Facing declining U.S. medical student interest and a legislative threat to curtail work hours, Timothy Flynn, M.D., knows surgery residency programs will change. It's a matter of when and how.
"There is general agreement among surgeons that some work-hour reform is needed and that some work-hour restrictions will apply to our programs," says Flynn, president of the Arlington, Va.,-based Association of Program Directors in Surgery.
Solutions for reducing workloads include asking hospitals to hire more allied health practitioners and support staff, changing faculty work responsibilities and reducing core surgery curricula, says Flynn, who also is program director of general surgery at Shands HealthCare at the University of Florida in Gainesville.
"We worry about the big safety-net hospitals that don't have the resources to comply," he says. "There is less money available for graduate medical education and teaching hospitals."
Despite the financial constraints, most of the nation's 7,750 residency programs are looking for ways to provide a better balance of education and work.
Pushing for limits
For more than a decade, since a grand jury investigation linked the accidental death of 18-year-old Libby Zion in a New York hospital emergency department to overworked residents and lack of supervision, residents and some activist program directors have been pushing for improved working conditions.
In November, Rep. John Conyers Jr. (D-Mich.) introduced the Patient and Physician Safety and Protection Act of 2001. The bill would require programs to adhere to work-hour restrictions similar to those governing residency programs in New York, where state law limits residents to an average of 80 hours per week over a four-week period. It also would provide funds to hospitals for hiring more staff.
And in May, several residents filed an antitrust lawsuit against the National Resident Matching Program and its sponsoring organizations, accusing the automated residency selection system of promulgating low pay, long hours and poor working conditions. If the suit prevails, it could force hospitals to pay residents more while working them less.
"Organized medicine in the absence of threatened regulation or legislative action will do nothing," says Peter Lurie, M.D., deputy director of health research at Public Citizen, a Washington, D.C.-based consumer advocacy group.
"Using residents as a cheap labor source is the dirty secret that organized medicine has been forced to sweep under the rug."
Accepting the work-hour challenge
Thomas Russell, M.D., executive director of the American College of Surgeons, says surgery residencies have accepted the challenge to change. "We are trying to get some consensus on what to do," he says. "Not all surgery programs have the same issues."
From 1978 to 1989, 10% of medical school seniors listed general surgery as their first choice of residency, according to a study in the March issue of Archives of Surgery. By 2002, it had dropped to about 6%.
Internal medicine residencies face similar challenges, according to David Battinelli, M.D., president of the Association of Program Directors in Internal Medicine and a program director at Boston University Medical Center.
In the 2002 match, more students chose specialties--radiology, anesthesiology and emergency medicine--that require shorter training periods, Battinelli says, while student demand has declined in fields with more unpredictable hours. "We need to be aware that medical graduates are selecting residencies and careers that offer reasonable hours and lifestyles."
Medical students also are aware that work hours are monitored by the Accreditation Council for Graduate Medical Education. ACGME data from 1999 to 2001 shows a three-year decline in residency work hour citations. But surgery and internal medicine residencies continue to be cited most often.
"We are going to make huge changes," Flynn says. "At the same time, we don't want surgery to lose its core values."
Jay Greene is a healthcare writer based in St. Paul, Minn. Staff writer Leigh Page contributed to this story.