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Dr. Hospitalist

Resident Restrictions Might Be HM Game-Changer

I have heard regulators are thinking about further restricting resident work hours. Is this true? Do you think this has helped or hindered patient care? Is there any discussion about restriction of hospitalist work hours? I am working harder than I ever did during training. Have these rules affected the hospitalist field?

H. Jackson, MD, Dover, Del.

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Dr. Hospitalist responds:

In 2003, the Accreditation Council for Graduate Medical Education (ACGME) established rules to limit the resident work schedule. The rules included an 80-hour limit on resident workweeks. Training programs around the country experienced difficulties in complying with the rules. Many hospitals established or expanded existing hospitalist programs to help their training programs comply with the rule change, which meant more jobs for hospitalists. From this perspective, the rules were a boon for hospitalists. But the rules also had some unintended consequences. Shorter resident shifts meant more handoffs, and this resulted in an increase in medical errors. Not only do we not do a good job of teaching patient handoffs to our trainees, but most attending physicians also do an inadequate job of communicating patient handoffs.

As you noted, a new report (www.nationalacademies.org/morenews/20081202.html) from the Institute of Medicine (IOM) called for changes to the ACGME rules. The IOM report does not call for a reduction in the 80-hour workweek, but it does recommend several changes to ACGME rules. The IOM calls for residents to work no more than 16 consecutive hours without sleep. It also calls for changes to the present ACGME rules regarding resident time off. Residents should:

  • Have 12 hours off after every night shift, 10 hours off after every day shift, and 14 hours off after any shift of 30 hours;
  • Not be on call in the hospital more frequently than every third night, with no averaging; and
  • Have at least one day off per week, with no averaging.

The IOM report also calls for increased on-site supervision of residents, including immediate access to a supervisory physician for interns. For now, the IOM report is just that—a report. We’ll have to wait and see how ACGME reacts to these recommendations.

What is the potential impact for hospitalists? The work-schedule recommendations could mean residents will work fewer consecutive hours in the hospital. This has the potential to increase the demand for hospitalists to see patients, not only on the medical service, but on other clinical services as well. For example, we may see more hospitalists working with surgeons to manage surgical inpatients. Hospitalist programs will have to figure out a way to work with surgeons without feeling as though the surgeons are “dropping off” patients after surgeries.

With the current shortage of hospitalists, institutions and HM programs could hire more nonphysician clinical providers, such as nurse practitioners and physician assistants. Many hospitalist programs have struggled to incorporate these providers into their workflow in an efficient and cost-effective fashion. Such problems represent opportunities for HM.

The further fragmentation of the resident schedule could create additional patient handoffs. Early in the HM movement, the “voltage drop” issue was a hot topic. Since then, HM has not done enough to standardize the handoff and teach it to others. I encourage all HM programs to resolve the issue of patient handoffs. This is imperative to the safety of our patients.

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