Losing Sleep over Residents’ Work Week Restrictions

Dr. Johns explained that hospitalists manage medical issues, calling in subspecialty residents as needed. The 15 otolaryngology residents deployed in three hospitals serve mostly as consultants and co-managers, with an average daily census of six to eight patients per facility. For example, a hospitalist might call in an otolaryngology, ophthalmology, or neurology resident for a patient with periorbital cellulitis. Dr. Johns said hospitalists allow his program to meet its educational goals without exceeding work hour restrictions. There are fewer battles over ER patients, things flow more smoothly, and care quality is high. The hospitalist-subspecialty resident paradigm works, and residents gain considerable control over their professional lives. Dr. Johns sees the 80-hour work week as a blunt instrument to correct fatigue, burnout, and depersonalization.

The view is different from the hospitalist’s side of the street. William Odette Jr., MD, a full-time IPC hospitalist at Tucson Medical Center in Arizona, has seven full-time and eight part-time colleagues, including a nocturnalist. The team handles an average of 120 admissions and consults a day, and distributes call equally. Dr. Odette said, Our hospital doesn’t rise or fall with the residents because the hospitalist is the responsible attending. The hospitalist admits with the resident handling orders, but the hospitalist supervises and provides continuity of care. Subspecialty residents, including otolaryngologists, are called in to co-manage patients.

Although residents are supposed to cover call, Dr. Odette said that at least one-third of the time the nurses call the hospitalist because the residents, who are paged automatically, don’t respond. They’re not putting in an 80-hour week, in my opinion, he concluded.

His fellow IPC hospitalist Douglas Kirkpatrick, DO, a pulmonologist and critical care specialist, finds it annoying that residents often can’t be found and that nurses page the hospitalists instead. The upside is that the hospitalists provide more seamless care, avoiding awkward and time-consuming handoffs. Dr. Kirkpatrick is accessible to his residents, working long hours the day before covering call, arranging for residents to round at the bedside of interesting and complex cases, and supporting them as they practice procedures. Often the residents don’t realize how much we do. We even model for them how to make a smooth transition from inpatient to outpatient, directing them to case management, calling the PCP, and so on, he said.

For teaching hospitals, adding hospitalists to cover the workload formerly carried by residents involves increased faculty pay without significantly increasing professional fee revenue. Although expecting financial self-sufficiency of such programs is unrealistic, some programs incrementally increase consultative revenue as specialty patients get placed on general medical services rather than being cared for by a resident and a specialist attending.