Learn how a novel scheduling option encouraged former hospitalists to switch to a primary care practice.
The chief of the Department of Internal Medicine at Hennepin County Medical Center (HCMC) in downtown Minneapolis, MN asked a group of internal medicine residents an important question: “Why can't we get more internists to practice primary care?” One resident responded that the schedule of a primary care physician appeared far less appealing than that of non-primary care specialists (such as hospitalists), due to the sense that the work of primary care physicians carried over past the end of a workday to a greater degree than that of hospitalists. This discussion triggered the launch of a pilot program to try an innovative scheduling model.
Developing the Intervention
The chief pitched an idea to 2 internists who had been hospital-based for a decade: switch to a primary care clinic outside the hospital with a schedule that is tailored to your specific needs, eg comparable to your current schedule. These 2 hospitalists, Peter Sandgren, MD, and Veeti Tandon, MD, a married couple who both trained at HCMC, were comfortable with the 7 days on/7 days off schedule used by many hospitalists. They decided to use a similar schedule for the clinic, with each physician working alternating 7-day periods. The on-week included 10 4-hour sessions: mornings, afternoons, and evenings on weekdays (except Wednesday mornings), plus Saturday mornings. To start, the clinic included Dr Sandgren and Dr Tandon, 3 nurse practitioners, and 2 embedded clinical psychologists. Over time, the clinic added medical assistants and a pharmacist.
“We chose a week-on/week-off schedule, but it's not about seven-on/seven-off—it's about having flexibility, so that the schedule goes along with your life. Physicians with younger children may want to work more Saturday mornings and have fewer evening sessions. Others may want more evenings and fewer Saturdays.”
—Veeti Tandon, MD
Wednesday mornings were dedicated to a care coordination meeting. This session is attended by both physicians, as well as nurse practitioners and/or nurses, medical assistants, a pharmacist, and 2 clinical psychologists. The session is considered direct patient care time. During the meeting, the multidisciplinary group discusses care plans, consults, and medication management. They consider each practitioner's patient panel and daily census with a focus on chronic disease management (eg, diabetes management and preventive care, colon cancer screening, depression screening). The meeting is also an opportunity to check that diagnoses and complexity scores are correct, and to streamline and optimize billing.
The largest obstacle that Dr Sandgren and Dr Tandon encountered in launching the clinic was keeping up with the electronic health record (EHR) inbox during their off weeks. They chose to work 1 session during their off week to spend time on inbox messages.
Dr Sandgren and Dr Tandon say the keys to success for the schedule and the clinic overall are:
The care coordination meeting
The presence of nurse practitioners with whom they collaborate
The small size of the clinic
The group's intentionally supportive culture
“We have a clear identity as a group. We understand that the schedule matters and that physicians won't last or will be unhappy if the schedule doesn't work. It helps that we are a group of five clinicians; it makes it easier to reconcile different interests related to the schedule.”
—Peter E. Sandgren, MD
It's too soon to say whether the new model will help attract or retain primary care physicians; however, Dr Sandgren and Dr Tandon are pleased with the schedule and their ability to transition to primary care, as both physicians were ready for a career shift. The system also expanded access for patients, providing more evening hours than many other clinics. The small size of the group allowed them to pilot new care processes, such as the use of scribes to decrease the burden of data entry.
The group is creating a second pod within the clinic, with positions for another 2 physicians. The first physician signed on for a flexible schedule that is not 7 days on/7 days off. A second physician will be recruited soon to craft a coordinated schedule for the second pod.
According to Dr Tandon, the ability to influence their schedules is important for long-term success.
“We need to create something that is sustainable for the physician. We need to balance access for patients with flexibility for us.”
—Veeti Tandon, MD
Hennepin County Medical Center is a part of Hennepin Healthcare, an integrated system of care that includes a nationally recognized Level I Adult and Pediatric Trauma Center, an acute care hospital, and a clinic system with primary care clinics located in Minneapolis and across Hennepin County. The health care system includes a 484-bed academic medical center, a large outpatient Clinic & Specialty Center, and a network of clinics. Hennepin Healthcare has a large psychiatric program, home care, and hospice, and operates a research institute, innovation center, and philanthropic foundation. The system is operated by Hennepin Healthcare System, Inc., a subsidiary corporation of Hennepin County.