Effective July 1, the Accreditation Council for Graduate Medical Education (ACGME) is adopting rules changes to further restrict the number of patients internal medicine residents follow. The impact of this change may reach beyond academic institutions and teaching services. Non-teaching services and institutions may see some fallout, as hospital administration shuffles caseloads of residents and hospitalist attendings. The potential results likely will impact resident training, hospitalist training, and hospitalist practice management, namely recruitment and hospitalist job satisfaction.
Why the Change?
With the 2003 restrictions on resident work-hours duty and now the capping of patient caseloads, the ACGME is attempting to ensure residency programs are not viewed as a source of cheap labor and excessive stress. Also, “the Residency Review Committee (RRC) is cognizant too much service can be a barrier to education,” says Lenny Feldman, MD, a hospitalist and associate program director at Johns Hopkins Medical Center in Baltimore. But there is a danger in the reverse: too little service may undersupply residents with the depth and breadth of cases they need under their belts to competently enter practice. “Education should be the foremost mission for residency programs, but trying to find that exact balance between service and education is tough,” Dr. Feldman says.
In a Nutshell
As leader of the 70-hospitalist Health Partners Medical Group in Minneapolis-St. Paul, a University of Minnesota affiliate working with internal medicine residents, Burke T. Kealey, MD, views the ACGME rule change on a professional and personal level. In the big picture, Dr. Kealey observes three main effects:
- Hospitalists will be seeing more patients and probably more patients at night;
- The cost of hospital care will increase for hospitals and hospital medicine groups (HMGs); and
- The experience level of new graduates applying to be hospitalists will diminish.
In essence, there are few ways to handle the looming cap on residents’ patient caseloads. (see Practical Approaches, p. 24) Given the financial constraints imposed by this new, unfunded mandate, and taking into account the fact most residency programs depend on federal funding, it generally is believed increasing the number of residents cannot be considered an option. “Given the looming physician shortage, there is pressure on the federal government to increase the amount of GME support and the number of residency spots,” Dr. Feldman says. “Medical schools have increased enrollment pretty significantly, but the bottleneck is the number of GME-supported residency positions.”
Leslie Flores, MHA, principal with Nelson Flores Hospital Medicine Consultants, and the director of SHM’s Practice Management Institute, believes the new rule dramatically will impact teaching hospitals and HMGs. “I think it is likely to be harder for academic hospitalists, who are working on teaching services, to generate reasonable productivity, which will place an even greater financial burden on academic practices,” she says. “But the larger effect will be that non-teaching services in teaching hospitals will be expected to pick up the slack and, subsequently, grow in order to accommodate the patient numbers.”
Asking staff physicians to increase their patient load, even incrementally, is a poor solution, at best, Dr. Kealey says. And it may be tough for some places to recruit more hospitalists, a function of the hospitalist labor shortage.
William Rifkin, MD, a hospitalist and associate director of clinical medicine at Albert Einstein College of Medicine, and director of the residency program at Jacobi Medical Center, Bronx, N.Y., estimates hospitalist jobs in teaching institutions will increasingly morph into non-teaching positions. “Where currently the ratio of teaching to nonteaching jobs is 50-50,” Dr. Rifkin says, “by 2009, 80% of internal medicine training programs will have to build or expand a new, non-teaching service, and more than half of hospitalist duties will be non-teaching.”