One solution at Lehigh Valley has been to rotate resident teams admitting patients in the afternoon and evening hours, but only to their service. This ensures resident continuity for those patients and meets ACGME requirements. All other patients are admitted through the hospitalist service.
Capitalize on Uniqueness
It’s crucial to identify areas where hospitalists and program directors can dovetail efforts so the programs are not at loggerheads.
Program directors and medical directors can have a positive effect on meshing residency and private hospitalist programs. “We have to talk with our hospitalists, explain that we have no way around this [ACGME guideline], how it will impact them, and figure out a way [together] to help minimize that impact,” says Dr. Pistoria.
Dr. Amin believes the goals of the residency and hospital medicine programs can be mutually beneficial. “Some people may have inherent biases against the concept of hospital medicine,” he says. “But hopefully, as time goes on, you’ll find more and more hospitalists serving in program director or associate program director roles. My view is that the residency program ought to turn to the hospitalist when they’re looking for general inpatient, consultative, and perioperative curricular development. They could turn to hospitalists in the same way that they ask nephrology groups to help design a nephrology curriculum.”
The situation requires planning to make sure all stakeholders can accept the impact of having residents, Dr. Iobst points out. “The program director’s role is to work with the hospitalists and make sure that they understand that the residents have to adhere to their service caps,’’ he says. “The issue then would be to find other meaningful learning opportunities for residents that would not involve admitting patients.”
Dr. Iobst agrees with Dr. Amin. Some opportunities, he says, “are to ensure that a program director is capitalizing on what a hospitalist does.” If hospitalists are offering only “another general internal medicine inpatient service rotation to residents,” they are not capitalizing on their own uniqueness. Instead, hospitalists could offer hospital medicine as a senior rotation for residents. The residents could receive training and exposure to quality improvement; the business aspects of medicine, including the importance of length of stay and appropriate ICD-9 coding; and an evidence-based approach to care.
Embrace Teaching
Although ACGME work-hour caps sometimes create pressures, it’s up to hospitalists to be flexible with residents on their service, says Hasan Shabbir, MD, a hospitalist and associate medical director of quality at Emory Johns Creek Hospital in Duluth, Ga., and an assistant professor of medicine at Emory University in Atlanta.
This is especially true when particular residents are on night float rotation; admitting and managing patients into the early morning can bring them close to their work-hour caps. “We have to be cognizant of that [the ACGME guidelines], give them leeway, and let them go early whenever possible,” he says.
Having the right attitude toward residents is key. “I think we’ve approached [teaching residents] with the attitude that we’re quite fortunate to have residents to do a lot of the upfront work and to be able to help and teach them along the way,” explains Dr. Shabbir. “I think the negative feeling [about residents] is often tied to expectations. If one comes into our program, for example, and expects to just lie back and let the residents do all the work, that would be a bad expectation to have. All of us, having been [residents] at some point, can understand what residents go through. Not every hospitalist has the good fortune of having residents with them.”