Balancing act: How ACGME work-hour limits are changing hospital medicine

When the Accreditation Council for Graduate Medical Education decided in 2003 to limit residents' work to 80 hours per week, opponents said that the change would be a disaster for hospital medicine. But while the ruling has presented staffing challenges, patients have not suffered and hospitalists are in higher demand than ever on the job market.

When the Accreditation Council for Graduate Medical Education (ACGME) decided in 2003 to limit residents' work to 80 hours per week, opponents said that the change would be a disaster for hospital medicine. But while the ruling has presented staffing challenges, patients have not suffered and hospitalists are in higher demand than ever on the job market.

“There were the usual sky-is-falling arguments—we can't afford this, the signouts will be terrible, there will be dropped balls, housestaff won't learn anything,” said Robert M. Wachter, FACP, chief of medical service and the division of hospital medicine at the University of California, San Francisco.

Today, the prevailing wisdom has changed. “I think most observers of this look at it four years later and say, ‘Yes, a little of that happened, but probably on average this was a good thing to do,’” Dr. Wachter said.

One less attractive aspect of nonteaching jobs is the possibility of doing more low-level work Photo by Ryan McVay Getty Images
One less attractive aspect of nonteaching jobs is the possibility of doing more low-level work. Photo by Ryan McVay, Getty Images.

Supporting his impression, two studies published recently in Annals of Internal Medicine provide statistical evidence that work-hour limits do not harm and may benefit patients. Comparing patient outcomes before and after the cap, the studies found that intensive care utilization, discharge to home, pharmacist interventions and short-term mortality in high-risk medical patients all improved after the regulations were instituted.

Two additional studies, published in the Sept. 5 Journal of the American Medical Association, compared outcomes in Medicare and Veterans Administration (VA) patients, and found that shorter work hours were associated with less mortality in the VA medical patients and had no significant impact on VA surgical patients or Medicare beneficiaries.

One clearly positive effect of the work hour cap for hospitalists has been growth in the field, especially in academic medical centers. Hospitalists have increased in number from 10,000 in 2002 to 20,000 today, with at least some of the growth driven by duty-hour restrictions.

It's not only nonteaching jobs that have grown out of residents' absence. At many hospitals, new attendings have been hired and asked to split their time between teaching and nonteaching services. At others, new nurse practitioners and physician assistants are assigned to help care for nonteaching patients.

“Hospitals are realizing that we need a nonteaching service where we have a nonresident team taking care of these patients,” said Daniel J. Brotman, FACP, director of the hospitalist program at Johns Hopkins in Baltimore, which has added seven hospitalists since the work-hour change. “The impact—if you're one of those hospitalists who is working on a nonteaching service—is that there's a job available where there wasn't one before.”

Growing pains

At the University of Chicago, the hospitalist scholars program hires a few recent residency graduates every year to divide their time between patient care and work on a health-related master's degree to prepare them for a faculty position. Chad Whelan, ACP Member, co-director of the program, said that regardless of the method they adopt to deal with the work hours, new or expanded hospitalist programs run into many of the same problems.

“We faced the same problems that almost all new hospitalist programs face, which include: How do you get people excited about working nights? How do you balance the academic mission with the service requirements? How do you start having faculty members take care of patients in a system that has relied on house officers getting the work done?” Dr. Whelan said.

Hospitalist program directors seem to be universally stumped by Dr. Whelan's first question. Many hospitals, including UCSF, rely on a pool of moonlighters, usually fellows, for night coverage. That solution is not the ideal, Dr. Wachter acknowledged.

“My guess is the quality would be more consistent and better if it were our own people and a smaller group,” he said.

The alternative, which the University of Michigan Health System chose, is hiring nocturnalists. “A lot of residents find that a very attractive job because it has fewer shifts per month and pays a good salary,” said Vikas I. Parekh, ACP Member, assistant director of the hospitalist program and associate director of the residency program.

However, despite the high pay, most new residency graduates are not taking these spots as a long-term career move, noted Dr. Whelan. “These will be people who are looking for a one-year, maybe two-year job before they move on to a fellowship,” he said.

In the current hypercompetitive recruitment environment, the likelihood of frequent turnover dissuades other hospitalist programs from trying to hire nocturnalists. Despite UCSF's appealing location and prestigious reputation, Dr. Wachter has had to prioritize his staff expansions between night coverage and comanagement.

“Even our institution is at the edge of our ability to recruit the quality of people we want,” he said. “I think we probably add more value by having a hospitalist manage sick patients on the neurosurgery service than we would on night service.”

Cut the scut

One aspect of nonteaching jobs that does not attract hospitalists is the possibility of doing more low-level work.

“In community hospitals, they have figured out ways to make sure that blood gets drawn by a nonphysician,” Dr. Brotman said. “In an academic center, that economic incentive is not there because the cheapest people [in hourly pay] are the house officers.”

With the residents gone from the nonteaching services, their work often falls to hospitalists. “It's not good economic sense, but it's what the institution has been used to,” said Dr. Brotman.

Dr. Parekh has pushed his hospital to make internal systems more efficient and better suited to nonteaching services. “We've really tried to argue to our institution that this is a really dramatic change and the reason that faculty are frustrated with inpatient work is that hospitals are designed around residents,” he said.

At Brigham and Women's Hospital in Boston, the hospitalist service has added physician assistants to reduce the workload. “I think they do add value by sharing the workload while the hospitalist thinks about the big picture,” said Christopher Roy, ACP Member, associate director of the hospitalist service.

UCSF also looked at adding nonphysician providers, but the hospitalists decided they would rather add physician help than spend their resources on a nurse practitioner, said Dr. Wachter. “The group unanimously said we'd rather have more physicians and basically suck it up. The decision about whether to have an NP or PA versus another three-quarters of a hospitalist is not a slam dunk in either direction.”

Not perfected yet

None of the hospitalist leaders are convinced that they have found the ideal response to the issues raised by work-hour limits. “We are tweaking every year,” Dr. Whelan said.

Lee Goldman, FACP, is concerned even about the level of effort that hospitalist programs have put into the problem. “The best hospitalist services, in my mind, do not focus exclusively on work-hour protection by creating nonteaching services,” said Dr. Goldman, who is dean of health sciences and medicine at Columbia University in New York City.

“That's not the reason that people get up every morning is to say, ‘How can I help reduce work-hour problems?’” he added.

Dr. Brotman also worries about the demoralization of nonteaching academic hospitalists. “You add the pressures to succeed academically when you don't have the time to do it, and the fact that you're probably still making less than your community hospital counterpart, and that you are perceived by other attendings as being a second-class citizen because you're taking direct care of patients and they think that's a job for house officers. You end up very prone to being dissatisfied,” he said.

Every director would like to develop a better program and have a staff of satisfied hospitalists, but current industry pressures just don't allow the time, said Dr. Parekh. “People haven't had a chance to think through a long-term sustainable model. Every year, you're just trying to recruit to get to a number you need, not having a chance to really think about what it means to be an academic hospitalist program.”

Planning ahead

The bad news is that program directors aren't likely to have any more free time to think about these issues in the near future. The good news is that hospitalists will continue to have a plethora of job opportunities.

Comanagement of nonmedical patients—motivated in some cases by other specialties' work-hour staffing problems—will continue to drive growth in the hospitalist field. Dr. Wachter predicts there will be 50,000 hospitalists in the U.S. by 2017.

Stricter work-hour limits also seem to be a continuing trend, at least in the rest of the world. Residents in Great Britain and much of Europe work a maximum of 56 hours per week; those in the Netherlands only work 48 (see related story).

However, the ACGME is not likely to follow the European example any time soon, according to Ingrid Philibert, the council's senior vice president for field activities. “We have a very different mental model underpinning how care gets done,” she said. “In Scandinavian countries, they turn over the operating room team in the middle of surgery because they are on narrowly constrained duty hours. In this country, we don't turn the team over. We do the heroic effort.”

If the ACGME did limit work hours further, the change would have to be based on more evidence than is currently available, for which more pilot tests of limited work hours are needed, Ms. Philibert said.

Dr. Wachter, however, predicted that the impetus for future work-hour changes will come from outside of the medical field. “I see all of the arrows lining up toward more regulation, more outside scrutiny of our practices, particularly in areas that are visible and visceral to the public,” he said.

With studies on the impact of sleep deprivation on performance readily available, and more stringent regulations on how long truck drivers and airplane pilots can work, public pressure in favor of physician work-hour limits is only going to grow, he said.

But Dr. Goldman believes all the focus on work hours is missing an important point. “If you go back to the original Bell Commission report which got all this started, they made at least as strong, if not stronger, an argument for the need for better supervision of housestaff than for cutting back hours per se,” he said.

What would that mean for hospitalists? Think of it as more job security. “I think that an emerging role here for hospitalists will be as the 24/7 in-hospital physicians so that residents are well supervised,” Dr. Goldman said.

Competing for new hires

For potential hospitalist hires, academic opportunities—even in a nonteaching position—often hold as much value as a high salary.

Vikas I. Parekh, ACP Member and director of the hospitalist service at the University of Michigan Health System, offers his nonteaching physicians community-matched salaries and loan forgiveness, but has found that the academics are what keep the new hires there.

“The way this is going to be sustainable is to create these jobs in a way that makes them long-term career tracks. That means some form of academic role for these physicians, whether it's as teachers, researchers, quality improvement experts or administrators,” he said.

Physicians on the University of Michigan nonresident service also have the opportunity to work with medical students, a system that several other academic medical centers have adopted. The setup pleases students as well as hospitalists, noted Robert M. Wachter, FACP, chief of medical service and the division of hospital medicine at the University of California, San Francisco. “They work directly with the faculty without all the intermediary interns and residents.”

Because most of these programs incorporate at least some academic component, there is a natural temptation for interviewers to emphasize the teaching aspects of a nonteaching position, but honesty is the best policy, said Daniel J. Brotman, FACP, director of the hospitalist program at Johns Hopkins in Baltimore.

“There's a fair amount of frustration that can be created if the person who is hiring that hospitalist is not very up-front in saying, ‘Look, I'm hiring you to see patients. I'm not hiring you to be a teacher,’” he said.

Interviewers need to emphasize the true academic benefits of the jobs—access to research opportunities, time off for academic pursuits and the possibility of teaching in the future—and know that some candidates will have their own reasons for joining the staff.

“In some cases, it may be that they just really like to have the name of your academic institution on their CV,” said Dr. Brotman.