In an ideal world, the directors of hospitalist programs and residency programs would be perfectly aligned in their efforts to advance the hospital’s financial health, education initiatives, and quality of patient care. In reality, friction among them is common.
The roots of the tensions lie in their differing responsibilities.
“The goals for residency programs, which are governed by rules of the ACGME [Accreditation Council for Graduate Medical Education], don’t necessarily always match with those of the hospitalists for patient care delivery,” notes Alpesh Amin, MD, MBA, FACP, professor and chief, general internal medicine, executive director and founder of the hospitalist program at the University of California Irvine (UCI), and also associate program director of the UCI internal medicine residency program. Dr. Amin is also a member of SHM’s board of directors.
In teaching hospitals, residency program directors must ensure their residents comply with the ACGME work hour and patient load caps. These requirements limit residents to an 80-hour workweek and continuous on-site duty no longer than 24 consecutive hours, and multiresident internal medicine teams to no more than 24 patients at a time.
Compliance can pressure house staff hospitalists to pick up the slack. In addition, to advance the educational mission, a residency program director might want to have his or her residents read three hours a day. But the hospitalist, charged with caring for as many patients as possible, may want residents on his or her service to spend that time admitting, managing, and discharging patients.
William Iobst, MD, designated institutional official at Lehigh Valley Hospital in Allentown, Pa., and associate program director of the hospital medicine program, knows these issues firsthand. “The conflict usually comes up in that most hospitalist programs are put in place to provide streamlined and efficient service in the hospital,” he says. “To that end, they have targeted goals of improving efficiency, reducing length of stay, and using their expertise in repetitive treatments of the same condition [such as congestive heart failure or pneumonia] over time.”
Hospitalists, says Dr. Iobst, “get very efficient at providing care. In some ways, asking a hospitalist to serve as an educator potentially disrupts that charge of efficiency, quality, and rapid transit through the hospital. So, they may be put in a position of having conflicting bosses.”
—Alpesh Amin, MD, MBA, FACP, professor and chief, general internal medicine, executive director and founder of the hospitalist program at the University of California Irvine
Some hospitalists work in both worlds: They serve as associate program directors for residency programs as well as directors of hospitalist programs. This can set the stage for conflicts.
Such is the case with Michael Pistoria, DO, chief of the division of hospital medicine at Lehigh Valley Hospital and associate program director for the free-standing medicine residency program.
“There are times when something in one area is impacting—sometimes adversely—the other areas for which I’m responsible,” he says. “One big issue that we really struggle with is how to deal with the [sometimes overwhelming] volume of patients when residents are able to do less and less according to ACGME rules.”
This is especially tricky, he says, when mapping coverage for overnight shifts. Not only are residents’ work hours capped, but the Residency Review Committee (RRC), which provides ACGME oversight, also stipulates that residents must have continuity with patients. They are not supposed to admit patients who won’t be seen by a resident the next day. This can create tension between the resident and hospitalist programs—especially when the latter face high patient loads.
One solution at Lehigh Valley has been to rotate resident teams admitting patients in the afternoon and evening hours, but only to their service. This ensures resident continuity for those patients and meets ACGME requirements. All other patients are admitted through the hospitalist service.
Capitalize on Uniqueness
It’s crucial to identify areas where hospitalists and program directors can dovetail efforts so the programs are not at loggerheads.
Program directors and medical directors can have a positive effect on meshing residency and private hospitalist programs. “We have to talk with our hospitalists, explain that we have no way around this [ACGME guideline], how it will impact them, and figure out a way [together] to help minimize that impact,” says Dr. Pistoria.
Dr. Amin believes the goals of the residency and hospital medicine programs can be mutually beneficial. “Some people may have inherent biases against the concept of hospital medicine,” he says. “But hopefully, as time goes on, you’ll find more and more hospitalists serving in program director or associate program director roles. My view is that the residency program ought to turn to the hospitalist when they’re looking for general inpatient, consultative, and perioperative curricular development. They could turn to hospitalists in the same way that they ask nephrology groups to help design a nephrology curriculum.”
The situation requires planning to make sure all stakeholders can accept the impact of having residents, Dr. Iobst points out. “The program director’s role is to work with the hospitalists and make sure that they understand that the residents have to adhere to their service caps,’’ he says. “The issue then would be to find other meaningful learning opportunities for residents that would not involve admitting patients.”
Dr. Iobst agrees with Dr. Amin. Some opportunities, he says, “are to ensure that a program director is capitalizing on what a hospitalist does.” If hospitalists are offering only “another general internal medicine inpatient service rotation to residents,” they are not capitalizing on their own uniqueness. Instead, hospitalists could offer hospital medicine as a senior rotation for residents. The residents could receive training and exposure to quality improvement; the business aspects of medicine, including the importance of length of stay and appropriate ICD-9 coding; and an evidence-based approach to care.
Although ACGME work-hour caps sometimes create pressures, it’s up to hospitalists to be flexible with residents on their service, says Hasan Shabbir, MD, a hospitalist and associate medical director of quality at Emory Johns Creek Hospital in Duluth, Ga., and an assistant professor of medicine at Emory University in Atlanta.
This is especially true when particular residents are on night float rotation; admitting and managing patients into the early morning can bring them close to their work-hour caps. “We have to be cognizant of that [the ACGME guidelines], give them leeway, and let them go early whenever possible,” he says.
Having the right attitude toward residents is key. “I think we’ve approached [teaching residents] with the attitude that we’re quite fortunate to have residents to do a lot of the upfront work and to be able to help and teach them along the way,” explains Dr. Shabbir. “I think the negative feeling [about residents] is often tied to expectations. If one comes into our program, for example, and expects to just lie back and let the residents do all the work, that would be a bad expectation to have. All of us, having been [residents] at some point, can understand what residents go through. Not every hospitalist has the good fortune of having residents with them.”
There is value to having residents, agrees Dr. Iobst. “There’s the value of serving as a mentor; of training future colleagues; and the value for people who are enthused by the opportunity to teach. The key is to clearly establish all the boundaries and get them on the table to begin with, define which ones are absolutely required and are not flexible, and to ensure that the administration of the hospital that is supporting the hospitalists understands that need.”
Dr. Amin believes program directors need hospitalists to serve as faculty and that hospitalists need to take into account residency rules and regulations so the program can retain accreditation status.
“It’s a two-way street,” he says. “It doesn’t help anybody if the residency program is not accredited, and it doesn’t help anybody if the hospitalist faculty members don’t have good morale.” At UC Irvine, he says: “We try not to develop systems that overwhelm the residents; we also try not to develop systems that allow faculty to be overwhelmed. On the other hand, patient care is not predictable all the time, so some of the ACGME rules may put people into difficult situations.”
Goals and Relationships
Dr. Amin believes that if hospitalists and residency program directors can advocate for their own programs and work together for the greater good, they can craft an exponentially better team model.
One way to achieve this is to encourage more hospitalist directors to also serve as associate program directors/program directors of residency programs. This, he says, “could potentially help facilitate a stronger bridge between both programs.”
Within hospitalist groups, directors can encourage understanding about the dual sets of goals. It’s important for group leaders to involve everyone in the group when making decisions so people feel they are part of the process, says Alan L. Wang, MD, chief medical officer at Emory Johns Creek Hospital in Ga., and co-director of the hospitalist program.
Another tool for aligning hospitalists on their team with hospital goals, he says, is to share the patient workload. “One of the most important ways for medical directors to increase their credibility with the team members is to do shift work,” he asserts. “Getting in the trenches allows you to understand the day-to-day issues and problems that your hospitalists face.”
Dr. Shabbir notes that the burden of good relationship building should not fall solely to the group leaders. “There has to be an effort on all sides,” he says. “It can’t work with the leader alone trying. As a hospitalist, I think the focus has to be not only patient care, but also system efficiency, because, in the end, that makes for better overall patient care.”
Dr. Amin and others believe tensions between residency and hospitalist programs will resolve over time, in part due to hospitalists taking associate program director and program director roles, and in part to increased cooperation.
“The hospitalist could be the program director’s best friend and viewed as a vehicle for developing and training residents in system-based practice, competency-based learning and refinement of communication skills,” he says. TH
Gretchen Henkel is a frequent contributor to The Hospitalist.