For many new programs, it may be easier to create one uniform faculty role that mixes non-resident-based and resident-based service duties and avoids the appearance of two classes of hospitalists. For many mature programs, however, the only option may be to hire new faculty who predominantly work on non-resident services. For these groups, we believe that differences in the positions must be addressed. One solution to this problem is creating viable teaching roles for these new faculty. Options that we are examing include medical student teaching, training allied-health professionals, and some involvement in resident education during the night and at regularly scheduled daytime lectures. Each of these roles requires time and will come at the expense of efficiency or work capacity. We also have struggled to create program-level rapport. We have encouraged weekly meetings and have found that clinically oriented collaboration such as case conferences and quality-improvement initiatives seem to provide the best way for the entire faculty to interact. Another solution that has been offered is to create a vigorous inpatient research agenda that uses the non-resident services as the laboratory; we encourage this approach but feel that it may not be a realistic near-term goal for many programs.
In the end, however, while creating these roles will add to faculty satisfaction and long-term viability, there will be ongoing problems similar to those faced by academic primary care faculty who have limited interactions with residents. Our program relies on junior-level faculty who are in transition between residency and further training or faculty who aspire to eventually grow into more traditional academic teaching roles and take on a more hybridized role. There is likely to be value in this variety, and we imagine that large academic programs will have faculty that run the gamut from those who are primarily research focused to those who spend most of their time in direct front-line patient care.
Results: Work Hours Success
Since the implementation of our non-housestaff service, we have seen dramatic improvements in resident work-hours compliance. Prior to our service, 40% of residents were in violation of the 80-hour week and the “24+6” hour shift limit. After successfully removing 15% of the total inpatient (non-ICU) census from resident-coverage, there have been only sporadic violations during the first 3 months of operation. Therefore, violations of the 80-hour work week rules have been virtually eliminated. Our residents have widely praised the new service and overall morale in the residency program has improved. Yet despite what has been perceived as a significant reduction in resident patient load, there are continued violations of the “24+6”-hour shift rule. In fact many have suggested that violation of the “24+6”-hour rule is a reflection of the competing tension between compliance with external regulation and our residents’ professionalism and dedication to patients. While further reductions in volume might help (although even our residents say that this might jeopardize their education), the more likely solution to this problem is both culture change over time and some re-engineering of the timing of resident shifts.
Conclusions
We envision that in the next few years, non-resident services will exist in almost every major medical center. As our experience highlights, these services can be an effective solution to the resident work-hours problem. We caution, however, that implementation is not an easy task. To be successful, programs should invest significant time in the planning stages and have clear goals in mind. Staffing and finances are likely to remain challenging as is the creation of academically viable roles. Eventually, however, we believe these services will succeed. Their growth will add to the future standing of hospital medicine in academic centers by creating a more diverse group of hospitalist faculty who focus on research, education, and, increasingly, quality patient care.