For decades, young doctors-in-training in the surgical program at Yale University's prestigious teaching hospital were accustomed to working 100 to 120 hours per week--the same kind of intense, fatigue-inducing routine that has churned out scores of top-flight physicians before them.
But that long-accepted routine began to change last year in the wake of mounting concern that some weary students were so burned out they posed a threat to their patients. In a decision with wide-ranging implications for medical schools, hospitals and tens of thousands of future physicians, the Chicago-based association that oversees resident training threatened last March to withdraw accreditation from Yale-New Haven (Conn.) Medical Center unless sweeping changes were made to reduce work hours.
It was the first major step in what has become the most significant evolution in many years regarding the way teaching hospitals train young doctors. For better or worse, medical residency programs--and the role of the physician executives 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 spearhead efforts to adapt work hours at the prestigious university. "In the long run, I think it will help residency training. I think we'll see more of a team concept and less of an individual concept. That's anathema to how we were trained, but I think it's going to make surgical training more attractive to a broader segment (of future physicians)."
Faced with a "death sentence" from the Accreditation Council for Graduate Medical Education, Udelsman, along with a key corps of other physician executives at Yale's School of Medicine, jump-started a costly restructuring of the surgical residency program. In addition to hiring a dozen new physician assistants, Yale overhauled the shift-rotation system and instituted safeguards to help ensure residents use their time more efficiently.
Physician execs' big challenge
With its bold efforts, Yale retained its accreditation without a lapse when the ACGME returned for a follow-up visit in August. Now Yale is widely viewed as a trendsetter, a national model at a crucial time when teaching hospitals across the nation are scrambling to meet the fast-approaching July 1 deadline on new ACGME guidelines limiting residents across the nation to an average of 80 hours per week, averaged over a month.
The controversial new rules will affect about 99,700 residents in 7,800 residency programs--and every teaching hospital in the U.S.
For most of these institutions, the transition to the new national guidelines has been far less traumatic than Yale's. Most residency programs already impose regulations that limit doctors-in-training to 80-hour workweeks. Pressured from all sides over concerns about patient safety, even work-intensive programs such as surgery, in which 120-hour weeks still are fairly common, have cut back in recent years.
"I think the majority of hospitals have already implemented the new guidelines," says David Leach, the ACGME's executive director. "We were anticipating more resistance than we got. But everyone realized that this was necessary."
For a renowned institution such as Yale, the loss of accreditation would have done far more than just tarnish its gold-plated reputation. It also could have meant forfeiting tens of millions of dollars in federal funds that help underwrite residency programs.
"It would have been devastating," Udelsman says. "The bottom line is we were willing to deal with whatever (ACGME) wanted us to do. My whole life changed. Our goal was never to just meet the minimum requirements. We wanted to become the poster child for the ACGME."
Leach wouldn't discuss Yale's case directly, but acknowledged that the threat of sanctions against such a well-known institution underscored the notion that his agency meant business.
"I think it did serve as something of a wake-up call for the world at large," he says of the guidelines and the far more stringent enforcement effort.
The big change for residency programs, however, doesn't end with doctors-in-training. Dramatic adjustments are expected as well for program directors--the physician executives whose principal role, up until now, often involved largely unrewarding administrative duties. Leach, the ACGME's top official, says annual turnover for program directors, which once hit about 25%, has dropped to just 12% because "the work is being taken much more seriously."
"Until recently, it was a relatively thankless job," Leach says. "It's become more of an intellectual task--a job that really involves the development of physicians. It's requiring some really creative work. It's become valuable work as opposed to just scheduling."
What's more, the new rules haven't made the job any easier. "Duty hours have definitely complicated the lives of program directors," Leach says. "And it's called into question whether the purpose of residency programs is to provide patient care or teach residents how to become doctors. Our view is that residents are students, and they are there to learn enough practical skills to be self-sufficient as doctors. They're not a form of cheap labor."
Leach calls the change "evolutionary" rather than revolutionary, a significant step in modifying and improving the way young doctors are taught. Though almost universally accepted, the new guidelines have posed considerable challenges to many institutions and have triggered widespread concerns about the costs involved in changing what amounts to one of medicine's most enduring legacies.
Yale, for instance, spent $1.5 million to get its surgical residency program up to speed. When the guidelines were introduced last year, many experts suggested that most hospitals would incur similar expenses--primarily for the salaries of new "extenders" such as physician assistants and nurse practitioners. Moreover, these are recurring expenses. Some observers say hospitals will be forced to spend hundreds of thousands of dollars or more each year to comply with the new guidelines; others say the numbers are exaggerated, suggesting that most programs will need only to adjust schedules and focus the efforts 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 help determine the most efficient and economical methods. "Most of the figures have been wild and speculative. At this point, we just don't know."
Ingrid Philibert, the ACGME's director of field activities, says a study conducted in the late 1980s in New York, where the nation's first and only work-hour law for residents took effect nearly two decades ago, pegged the total cost at $358 million for the state's 84 teaching hospitals. Much of the costs involved the replacement of low-paid residents, who typically earn about $40,000, with nurse practitioners, whose salaries can run as high as $95,000 per year, she says.
"The costs will greatly depend on the mix of programs and the degree to which the residents' hours currently exceed (the new guidelines)," Philibert says.
Yet most hospitals acknowledge that the loss of accreditation would be far more painful than the price paid to comply with the guidelines.
"It's going to cost us some money," says Mark Nehler, program director of general-surgery residents at the Denver-based University of Colorado Health Sciences Center. "We're going to have to pony up some money for extra 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--a perspective echoed by Philibert, who works closely with program directors across the nation. "This is a chance to participate in the education of the next generation of physicians," she says. "And the residents you're working with are smart folks--high-energy, a fun group to work with. There probably isn't a better job in the country. These (program directors) care very deeply about education and patient care."
Like most of his fellow program directors, Nehler--who stepped into the job last October after about three years as the assistant program director--is spending the majority of his time making sure the university is in compliance with the new guidelines. "At this juncture, it probably encompasses about 50% of my time," says Nehler, who can't yet estimate what the total costs will be. "Once we get some sort of system in place, I anticipate that will diminish."
The University of Arkansas for Medical Sciences in Little Rock, like most other teaching hospitals, created a work-hours task force last fall to develop new policies and institute a monitoring system for its residents. In addition to a night-float system, the university is hiring an as-yet-undetermined number of nurse practitioners to lighten residents' loads.
The extra manpower is expected to add at least $250,000 to the budget, says Jeanne Heard, associate dean of graduate medical education at the university and a nationally recognized authority on the work-hours issue. On-call duty also is being closely monitored. Each of the 48 residency programs at Little Rock's University Hospital of Arkansas and its affiliated institutions will be required to submit written documents that duty hours have been reviewed and do not exceed the limits, Heard says.
Like Arkansas and other teaching hospitals, Massachusetts General Hospital in Boston is surveying its residents on ways to cut paperwork so they can focus on the kinds of duties that will help them become better doctors. Other teaching hospitals, such as the University of Washington Medical Center in Seattle, have placed strict limits on the number of patients a resident can admit--a sure way to reduce workload.
Says Udelsman: "The paradox is: Train 'em better--but train 'em in less time."
At the University of Florida in Gainesville, officials have cut residents' hours by hiring a number of physician extenders and adding new faculty. The university also instituted a night-float system and changed the schedule for daytime resident conferences, according to Timothy Flynn, associate dean of graduate medical education at the university, which sponsors 55 different residency programs for about 500 students. Like other physician executives, he can't cite a cost figure. He is certain of only one thing: Residents in some programs were spending an inordinate amount of time on the job.
"We had a number of programs with (residents working) well over 100 hours (per week)," Flynn says.
Time and training
One key effort for almost all hospitals involves making sure that residents are 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 in many residency programs when student doctors are "neither learning anything nor doing much work." He says he has tried to "re-educate" the faculty about residents' priorities, as well as asking nurses to assume more authority in their own right to help deal with minor problems that might distract 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 do anything, including mop the floors, just doesn't work anymore."
Continuity of care also is a major issue. Many physicians believe patient care is compromised when a resident is forced to hand off a patient before completing a course of treatment. At the same time, even those who have mixed feelings about the new guidelines raise concerns about how residents function after working almost nonstop for 24 hours or more. That group includes Michael Edwards, who oversees the residency program at Arkansas as chairman of the university's department of surgery.
"A tired resident does not learn as well at the end of a long time period," Edwards says.
Still, Edwards says he wonders if the training of the next generation of doctors has been diminished by a cookie-cutter approach for residency programs.
"Is it normal for a person to run a mara-thon?" he asks. "No. Or to condition yourself to be a gymnast? No. In the training of a surgeon do we aspire to mediocrity? I do agree there needs to be an open and vigorous debate about what constitutes appropriate training, but some simplistic extrapolation (of hours) is not necessarily consistent with that training. Let's not miss the point here--we've been getting it right for a long time."
Nehler, program director at the University of Colorado, supports the new rules 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 early 1990s, Nehler recalls working more than 120 hours during some especially exhausting weeks.
"The rules right now are relatively inflexible," he says. "It seems to me a little strange to have the same hours requirements for a resident like general surgery, which everyone knows is very labor-intensive, and an outpatient residency like dermatology. Why should those rules be the same? I expect, at some point, the (limits on hours) will be modified. I think there needs to be some adjustments."
There is some anxiety, however, that strict work hours might rob residents of the kind of case volume they need not only to graduate from the program but to become good doctors. That's especially true in surgical residencies, where students 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 a textbook," 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. A rebellion against work-hour limits might be triggered by the very individuals they're designed to help--the residents themselves.
"Residents don't want to leave and risk missing out on educational opportunities," Nehler says. "Surgery is an apprenticeship. And the apprentices are acutely aware that they've got a fixed amount of time to learn their craft. We're trying to implement things for people who aren't very interested 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 of hours residents could work. That 13-year-old law, which set the limit at 80 hours per week, largely was ignored until about a year ago, when the state health department began citing violators and imposing fines that can run as high as $6,000 for each violation. Last June, the agency discovered work-hour violations at 54 of 82 teaching hospitals inspected over about a six-month period.
In fact, much of the controversy over resident work hours and the impetus of New York's unique legislation was triggered by the case of Libby Zion, an 18-year-old college freshman who died in 1984 at New York Hospital-Cornell Medical Center after being admitted with a high fever. A grand jury determined that 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 workweeks to 80 hours, averaged over four weeks, with at least one day off per week and a minimum 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 Student Association and allied consumer advocates that long work hours were contributing to 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 a way to forestall government intervention. Even Leach has acknowledged that the threat of federal activity played a role in the ACGME's guidelines, which continue to come under attack from critics who regard the new rules as toothless and unenforceable.
"These guidelines aren't at all strict," says Stephen Cha, a third-year internal medicine resident at 1,119-bed Montefiore Medical Center in New York and a graduate trustee for the American Medical Student Association. "You might see some changes the first year--all the program directors will talk about how they've changed things for residents. But they'll all slide back to the old routine after all the media coverage ends."
Leach downplayed the criticism. While consumer groups and union officials continue to call for statutory requirements like New York's, he says the fines imposed on some hospitals represent a mild slap on the wrist compared with the consequences that accompany the withdrawal of accreditation.
"If we withdraw accreditation on an institutional level," Leach says, "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 the 2,100 programs it reviews each year. That means about 170 programs, out of the total of 7,800, must take some level of corrective action. Yet the number of serious actions--including probation or the withdrawal of accreditation--occur far less frequently.
In 2001, the last year in which statistics are available, the ACGME surveyed 1,920 programs and withdrew accreditation in just 15 cases. In most instances, though, these programs were then placed on probation pending a resolution of whatever problem was discovered by the residency-review committee.
Mark Levy, executive director of the Committee of Interns and Residents, a New York City-based union group that represents more than 12,000 residents in five states and the District of Columbia, wonders whether doctors-in-training are likely to blow the whistle on their own program and risk the consequences of a loss of accreditation. In some cases, the students would be required to repeat training in an accredited program.
"Even if you've got a hydrogen bomb, are you going to use it?" he asks. "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 remains confidential. Unlike New York's law, which includes the release of information about specific hospitals and their violations, the ACGME's guidelines effectively 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 the most egregious cases ever get publicized."
Policing work hours and monitoring all these physicians-in-training will present a huge logistical problem, experts agree. A handful of methods are already in place, including everything from self-policing to time cards and computer chips. Some teaching hospitals have gone back to basics, assigning a clerk to monitor the comings and goings of residents.
"We have not yet come up with a great idea on how to do it," says Nehler, who adds that officials are considering some kind of a computerized swipe 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 survey every resident in the three months before each program's review. There also will be individual interviews with residents and faculty members, providing an accurate picture of compliance through this "unfiltered data," he says.
Despite working under the pressure of a July 1 deadline, physician executives across the nation are invariably optimistic about meeting the ACGME's guidelines--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 at 289-bed Denver Health Medical Center. "The problem will be sustaining it."
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