The problem with round the clock hospitalist coverage

Two recent articles, one from the New York Times, the other from The Hospitalist, initiated some 24/7 staffing issue rumination on my behalf.  It stems originally from a recent op-ed by Lucian Leape: “Given the accrediting council’s reluctance to act, the federal government needs to get tougher. If we are serious about curbing the tide of injuries stemming from medical errors, Medicare should make its funding of graduate medical education contingent on hospitals’ limiting work hours. We can’t afford to wait another 40 years.”

How do the aforementioned pieces resonate with the above quote?

The Times article, well written, examines pediatric training, errors that stem from doctor “fatigue,” and the root causes behind these errors—presumably due to burdensome hours and the legacy of educational norms of decades past.  The author, chief of pediatric cardiology at UMass Medical School, cites the evidence before and after implementation of trainee work hour restrictions in 2003 (not overwhelmingly positive incidentally), and concludes that it may not be the stretch worked—although this is a factor, but how information is communicated doc to doc, and shift to shift.  This is not news to hospitalists.

The urgency of 24/7 hospitalist coverage to remedy the “problem,” as discussed in The Hospitalist feature, does not offer many solutions.  It does expose the problems hospitals will face as work force and dollars become scarcer.  That is only story subtext and not the primary message however.  For the casual reader, the crux of the report is “hospital medicine is the answer.”

I am undecided.

The piece speaks of recruitment difficulties, the undesirability of night work, the need for mid-levels (who comprise sizable portion of overnight staffing), and the dependency of programs on the coveted nocturnalist, who, if removed from the schedule, would cause chaos.  Nevertheless, again, “hospitalists will get the job done.”  I say, “where is the beef?”

For those with a “24/7 fix” prescription pad, and their intentions are well founded and sound, I am unsure how to implement resolves.  Others similarly share my view:

That’s the commonsense part.  The hopeless part is that Long and Vaswami, both affiliated with the Institute for Healthcare Optimization, seem to believe that doctors, nurses and hospital execs will read their article and then spontaneously volunteer to work the weekend shift.

We, physicians on the frontlines of acute care, comprehend what is at stake, the inherent flaws in our fragmented system, and the solutions needed, that is, if we lived in a perfect world.

We do not.

Here are my reflections:

  • Despite pleas for an increase in our physician workforce (AAMC—120K+), I cannot account for the needed funds, both to train, and pay, additional doctors to ramp up coverage.  In 2011 dollars, you can visualize the shortfall: 120,000 doctors x $200,000/year average .  Yes, allocation, efficiency, etc., all need consideration, and the calculation is beyond rough, but you get the idea.  Our country is in fiscal trouble and this is an improbable sell.  Either we train fewer cardiologists or radiologists, pay providers less, use trainees or mid-levels, or improve overnight and weekend coverage in ways undiscovered via technology and systems improvement.  More docs in the hospital mean less in the field, and those who evaluate physician workforce allocation must take 24/7 staffing into account when and if the chessboard pieces are rearranged.
  • On training more physicians, to additionally augment above, note the current physician supply in our country versus other OECD nations.  We are not laggards, and the U.S. as outlier is not resonant:

The problem with round the clock hospitalist coverage

  • In speaking with ER colleagues, I am not persuaded that overnight and stuttered scheduling is maintainable long-term.  For some, emergency medicine finds individuals, and for others, it is the opposite—but it is a unique lifestyle, as is 24/7, shift-based hospital medicine (HM).  The question is, is it sustainable, and are there enough physicians with the “appropriate” DNA code to fulfill the needs of continuous hospital staffing.  Query physicians if they crave nights and weekends, and the answer is often no.  Which gets us to incentives, and how to make the transition if the system demands what most stakeholders do not desire?
  • I am willing to forgo a percentage of my salary if I knew it would produce a sturdier primary care infrastructure, more investment in preventative and population health, and targeted reductions in health disparities.  For me, this is fact, even gospel.  However, if you want individuals to work  disagreeable hours, there is a premium attached.  It might be hours toiled, or currency, but in the end, there is no difference (time is money, right?), and most folks seek parity.
  • This gets back to my original point: the labor force will not expand (assuming workforce allocation and pay is not overhauled significantly), and dollars are in short supply, especially for hospitals.  Convincing enough physicians to pursue HM as a career path, so, a) there is a critical mass of HM certified persons in the realm (MOC and what follows), b) that the movement does not develop on a shaky foundation, and c) we actually deliver what we promise, i.e., better value. The most recent AIM study on HM efficiency, while not the last word, is a sobering factual on what might be a movement utilizing hobbyists and non-committed HM practitioners.  That is a leap however, which I acknowledge.  Nonetheless, lack of organization in many programs played a role in the findings, and that I am certain.
  • American exceptionalism aside, how do systems in the Netherlands, UK, Germany, Canada, France and Switzerland manage the overnight, 24/7 staffing dilemma?  Is there on-site physician coverage at all times?  Are their adverse event rates lower?  Do they suffer transition problems similar to the United States?  What do they pay doctors with this scheduling model, and relative to primary, ER, and subspecialty docs, what kind of work-life balance and salary does their inpatient staff command?  This would be helpful information.

I hope to revisit this topic in the future, but I am uncertain, if given current constraints as mentioned above, the field of HM will continue to grow if lifestyle and salary do not keep pace or meet expectations.  We must be careful what we wish, or what we think we wish for–because the genie, once out of the bottle, is not slinking back in.

Bradley Flansbaum is Director, Hospitalist Services at Lenox Hill Hospital in New York City. He blogs at The Hospitalist Leader.

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  • Anonymous

    So what if we just slash high end specialty residency slots in areas of the country over populated with a specialty based on Medicare demand in favor of funding hospitalist and more family medicine medicine residency programs?  

    Institutions can choose to change their orientation … or lose their funding.    

  • heartsurgeryguide.net/

    obviously,  dr flansbaum has given this much thought. a think there are 2 problems being lumped as one. first, the 80 hour resident work limitation and now more stringent restriction of overnight call has not really impacted medical errors. these hours have had the most effect on providing 24/7 surgical coverage and every program is struggling to increase utilization of physician extenders  (pa’s, nurse practitioners). for academic centers, the pass offs are the problem,poor and miss communication from shift to shift and person to person causes more trouble than overtired house staff.  the answer to this is complicated, but staggering shifts to allow more time and inservice training can help. but the majority of hospitals do not have house staff and 24/7 coverage is provided by hospitalists. no question having these individuals on site rather than attendings on call is in patients’ best interests. i do not see the resources in this economic climate to increase incentives for more of these specialists to be trained and rewarded. i think the future is better training of physician extenders with stingent and uniform best practices guidelines. i personally believe protocols are very effective, can be taught to a range of professional staff and when supplemented with strict default option  (i.e. now is time to call senior, responsible staff) fewer hospitalists can cover effectively more in patients.

  • Anonymous

    Not to be a buzzkiller, but this is how it might go down:  Policy pushers who have limited knowledge of how medicine really operates will continue to demand decreased training hours to improve safety and 24/7 hospitalist coverage.  The government, with its own dupes, will nod in agreement.  Attempts will be made to hire these docs, attempts that will yield inadequate results, for the obvious reasons that Dr. Flansbaum so carefully and yet somewhat indirectly discusses:  Admin:  “Doctor, we would like you to work more and work in the middle of the night, and weekends of course , but for less money, because money is tight.  It’s for the good of the system, you see. ”  Doctor: “Uh, no.” And of course more docs will not be trained because that costs too much, and admin will find, much to its consternation, that actual enserfment of physicians and forced labor is not allowed, outside of residency, of course. So the system will, in time, realize that physician shortages and money shortages will cause our society’s reach in this arena to exceed its grasp, so we’ll go back to abusing medical residents for their labor, which is where we started.

    • Anonymous

      Cool. Solution is simple then … all the really sick people will die off until the population is small enough for the healthcare system capacity to manage.  Added benefit is that our total health care outlay will go down as well. 

      • Anonymous

        No, the sick will live, as will the residents, although the residents will often feel like zombies.

    • Anonymous

      Population effect:  Too many people in the country and not enough doctors to allow practicing physicians to participate in the formation of policies that affect the profession.  So, bureaucrats and legislators (or non-practicing physicians divorced from reality) do it instead.  One can only grimace in expectation of the results.  What about the AMA?  Well … they appear to be part of the crowd that believes a strong, centralized government is the solution to the ails of society.  I disagree.

      Hospitalists: We send our patients to a local med/surg facility that uses hospitalists.  Thus far we are most unimpressed by the frequent physician staffing turnover in that group and the discontinuities of care that occur across shifts.  To compensate, we do our own monitoring of these patients during their med/surg admissions (where we don’t have privileges.)

      Though the local docs are glad for the hospitalist’s impact on quality of life, I worry now about loss of a skill set.  I picked a local internist for myself based on his reputation … but grew to realize afterward that this internist has not done inpatient care for a few years now.  If I sicken and am hospitalized at this local hospital, I no longer have access to my own doc, whose inpatient skill set has grown rusty anyway.  I must use docs I cannot choose.  My solution: I’ll use a different hospital, if I can.

  • http://jimcarroll.pip.verisignlabs.com/ Jim

    Clearly we have no self-regulating professions left.  Leape urges that the Federal government “get tougher.”  Yes: let’s advocate for the overarching hand of government in every aspect of our practice.  Bureaucrats and legislators obviously have the answers.  It’s not too much of a Leape to expect them to make it all right for everyone.

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