80hrs/week - any takers?

[shorrin]

where is search? grrr. I can't find that old residents sue thread.

Anyway things are changing for the better!

Hospital Accreditor Will Strictly Limit Hours of Residents
By LAWRENCE K. ALTMAN and DENISE GRADY

n a move that is expected to make a significant change in the way doctors are trained, the group that accredits the nation's teaching hospitals said yesterday that it would impose strict new limits on the number of hours worked by medical residents.

The rules, intended to reduce the risk of dangerous errors by sleep-deprived young doctors, are to take effect in July 2003. They will limit the workweek to 80 hours, require at least 10 hours of rest between shifts, restrict duty to no more than 24 hours at a time and restrict work outside the hospital.
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They will also require stricter supervision and accountability from the hospitals that train the residents. Faculty members and program directors will be required to assess the residents for signs of sleep loss and fatigue.

Residents are newly minted doctors who spend three to seven years training as specialists in hospitals after they earn a medical degree. Many of the nation's 100,000 residents complain that they now work 100 or more hours a week.

Some specialties like internal medicine and emergency medicine have already limited residents' workweek to 80 hours. But the new working-hour rules are the first ever imposed on all specialty training programs by the Accreditation Council for Graduate Medical Education, an organization in Chicago that monitors the training of residents in 114 specialties in 7,800 programs throughout the country.

New York is the only state with a law limiting such work hours, to 80 a week for all residents. The council's action coincides, however, with the introduction of federal legislation by Senator Jon Corzine, Democrat of New Jersey, and Representative John Conyers Jr., Democrat of Michigan, that would also limit residents' hours. Concern about residents' schedules has intensified, the council noted, now that hospitals are under ever greater pressure to discharge patients quickly as a way to control costs.

Responding to the new rules, a union representing residents said the council had done little to enforce existing rules that it adopted in the 1980's. Those rules say residents should get at least one day off in seven and be on call no more often than every third night.

The union's national president, Dr. Ruth Potee, said the council had "come a long way in this year in recognizing that residents' hours are extreme" and was now "closer to where we'd like them to be." But she added that the union was not happy with a provision of the rules that will allow hospitals to increase the 80-hour week by 10 percent if they can justify doing so on educational grounds.

"We feel strongly that 80 hours a week is truly the limit," said Dr. Potee, a family medicine resident at Boston Medical Center.

Dr. Potee said some residents now worked 120 hours a week. Hours tend to be longest, she said, in surgery, obstetrics and gynecology, and family medicine.

Her union, the Committee of Interns and Residents, has about 12,000 members ? some 10 percent of the nation's residents ? and is affiliated with the Service Employees International Union, the largest union in the A.F.L.-C.I.O.

Among the groups represented on the accreditation council are the American Hospital Association, the Association of American Medical Colleges, the American Medical Association and the American Board of Medical Specialties.

Dr. David Leach, the council's executive director, said it intended to enforce the new rules aggressively, using confidential Internet surveys of residents to find out whether hospitals are violating them. Reports of egregious violations could lead to a quick visit to the hospital to evaluate them on site, he said.

Violations could be costly: a training program might be stripped of accreditation. If so, the hospital would lose some of its reimbursement from Medicare and Medicaid. In addition, doctors cannot be certified as specialists unless they graduate from a training program that is accredited.

Last month the council threatened Yale-New Haven Hospital, a teaching affiliate of the Yale School of Medicine, with loss of accreditation of its surgical program because residents were on call too many nights and were working weeks of 100 hours or more. Although existing rules place no specific limit on the workweek of surgical residents, in general the council can act when it finds that a hospital has breached the rules' spirit.

In any event, the new changes "will force a redesign of the entire training system," Dr. Leach said.

Strict compliance with the rules could increase teaching hospitals' costs by millions of dollars, since those hospitals often rely on residents as a source of low-cost labor.

In separate interviews, Dr. Leach and Dr. Potee noted that budget constraints had forced many teaching hospitals to reduce their staffs, including nurses and workers who draw blood and move patients. Although many hospitals have hired aides called "physician extenders" to help with such work, much of the burden has fallen on residents, increasing their hours and interfering with their education.

In 1999, the Institute of Medicine of the National Academy of Sciences issued a report citing evidence that medical errors in hospitals killed 44,000 to 98,000 people a year.

A number of experts have come to believe that most medical errors result from systemic flaws in the way hospitals, clinics and pharmacies operate, not from individual recklessness. Training programs are part of the larger system, and the council wanted to fix its part of the systemic problem, Dr. Leach said.

The rules will have a big effect on surgery because that specialty has not set workweek limits on its own.

Leading surgical educators recognize that patients have a right to an alert physician to deliver appropriate care. But they also say surgical training requires a commitment to continuity in patient care, regardless of the time of day, number of hours already worked or on-call schedules.

Standards set by the surgical specialty specified only that surgical residents were supposed to spend at least one day out of seven free of hospital duties and not be on call any more than every third night. There were a variety of reasons for the absence of a maximum workweek.

One was the widely accepted belief that the more often a surgeon does a procedure, the better the performance. In their desire to do as many operations as possible, surgical residents have tended to stay at the hospital longer to get the experience.

Another reason was the importance of continuity in patient care. Surgeons have felt a heavy obligation to stay with a patient, particularly if a complication arises, until they recover.

Although New York State limits all residents to an 80-hour workweek, the accreditation council's surveys have found those regulations "were not all that effective," Dr. Leach said. But, he said, in recent months New York had stepped up the enforcement and fines associated with the regulations.

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[Mystique]

I read this yesterday, and I had a question. Do you think this will affect resident salaries?

 

[shorrin]

Oh you mean we'd make even less than .50 an hour?

Sorry to sound bitter but I really don't think that residents are compensated adequately for their time and level of education.

It's a good question though.

 

[atsai3]

Unless there are other reforms (eg, see the thread on the match class action lawsuit), with reduced workweeks residents may draw even smaller salaries.

-a.

 

[time quaker]

It is also important to consider that since each individual resident is working less, will they have to hire more residents? More residents means more medical students doesn't it? Many doctors would claim this is a bad idea because it actually reduces training and experience for residents. A resident may admit a patient and then not learn anything more about the case since they are off work before they can actually learn something.

As for the pay, residents really don't have any time to spend money (except I suppose on paying back loans). I don't think we should be complaining about doctor's compensation on the whole.

 

[shorrin]

tq

Have you any idea what the payback per month is on a 200,000 student loan? I have no idea how as a single person living in a city would begin to even pay for rent let alone, food, car etc. on 35k.

Many of the nurses I talk to while volunteering tell me that they often feed the residents because they have no money. Many residents they tell me eventually moonlight to make ends meet.

If you look at other professional grads such JD's there is a great discrepancy in the compensation to education level ratio.

I think they do have a right to complain about an archaic system such as this.

 

[Tazdoc]

Hey guys, resident salaries are not paid by the hospitals but by the government. So salary is not affected.

 

[paean]

Actually, the gov't gives hospitals about 100K per year per resident, and the hospital decides how much out of that they want to pay the resident. Most residents get about 35K per year, plus some sort of health and liability insurances. The total cost of employment to the hospital is about half what they get from the gov't, and they are free to raise or lower residents' salaries at any time. So, yes salaries could go down, but the hospital is not being forced to lower compensation by the new rules. If they lower compensation, they are just wringing even more benefit out having the resident rather than hiring a doctor or PA or nurse to cover the workload.

 

[shorrin]

A bit more info:

Sleep-Deprived Doctors

atients can only welcome the prospect of stricter limits on the number of hours that medical residents will be allowed to work in the nation's teaching hospitals. Nobody wants a bleary-eyed beginning doctor, numb after extraordinarily long hours without rest, to be making critical medical decisions or performing surgical procedures.

The new rules are to be imposed in July 2003 by the Accreditation Council for Graduate Medical Education, which oversees doctor training in the United States. They are similar to a longstanding law in New York that limits the hours that residents can work. Unfortunately, that law has not always been vigorously enforced.

People accustomed to a 40-hour workweek may find it shocking that the new rules will reduce the residents' workload only to an average of 80 hours a week, with no more than 24 hours consecutive. Moreover, the hospitals can boost those numbers to 88 and 30 for certain purposes. But even that can be considered progress in a world where many residents have complained that they were working more than 100 hours a week, sometimes even 120 hours, often for 36-hour stretches at a time.

How vigorously the new rules will be enforced is not yet clear. The Committee of Interns and Residents, a union with some 12,000 members, complains that the council has been doing little to enforce its existing, weaker standards, so there is no certainty that it will get tough now. The council insists, however, that it will enforce the new rules aggressively, using confidential Internet surveys of residents to ferret out violations. Hospitals that violate the rules could lose their training accreditation and substantial government funding.

Despite the tough talk, the council faces an inherent conflict of interest. Its board is dominated by the trade associations for hospitals, doctors and medical schools, all of which benefit from the cheap labor provided by medical residents. The teaching hospitals alone could face millions in added labor costs at a time when their budgets are already strained. Bills have been introduced by Senator Jon Corzine of New Jersey and Representative John Conyers of Michigan, both Democrats, that would set limits on the time that residents can work. Codifying the rules into law would be a sensible step to increase the pressure for vigorous enforcement.

And another perspective:

Limits on Residents' Hours Worry Teaching Hospitals
By REED ABELSON

any of the nation's teaching hospitals, already under financial pressure, are raising concerns about the effect of new rules that will limit the number of hours worked by medical residents.

"For academic medical centers, the impact is going to be profound," said Dr. Peter Herbert, the chief of staff for Yale-New Haven Hospital, a teaching affiliate of the Yale School of Medicine, who estimates that the cost for some hospitals could run into the millions of dollars.

The rules, which are being imposed by the group that accredits teaching hospitals, will limit the average workweek to 80 hours and restrict a resident's duty to no more than 24 hours at a time.

Some hospitals consider residents an inexpensive source of labor. Some residents say they work 100 hours or more a week. Having significantly cut back on nurses and other staff, hospitals rely heavily on these new doctors, who spend several years training at a hospital after earning their medical degrees.

In addition to caring for patients, particularly the poor and uninsured, these doctors often handle paperwork, transport patients and perform tasks once delegated to others.

The new rules, which are aimed at reducing the risk of dangerous errors by inexperienced doctors who are sleep deprived, will take effect in July 2003. They are being applied by the Accreditation Council for Graduate Medical Education, which oversees the training of 100,000 residents in the nation's 7,800 programs.

While some specialties already limit residents' workweeks, the new rules will apply to all training programs and could require many hospitals to change how they staff.

Yale-New Haven Hospital, whose surgery program was threatened with a loss of accreditation because of the long hours residents worked, is hiring 12 physician associates to reduce the residents' workload, Dr. Herbert said.

"There is a huge financial hit," said Dr. Jon Cohen, the chief medical officer for the North Shore-Long Island Jewish Health System, which, like other New York hospitals, has had to adapt to a law that already limits residents' hours.

The cost of two to three physician assistants can run as high as $200,000 a year, compared with $50,000 to pay a medical resident, Dr. Cohen said. "No one knows where that money is going to come from," he said.

Many hospitals acknowledge that the new rules will require significant changes in how they do things and how they view residents.

"The big cultural change is the institutions have to recognize and treat residents as students," Dr. Cohen of North Shore said.

Some say this will force teaching hospitals to think seriously about the best way to deliver care and educate residents.

"The real challenge for us is to redesign the health care delivery model," said Dr. Thomas J. Nasca, dean of the Jefferson Medical College at Thomas Jefferson University.

In New York, the cost of adopting the law limiting residents' hours was estimated by the state at $220 million a year, some of which the hospitals recovered through higher reimbursements.

The New York law took effect in 1989, and a study done in the late 1990's suggested that many hospitals, particularly in New York City, were still asking residents to work longer hours than the law required. In recent years, however, enforcement of the law has been increased, and many hospitals have made more significant changes in their staffing.

New York hospitals are not likely to feel much impact from the new rules, said Kenneth Raske, the president of the Greater New York Hospital Association, with the exception of some surgical programs where hospitals are still allowed to ask their residents to work longer hours. "The surgical programs need to have some flexibility," Mr. Raske said.

Depending on how the hospital uses residents and the services they provide, the cost of complying will vary widely, the American Hospital Association said. "We really don't understand the cost or the adaptions," said James Bentley, the group's senior vice president for strategic policy planning.

While some hospitals will hire senior nurses or physician assistants, others may rely more on other doctors and may curtail some of the areas where residents provide care, Mr. Bentley said.

But hiring nurses or physician assistants may not add significantly to costs, others say. "The financial impact won't be catastrophic," said Mark V. Pauly, a professor of health care at the Wharton School at the University of Pennsylvania.

Still, the new rules are an example of rising costs for hospitals, said Mr. Bentley, who said the association was working to prevent cuts in federal and state payments that would further weaken the financial condition of many of its members.

Even specialities like internal medicine that already adhere to 80-hour workweek will have to adjust. At the University of Chicago hospitals many residents work 36 or 38 hours at a time to be able to provide follow-up care and attend educational programs, said Dr. Holly Humphrey, who oversees the residents in internal medicine. The 24-hour limit, even with a possible additional six hours for handing off patients or attending lectures, "is a big, big change," Dr. Humphrey said.

She is concerned that residency programs will "take on a mentality of shift work," she said.