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3
Adapting the Resident Educational and
Work Environment to Duty Hour Limits
Numerous factors in the learning and work environments contribute to the
content of work and the caseload that residents can manage. Trends over
time have shown that patients admitted to the hospital are less stable and
have more complex diagnostic and treatment needs than in past decades,
yet their hospital stays are shorter. These changes have compressed the
time residents have available to complete work and to learn from indi-
vidual patients. The intensity of resident work appears to have increased
for some specialties and rotations since the 00 duty hour limits when
they are expected to admit and manage the same caseload in fewer hours
on duty. The committee recommends the development of specialty-specific
workload guidelines by Residency Review Committees and continued
reduction of noneducational work to support both learning and patient
safety goals. The committee also concludes, based on a review of adapta-
tions since 00, that there is not a single approach to scheduling duty
hours that fits all training facilities or specialties.
The Accreditation Council for Graduate Medical Education (ACGME)
announced new duty hour limits in February 2003, with a required start
date of July 1, 2003 (ACGME, 2003). Many programs anticipated the
changes and had started to adapt a year or two prior to ACGME’s an-
nouncement. Sponsoring institutions and their program directors responded
by redesigning schedules, strengthening duty hour monitoring practices,
assigning some tasks usually performed by residents to other health pro-
fessionals and support staff, trying new educational approaches, and alter-
ing the work environment. No national funding allocation was dedicated
to these program adaptations, and teaching institutions report that the
changes were costly.
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0 RESIDENT DUTY HOURS
First, this chapter looks at how residents fit within a complex and
changing work and learning environment, with particular attention to the
influence of the content of residents’ work and workload on their ability to
meet duty hour limits. The committee makes recommendations with respect
to the content of resident work and caseload. Next, the chapter provides
examples of how programs responded to the challenges of the 2003 duty
hour limits, the variety of scheduling practices adopted, and the committee’s
comments on scheduling preferences. Finally, the chapter examines how
duty hour changes have required hiring substitutes for lost resident time,
resulting in additional costs.
RESIDENT EDUCATIONAL AND WORK SYSTEMS
Resident education takes place on a daily basis through the delivery
of direct care to patients, supplemented by lectures, conferences, and daily
review of their patients with attending physicians. Most of the education
occurs through the many conversations about their patients that residents
have with attending physicians, consultants, and fellow residents. Resi-
dency can be thought of as on-the-job training since very little is detached
from direct patient care. Yet educationally valuable work has not always
been given priority over the service needs of institutions (Cohen, 1999;
Ludmerer, 1999). The 2003 reduction in duty hours reemphasized the
need to find the right balance between education and service because
compressing unaltered workload into fewer hours can put pressure on
residents to violate duty hour limits or rush through their work, perhaps
leading to patient harm (e.g., forgetting to order a test, which delays
the diagnosis and care a patient receives, or forgetting to convey critical
information during handovers).
Residency programs and their sponsoring institutions needed to take
many workplace factors into account when they redesigned resident work
schedules in response to the 2003 limits, and these will remain consider-
ations as additional duty hour adjustments are implemented. Ideally, the
redesign took into account the ultimate outcomes of patient safety, resident
safety, and educational attainment not just compliance with duty hours. A
useful framework when redesigning healthcare operations in the context of
patient safety is an adaptation by Vincent and colleagues of Reason’s tax-
onomy of factors that contribute to accidents and adverse events in clinical
environments. These include patient characteristics, task factors (includ-
ing the content of work and workload), team factors, work and learning
environment, and organizational and management factors (Reason, 1990;
Vincent et al., 1998). Change in one area is not without repercussions in
others, because change in the “work situation can alter substantially the
individual’s level of performance or decrease the probability that the per-
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RESIDENT EDUCATIONAL AND WORK ENVIRONMENT
formance will be maintained at a satisfactory level” (Chiles, 1982). These
other factors affect whether residents can comply with duty hour limits,
maximize their learning, and care for patients under the safest conditions.
Duty hours are not the only factor driving resident performance.
Patient Characteristics
The growing number of admissions to hospitals of complex patients,
and the availability of ever-expanding advanced technologies for diagnosis
and treatment have increased the intensity of the inpatient care experience
in hospitals in general and thus for residents in training (Anderson and
Horvath, 2004; Bodenheimer, 2005; Lawler et al., 2001; Vogeli et al., 2007).
A declining overall number of acute care beds due to cost containment mea-
sures, the shifting of many formerly hospitalized patients to outpatient care
(e.g., increased use of ambulatory surgery), and reduced length of stay have
meant that the inpatient population that residents care for today is sicker
and more equivalent to the patients in intensive care units (ICUs) 20 to 30
years ago (Carayon and Gurses, 2005; Ludmerer, 1999; Oransky, 2003).
As the U.S. population ages, some experts have advocated for new bed ca-
pacity; if demand increases without growth in beds, or better management
of existing beds, there will be pressure to turn over beds sooner increasing
throughput (Bazzoli et al., 2003; The Chartis Group, 2007).
The average length of stay over the past 25 years has decreased dra-
matically: 7.3 days in 1980, 6.4 in 1990, 4.9 in 2000, and 4.8 in 2004
(Kozak et al., 2006). In fact, many hospital stays are shorter than 4.8 days.
One university-teaching hospital reported that patients with 29 of their 88
most frequent diagnostic codes in 1986 were out of the hospital in less than
2 days, and if residents were to obtain the same breadth of experience as
1980, they would need more ambulatory care experiences (Rosevear and
Gary, 1989).
Brief intense patient stays in the hospital today also mean that residents
have less time to get to know their patients and observe the progression of
a patient’s illness or injury and recovery than they did 25 years ago. Duty
hour limits implemented in 2003 may have further eroded the time for
interacting with individual hospitalized patients. For example, Horwitz et
al. (2006a) reported that the primary admitting resident team covers ap-
proximately 47 percent of an average inpatient’s 4-day hospitalization on
an internal medicine service compared with 70 percent reported prior to the
2003 duty hour limits (Petersen et al., 1998). Depending on how training
programs schedule their residents under duty hour limits, a resident who
admits a patient may or may not be available the next day to evaluate the
patient’s progress before discharge (Gilsdorf, 2008).
Teaching hospitals usually have a more complex inpatient case mix
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RESIDENT DUTY HOURS
TABLE 3-1 Case Mix Index by Teaching Status for FY 2007
Case Mix Index (CMI) FY 2007
Number of
Teaching Status Hospitals % of Total Mean Median Minimum
Major teaching 303 8.24 1.60 1.59 0.84
Other teaching 795 21.62 1.49 1.49 0.80
Non-teaching 2,579 70.14 1.28 1.24 0.41
All 3,677 100.00 1.36 1.31 0.41
NOTE: CMIs are transfer adjusted and based on Medicare Grouper Version 24. Major
teaching is defined as having an intern and resident-to-bed ratio greater than or equal to
0.25.
SOURCE: Inpatient Prospective Payment System (IPPS) Final Rule FY 2007; data analyzed
and provided by AAMC (September 30, 2008).
than other hospitals, and the case mix index (CMI) is often used as a proxy
for the relative severity of illness. The CMI measures the amount of services
provided to patients with different diagnoses. The higher the case mix aver-
age, the greater the severity of illness in that institution’s patient population
tends to be, and therefore, more resources are used, on average, to care for
them (Andrews et al., 2007). The Centers for Medicare and Medicaid Ser-
vices (CMS) takes this more complex caseload and the greater number of
services that may be delivered in the course of teaching into account when
determining payments for teaching hospitals through its indirect medical
expenditure payment for graduate medical education. As illustrated in
Table 3-1, the mean and the median CMIs for teaching hospitals are higher
than for non-teaching hospitals, although there is considerable variation
within each category, reflecting the diversity of specialized services (e.g.,
transplantation, burn units) offered to their patient populations (COTH,
2008). The mean and median CMIs have not changed much from fiscal year
2000 to the present. Comparisons of the CMI over a longer period of time
to assess changes in the severity of patients and the services provided are
of questionable validity because there have been changes in the classifica-
tion of certain illnesses within the relative diagnosis-related group weights
established by CMS, on which the CMI is based.1
Since patients differ in terms of severity of illness and length of stay
from specialty to specialty (e.g., obstetrics vs. other types of surgery) and
even among rotations within specialties (e.g., ICU rotation vs. ambulatory
care), patient factors must be considered when determining what type of
resident work schedule will best provide continuity of patient care and
1 Personalcommunication, Erika Steinmetz and Karen Fisher, Association of American Medi-
cal Colleges, April 18, 2008.
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RESIDENT EDUCATIONAL AND WORK ENVIRONMENT
high-quality learning experiences. Patient severity is a key factor in deter-
mining the number of cases that a resident might manage within his or her
duty hours.
Task Factors
Noneducational Activities
With reduced duty hours, it is critical to assess not only the number
of hours that residents spend in the hospital but also the educational value
of that time. A review of the literature on how residents spend their time,
covering studies from the time of the Bell Commission to 2003, found that
residents spent up to 36 percent of their time learning while delivering pa-
tient care services, an additional 15 percent was spent in formalized teach-
ing activities (e.g., conferences, grand rounds), but up to 35 percent of the
day was spent in non- or marginally educational patient-related activities
(Boex and Leahy, 2003). Although more limited duty hours and ACGME
guidance have encouraged the transfer of some tasks with marginal edu-
cational value (e.g., transport, phlebotomy) to others, residents typically
still spend a substantial amount of time searching for test results and sup-
plies, completing paperwork, obtaining and transporting specimens for
laboratory tests, moving patients, making appointments, and completing
paperwork for patient discharges (Gabow et al., 2006). The content of resi-
dents’ work and the amount of time residents spend on different tasks have
received little analysis since the 2003 change in duty hour regulations, but a
few limited studies indicate that a considerable amount of noneducational
work remains: from 8 to 24 percent for residents in one surgical program,
with the highest values for PGY-1s, -2s, and -5s (Brasel et al., 2004), and
10 to 30 percent for another institution’s residents across multiple special-
ties and training years (Dola et al., 2006). In a national survey of internal
medicine programs, only 9 percent reported that ancillary services were
more available now to help with these tasks than prior to duty hour reduc-
tion (Horwitz et al., 2006b). Addressing this issue now is a way to add to
the number of resident hours available for direct patient care, enhancing
both their ability to meet patient care needs and their learning.
Currently, ACGME requires that sponsoring institutions “must provide
services and develop health care delivery systems to minimize residents’
work that is extraneous to their GME [graduate medical education] pro-
grams’ educational goals and objectives.” These services and systems must
include patient support services: Peripheral intravenous access placement,
phlebotomy, and laboratory and transporter services must be provided in
a manner appropriate to and consistent with educational objectives and
quality patient care (ACGME, 2007b). As noted, such practices are not
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4 RESIDENT DUTY HOURS
always followed. The committee concludes that ACGME should expand
the protections for residents by monitoring and assessing these practices
as well as broadening the current definition of support services to include
administrative and secretarial support in order to reduce resident time
unnecessarily spent on those tasks (e.g., making appointments, tracking
down paperwork). Later, in this chapter’s discussion of support services
adaptations, the experiences of several programs in transferring these tasks
to others are illustrated.
Reducing the amount of time residents spend on these marginally edu-
cational activities is not meant to undermine multidisciplinary team-based
approaches to medical care or to establish silos of work effort (“that’s not
my job”) and cause delays in care delivery. There may be times when a
resident might be able to do such tasks in a manner that is more timely,
accurate, and complete, than others can, thereby accelerating care delivery
to the patient or better coordinating care by assisting in the navigation of
hospital systems.
Resident Caseload
The reduction of duty hours in 2003 was not typically accompanied
by a reduction in the caseload that residents manage. Workload has been
implicated as a factor in resident error, delays in patient care, and possible
effects on patient outcomes (Jagsi et al., 2008; Ong et al., 2007; Vidyarthi
et al., 2007). Working beyond shift length because of workload contributes
to violations in duty hour limits and is observed in the practice of residents
as noted in Chapter 2 and of nurses as well (Rogers et al., 2004; Scott et
al., 2006; Tucker and Spear, 2006). Reports on nurses find that heavy work-
load (e.g., nurse-patient ratios), time pressures due to work system factors
(e.g., patient severity, having to perform nonnursing tasks; spending time
tracking down patients’ charts), and reduced supervision can contribute to
poorer patient care (e.g., delays in care, complications), increased mortal-
ity, and a climate for error (Aiken et al., 2001; Carayon and Gurses, 2008;
Lang et al., 2004; Tarnow-Mordi et al., 2000; Tibby et al., 2004). These
are of concern in the resident work and learning environment as well.
Specialty-specific and rotation-specific workload guidelines should take
into account the number and severity of patients as well as the number of
procedures required to determine the intensity of the experience and its ef-
fect on promoting safe conditions for residents and patients. The contribu-
tion of residents’ workload to error and patient safety has not received the
same investigative or public attention as their duty hours (Parshuram et al.,
2004). Common sense indicates that an excessive workload might result in
cutting corners that could affect patient safety (e.g., forgetting to transmit
vital information during a handover or to order a needed diagnostic test
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RESIDENT EDUCATIONAL AND WORK ENVIRONMENT
leading to delays in care). Additionally, Chapter 4 examines the impact of
excessive workload on learning.
Although the daily patient census for residents may have remained
the same or even decreased over the past 20 to 30 years, the number of
admissions and discharges has increased due to shorter lengths of stay.
For example, one institution reported that although its average length of
stay decreased by 13 percent and daily census decreased by 5 percent,
the daily number of admissions and discharges for residents increased
by 15 percent (Dellit et al., 2001). From a financial perspective, this is
just what hospitals want—greater productivity, higher throughput, and
faster turnover of beds, all of which maximize hospital revenues to ad-
dress their costs (The Chartis Group, 2007; Gregory et al., 2003; Larson,
2003).
After the 2003 reduction in duty hours, it appears that there has not
been a significant reduction in the number of patients a resident admits,
manages, or cross-covers based on reports across a variety of residency
specialties. Maintenance of the same caseload may lead to increased work
compression or intensity during work hours (Bellini, 2008; Dawson and
Zee, 2005; Horwitz et al., 2006b; Jagsi et al., 2008). A national survey of
ACGME-accredited programs in internal medicine found that only 28 per-
cent reduced the average daily census for interns in response to duty hour
limits (Horwitz et al., 2006b). Numerous reports from general and other
surgical programs report that they also have maintained pre-2003 surgical
volume despite the reduction in duty hours (e.g., Baskies et al., 2008; Bland
et al., 2005; Ferguson et al., 2005; Shin et al., 2008).
Admissions and discharges are among the most time-consuming and
complex tasks that residents must complete (Dellit et al., 2001), and for
many specialties these activities are limiting factors in the caseload that can
be managed thoroughly within allotted duty hours. For example, Ong et
al. (2007) found that increased resident workload for an internal medicine
service on admission days (i.e., each additional team admission) was as-
sociated with increases in average length of stay, total costs, and risk of
mortality, with the risk even higher when more than nine patients were
admitted to a team on their admitting day. The authors suggested that the
increased workload may have led to residents’ making an “inaccurate ini-
tial clinical assessment or pushing workup activity onto subsequent days,
leading to longer lengths of stay,” thereby increasing the costs per patient
and potentially having a detrimental impact on patient mortality. This
study examined the care experiences of more than 5,000 patients over 3
years, but the authors recommend additional trials to increase the statistical
power to detect changes in mortality (Ong et al., 2007). Teams were able
to make some short-term adjustments to respond to increasing workload;
the authors suggest that these short-term adjustments might mean that
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RESIDENT DUTY HOURS
residents skip offered didactics or stay overtime to catch up on work in
order to reduce the overall patient census. However, it appears that fatigue
may accumulate as the team once again becomes less efficient if the census
remains high over the month-long rotation.
Ong et al. (2007) also make a business case for reducing workload per
team and using the savings to support additional physician-level staff or
midlevel providers. Earlier studies have also found effects for the number and
timing of admissions on length of stay and total charges (Griffith et al., 1997;
Hillson et al., 1992). An additional approach to workload management is
having teams admit a few patients each day rather than in boluses of a large
number of cases every third to fourth night (Volpp and Landrigan, 2008).
Maintenance of the same caseload can affect the time available for
conference attendance, educational activities other than direct patient care,
adherence to duty hour limits, and on-call sleep (Arora et al., 2008a;
Horwitz et al., 2006b). These effects may not be static over the training
year and may differ according to various measures of caseload (e.g., new
admissions vs. overall census). For example, Arora et al. (2008a) found
that interns early in the training year (July-October) had 10.5 minutes less
sleep for each additional on-call admission, and this declined to 1.9 min-
utes less sleep per admission later in the year (March-June) on extended
duty periods (30-hour shifts). Thus, workload measures should recognize
the growth in competence of residents over time. The study also showed
that each additional patient added extra time to shift duration (e.g., 13.2
and 15.5 minutes per patient, respectively); approximately 30 percent of
extended duty periods on this internal medicine service were found to be
noncompliant (i.e., more than 30.5 hours in length). Reduction in workload
can assist in greater adherence to duty hours.
It appears that efforts to maintain caseload have not been supported by
sufficient reductions in noneducational tasks that consume large amounts of
resident time. This likely leads to a smaller proportion of available time for
educational activity as throughput increases and sacrifices depth of learning
for greater exposure to learning episodes that are more brief and may be
less rich depending on the specialty and resident rotation. A well-designed
caseload of the right variety and number of patients can enhance learn-
ing, while too much work can overwhelm cognitive processing and lessen
learning (Chewning and Harrell, 1990; Choo, 1995; Wiener et al., 1984).
A reduction in duty hours suggests that the number of patients a resident
can care for at one time, especially in the first year of residency, and the
amount of noneducational work need to be reduced so that resident time
and workload are maximally attuned to the higher-yield learning events
of a patient stay. The amount of time spent in daily care of patients varies
from specialty to specialty, necessitating specialty-specific workload guid-
ance; for example, the most time-demanding portion of the work day for
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RESIDENT EDUCATIONAL AND WORK ENVIRONMENT
surgical residents may be the time spent in preparation and performance of
procedures rather than admissions and discharges.
Team Factors
One of the key elements of the residency experience is working as part
of teams, both resident teams and a larger interprofessional team (e.g.,
nurses, physicians, pharmacists). Each resident team is made up of several
levels of residents and medical students, with those in each advancing year
of training having increasing levels of responsibility. Even when working
in teams, the ultimate responsibility for patient care resides with each in-
dividual patient’s attending physician. Reducing resident duty hours has
meant changing team dynamics and potentially affecting teaching, learning,
and performance. A few studies indicate that some work has shifted within
existing team structures, particularly from interns to more senior residents
and from residents to faculty; the volume of work and/or its intensity, as
noted above, appears to have remained the same or even increased for some
training years but not others (Coverdill et al., 2006a,b; Hutter et al., 2006;
Parekh et al., 2005). Reorganization of team structures has been necessary
to enhance patient continuity (Mathis et al., 2006) and provide coverage
of services around the clock.
The effects of reduced hours on resident team dynamics vary according
to specialty and the size of programs. Neurosurgery programs that often
only have one resident per training year, very long operations, and patients
who need close observation after surgery have had difficulty meeting the
80-hour limit (ACGME, 2007a; Cohen-Gadol et al., 2005). Having to
cover duty hours with just a few residents per year makes it difficult to
sustain traditional hierarchical relationships and progressively increasing
training and experience from intern to second year to third year and up
until the attending; these programs may have to match individual residents
with attending physicians. This diminishes the traditional involvement of
senior residents in teaching junior residents (Cohen-Gadol et al., 2005).
Training programs, regardless of specialty, that have just a few residents
will have a harder time adapting to reduced duty hours than those with
more residents; these programs will need to find alternatives to resident
coverage and redesign their approaches to care, or they might be unable to
maintain accreditation.
Under duty hour restrictions, an excessive workload (i.e., numbers of
patients, complexity of caseload, amount of noneducational work) for the
given time is one of the obstacles that residents, their mentors, and other
professionals must overcome in providing quality care to patients. There is
extensive research in other fields that indicates the detrimental effects on
individual performance of excessive workload (Gonzalez, 2005; Hancock
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RESIDENT DUTY HOURS
et al., 1995; Rahman and Haque, 1992), but teams can help buffer these
detrimental effects and even increase productivity by distributing work and
workload among team members (Jung et al., 2002). Individuals in teams
that work as a unit have a shared idea of how to accomplish a task and
therefore provide assistance to one another (e.g., by providing backup or
monitoring the situation for work to be done or to prevent errors). Team-
work has been shown to improve performance even under conditions of
sleep deprivation (Baranski et al., 2007; Vander Wood et al., 2007).
In some programs, staff members have been added to the care team to
help complete the work formerly done by residents; these include hospital-
ists, physician assistants, and nurse practitioners. This is discussed in more
detail later in the chapter. Sometimes these additional staff members are
well integrated into the resident team with good communication to provide
continuity of care; for example, they might all have rounds together. How-
ever, others have more of a stopgap function to fill uncovered hours (e.g.,
moonlighting physicians) (Horwitz et al., 2006a).2
Work and Learning Environment
The philosophy of the sponsoring organization and the residency pro-
gram director determines whether the balance of resident work is tilted
toward service or education. The size and scope of residency programs vary
greatly from site to site. Sponsoring institutions may have a handful of spe-
cialty residency programs, while others might have more than 100 different
programs; medical school sponsors tend to have the most programs, an
average of 35.5. There are numerous types of sponsoring organization (e.g.,
for-profit and nonprofit groups including government, church, or private
ownership) with the majority being nonprofit (ACGME, 2007d).
Some organizations, regardless of philosophy, have limited resources
and thus may have trouble providing supplementary services or hiring
replacements for residents even if they would like to do so. The commit-
tee is cognizant of this and in Chapter 9 recommends additional funding
to implement changes in workload and hours, with special consideration
for safety net teaching hospitals so that they can maintain robust training
programs while providing desirable community service.
Some educators and residents have expressed concern that educational
opportunities are diminished for today’s residents. Studies report decreased
attendance at formal didactics, less availability for ambulatory care clinics,
less opportunity for residents to discuss their cases thoroughly with attend-
ings, and fewer other educational opportunities since 2003 (Arora et al.,
2008b; Parekh et al., 2005; Reed et al., 2007). On the other hand, orga-
2 Personal communication, D. Meltzer, University of Chicago, August 12, 2008.
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RESIDENT EDUCATIONAL AND WORK ENVIRONMENT
nizations report on how they redesigned their programs to preserve these
elements and how they maintained or even improved educational outcomes
(Basu et al., 2004; de Virgilio et al., 2006; Horwitz et al., 2007). More
information from reports on education after resident duty hours reform is
contained in Chapter 4.
Many of the work processes in the system as a whole are inefficient,
affect residents’ performance, and inhibit their ability to complete their
work in a timely fashion. Gabow and others have found that the workflow
of residents is fragmented by frequent interruptions and changes in focus
that interfere with task completion and cognitive processing, and that often
(e.g., 25-26 percent) these interruptions are rated as being for unimportant
reasons (Blum and Lieu, 1992; Gabow et al., 2006). Specifically, Gabow
and her colleagues (2006) found that residents performed 5.0 to 11.3 dif-
ferent activities per hour of non-sleeping time. Residents “experienced fre-
quent interruptions and changes in focus”; interruptions can lead to errors,
and sleepy residents will have more trouble recovering from interruptions to
focus on their tasks (Gabow et al., 2006). Research in other environments
finds that as interruptions increase, the frequency of error also increases
(Hirst and Kalmar, 1987; Speier et al., 1997). Such interruptions have been
implicated as contributing to pilot error (Dismukes et al., 1998) and to
medication-dispensing errors by nurses and pharmacists (Flynn et al., 1994;
Gladstone, 1995; Peterson et al., 1999).
Human factors and systems engineering approaches help programs
analyze their current work practices to determine the amount of time
residents spend on key activities and how they interact with others in the
work environment (Barach and Johnson, 2006). These could reveal ways to
reorganize work processes and resident work time to increase efficiency and
decrease interruptions (Chung and Ahmed, 2007; Gabow et al., 2006). For
example, one surgical program’s self-study revealed a need to reorganize
morning and evening rounds to make them more efficient. These activi-
ties designed to improve both time and team management also resulted in
other improvements (e.g., greater punctuality at conferences, clinics, and
operations). Resident satisfaction improved as well because they did not
perceive that time was wasted when they were on duty (Chung and Ahmed,
2007). Other programs have drawn up schedules and shift changes to
match patient admission flow, thus reducing the amount of time residents
spend waiting for patients to arrive (Levin et al., 2007; Ogden et al., 2006).
Rethinking and reengineering how residents spend their time might help
reduce the hours needed to complete the desired tasks; with increased effi-
ciency, they could spend more time at the bedside caring for patients and in
other learning activities, and when on night call they would have additional
time for sleep (Lamberg, 2004; Morton et al., 2004; Viney, 2008).
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4 RESIDENT DUTY HOURS
educational capacity (sufficient cases and faculty) and resources other than
Medicare to fund the position.4
COSTS OF ADAPTING TO THE 2003 DUTY HOUR LIMITS
The replacement of resident duties and coverage of hours of work by
other personnel required as a result of the 2003 ACGME rules came with
no dedicated funding from outside sources. Such help for transition fund-
ing had been included in House and Senate legislative proposals to regulate
resident duty hours; these proposals have not been called up for a vote in
either body (GovTrack.us, 2005a,b).
Individual Program Costs
A few programs have reported in the literature and in testimony to
the committee that adjusting to duty hours has carried substantial annual
recurring costs. These estimates run from $1 million for a single specialty
program to $7 million for all residencies across several hospitals (Knapp,
2002; Liekweg, 2008; Noah, 2008; Opas, 2008; Oransky, 2003). These
funds primarily went to pay for hiring physician extenders, moonlight-
ing physicians, and hospitalists and to privately fund additional residency
positions.
Teasing apart the costs associated with duty hour reduction is difficult.
The addition of personnel is the most visible component. Other expenses
might include costs of monitoring such as electronic duty hour verification,
capital investment in rooms for napping, additional office space for the resi-
dents to work in, and hidden costs of additional faculty work (Daschbach,
2008; Opas, 2008).
Medicare is a principal source of payments for graduate medical edu-
cation, about $8.5 billion in 2007. For graduate medical training facilities
without a Medicare population, other sources must suffice. For example,
the Los Angeles hospital system received little of its funding from a dedi-
cated source for graduate medical training (e.g., 0.6 percent of its funds
came from Medicare because it does not have a large Medicare popula-
tion). The hospital system and its graduate medical education programs
must compete with other county and state needs for appropriations; 70.8
percent of their support comes from state and other federal funds (e.g.,
Medicaid), 25 percent from county taxes, and 0.6 percent from the DSH
(disproportionate share hospital) program (Opas, 2008).
There is a clear need to address the costs of supplementing reduced
4 Personal
communication, S. Hamlin, Cincinnati Children’s Hospital Medical Center, Febru-
ary 20, 2008.
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RESIDENT EDUCATIONAL AND WORK ENVIRONMENT
resident work hours by hiring other medical providers as well as other
expenses. These costs will be a factor in the ability of some but not all
residency programs to adapt to future duty hour adjustments. See further
discussion of costs in Chapter 9.
REFERENCES
ABMS (American Board of Medical Specialties). 2008. Presentation by Kevin Weiss to the
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