Use Outside Help

Addressing the clinical and political issues raised by the use of non-housestaff services is one of the biggest challenges facing hospitalists at academic medical centers, according to a paper in this month’s issue of the Journal of Hospital Medicine.

Lead author Niraj Sehgal, MD, assistant clinical professor of medicine at the University of California, San Francisco (UCSF), and colleagues studied the non-housestaff services at five academic medical centers around the United States to identify what it takes to make the best use of non-housestaff services.

Reliance on these services will grow largely because of restrictions established in 2003 by the Accreditation Council of Graduate Medical Education (ACGME), which limit residents to an 80-hour workweek.

Read this Research

Find this study (“Non-Housestaff Medicine Services in Academic Centers: Models and Challenges”) in the July-August Journal of Hospital Medicine.

What’s more, it is possible that the ACGME may cut hours even more, given that many other countries have lower restrictions.

In other words, “most academic medical centers now realize residents no longer will be providing as much patient care as they used to,” Dr. Sehgal says.

For example, at UCSF, residents’ hours have been reduced by one-third since the restrictions were established. One way to handle the situation was to reduce the number of patient-hours per resident.

However, at the same time that ruling went into effect, UCSF also increased the number of beds in its hospital. In an effort to determine who is best suited to care for these patients, UCSF and other academic centers turned to non-housestaff services to pick up the slack. “Every residency program has struggled with different models,” he explains.

In their paper, Dr. Sehgal and his colleagues identify nine questions to consider in developing non-housestaff medicine services. The questions reflect key challenges facing medical centers that are building these services, such as:

  • System equities: Avoid creating a two-tiered system in which non-housestaff hospitalists who mostly provide clinical care are viewed as second-class citizens compared with academic hospitalists, who also teach and conduct research. This also raises the question of how to define an academic hospitalist;
  • Define the patient mix: Should non-housestaff physicians handle less acute patients, specific patient populations, or all patients above the limit for residents?;
  • Recruitment and retention: Academic centers may have to offer non-housestaff hospitalists incentives, such as teaching or research opportunities, or financial rewards such as student loan forgiveness, to attract talented clinicians; and
  • Compensation and incentives: This should reflect all aspects of the physician’s job, including quality improvement efforts, research activities, and excellence in teaching, as well as clinical productivity.
Smoothly integrating non-housestaff services into day-to-day function is another opportunity for hospitalists to demonstrate their leadership skills, because the use of these services will increase.

“How these questions are answered is often driven by local factors, such as the vision of local leadership and the availability of important resources,” Dr. Sehgal and his coauthors write. “Nevertheless, it is important for hospitals to share their experiences since best practices remain unclear.”

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