I have doubts: Are there any guidelines about “bouncing” patients between teaching and nonteaching services in a teaching hospital?

Srikanth Seethala, MD

Pittsburgh

Dr. Hospitalist responds: Several thoughts came to my mind when I read your question. What did you mean by the term “bouncing”? When you refer to “nonteaching service,” are you referring to the cohort of inpatients in your teaching hospital cared for by attending physicians without the involvement of trainees? Of course, the most obvious question is what is causing your “doubt”?

As you may know, all U.S. postgraduate physician training programs are governed by the rules and standards set forth by the Accreditation Council for Graduate Medical Education (ACGME). You can find all of ACGME’s rules online at www.acgme.org. Regardless of whether you are a trainee or an attending physician, the ACGME expects the same interpretation and enforcement of their standards.

Our general medical service is divided into the resident-covered service and a separate, nonresident-covered service. Resident-covered service means IM residents are involved in the care of the patient under the supervision of an attending physician. No residents are involved in patient care on the nonresident-covered service. The development of our nonresident-covered service was clearly a product of ACGME duty-hour standards, which were originally enacted in 2003 and recently revised.

Our IM program has the same number of residents that we did before the new rules were put in place. Before 2003, we did not have a nonresident-covered medical service because we had a sufficient number of residents to care for all patients on our medical service. We found that the 2003 standards restricted the number of hours our residents could work in our hospital, so despite no change in the size of our medical service or the number of residents, we found ourselves without sufficient numbers of residents to meet the clinical demand. To meet this demand, we developed a hospitalist-run, nonresident-covered medical service.

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We discussed a number of issues during the planning stages of our new service:

How many hospitalist full-time equivalents (FTEs) would we need to staff this service?

Would we have hospitalists physically in the hospital 24/7 or take call from outside the hospital?

How much would it cost?

Do we have two groups of hospitalist staff, one for the resident-covered service and a separate one for the nonresident-covered service? Or do we maintain one cohort of hospitalists and ask the staff to work on both the resident- and nonresident-covered services?

Do we ask our hospitalists to rotate month by month or week by week, separately on the resident- and then the nonresident-covered service? Or do we ask hospitalists to see both patients on any given day?

Do we geographically cohort our resident-covered patients on floors separate from our nonresident-covered patients?

The new rules fueled a lot of discussion between educators and trainees. Your question about the transfer of patients between resident- and nonresident-covered services does not surprise me. Some training programs tried to minimize the necessary number of attending level staff in the hospital by allowing trainees to “cross-cover,” or essentially care for patients on the nonresident-covered service, when the attending staff was not present in the hospital. It is my understanding that trainees are never allowed to cross-cover patients on the nonresident-covered service.

To my knowledge, however, there are no rules against transferring patients from the nonresident-covered service to the resident-covered service, or vice versa. TH

Turn to ACGME for Transfer, Resident Supervision Rules