Whose patient is this?

March 1, 2011

What do the new resident work hour restrictions have in common with the medical home concept? Both require teamwork-acknowledgement of a shared responsibillity for the health and well-being of each patient.

What do the new resident work hour restrictions have in common with the medical home concept? Both require teamwork-acknowledgement of a shared responsibility for the health and well-being of each patient.

The Accreditation Council for Graduate Medical Education (ACGME) has issued new and more restrictive requirements that will limit duty assignments for interns to no more than 16 hours and for PL2s and PL3s to no more than 24 hours, with the possibility of 4 additional hours for safe transfer of patients. The weekly limit on work hours remains at 80 hours per week, but the new requirements will change the configuration of those hours.

One of the important consequences of these new rules is that residents and faculty members will have to accept the concept that each patient is the responsibility of a team of residents. It no longer will be possible for a single intern to claim that a patient is his or hers. Individual interns will, of course, be assigned to care for specific patients during the hours they are in the hospital, but another intern-their teammate-will care for those patients for essentially half of each 24-hour day.

We always have known that effective medical care requires thoughtful communication and coordination among providers. The medical home concept envisions comprehensive care in partnership with families, but the medical home also is seen as facilitator and coordinator of the care a child receives from other providers, including subspecialists, nonphysician professionals, and, when the time comes, adult medical services.

"Sign-out," "hand-offs," and "transitions" of care all are familiar concepts to pediatric residents and practicing pediatricians. We know that the health of our patients does not begin and end with our interventions. We may have clung too long, however, to the concept of a "primary provider"-in both our residency programs and in community practices. It is time to admit that each physician who cares for a pediatric patient is a part of a medical care team, whether that physician is an intern caring for a patient whose illness requires hospitalization, a subspecialist who cares for specific medical or psychosocial problems, or a community pediatrician providing the coordinating function that links all the other providers.

Electronic medical records will, in time, facilitate the communication that is required to link all the teammates involved in the care of patients. Shared accessibility to information about each patient has become increasingly important as medical care is sought from a variety of sources. It is unlikely, however, that electronic records will completely replace the nuances and prioritization that can be conveyed through conversation. Every pediatric resident knows that "sign-out" involves more than listing laboratory studies and medications.

Many medical educators have objected to the new ACGME work hour rules on the grounds that they prevent interns from "taking ownership" of their patients. Rather than working to preserve the concept of ownership, we should seize this opportunity to emphasize that patients are not owned-they are shared. The earlier in the medical education process we can help future pediatricians to recognize that concept, the more effective their future care of patients will be.