Despite the $1.7 billion price tag, IOM representatives are confident that funding can be found, given the important role that teaching hospitals play in healthcare. The committee definitely recognizes that there are costs, said David Dinges, a a University of Pennsylvania School of Medicine professor who served on the committee that wrote the report. But there could be savings in the long run with improvements in patient safetybut that has not been proven.
The report said that there are 105,000 residents training at the nations 1,206 teaching hospitals and gave two options for meeting the labor demands: Either add 8,247 new residency positions or hire the equivalent of an additional 5,984 midlevel providers, such as physician assistants or nurse practitioners, 5,001 attending physicians, 229 nursing aides and 45 laboratory technicians.
Dinges, who is also chief of UPenns Psychiatry Departments sleep and chronobiology division, said the report was evidence-based and reflects the fact that there is more known about how much sleep people need than how much they should work. Were hoping the important issues dont get lost in debates about cost and who should regulate, he said.
Another member of the committee, Ann Rogers, an associate professor at the University of Pennsylvania School of Nursing, said the need to combat fatigue and ensure alertness is more critical than ever. The workload has gotten much, much heavier, she said.
Donald Girard, associate dean for graduate and continuing medical education at the Oregon Health & Science Universitys School of Medicine, agreed with this assessment. My colleagues out there are saying These young people are lazy; this is the way we were taught. But when I was in training 40 years ago, we didnt have an ICU, and patients were in the hospital for weeks at a time, he said.
Also supporting the move was Toni Lewis, president of the Committee for Interns and Residents for the Service Employees International Union, who said: What it comes down to is Is it worth it? And yes, it is, she said. The committee represents some 13,000 resident physicians.
Among those disputing the wisdom of a 16-hour shift limit was the American College of Surgeons. On March 4, the group released a position paper that called for exempting chief surgical residents from duty-hour limits to allow a more realistic transition to a postgraduate career, and said that restricting surgical resident work weeks to less than 80 hours could result in deteriorating quality and could cause irrevocable damage to a surgical residency training system.
In a written statement released last week, the American College of Surgeons applauded the IOM report for not recommending a reduction in the 80-hour weekly limit, but then also slammed it for its recommendation to limit shifts to 16 hours, declaring that this could compromise the education of the residents and possibly affect the continuity of patient care.
Carol Rumack, associate dean of medical education at the University of Colorado School of Medicine in Denver, agreed. If someone needs a surgeon in the middle of the night, we dont say Sorry, theres nobody here, Rumack said. The IOM report may be an ideal, but whats realistic in this economic downturn were in? she asked. Its reasonable to say it will be a major expense to do everything in this report.
Although the report allows for flexibility, Joanne Conroy, chief healthcare officer at the Association of American Medical Colleges, said flexibility and customization can create their own challengesespecially at larger institutions. When youre dealing with 500 residents, you wind up developing hard-and-fast rules because you find you can come up with exception after exception, she said.
The IOM report committee called for implementation of its recommendations within two years, with one exception: making sure exhausted residents get home safely or provide them a place to sleep on-site. Susan Vanderberg-Dent, associate dean of GME at 676-bed Rush University Medical Center in Chicago agreed with the urgency of that situationin part because of her own experience in an incident that occurred after arriving at the hospital at 7 a.m. and leaving the next day at 8 p.m. I fell asleep and came to just as I was about to drive off the roadon the wrong side of the road, she said.
The report also calls for strengthening the current monitoring process by increasing the frequency of hour-duty audits, which are currently done every three years, making unannounced site visits, and developing whistle-blower protection mechanisms. ACGME Chief Executive Officer Thomas Nasca said his organization was up to the task of oversight. We couldnt do it next week, but we could ramp up pretty quickly, Nasca said.
And, while Nasca said he appreciated the IOM committees work, he added how residents have to be prepared for the physical aspects of the job. Residency is not just education, its also training, he said. One does not become a marathon runner without a significant amount of practice and discomfort. Residency provides exposure to the physical rigors of being a physicianwhich are not insignificant.