Published in the September 2005 issue of Today’s Hospitalist
At the University of Michigan Health Center, Vikas Parekh, MD, arrives at work at 6 a.m. on the days his housestaff team has post-call rounds. To meet the new rules that limit their workweek to 80 hours, his interns must leave the hospital by 1 p.m. As a result, Dr. Parekh needs to come in early to read notes before rounds.
Kathlyn E. Fletcher, MD, a hospitalist at the Milwaukee VA who works with residents from the Medical College of Wisconsin, says that since the work-hour rules took effect two years ago, she frequently writes her own patient orders. While attendings are technically not supposed to write orders, she says it’s easier than finding housestaff to do the job.
“Do you really call the cross-cover intern to write a simple order?” she asks. “Not only do they not know the patient, but they have less experience. They are busy with their own patients and their own admissions, so I end up going to the floors in the late afternoon or early evening to take care of things that in the past would have been taken care of by residents.”
And at the University of California, San Francisco, discharge coordination, a task that housestaff used to handle, is now the responsibility of hospitalist attendings. Physicians in UCSF’s hospitalist service are also drafting, tweaking and learning new sign-out procedures designed to minimize problems with discontinuity that are the result of an increased numbers of hand-offs and more cross-coverage.
“There are a lot of tasks that have devolved from things that residents used to do to tasks others now do,” explains Robert Wachter, MD, professor and associate chair of medicine at UCSF, where the average number of weekly hours the university’s internal medicine residents work has dropped from 90 to below 80 since 2003.
As Arpana R. Vidyarthi, MD, a UCSF hospitalist, explains somewhat wistfully, “Attendings are having to take much more responsibility in terms of knowing what’s going on with the patients and managing them. It’s very different from the olden days.”
When she talks about the olden days, Dr. Vidyarthi is referring to two years ago, before the Accreditation Council for Graduate Medical Education (ACGME) introduced new limits on residency work hours. Put simply, the rules state that residents can’t work more than 80 hours per week, must have one day off in seven, and must take in-house call no more than every third night.
While the rules affect physicians of all stripes at the nation’s academic medical centers, hospitalists have been hit hard by the fallout of the new 80-hour workweek. Someone has to pick up the duties previously assigned to residents, and anecdotal evidence says that academic hospitals have turned to hospitalists, hiring more physicians or setting up new hospitalist services.
When the ACGME enacted the work hours rules in July of 2003, the rationale was simple: Shifts of 24 hours or longer were compromising both patient safety and resident well-being. While changes to work-hour rules seem to have taken the pressure off of residents, some say that it has simply been transferred to faculty. While everyone assumed that residents could handle anything thrown at them by working harder and faster, the same assumption is now being made of attendings.
“My sense is that people are more stressed and more worried and working harder than they did before to cover the gaps that are now inherent in most systems because the residents are working less,” says Dr. Fletcher, who was the lead author of the largest study of the effects of the work-hours rules on patient safety.
“There is an implicit assumption that the faculty will fill in [when residents have to leave the hospital],” she says, “and that’s hard. Faculty are concerned that they have to do more to put out fires and make sure that nothing bad happens, rather than getting to do the things they used to be able to do, like teaching more and thinking more.”
By all accounts, academic hospitalists have been dramatically affected in how they function. Many say they now work an hour or two longer a day when they are on service. Some are even joining their nonacademic colleagues in working schedules that include in-house night coverage.
Hospitalists also report adding responsibilities to their job descriptions that previously were the bailiwick of housestaff, from responding to codes to staffing rapid response teams. Many also say they are more likely now to work alongside physician assistants, nurse practitioners and moonlighters.
To cope, hospitalist programs have created a patchwork of fl oat systems, and many have reworked schedules and hired more clerical or social workers to cover some of the work formerly assigned to residents. But one of the most common solutions, particularly at hospitals that are operating at full capacity, is to introduce a non-teaching hospitalist service.
The University of Michigan started a non-resident hospitalist service a couple of years ago. Hospitalists in the new program work 12-hour shifts for about seven days, followed by roughly seven days off. Traditional attendings, by comparison, work a standard 25 to 26 days each month on the teaching service.
When patients are admitted to the hospital, they go to Michigan’s resident teams. Once the housestaff teams reach a predefined census goal, the hospital sends patients to the non-resident hospitalist service on an alternating basis with the resident teams. The physicians who work on Michigan’s newer hospitalist service are typically young internists looking for work for a year or two. Many want a way to earn some money before starting a fellowship in a medical subspecialty.
“We have a huge residency program,” Dr. Parekh explains, “and we always have three or four people who want to do that. It fills a niche for us, and it allows us to keep quality residents on as faculty for a short period of time.” UCSF similarly created a new non-teaching hospitalist service this summer. Like Michigan’s, the new program is also designed to be staffed primarily by young physicians just out of residency who are looking for a hospitalist job that will last a couple of years before they go off to do a fellowship.
Instead of working on the UCSF campus, however, the new hospitalist group will work at the UCSF-affiliated Mt. Zion Hospital, which is located a couple of miles from the academic medical center. The new service, which also includes nurse practitioners, will care for patients with a much lower acuity than the individuals seen by the resident services at the main medical center.
The University of Chicago has also created a new hospitalist service to not only see patients that residents don’t have time for, but to train more highly skilled academic hospitalists. In July, the university hired two “hospitalist scholars” to work for a two-year stint.
Because the new hospitalists will see patients half-time, they’ll be paid about half the salary of a regular starting faculty member. During their off hours, the physicians will work toward a master’s degree paid for by the Hospitalist Scholars Training Program in areas such as health studies, public policy, or medical education.
Chad Whelan, MD, director of the new program, says the system will help address workforce issues stemming from the change in resident work rules.
“We have always developed systems that have relied on putting more and more work on the back of the residents,” Dr. Whelan says. “They were here for three or four years and they were willing to work extremely hard. We have never had to develop the infrastructure to handle the workload. Our infrastructure was the residents.”
The second wave
While changes to resident work hours have kept hospitalists busy, UCSF’s Dr. Wachter says it is just the beginning. He predicts that hospitalists are about to get even busier “and that programs are poised for even more growth “because of cutbacks triggered by the duty-hour rules.
He says that one emerging trend, for example, is for orthopedic surgery and neurosurgery programs to ask hospitalists to take on more of the medical management of surgical patients. While this work was previously done by surgical residents, they are in short supply because of changes in work hour rules.
“When duty hours hit,” Dr. Wachter says, “it led to growth in hospital medicine programs across the country. We are now going to see the second wave of that trend.” While the duty-hours rules may help hospitalist services grow in size “and importance “within the nation’s academic medical centers, there is a caveat: Hospitalists need to make sure they’re not viewed and treated by the rest of the hospital as nothing more than “super residents.”
“If you restrict resident hours, somebody has to pick up the slack, and it has become hospitalists,” says Sylvia C.W. McKean, MD, medical director of BWF Hospitalist Service at Brigham and Women’s Hospital in Boston. “Work life balance needs to extend to attending physicians as well as to residents in training.”
To both meet the needs of the hospital’s residency program and cope with a rising inpatient census, the hospitalist group started an inpatient service in July that does not involve residents. The role of the new service is in keeping with the academic mission of the Brigham and Women’s Hospital, Dr. McKean says, but the hospitalists supervise physician assistants (PAs), not residents. “It will be a living laboratory for quality improvement initiatives,” she adds.
Three hospitalist attendings work under the directorship of one experienced hospitalist alongside five PAs on this service, which is known as PACE (Physician Assistant Clinical Educator). Dr. McKean says that the service will give hospitalists the opportunity to teach medical students and PA students, as well as a chance to teach PAs about hospital medicine.
While Dr. McKean says that “further study is needed to determine the optimum balance of resident medical education and clinical service within the constraints of the ACGME rules,” she clearly views the resident work-hour rules as both a threat and an opportunity for hospitalists.
“The special challenge for academic hospitalists is to define our role not as a Band-Aid to fix every problem,” she says, “but to promote a long and satisfying career in academic hospital medicine and to excel as teachers for all members of the multidisciplinary team.”
Deborah Gesensway is a freelance writer who reports on U.S. health care from Toronto, Canada.
Got residents? This program lost them all
While a number of teaching hospitals are scrambling to handle patient care with their residents working fewer hours, at least one hospitalist program is learning how to function with no residents at all.
In July of this year, Vanderbilt University pulled all its residents from St. Thomas Hospital in Nashville. Steven Embry, MD, who has worked as a hospitalist at St. Thomas for eight years, reports that Vanderbilt said it needed to bring the residents in-house because of the change in work hour rules for residents that took effect in July 2003.
To cope with life without 40 residents and four fellows, the group has had to dramatically rework how it organizes shifts, covers nights and takes care of intensive care patients.
To cope with the loss of housestaff, Dr. Embry says St. Thomas’s 12 hospitalists created a swing shift to help cover the early evening hours, the period when housestaff handled the largest number of admissions. Hospitalists also are now part of the code team, something that was previously the responsibility of housestaff.
“The ICU is the biggest loss,” he says. “The critically ill are so time-consuming, so that’s where the residents helped us out the most.”
But Dr. Embry is quick to note that hospitalists miss working with residents not just because they helped out with patient care. “It was enjoyable to work with housestaff.”
How five teaching hospitals are using non-teaching hospitalist services
1. Brigham and Women’s Hospital, Boston. The PACE service “which stands for Physician Assistant Clinical Educators “started in July. It includes five PAs working alongside three newly hired hospitalists, all supervised by one experienced hospitalist. The clinicians on the service see patients without residents; patients are assigned to the service on a first-come, first-served basis.
The hospitalists on the service work one week on and one week off, which is a different schedule than the other academic hospitalists at Brigham and Women’s. Moonlighters cover nights.
The hospital plans to conduct a number of research studies that will compare the quality of care provided by the PACE model to the traditional resident-attending teams. Research will look at everything from mortality and readmission rates to rates of DVT prophylaxis and pneumovax on the different services.
2. University of Chicago. The Hospitalist Scholars Training Program hired its first two hospitalists in June. The university plans to hire two hospitalists a year for two-year stints.
Hospitalist scholars will attend on the uncovered service an average of about 30 percent to 40 percent of their time. That is unlike Chicago’s other five hospitalists, who attend only on teaching services. Hospitalists in the new program will spend the rest of their time pursuing a master’s degree paid for by the program. They will receive a salary that is about halfway between the pay of a starting faculty member and a traditional fellow. The service will include four hospitalist scholars and a nurse practitioner.
The hospitalist scholars service will treat patients who are admitted by moonlighters hired to work at night. It will also take care of morning admissions, freeing up residents to attend morning report, participate in formal teaching rounds and attend noon conferences. One hospitalist scholar will take phone call at night, but a moonlighter will be onsite overnight.
3. Medical College of Wisconsin, Milwaukee. There are two non-teaching PA teams, one put into place just after the duty-hours rules took effect and another added recently. Hospitalist attendings rotate to supervise both resident teams and PA teams. Hospitalists work about four months on the teaching service and two months on the non-teaching service.
To deal with the added workload, the group has hired more hospitalists “three and a half more since last year “including two who work only nights. There are plans to hire two more hospitalists as soon as possible.
4. University of California, San Francisco (UCSF). In July, UCSF hired three hospitalists to staff an overflow non-teaching service that will operate at a community hospital that is part of the UCSF system but in a separate building. This service will cover patients with lower acuity than those on the teaching services.
Their salaries are higher than those of the hospitalists working on the regular academic track to reflect the fact that their job descriptions call for all clinical care and no teaching. They will work alongside nurse practitioners. In addition to their non-teaching work, they will spend 25% of their time serving as traditional ward attendings at Moffitt Hospital, UCSF’s academic medical center.
The hospitalists hired for those posts are not looking for long-term academic hospitalist jobs, but instead are planning to work in those posts for a year or two before starting fellowships.
5. University of Michigan, Ann Arbor. In two years, the hospitalist group has more than doubled in size, growing from eight to 18 physicians.
At first, the new hospitalists were hired to work only on the new non-resident service, which operates like many community hospitalist programs.
The service includes four physician assistants and the hospitalists who work between 15 and 16 12-hour shifts a month.
While the hospitalists hired for the non-resident service originally were to work exclusively in that track, some faculty are now crossing over and working months on both services.