In the three years since the Accreditation Council for Graduate Medical Education (ACGME) instituted duty hour standards, academic and community-based internal medicine (IM) residency programs have had to change the way they do business. Although several surveys have documented residents’ satisfaction with reduced duty hours, some program directors and medical directors are concerned that complying with the standards can contribute to faculty burnout, affect continuity of patient care, and diminish residents’ educational opportunities. In recent interviews, IM program directors and medical directors of hospital medicine services shared their challenges of complying with the standards.
Who Takes Care of Patients?
The major provisions of the ACGME Common Duty Hour Standards, which took effect July 1, 2003, call for a weekly work limit of 80 hours, averaged over four weeks; a 24-hour limit on continuous duty time, with an additional period of as many as six hours to allow for continuity of care and educational activities, referred to as the “30-hour rule”; one day in seven free from all patient care; in-house call no more than once every three nights; and a 10-hour rest period between duty periods and in-house call. For more information on the new standards, visit www.acgme.org.
By instituting decreased duty hours, the council aimed to ensure that residents would be well rested, medical errors would be reduced, and patient safety would be improved. Tom Baudendistel, MD, associate residency program director at California Pacific Medical Center, a community-based hospital in San Francisco operated by Sutter Health, believes, however, that at the administrative level, the standards create “a potential for residency programs to be at odds with hospitals’ missions. Residency is making less money for the hospitals: For the same amount of dollars, they are receiving less coverage. So, hospitals hire additional attending physicians and physician extenders, which are a lot more expensive.”
With residents less available for extended duty hours, one of the largest challenges is to “figure out who’s going to take care of the patients,” notes Daniel Dressler, MD, MSc, director of the Hospital Medicine Service at Emory University Hospital, Atlanta. “At least in our institution, hospital medicine has stepped in to provide that care for many of the patients. We cannot get any additional house staff, and because their hours have been cut—reasonably so—we’re having to fill in the necessary gaps.”
The same phenomenon has occurred at Virginia Commonwealth University, Richmond, where Alan Dow, MD, MSHA, is assistant professor of Internal Medicine and director of the Academic Hospitalist Service. “My group has gone from two physicians four years ago, to now having 15 physicians,” he said recently. “We’ve grown, in large part, because we’re making up for the residency caps, but also because we’ve found other roles for ourselves in the health system to contribute and help.”
Another effect of decreased duty hours has been to contribute to the advent of non-teaching services, notes Dr. Baudendistel and Arpana R. Vidyarthi, MD, assistant professor of medicine and director of Quality-General Inpatient Medicine, University of California, San Francisco. At a recent panel she conducted at the SHM annual meeting, Dr. Vidyarthi said the main reason panelists cited for instituting non-teaching services was to reduce workloads for residents and comply with duty hours standards.
As duty-hour decreases have changed the nature of the academic hospitalist’s job, this leaves less and less time to do not just the things that you may enjoy and find intellectually satisfying, but also the things that are expected for getting promoted—a necessary part of life as an academic hospitalist.
—Arpana R. Vidyarthi, MD