The Cost of Regulation

The Hospitalist. 2010 June;2010(06):

June 1, 2010 | The Hospitalist

“The residency work-hour restrictions have inhibited our ability to train people to work as efficiently as trainees who were taught in the past,” says Dr. Frost, an SHM board member. “That doesn’t necessarily mean you can’t teach people to work more efficiently . . . but in the future, my hope is that residency training programs will recognize the deficit that exists in personal work efficiencies between their completion and their responsibilities as a hospitalist.”

To that end, Dr. Frost works with others to develop both structured curriculum and classroom didactics that help new hospitalists make up for gaps in preparation that weren’t addressed in residency. In some cases, that can be practice management and billing issues, but often, according to Dr. Frost, it is addressing personal workflow and bridging the “unnatural discontinuity” in patient care from residency to the real world.

“There is a cost to this investment for the future,” Dr. Frost adds. “If people don’t recognize the potential return on investment as being critical to the development of an educated workforce—an efficient and competent workforce—and thus critical to the retention of high-performing hospitalists, they are selling themselves, unfortunately, significantly short.”

Work-Hour Regulations

Rules regarding capping residents’ patient caseloads on IM inpatient rotations (2009 changes in italics):

A first-year resident must not be assigned more than five new patients per admitting day; an additional two patients may be assigned if they are in-house transfers from the medical services;
A first-year resident must not be assigned more than eight new patients in a 48-hour period;
A first-year resident’s census must be no more than 10 patients;
When supervising more than one first-year resident, the supervising resident must not be responsible for the supervision or admission of more than 10 new patients and four transfer patients per admitting day or more than 16 new patients in a 48-hour period;
When supervising one first-year resident, the supervising resident must not be responsible for the ongoing care of more than 14 patients; and
When supervising more than one first-year resident, the supervising resident must not be responsible for the ongoing care of more than 20 patients.

Source: American Council on Graduate Medical Education

Caught in the Middle

One man’s trash is another man’s treasure, the axiom tells us. Well, in healthcare circles, that could just as easily read: The woes of academic hospitalists are the wealth of community hospitalists.

The new rules “may result in more opportunities for hospitalists to provide needed clinical services,” Dr. Wright says.

The long-term implications, though, remain to be seen. While academic hospitalists say they have seen preliminary increases in care-delivery costs because of the latest rules changes, many say it’s too soon to tell just how high those costs might climb and what ripple effect might follow.

Some physicians, including Dr. Del Valle, note that while the 2009 changes and the expectation of more changes in 2011 are cause for attention, that doesn’t translate to cause for concern. In 2003, months before the 80-hour workweek rules were first put in place by ACGME, many of the same debates were already under way: How will the faculty of IM residency programs cope? How will institutions pay the bills while putting money aside for other physicians picking up the slack?

“This is a pendulum,” Dr. Del Valle says. “I think it will come back to a balanced place.”

Dr. Fried, who is more optimistic that the residency rules can have a positive, long-term effect, agrees. He says residency caps and limits should not be viewed as “things that limit education. We [should] look at them as things that ensure education continues while patient care continues.” TH