I heard that there are new resident work-hour rules that preclude interns from spending the night in the hospital. Tell me this isn’t true! I am an old-timer.
Thad Horton, MD
Dr. Hospitalist responds: On Sept. 26, 2010, the Accreditation Council for Graduate Medical Education (ACGME) approved new resident duty-hours and supervision standards; the new rules go into effect July 1. ACGME accredits more than 8,800 medical residency programs in the U.S. in more than 130 specialties and subspecialties. More than 111,000 residents and fellows train in these programs annually. ACGME first instituted duty-hour regulations in 2003; those led to a dramatic decrease in resident work-hours.
Basically, the highlights of the new rules are:
- Residents are limited to 80 hours weekly, averaged over a four-week period, and inclusive of all in-house call activities and moonlighting;
- Residents must be allowed one day free of duty every week (at-home call cannot be assigned on these free days);
- PGY-1 residents cannot work more than 16 hours daily, and residents beyond their PGY-1 year cannot work more than 24 hours daily;
- Residents must have at least eight hours off between shifts, and residents who work a 24-hour shift must have a minimum of 14 hours off before starting another shift;
- Residents cannot work more than six consecutive nights as night float; and
- Residents cannot be scheduled for in-house call more frequently than every third night.
I have not seen any specific prohibition on interns working overnight in the hospital. However, the new rules restrict interns to working no more than 16 hours daily, so that will mean interns who stay overnight in the hospital, until 7 or 8 a.m., cannot begin that overnight shift until 3 or 4 p.m. the day before. That means programs planning to keep their interns in-house overnight will have to be creative in their scheduling.
The demand for innovative scheduling won’t be the only implication of these new regulations. A number of forces have driven the rapid expansion of HM over the past decade. We have seen the development of sizable hospitalist programs at a number of teaching hospitals across the country. Hospitalists at teaching hospitals are not only supervising the care provided by residents, but they are also caring for patients without resident involvement. Since the original ACGME duty-hours cutback in 2002, we have seen the development and expansion of hospitalist-staffed, non-resident-covered medical services at most teaching hospitals across the country. Any further restriction in resident work-hours likely will result in the need to hire additional hospitalists to care for patients.
Virtually all HM programs require financial support to make ends meet. The most recent SHM/MGMA compensation and productivity survey found that the average hospitalist full-time equivalent (FTE) requires a little more than $100,000 of support annually. Regardless of the employer, much of that support comes from the hospital. So it appears that hospitals with teaching programs will end up footing the bill for the new resident regulations. I expect HM programs at teaching hospitals will face pushback from hospital administrators, but hiring additional hospitalists is a cost-effective proposition—and not complying with the ACGME rules is not an option, unless your program wants to risk losing its accreditation.
If you are a hospitalist program leader at a teaching hospital, I encourage you to plan accordingly and discuss the impact of these revisions in duty-hours with your teaching program director and your hospital administration.
Communication, Comfort Zone Key to Managing Hypertensive Emergencies
I just saw a patient in our urgent-care clinic sent from an ophthalmologist’s office with newly diagnosed retinal hemorrhages in both eyes and repeated BPs of 170/115. She had no history of hypertension (HTN) and no other symptoms. Does this qualify as an emergency? I couldn’t find any literature in this regard. My sense was it was an emergency, as her vision seemed to be at risk, so I sent her to the ED for IV meds in a controlled environment. Did I overreact?
Dennis Swanson, MD
Grand Rapids, Mich.
Dr. Hospitalist responds: Thank you for your question. There are numerous potential causes of retinal hemorrhages. Aside from trauma, we most commonly see retinal hemorrhages in patients with diabetic retinopathy and/or HTN. As you know, the retina is the only part of the vasculature that we can visualize noninvasively. This is a good example of why it is always important for providers to perform a fundoscopy on every patient with newly discovered HTN.
Retinal hemorrhage is one of several ocular diseases directly related to HTN. Based on your description, it sounds as if the ophthalmologist discovered the retinal hemorrhages and sent the patient to you, given the concern that uncontrolled HTN was the cause of the hemorrhages. You stated that you sent the patient to the ED because you were concerned the patient’s vision “seemed to be at risk.” Most retinal hemorrhages are asymptomatic unless the macular is affected, in which case the patient experiences a change in their visual acuity. Progressive microvascular changes in the retina can cause a loss of visual acuity. Aside from addressing the underlying problem causing the hemorrhages, laser surgery is the typical treatment of retinal hemorrhages. The laser seals off the abnormally bleeding vessels in the retina.
It would be useful to know about any communication that occurred between you and the ophthalmologist. I imagine the ophthalmologist was going to perform laser surgery but sent the patient to the hospital to address the HTN. If you did not feel comfortable managing the patient’s HTN in the urgent-care clinic, you did the right thing by sending the patient to the ED. It also is important to note that patients with hypertensive retinopathy often have other microvascular diseases, including in the kidneys. This patient should be evaluated for any evidence of proteinuria, which can suggest progressive microvascular renal disease, also as a result of uncontrolled HTN. TH