Sprinting Through Care
So we begin our rounds without Diana and Don. Today, like every day, we'll design therapeutic strategies for very sick children who have rare or complicated or difficult-to-treat infections. Many of these children have compromised immune systems caused by an accident of nature or by chemotherapy for cancer or by immunosuppressing drugs to prevent a transplanted organ from being rejected. As we walk through one of the wards, a first-year resident stops me in the hallway.
"Dr. G, could I ask you a question?"
"We have a patient with hypogammaglobulinemia and a protein-losing enteropathy. Should we continue his IVIG and trim-sulfa?" The resident has just described, in these few words, a patient with low antibody levels, most likely because too much protein, including antibodies, is passing into his stools. She's asking if the child should continue to receive intravenous immunoglobulin therapy to replace the antibodies and if the child should continue to receive the antibiotic trimethoprim-sulfamethoxazole.
"Well, that's complicated," I answer. "For starters, how old is the child? Why does he have a protein-losing enteropathy, and how long has he had it?"
The resident shuffles the papers in her hand. "Um, I really don't know him very well. I'm just cross-covering because his primary resident is 'post-call'." Translation: She's filling in for the patient's resident physician who was on duty overnight and, because of resident work hour rules, is unavailable today.
"I can't begin to answer your question without knowing the details," I say. "Why is the patient on the trim-sulfa, anyway?"
"Will you be calling in our team to consult about this patient?" I ask.
"I don't think so. The senior resident told me to ask you about it."
"Well, I can't make recommendations about stopping treatment until I understand the whole situation. Put in for a consult and we'll figure it all out."
Is she a bad resident for asking me for a recommendation on a patient I don't know? No; like all residents, she has been given responsibility for the care of a very ill patient during the current eight-or ten-or twelve-hour shift, but she didn't take care of him yesterday and probably won't take care of him tomorrow. She doesn't know the full story of this patient's recent illness, doesn't know the long-term plans, and wasn't part of the previous decision making to design the patient's current treatment. This resident is filling an open shift in the schedule, and her goal is to place a check in the box beside the item on her list that says, "Ask PID about stopping IVIG and TMP-SMX."
Is this a bad hospital? No; stop-gap measures designed to provide physician care to all patients around the clock, seven days a week, are found in every teaching hospital in the United States. By limiting the number of work hours of each resident, however, the new ACGME rules have effectively decreased the hospital's resident physician workforce by 25 percent—in other words, a full quarter of them have gone missing.
The problem is that losing 25 percent of the workforce hasn't been accompanied by hiring additional physicians. As a regulatory agency, the ACGME issues mandates to ensure that young physicians receive excellent clinical training; it usually doesn't approve adding increased numbers of residents to a training program just to plug a hole in a hospital's need for clinicians.
A hospital's inability to increase the number of resident physicians isn't the only barrier to improved staffing—most hospitals can't afford increased numbers of residents anyway. At the same time that the new rules have come into effect, the resources to pay for medical care are vanishing. Medicaid and Medicare payments for health care services are decreasing, and insurance payments are following this lead. Furthermore, more and more patients—forty-seven million currently—have no insurance, which means that they don't pay—because they can't pay—the bill. Although so-called physician extenders (such as physician assistants and nurse practitioners) might take on some of the tasks of the missing physicians-in-training, nursing practice isn't medical practice; even advanced practice nurses or physician assistants haven't had the comprehensive training required to be good doctors. In addition, many physician extenders command salaries similar to those of physicians-in-training yet work only forty hours a week; hiring them as replacements would mean a 100 percent increase in costs.
Health Affairs. 2008;27(3):850-854. © 2008 Project HOPE
Cite this: The Disappearing Doctors - Medscape - May 01, 2008.