In this new era of hospitalist-employed physicians accompanied by a shift work mentality, how do you counsel your patient when there is a possibility of a plan-of-care change at the change of shift? The standard of care is maintained, but another physician feels that a different part of the algorithm needs to be started or evaluated. In the modern health care environment, hospitalists play a crucial role in ensuring continuous patient care. The nature of their work often involves shift-based schedules, which, while providing round-the-clock care, can also give rise to tensions rooted in differing management styles among colleagues.
This system, while essential, means that patient management is handed off between different physicians multiple times a day. Each hospitalist brings their own clinical judgment, experience, and management style to the table, which can lead to variations in patient care approaches. Unlike some private practices, where there may be unscheduled times of patient collaboration among colleagues, the same cannot be said for the hospitalist model.
For instance, in my discipline, trial of labor after a cesarean section (C-section) is always a sticking point. Several factors influence each physician’s decision to manage these particular cases. Liability, anesthesia availability, capabilities of the labor and delivery floor, rapid assistance in an emergency, and blood banks’ accessibility all play a role in an individual’s comfort level. Parameters and protocols may have been established beforehand, but every clinical case is different. One person’s comfort may be another person’s nightmare.
I listened as two colleagues argued over whether or not a patient with a history of two C-sections should be allowed to deliver vaginally. The physician on call at the time of admission felt the patient fulfilled American College of Obstetricians and Gynecologists definitions to proceed with reassuring fetal heart tones. The oncoming physician did not feel comfortable and changed the plan. Ultimately, the patient underwent a repeat C-section. Unfortunately, this caused tension between the colleagues, which resulted in meetings and administration with reconfirmation of standard of care.
Different hospitalists may have varying clinical approaches and decision-making styles, which can lead to conflicts or disagreements, especially if one physician feels their management plan is being altered without adequate justification. Egos are involved, feelings get hurt, and the tension sometimes results in unprofessional behavior.
Yes, the main result is to do the best for the patient no matter the management. I expect the best care for the patient from my colleagues; it’s how we get there that’s the conflict.
Shift work necessitates multiple handoffs, where patient care responsibilities are transferred between hospitalists. Effective communication during these transitions is crucial but can be difficult to achieve consistently. Incomplete or unclear handoffs can lead to misunderstandings about patient status and care plans. Hospitals often implement standardized protocols to mitigate variability, but individual interpretation and application of these protocols can still vary, affecting colleague relations. As hospital systems become bigger, the fragmentation of care becomes an even bigger issue.
For instance, our health care systems typically move hospitalists around from one hospital to another to cover shifts and continue 24-hour coverage as contracted with different departments. Different physicians are introduced to different staff and cultures. The situation, background, assessment, and recommendation (SBAR) are done, but the oncoming physician does not agree and may not initiate the plan of care. The hospitalists may know each other or may not. They may not be familiar with each other’s practice management. In this case, we encourage the core team leaders to be open to “off-shift” discussions. This can decrease conflict and delays in the plan of care for the patient.
Building a cohesive team can be challenging when hospitalists work different shifts and may not have regular opportunities to interact outside of patient care transitions. Differences in experience levels can create hierarchical tensions, with junior hospitalists feeling overshadowed or undervalued and senior hospitalists potentially feeling their expertise is not fully respected.
Once again, implementing structured handoff protocols, such as SBAR, can improve communication and reduce misunderstandings in hospital settings. However, this may not be enough. At our institution, we hold regular team meetings to discuss patient care, management strategies, and any concerns that can enhance understanding and alignment among colleagues. We try to educate and keep a level of “open” communication so physicians and the APP feel a continuous connection to each other. This includes feeling comfortable enough to call a colleague to discuss a case, even if they are not “on shift.” This benefits the team and is a positive adjunct to good patient care.
Organizing social events and team-building activities can strengthen relationships and improve teamwork among colleagues but is not always possible with people on different shifts.
Providing training in conflict resolution and communication skills can equip physicians with the tools to navigate and resolve disagreements constructively.
Offering mediation services for unresolved conflicts can help maintain a positive and professional work environment.
Establishing mentorship programs can promote knowledge sharing and mutual respect between junior and senior physicians.
Encouraging ongoing professional development can help physicians stay updated with the latest practices, reducing discrepancies in management styles.
Shift work in hospital settings can lead to challenges related to communication, variability in management styles, and interpersonal dynamics. By implementing effective communication strategies, promoting team-building activities, providing conflict resolution training, and supporting professional development, health care organizations can enhance colleague relations and improve the overall work environment for hospitalists.
How do you ensure uninterrupted patient care with shift work? Share in the comments.
Dr. Rohana Motley White is an obstetrician/gynecologist in Orlando. She enjoys traveling, reading, and hanging out with her daughter. Dr. Motley White is a 2023–2024 Doximity Op-Med Fellow.
Illustration by April Brust
