The resident work hour caps have created a kind of mismatch with daily hospital routines, says Dr. Dow. In the ideal world, residents could admit patients at 7 or 8 a.m., allowing ample time to perform a comprehensive history and physical, review patients’ tests results, synthesize all the information in an educational way, and then be able to leave at 5 or 6 p.m. that evening. “Unfortunately,” he says, “patients show up at 4 or 5 p.m., until about 8 or 10 p.m., depending on the day. Ideally, we would have the same person admit and discharge the patient, but that just isn’t feasible because of the work hour caps.”
At Virginia Commonwealth, Dr. Dow’s hospitalist group has found that assigning admitting duties and ongoing patient care to separate teams allows for better patient care. Designated admitting physicians handle the admitting work in the late afternoons and evenings when most patients come up to the floor. All of the patient care is then transferred to another group of physicians who work during the day, ordering tests, speaking with consultants, and talking with families and social workers.
“What we’ve done is try to focus on continuity from that second day of hospitalization until discharge,” says Dr. Dow, “because I think the most critical point for errors in care is at discharge. We want to make sure that by the time patients go home, the discharging physician and the rest of the group have a really good idea of what is going on with those patients: What kind of home situation are they going to? What kind of follow-up do they have? What kind of medications are they going to be on? What kind of home services will they need?”
Dr. Dow has also noticed that reduced resident hours have resulted in the necessity for faculty to be more “available and present, and to focus on making the team more efficient. For my group of hospitalists, this is not a problem because our clinical venue is the hospital. But for people who are active researchers or who need to go to other clinical venues, this can be very difficult because their obligations in the hospital are more than they were five years ago.”
Casualties of Caps
No one argues that decreased duty hours are a bad idea. As a consequence, however, more work has fallen to faculty. Because residents have to be out of the hospital at designated cut-off points, attendings must stay up-to-speed with nuances of paperwork and electronic medical records. Sources agreed that they have observed faculty members working harder and harder, and many worry about issues with potential burnout among the faculty.
“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,” says Dr. Vidyarthi.
Other program directors voiced concerns that certain provisions of the duty standards might foster less connection to both the treatment team and to patients. “I think the fear I have as an educator,” says Dr. Baudendistel, “is the erosion of the continuity and the professionalism that is a byproduct of the work hours decrease, with the implicit hand-offs that occur in care. This is a paradigm shift. When I was a resident, this was my patient because I didn’t have too many days off. I saw my patient through the long hospitalization.”
But with changes in the duty hours, he says, now “the residents with reduced work hours and mandated days off might only admit the patient. Then three other house staff will see the patients and discharge them, and it’s not their patient any more. Who’s there to provide the continuity? It’s the attendings. So then the residents can abdicate responsibility to the senior residents and the attendings because they are only at the hospital for, say, a 12-hour shift.