For community-based neurosurgeons and hospitals, it might be expected that the effects of the Accreditation Council for Graduate Medical Education’s mandate to restrict resident work hours would be minimal. Instead, the ACGME decision has had perhaps an unanticipated effect on physician practice coverage arrangements, hospital house coverage arrangements, and community-based trauma programs.
Neurosurgeons Rethink “Call” Strategies
Many community-based neurosurgeons have depended on an often informal affiliation between their very busy practices and nearby neurosurgical training programs as an effective means of providing call coverage during off hours, weekends and holidays. Due to the restrictions on resident work hours, such arrangements are no longer feasible except in unusual situations, prompting community-based neurosurgeons to rethink their call coverage obligations and strategies.
Hospitals Scramble for Alternatives
Hospital physician coverage has become an issue, particularly in many of the smaller community hospitals. Typically these hospitals employ a physician in-house during off hours, weekends and holidays to respond to inpatient emergencies such as postoperative chest pain, shortness of breath and medication reactions. Alternatively, emergency room physicians cover these types of emergencies, leaving the emergency room temporarily staffed by other medical personnel such as moonlighting residents. Such arrangements, for the most part, have been completely terminated because residents are not allowed to moonlight during their hours away from the training program; this circumstance has compelled hospitals to rapidly identify new sources of care providers to provide coverage in these situations.
In an attempt to identify physicians willing to cover call on nights and weekends, some hospitals canvassed the medical community; as one might imagine, the positive-response rate was quite low, forcing hospitals to enter into coverage arrangements that are sometimes convoluted, typically quite expensive, and often temporary in nature. Some hospitals increased the onus on the admitting physician to respond to in-house emergencies. This course of action has been distinctly unpopular with the admitting physicians and has created an incentive for them to concentrate their practices in hospitals with less coverage obligation. Occasionally hospital relations and referral patterns have been disrupted over these issues.
Trauma Programs Feel the Strain
Many trauma programs throughout the United States are based in community hospitals that do not have supporting neurosurgical training programs. The burden of taking level I and even level II trauma call for the average private practice neurosurgeon has been widely recognized. Many trauma programs previously sought to relieve the burden on neurosurgeons (who typically divide 365 days of call amongst three to five physicians) by supplying residents from general surgical and emergency room training programs to cover call. Such an arrangement is less feasible as resident work hours are trimmed.
With regard to trauma call coverage, withdrawal of resident support affects all surgical subspecialists. The sponsoring institution must support call services by investing additional funds to employ physician extenders, chiefly physician assistants and nurse practitioners, or increase the time commitment of already overburdened subspecialists.
Collateral Damage: The Bottom Line
The financial impact on most trauma programs further jeopardizes their long-term stability as hospital and healthcare systems tighten their budgets. Similarly, in the struggle of community-based hospitals to make alternative arrangements for coverage, unbudgeted dollars are being spent. This stress on hospital budgets has caused other programs and capital outlays to be postponed or canceled. In the often zero-sum fiscal environment, funds for updating neurosurgical equipment or acquiring state-of-the-art technology may be constrained.
There is ample evidence of the collateral damage in our communities resulting from resident work hour restrictions. Practicing neurosurgeons are unable to fill the void created by the work hour restrictions: Their small numbers do not allow for absorption of the additional time commitment, and while an increase in reimbursement could provide some incentive to take on additional call, the cost to community-based hospitals would be prohibitive. Furthermore, the downside risk of excessive work hours on patient care-to the extent that it exists-is simply shifted from the residents to the practicing neurosurgeons. The conclusion reached by many is that employing physician extenders, typically as hospital employees, is the most workable solution. Whether this is an acceptable solution that ultimately results in better, safer patient care remains to be seen.
Patrick W. McCormick, MD, is a neurosurgeon with Neurosurgical Network Inc. in Toledo, Ohio.