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From: The Hospitalist, August 2008

Be clear, fair when adding non-housestaff services to your hospitalist group

by Norra MacReady

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.”

To explore how different centers and services address these issues, they compared the non-housestaff medicine services at Brigham and Women’s Hospital in Boston, Emory University in Atlanta, the University of Michigan in Ann Arbor, Northwestern University Medical Center in Chicago, and UCSF. The information was obtained from representatives at each center and was current as of July 2007.

The services ranged in age from two to five years old and covered 168 to 212 clinical days per year, or 15 to 20 shifts per month. Depending on the number of hospitalists in the service, they saw anywhere from 12 to 95 patients per day.

Further, they all provided coverage for 50% of weekends. For night coverage, one service used dedicated nocturnists, two relied exclusively on moonlighters, and the remainder split coverage between the two.

All the services were located within the university hospital, except for the one at UCSF, which was at an outlying affiliated hospital.

Compensation for non-housestaff hospitalists matched that of staff physicians at two hospitals; the other three hospitals offered non-housestaff physicians some type of financial incentive, either in the form of higher salary, student loan forgiveness, or a combination of the two.

This is an interesting era for hospitalists, who are striving to carve an academic niche for themselves while still performing their clinical duties, Dr. Sehgal notes.

Among the ways they can achieve that is by becoming more involved in other areas of medical center operations, such as information technology, quality and system improvements, and committee work.

Handled properly, these opportunities to collaborate can increase hospitalist prestige and visibility, as they become more involved in hospital leadership and research and share management responsibilities with their medical and surgical colleagues.

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, Dr. Sehgal adds. This makes it necessary to keep studying the outside services and identifying the ways in which they differ from their housestaff counterparts in order to maximize their contributions.

This study shows that creating non-housestaff services involves the consideration of several important elements, including the patients to be seen by those services, and staffing issues, such as whether the service should be composed exclusively of hospitalists, or if other specialties also should be included.

Hospitalists will have to monitor quality control issues and staff retention, and make sure a two-tiered system does not develop between housestaff and non-housestaff physicians. “So far, there has been very little written about this,” Dr. Sehgal concludes. TH

Norra MacReady is a medical writer based in California.


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