Taylor says.

“We have been doing some education with hospitals over the last three or four years of just doing the math,” he adds. “How many doctors would you need to staff this census? … We often give a dual proposal. This is how much it will cost for seven-on/seven-off; this is how much it will cost with the Monday-through-Friday model. Obviously, the Monday-through-Friday model is a lower cost, but it may take a little bit longer to get it staffed.”

Staffing difficulties—particularly recruitment and retention—are a major driver of the popularity of the seven-on/seven-off schedule, says Gregory Martinek, DO, FHM, medical director of Lexington Hospitalists in Altoona, Pa. He says it’s tough to recruit hospitalists to work in a small town in central Pennsylvania, so offering a schedule those physicians want to work is helpful.

Dr. Martinek

In fact, Dr. Martinek offers his hospitalists an extra week of vacation in addition to the 26 weeks they don’t work. That allows some of his foreign-born physicians to take a three-week break from work, which many use as a chance to return to their birth countries.

“We had trouble recruiting when we had a different model,” Dr. Martinek says. “This has really worked for us. It’s allowed us to recruit.”

Cost Concerns

How do HM group leaders answer C-suite questions about whether the expenses associated with the seven-on/seven-off model are worth it? The short answer is data. Know basic metrics on length of stay, cost of care, etc., before having that conversation. For example, a traditional 40-hour workweek is 2,080 hours per annum (and probably less with vacation time). And while some might think that 26 weeks off a year equates to fewer hours, 26 weeks of 12-hour shifts totals 2,184 hours.

Per Danielsson, MD, medical director of Swedish Hospital Medicine in Seattle, says his group uses a hybrid seven-on/seven-off schedule that has demonstrated that their cost-of-care delivery is consistently $1,000 to $1,500 less per case than other physicians’ cases at Swedish Medical Center—and those other physicians often take care of patients with the same diagnoses.

Our program started with three physicians in 2004 and has grown to over 30 in 2012. There has been such great value brought to our community and our medical staff and our patients, just over and above what the bottom line would show on a monthly operational statement, that we don’t have the bean-counters knocking on our door.

—Kristi Gylten, MBA, director, hospitalist services, Rapid City (S.D.) Regional Hospital, SHM Administrators’ Committee member

“When you have those kinds of numbers, and you’re doing 7,000 admissions per year, the numbers add up quickly,” Dr. Danielsson says.

Kristi Gylten, MBA, director of hospitalist services at Rapid City Regional Hospital and a member of SHM’s Administrators’ Committee, says hospitalist group leaders should urge their administrations to look at more than just financial statements when judging the value of an HM group, particularly in rural areas.

“Our program started with three physicians in 2004 and has grown to over 30 in 2012,” she says. “There has been such great value brought to our community and our medical staff and our patients, just over and above what the bottom line would show on a monthly operational statement, that we don’t have the bean-counters knocking on our door.”

IPC’s Taylor says a complicating factor in moving away from the seven-on/seven-off format is the passion physicians have for their schedules. Or, to use his words: “You make major changes to schedules at great peril.”

John Frehse, managing partner of Core Practice, a Chicago consultancy that designs and implements labor strategies for shift-work operations, says that managers and administrators looking to change schedules often shy away from the upheaval.

“This emotional and potentially disruptive environment is something that makes them say, ‘We’re getting away with it now, so let’s not change it. Why rock the boat?’” Frehse explains. “They should be saying, ‘What is the methodology to get this out of here and put in something that’s financially responsible for the organization?’”

Practice Concerns

Ten years ago, Dr. Houser found the seven-on/seven-off schedule “a little bit unusual.” Now, his workweek of seven 10-hour days in a row seems natural. Even so, he understands those who voice concerns about hospitalized patients who would not be happy to know their hospitalist was on his 60th, 70th, or 80th hour of work that week.

“The physician’s side of me stays in a mode where I know I have to be a resource to the patient and I have to be a resource to my colleagues, and so I don’t think terms of being mentally drained,” he says. “Whether I’m starting or finishing, I just want to be as fresh as I can to approach those problems and mentally stay in the game that way. If I start thinking about being fatigued or tired, I feel like I won’t be able to provide the type of care that I can for that patient.”

Some groups using the seven-on/seven-off model allow physicians to leave the hospital at slow times while requiring they be on call. That allows hospitalists to recharge a bit midweek while ensuring that there is enough staff to provide coverage. Dr. Martinek says there’s no need to “hold them in the hospital if there is no work to do.” Daytime hospitalists also split admission to lighten the workload, he says.

Taylor says another practical concern for hospitalists working the seven-on/seven-off schedule is how engaged they can be with their institutions, particularly when they aren’t there half the year for committee meetings, staff gatherings—even water cooler conversation.

“I just have difficulty understanding how if half your workforce is gone every other week, how that group of doctors can become as integrated and ingrained and as part of the fabric of that facility as people who are there every week,” he says. “There are people who disagree with me on that, obviously.”

Richard Quinn is a freelance writer in New Jersey.

We have been doing some education with hospitals over the last three or four years of just doing the math. We often give a dual proposal. This is how much it will cost for seven-on/seven-off; this is how much it will cost with the Monday-through-Friday model. Obviously, the Monday-through-Friday model is a lower cost, but it may take a little bit longer to get it staffed.

—Jeff Taylor, president, chief operating officer, IPC: The Hospitalist Co., North Hollywood, Calif.

Robert Houser, MD, MBA, co-medical director of Rapid City Regional Hospital in Rapid City, S.D., left his primary-care practice a little more than 10 years ago to become a hospitalist. At the time, his new schedule—working seven days in a row, then taking off seven days in a row—struck him as odd. But the idea of being able to throw himself completely and alternately into both his job and his family appealed to him. More than a decade later, he still believes his schedule is a perfect mix of personal and professional time.

Bradley Eshbaugh, MBA, FACMPE, chief administrator of Hospitalists of Northern Michigan (HNM) in Traverse City, Mich., and a SHM Administrators’ Committee member, doesn’t see it that way. His hospitalists tell him the work-a-week, skip-a-week schedule is too inflexible for the work-life balance they crave. Even when newly hired physicians accustomed to the week-on/week-off schedule ask if they can continue it, Eshbaugh says, most quickly realize the flexible-schedule option that HNM utilizes offers them a more balanced approach to time off work.

Dr. Houser

Dr. Eshbaugh

Welcome to the world of seven-on/seven-off scheduling, where detractors and supporters often have the same reasons for their differing viewpoints. Those who favor the model say that its simple-to-implement block approach to scheduling allows physicians to know far in advance when their time off is. That allows clinicians to plan their lives way in advance, a carrot hospitalist groups have used for more than a decade to attract new hires. Those who prefer other scheduling methods say the seven-on/seven-off model’s rigidity leaves little flexibility to deal with the unscheduled inevitabilities of life (sickness, personal time, maternity leave, resignations, etc.) and is not the best construct to match staffing to the busiest admissions periods.

And while everyone agrees that the seven-on/seven-off model is among the most popular, there is as yet no clinical data that show whether its practitioners are more or less likely to provide higher-quality care. So the oft-asked question of whether the schedule is sustainable comes down not to care delivery but financial pressure. Three-quarters of HM groups (HMGs) rely on their host hospitals for financial support, and that support-per-FTE at nonacademic groups serving only adults rose to an median of $140,204 this year, according to SHM’s 2012 State of Hospital Medicine report—a 40% increase over data in the 2010 SHM/MGMA‐ACMPE survey.

“When we started in this business 15 years ago, the average hospital might have three to five hospitalists, maybe a subsidy of $300,000 to $500,000,” says Martin Buser, a partner in Hospitalist Management Resources of Del Mar, Calif. “That same program today is probably running 15 to 20 hospitalists, a subsidy of $3 million-plus. It’s really strongly on the radar screen for administrators to look at, ‘Can I keep affording this, or do I need to find less expensive ways to get the same result?’”

Viewpoints Vary

The origins of the seven-on/seven-off schedule are a bit murky. Some believe it was borrowed from the shift-work model in the ED. Others think it has roots in the nursing ranks. Still others think that in the nascent days of HM, two- and three-physician groups developed the schedule by simply splitting monthly schedules by weeks. Regardless of pedigree, the model has grown to be just about the most common schedule for HMGs serving adults only. The State of Hospital Medicine report reported that 41.9% of adult groups use the seven-on/seven-off schedule, with 41.6% reporting their schedule as “variable” and “other.”

SHM has never queried hospitalists specifically about their schedules before, so no comparative data are available for information. Interestingly, the State of Hospital Medicine report found that hospitalist management companies and private HM groups were less likely to use the seven-on/seven-off schedule than hospital-owned or academic groups.

Jeff Taylor, president and chief operating officer of IPC: The Hospitalist Co., a national physician group practice based in North Hollywood, Calif., says just 10% of his 1,400 providers nationwide uses the seven-on/seven-off construct. He argues the model “is economically inefficient.” For example, he says, take a hospital with a census of around 60 inpatients per day. An HM group that wants to limit daily censuses to about 15 patients would need four doctors to staff that patient load. Using the seven-on/seven-off schedule, the group would need eight dayside hospitalists (not counting nocturnists). In a more traditional staffing model of a five-day workweek and call coverage, a group likely could handle the same workload with five FTE hospitalists, Taylor says.

“We have been doing some education with hospitals over the last three or four years of just doing the math,” he adds. “How many doctors would you need to staff this census? … We often give a dual proposal. This is how much it will cost for seven-on/seven-off; this is how much it will cost with the Monday-through-Friday model. Obviously, the Monday-through-Friday model is a lower cost, but it may take a little bit longer to get it staffed.”

Staffing difficulties—particularly recruitment and retention—are a major driver of the popularity of the seven-on/seven-off schedule, says Gregory Martinek, DO, FHM, medical director of Lexington Hospitalists in Altoona, Pa. He says it’s tough to recruit hospitalists to work in a small town in central Pennsylvania, so offering a schedule those physicians want to work is helpful.

Dr. Martinek

In fact, Dr. Martinek offers his hospitalists an extra week of vacation in addition to the 26 weeks they don’t work. That allows some of his foreign-born physicians to take a three-week break from work, which many use as a chance to return to their birth countries.

“We had trouble recruiting when we had a different model,” Dr. Martinek says. “This has really worked for us. It’s allowed us to recruit.”

Cost Concerns

How do HM group leaders answer C-suite questions about whether the expenses associated with the seven-on/seven-off model are worth it? The short answer is data. Know basic metrics on length of stay, cost of care, etc., before having that conversation. For example, a traditional 40-hour workweek is 2,080 hours per annum (and probably less with vacation time). And while some might think that 26 weeks off a year equates to fewer hours, 26 weeks of 12-hour shifts totals 2,184 hours.

Per Danielsson, MD, medical director of Swedish Hospital Medicine in Seattle, says his group uses a hybrid seven-on/seven-off schedule that has demonstrated that their cost-of-care delivery is consistently $1,000 to $1,500 less per case than other physicians’ cases at Swedish Medical Center—and those other physicians often take care of patients with the same diagnoses.

Our program started with three physicians in 2004 and has grown to over 30 in 2012. There has been such great value brought to our community and our medical staff and our patients, just over and above what the bottom line would show on a monthly operational statement, that we don’t have the bean-counters knocking on our door.

—Kristi Gylten, MBA, director, hospitalist services, Rapid City (S.D.) Regional Hospital, SHM Administrators’ Committee member

“When you have those kinds of numbers, and you’re doing 7,000 admissions per year, the numbers add up quickly,” Dr. Danielsson says.

Kristi Gylten, MBA, director of hospitalist services at Rapid City Regional Hospital and a member of SHM’s Administrators’ Committee, says hospitalist group leaders should urge their administrations to look at more than just financial statements when judging the value of an HM group, particularly in rural areas.

“Our program started with three physicians in 2004 and has grown to over 30 in 2012,” she says. “There has been such great value brought to our community and our medical staff and our patients, just over and above what the bottom line would show on a monthly operational statement, that we don’t have the bean-counters knocking on our door.”

IPC’s Taylor says a complicating factor in moving away from the seven-on/seven-off format is the passion physicians have for their schedules. Or, to use his words: “You make major changes to schedules at great peril.”

John Frehse, managing partner of Core Practice, a Chicago consultancy that designs and implements labor strategies for shift-work operations, says that managers and administrators looking to change schedules often shy away from the upheaval.

“This emotional and potentially disruptive environment is something that makes them say, ‘We’re getting away with it now, so let’s not change it. Why rock the boat?’” Frehse explains. “They should be saying, ‘What is the methodology to get this out of here and put in something that’s financially responsible for the organization?’”

Practice Concerns

Ten years ago, Dr. Houser found the seven-on/seven-off schedule “a little bit unusual.” Now, his workweek of seven 10-hour days in a row seems natural. Even so, he understands those who voice concerns about hospitalized patients who would not be happy to know their hospitalist was on his 60th, 70th, or 80th hour of work that week.

“The physician’s side of me stays in a mode where I know I have to be a resource to the patient and I have to be a resource to my colleagues, and so I don’t think terms of being mentally drained,” he says. “Whether I’m starting or finishing, I just want to be as fresh as I can to approach those problems and mentally stay in the game that way. If I start thinking about being fatigued or tired, I feel like I won’t be able to provide the type of care that I can for that patient.”

Some groups using the seven-on/seven-off model allow physicians to leave the hospital at slow times while requiring they be on call. That allows hospitalists to recharge a bit midweek while ensuring that there is enough staff to provide coverage. Dr. Martinek says there’s no need to “hold them in the hospital if there is no work to do.” Daytime hospitalists also split admission to lighten the workload, he says.

Taylor says another practical concern for hospitalists working the seven-on/seven-off schedule is how engaged they can be with their institutions, particularly when they aren’t there half the year for committee meetings, staff gatherings—even water cooler conversation.

“I just have difficulty understanding how if half your workforce is gone every other week, how that group of doctors can become as integrated and ingrained and as part of the fabric of that facility as people who are there every week,” he says. “There are people who disagree with me on that, obviously.”

Richard Quinn is a freelance writer in New Jersey.