The academic or teaching center offers special considerations and challenges regarding hospital and departmental efficiency. The combination of housestaff with medical students changes the efficiency dynamic immeasurably.
The large teaching institution may have 500 – 1000 inpatient beds with as many as 500 – 1000 staff physicians accompanied by 100 – 500 residents in training. This adds tremendous variability to the credentialing process, providing additional areas of uncertainty.
The residents themselves also have varying degrees of expertise and motivation. Remember, good training attracts the best quality housestaff, providing a more predictable work product. There is a commonly held belief that having housestaff provides greater efficiency. In fact, some staff physicians will not admit to a hospital without housestaff to write the orders and see the patient in the evening. This allows the attending physician to have a 9 – 5 workday practice within some limits if they wish.
Hospitals view them as a “bargain” as well. In 2008, the average salaries of the housestaff ($42,000) were one-half the cost of a midlevel practitioner ($72,000) and one-third that of an employed physician ($160,000). The housestaff have less rights than either other group in the workplace, and only recently has there been legislation to regulate housestaff work conditions.
In reality, the efficiency of these hospitals can be decreased with the additional layer of residents and in some cases fellow level decisionmakers; they can facilitate the care process, but can often slow the patient care processing as well. This observation is often borne out in the prolonged ED average turnaround times [TAT] (2.5 versus 4.5 hours) or hospital length of stay (3.5 days versus 5.5 days).1
The Accreditation Counsel for Graduate Medical Education (ACGME) recommends a maximum faculty supervision rate of 4.5 residents per faculty member.2 There is a medicolegal risk as well as if physicians-intraining are substituted for staff physicians. A large pediatric emergency department that increased attending physician coverage four-fold, from 7600 to 26,820 hours annually, was associated with a 42% decrease in malpractice cases.1 They found an improvement in attending physician patient evaluation from 15 to 100% of cases. The total legal financial disbursements decreased from $807,500 (an average of $73,406 per closed claim) to $450,000 (an average $64,256 per closed claim) in 1987 – 90.
Obviously, the presence of full-time attending coverage in a pediatric ED appears to decrease the frequency of malpractice litigation, as well as the amount of claims disbursement.
Therefore, although there appears to be a cost savings, in fact additional supervisory staff can most often be employed to transfer the residents from a primary to the auxiliary care role.
The patient interface is an interesting one as well, spanning the spectrum of acceptance. A minority of patients and families are not accepting of the medical training system, “not wanting anyone to practice on them.” Likewise, others are very happy to talk to residents and often enjoy the youthful enthusiasm of trainees and students and are proud of their “interesting case” status.
An interesting patient – physician interface was explored, examining senior ED resident preferences for their own personal healthcare. 75% of the residents stated that they were willing to be seen by unsupervised residents for minor illness or injury, 50% for moderate conditions, but only 20% for major conditions.3 The willingness to be seen increased with a hypothetical 2-hour care delay, before an attending physician could be consulted.
Ironically, the residents who were willing to be seen by a midlevel provider was decreased at all levels of severity. This was modified in that 84% were willing to be seen by a non-physician if a subsequent physician exam would occur, but only 50% would allow care by a midlevel if there was no subsequent physician evaluation.
The dual standard issue raised is inherently obvious. Either way, it is helpful to understand the benefits and detriments of the addition of housestaff to the hospital care delivery system.
1. Press, S., Cantor, J., Russell, S., Jerez, E. “Full-time attending physician coverage in a pediatric emergency department: effect on risk management.” Archives of Pediatrics & Adolescent Medicine 1994; 148(6): 578 – 81.
2. Accreditation Council for Graduate Medical Education (ACGME). Emergency Medical Guidelines. ACGME 2000 – 2007.
3. Larkin, G.L., Kantor, W., Zielinski, J.J. “Doing unto others? Emergency medicine residents’ willingness to be treated by moonlighting residents and nonphysician clinicians in the emergency department.” Academic Emergency Medicine 2001; 8(9): 886 – 92.