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Lightening Their Load

May 15, 2003
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This article was originally published in Modern Healthcare.

For decades, young doctors-in-training in the surgical program at YaleUniversity's prestigious teaching hospital were accustomed to working 100 to 120hours per week--the same kind of intense, fatigue-inducing routine that haschurned out scores of top-flight physicians before them.

But that long-accepted routine began to change last year in the wake ofmounting concern that some weary students were so burned out they posed a threatto their patients. In a decision with wide-ranging implications for medicalschools, hospitals and tens of thousands of future physicians, the Chicago-basedassociation that oversees resident training threatened last March to withdrawaccreditation from Yale-New Haven (Conn.) Medical Center unless sweeping changeswere made to reduce work hours.

It was the first major step in what has become the most significant evolutionin many years regarding the way teaching hospitals train young doctors. Forbetter or worse, medical residency programs--and the role of the physicianexecutives who oversee them--will never be the same.

"I think this will change training forever," says Robert Udelsman,Yale's chairman of surgery and the physician executive who helped spearheadefforts to adapt work hours at the prestigious university. "In the longrun, I think it will help residency training. I think we'll see more of a teamconcept and less of an individual concept. That's anathema to how we weretrained, but I think it's going to make surgical training more attractive to abroader segment (of future physicians)."

Faced with a "death sentence" from the Accreditation Council forGraduate Medical Education, Udelsman, along with a key corps of other physicianexecutives at Yale's School of Medicine, jump-started a costly restructuring ofthe surgical residency program. In addition to hiring a dozen new physicianassistants, Yale overhauled the shift-rotation system and instituted safeguardsto help ensure residents use their time more efficiently.

Physician execs' big challenge
    With its bold efforts, Yale retained its accreditation without a lapse whenthe ACGME returned for a follow-up visit in August. Now Yale is widely viewed asa trendsetter, a national model at a crucial time when teaching hospitals acrossthe nation are scrambling to meet the fast-approaching July 1 deadline on newACGME guidelines limiting residents across the nation to an average of 80 hoursper week, averaged over a month.

The controversial new rules will affect about 99,700 residents in 7,800residency programs--and every teaching hospital in the U.S.

For most of these institutions, the transition to the new national guidelineshas been far less traumatic than Yale's. Most residency programs already imposeregulations that limit doctors-in-training to 80-hour workweeks. Pressured fromall sides over concerns about patient safety, even work-intensive programs suchas surgery, in which 120-hour weeks still are fairly common, have cut back inrecent years.

"I think the majority of hospitals have already implemented the newguidelines," says David Leach, the ACGME's executive director. "Wewere anticipating more resistance than we got. But everyone realized that thiswas necessary."

For a renowned institution such as Yale, the loss of accreditation would havedone far more than just tarnish its gold-plated reputation. It also could havemeant forfeiting tens of millions of dollars in federal funds that helpunderwrite residency programs.

"It would have been devastating," Udelsman says. "The bottomline is we were willing to deal with whatever (ACGME) wanted us to do. My wholelife changed. Our goal was never to just meet the minimum requirements. Wewanted to become the poster child for the ACGME."

Leach wouldn't discuss Yale's case directly, but acknowledged that the threatof sanctions against such a well-known institution underscored the notion thathis agency meant business.

"I think it did serve as something of a wake-up call for the world atlarge," he says of the guidelines and the far more stringent enforcementeffort.

The big change for residency programs, however, doesn't end withdoctors-in-training. Dramatic adjustments are expected as well for programdirectors--the physician executives whose principal role, up until now, ofteninvolved largely unrewarding administrative duties. Leach, the ACGME's topofficial, says annual turnover for program directors, which once hit about 25%,has dropped to just 12% because "the work is being taken much moreseriously."

"Until recently, it was a relatively thankless job," Leach says."It's become more of an intellectual task--a job that really involves thedevelopment of physicians. It's requiring some really creative work. It's becomevaluable work as opposed to just scheduling."

What's more, the new rules haven't made the job any easier. "Duty hourshave definitely complicated the lives of program directors," Leach says."And it's called into question whether the purpose of residency programs isto provide patient care or teach residents how to become doctors. Our view isthat residents are students, and they are there to learn enough practical skillsto be self-sufficient as doctors. They're not a form of cheap labor."

Leach calls the change "evolutionary" rather than revolutionary, asignificant step in modifying and improving the way young doctors are taught.Though almost universally accepted, the new guidelines have posed considerablechallenges to many institutions and have triggered widespread concerns about thecosts involved in changing what amounts to one of medicine's most enduringlegacies.

Yale, for instance, spent $1.5 million to get its surgical residency programup to speed. When the guidelines were introduced last year, many expertssuggested that most hospitals would incur similar expenses--primarily for thesalaries of new "extenders" such as physician assistants and nursepractitioners. Moreover, these are recurring expenses. Some observers sayhospitals will be forced to spend hundreds of thousands of dollars or more eachyear to comply with the new guidelines; others say the numbers are exaggerated,suggesting that most programs will need only to adjust schedules and focus theefforts of residents while they're on the job.

"No one has a good answer about what this is all going to cost,"says Leach, who expects to survey hospitals sometime in the near future to helpdetermine the most efficient and economical methods. "Most of the figureshave been wild and speculative. At this point, we just don't know."

Ingrid Philibert, the ACGME's director of field activities, says a studyconducted in the late 1980s in New York, where the nation's first and onlywork-hour law for residents took effect nearly two decades ago, pegged the totalcost at $358 million for the state's 84 teaching hospitals. Much of the costsinvolved the replacement of low-paid residents, who typically earn about$40,000, with nurse practitioners, whose salaries can run as high as $95,000 peryear, she says.

"The costs will greatly depend on the mix of programs and the degree towhich the residents' hours currently exceed (the new guidelines),"Philibert says.

Yet most hospitals acknowledge that the loss of accreditation would be farmore painful than the price paid to comply with the guidelines.

"It's going to cost us some money," says Mark Nehler, programdirector of general-surgery residents at the Denver-based University of ColoradoHealth Sciences Center. "We're going to have to pony up some money forextra salaries. But if you're cited (by the ACGME) and lose your accreditation,your expenditures to fix it likely will run in the millions of dollars."

Finding some fun
    Despite the problems, Nehler says his job is challenging and rewarding--aperspective echoed by Philibert, who works closely with program directors acrossthe nation. "This is a chance to participate in the education of the nextgeneration of physicians," she says. "And the residents you're workingwith are smart folks--high-energy, a fun group to work with. There probablyisn't a better job in the country. These (program directors) care very deeplyabout education and patient care."

Like most of his fellow program directors, Nehler--who stepped into the joblast October after about three years as the assistant program director--isspending the majority of his time making sure the university is in compliancewith the new guidelines. "At this juncture, it probably encompasses about50% of my time," says Nehler, who can't yet estimate what the total costswill be. "Once we get some sort of system in place, I anticipate that willdiminish."

The University of Arkansas for Medical Sciences in Little Rock, like mostother teaching hospitals, created a work-hours task force last fall to developnew policies and institute a monitoring system for its residents. In addition toa night-float system, the university is hiring an as-yet-undetermined number ofnurse practitioners to lighten residents' loads.

The extra manpower is expected to add at least $250,000 to the budget, saysJeanne Heard, associate dean of graduate medical education at the university anda nationally recognized authority on the work-hours issue. On-call duty also isbeing closely monitored. Each of the 48 residency programs at Little Rock'sUniversity Hospital of Arkansas and its affiliated institutions will be requiredto submit written documents that duty hours have been reviewed and do not exceedthe limits, Heard says.

Like Arkansas and other teaching hospitals, Massachusetts General Hospital inBoston is surveying its residents on ways to cut paperwork so they can focus onthe kinds of duties that will help them become better doctors. Other teachinghospitals, such as the University of Washington Medical Center in Seattle, haveplaced strict limits on the number of patients a resident can admit--a sure wayto reduce workload.

Says Udelsman: "The paradox is: Train 'em better--but train 'em in lesstime."

At the University of Florida in Gainesville, officials have cut residents'hours by hiring a number of physician extenders and adding new faculty. Theuniversity also instituted a night-float system and changed the schedule fordaytime resident conferences, according to Timothy Flynn, associate dean ofgraduate medical education at the university, which sponsors 55 differentresidency programs for about 500 students. Like other physician executives, hecan't cite a cost figure. He is certain of only one thing: Residents in someprograms were spending an inordinate amount of time on the job.

"We had a number of programs with (residents working) well over 100hours (per week)," Flynn says.

Time and training
    One key effort for almost all hospitals involves making sure that residentsare focused on their training--not the time-consuming "scut" work,such as patient transport, that often has contributed to long work hours.

Historically, Flynn says, there's been a considerable amount of downtime inmany residency programs when student doctors are "neither learning anythingnor doing much work." He says he has tried to "re-educate" thefaculty about residents' priorities, as well as asking nurses to assume moreauthority in their own right to help deal with minor problems that mightdistract the residents from their roles.

"Residents can no longer be treated like indentured servants,"Yale's Udelsman says. "The concept that they should be willing to doanything, including mop the floors, just doesn't work anymore."

Continuity of care also is a major issue. Many physicians believe patientcare is compromised when a resident is forced to hand off a patient beforecompleting a course of treatment. At the same time, even those who have mixedfeelings about the new guidelines raise concerns about how residents functionafter working almost nonstop for 24 hours or more. That group includes MichaelEdwards, who oversees the residency program at Arkansas as chairman of theuniversity's department of surgery.

"A tired resident does not learn as well at the end of a long timeperiod," Edwards says.

Still, Edwards says he wonders if the training of the next generation ofdoctors has been diminished by a cookie-cutter approach for residency programs.

"Is it normal for a person to run a marathon?" he asks. "No.Or to condition yourself to be a gymnast? No. In the training of a surgeon do weaspire to mediocrity? I do agree there needs to be an open and vigorous debateabout what constitutes appropriate training, but some simplistic extrapolation(of hours) is not necessarily consistent with that training. Let's not miss thepoint here--we've been getting it right for a long time."

Nehler, program director at the University of Colorado, supports the newrules but wonders if there's a compromise to be struck somewhere down the road.As a surgical resident at Oregon Health & Science University in the early1990s, Nehler recalls working more than 120 hours during some especiallyexhausting weeks.

"The rules right now are relatively inflexible," he says. "Itseems to me a little strange to have the same hours requirements for a residentlike general surgery, which everyone knows is very labor-intensive, and anoutpatient residency like dermatology. Why should those rules be the same? Iexpect, at some point, the (limits on hours) will be modified. I think thereneeds to be some adjustments."

There is some anxiety, however, that strict work hours might rob residents ofthe kind of case volume they need not only to graduate from the program but tobecome good doctors. That's especially true in surgical residencies, wherestudents often don't start wielding the knife until their third year.

"One of the things about surgery is that you can't learn it from atextbook," Nehler says. "It requires you to do multiple big cases,over and over again."

That may help illustrate an ironic problem with the work-hour limits. Arebellion against work-hour limits might be triggered by the very individualsthey're designed to help--the residents themselves.

"Residents don't want to leave and risk missing out on educationalopportunities," Nehler says. "Surgery is an apprenticeship. And theapprentices are acutely aware that they've got a fixed amount of time to learntheir craft. We're trying to implement things for people who aren't veryinterested in complying. It's a Catch-22."

Limits and the law
    Only one state--New York--has imposed clear-cut legal limits on the number ofhours residents could work. That 13-year-old law, which set the limit at 80hours per week, largely was ignored until about a year ago, when the statehealth department began citing violators and imposing fines that can run as highas $6,000 for each violation. Last June, the agency discovered work-hourviolations at 54 of 82 teaching hospitals inspected over about a six-monthperiod.

In fact, much of the controversy over resident work hours and the impetus ofNew York's unique legislation was triggered by the case of Libby Zion, an18-year-old college freshman who died in 1984 at New York Hospital-CornellMedical Center after being admitted with a high fever. A grand jury determinedthat unsupervised residents working long hours contributed to the woman's death.

Massachusetts and New Jersey are considering similar bills. In January,Puerto Rico enacted a law almost identical to New York's that limits workweeksto 80 hours, averaged over four weeks, with at least one day off per week and aminimum of eight hours between shifts.

The crackdown in New York helped to highlight the national problem,reinforcing concerns from groups such as the American Medical StudentAssociation and allied consumer advocates that long work hours were contributingto medical errors.

When Congress began to consider a federal law mandating the 80-hour workweek,the ACGME quickly took the initiative and pushed through its own guidelines as away to forestall government intervention. Even Leach has acknowledged that thethreat of federal activity played a role in the ACGME's guidelines, whichcontinue to come under attack from critics who regard the new rules as toothlessand unenforceable.

"These guidelines aren't at all strict," says Stephen Cha, athird-year internal medicine resident at 1,119-bed Montefiore Medical Center inNew York and a graduate trustee for the American Medical Student Association."You might see some changes the first year--all the program directors willtalk about how they've changed things for residents. But they'll all slide backto the old routine after all the media coverage ends."

Leach downplayed the criticism. While consumer groups and union officialscontinue to call for statutory requirements like New York's, he says the finesimposed on some hospitals represent a mild slap on the wrist compared with theconsequences that accompany the withdrawal of accreditation.

"If we withdraw accreditation on an institutional level," Leachsays, "that could mean $100 million in indirect and direct (federal)reimbursement a year (to large institutions)."

Leach says the ACGME takes "adverse" action against about 8% of the2,100 programs it reviews each year. That means about 170 programs, out of thetotal of 7,800, must take some level of corrective action. Yet the number ofserious actions--including probation or the withdrawal of accreditation--occurfar less frequently.

In 2001, the last year in which statistics are available, the ACGME surveyed1,920 programs and withdrew accreditation in just 15 cases. In most instances,though, these programs were then placed on probation pending a resolution ofwhatever problem was discovered by the residency-review committee.

Mark Levy, executive director of the Committee of Interns and Residents, aNew York City-based union group that represents more than 12,000 residents infive states and the District of Columbia, wonders whether doctors-in-trainingare likely to blow the whistle on their own program and risk the consequences ofa loss of accreditation. In some cases, the students would be required to repeattraining in an accredited program.

"Even if you've got a hydrogen bomb, are you going to use it?" heasks. "If you complain about the hours, and get your own program dis-accredited,you're dropping that bomb right on your own head."

He says the idea that the ACGME's guidelines will change the culture is"fallacious" because any penalty imposed on teaching hospitals remainsconfidential. Unlike New York's law, which includes the release of informationabout specific hospitals and their violations, the ACGME's guidelineseffectively shield violators, Levy complains.

"The threat of publicity is where the real enforcement comes in,"he says. "What they're (the ACGME) doing is protecting each other. Only themost egregious cases ever get publicized."

Policing work hours and monitoring all these physicians-in-training willpresent a huge logistical problem, experts agree. A handful of methods arealready in place, including everything from self-policing to time cards andcomputer chips. Some teaching hospitals have gone back to basics, assigning aclerk to monitor the comings and goings of residents.

"We have not yet come up with a great idea on how to do it," saysNehler, who adds that officials are considering some kind of a computerizedswipe card to track residents' hours.

For its part, the ACGME intends to go directly to the residents themselves.Leach says the accreditation agency will use Internet-based systems to surveyevery resident in the three months before each program's review. There also willbe individual interviews with residents and faculty members, providing anaccurate picture of compliance through this "unfiltered data," hesays.

Despite working under the pressure of a July 1 deadline, physician executivesacross the nation are invariably optimistic about meeting the ACGME'sguidelines--at least for now.

"It's easy to get in compliance for a few weeks, or a few months,"says Michael Wilson, chairman of the graduate medical education committee at289-bed Denver Health Medical Center. "The problem will be sustainingit."

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