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At Hennepin County Medical Center (HCMC) in downtown Minneapolis, MN, a conversation between the chief of the Department of Internal Medicine, a resident training in internal medicine, and an administrator triggered the launch of a pilot program to try an innovative scheduling model. The question they were discussing was: “Why can't we get more internists to practice primary care?” The resident responded that the schedule of a primary care physician appeared far less appealing than that of non-primary care specialists. In addition, there was a sense that the work of primary care physicians carried over past the end of a work day to a greater degree than that of hospitalists. The chief pitched an idea to two internists who had been hospital-based for a decade: switch to a primary care clinic outside the hospital with a schedule that is more responsive to your preferences and responsibilities.
Peter Sandgren, MD, and Veeti Tandon, MD, a married couple who both trained at HCMC, were invited to set up a primary care clinic at the medical center with a schedule tailored to their needs. Sandgren and Tandon were comfortable with the seven days on/seven days off schedule used by many hospitalists. Their initial plan was to use a similar schedule for the clinic, with each physician working alternating 7-day periods. The on-week would include 10 four-hour sessions: mornings, afternoons, and evenings on weekdays (except Wednesday morning), plus Saturday mornings. Both Sandgren and Tandon opted for part-time work; full-time requires 12 sessions per week.
To start, the clinic included Sandgren and Tandon, three nurse practitioners, and two embedded clinical psychologists. “We've chosen 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.”
Wednesday mornings are dedicated to a care coordination meeting. The session is attended by both physicians, as well as nurses, medical assistants, a pharmacist, and the two 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 provider's patient panel and daily census with a focus on chronic disease management (e.g., 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 Sandgren and Tandon have encountered in launching the clinic has been keeping up with the electronic health record inbox during their off weeks. They have chosen to work one session during their off week to spend time on inbox messages.
Sandgren and Tandon say the keys to success for the schedule and the clinic overall have been the coordination meeting, the presence of nurse practitioners with whom to collaborate, the small size of the clinic, and 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,” says Sandgren.
It's too soon to say whether the new model will help attract or retain primary care physicians; however, Sandgren and 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 has also expanded access for patients, providing more evening hours than many of the other clinics. The small size of the group has allowed for piloting of 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 two physicians. The first physician has signed on for a flexible schedule that is not seven days on/seven days off. A second physician will be recruited soon to craft a coordinated schedule for the second pod.
According to Tandon, the ability to influence their schedules is important for the long term. “We can't think only of the patient. We need to create something that is sustainable for the physician. We need to balance access for patients with flexibility for us.”
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