A recent recommendation from the Institute of Mecidine (IOM) reinforces the national movement to restructure resident work hours and duties. Released Dec. 2, 2008, the “Resident Duty Hours: Enhancing Sleep, Supervision, and Safety” report calls for a maximum shift length of 30 hours with admission of patients for up to 16 hours, plus a five-hour, uninterrupted sleep period between 10 p.m. and 8 a.m., with the remaining hours for transitional and educational activity.
The consensus is the ACGME rules changes likely will alter the hospitalist job description and produce an even greater shortage of qualified, experienced physicians. Leora Horwitz, MD, MHS, an assistant professor in internal medicine at Yale University School of Medicine in New Haven, Conn., says “hospitalists are really an amalgamation of two very distinct types: the short-term hospitalist who takes the job for a year or two right after residency and before fellowship, and the longer-term hospitalist who takes on the job as at least an intermediate-term career. It could be that recruitment and retention differ for these types.”
Dr. Rifkin isn’t alone when he asks, “Can a hospitalist last that long doing patient care alone? There are only so many people who will move up to be leaders in HMGs. So while this will probably be good for recruitment in the short term, in the long term, we don’t know.”
Immediate Consequences
Some ramifications of hospital medicine as a whole taking on more patients and more hospitalists will parallel the growing pains of individual HMGs. For instance, hospitalist group’s social bonds may not be as tight, says Dr. Feldman. But where many obstacles are surmountable, “what is not surmountable is if hospitals don’t choose to increase the size of their hospitalist programs. The deathblow to most hospitalist programs is if you ask the group, and each individual, to do more work that is not commensurate with the original expectations. And with the market already tight, most hospitals can’t afford to have unhappy hospitalists.”
Financially, the new rules will place a heavy burden on HMGs and hospital administrators. With no additional reimbursement under the GME system, most hospitals will have to get creative with existing budgets. “Part of the concern is that patients that hospitalists see on a teaching service tend to be the lower socioeconomic population of patients―Medicaid and self-pay patients―where there is inadequate reimbursement anyway,” Flores says. The answer likely will be sending those patients to a non-teaching service, which in essence transfers the financial burden. “Hospitals will have to find money from somewhere.”
Teaching hospitals not part of large academic medical centers contribute to hospitalists’ compensation when they help train family medicine and internal medicine residents. “Because they are not technically academic hospitalists,” Flores says, “they need to be alerted about how these rule changes may influence the way they manage and run the finances of their practice.”
Some of the solutions to the problems inherent in this change depend on the practice and scheduling model. In the aftermath of the work-hour restriction, many hospitalist programs changed their scheduling method to day float/night float, or the “drip” method of admission (taking admissions every day), versus the “bolus” method (every fourth or fifth day), Dr. Feldman says. The bolus method likely leads to scenarios where the new ACGME cap will come into play.