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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 2003 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 2003, 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 ACGMEâs 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. 89
90 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 residentsâ 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 committeeâs 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 Âdetached from direct patient care. Yet educationally valuable work has not always been given priority over the service needs of institutions (Cohen, 1999; L Â udmerer, 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 informaÂtion 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 Reasonâs 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 âwork situation can alter substantially the individualâs level of performance or decrease the probability that the per-
RESIDENT EDUCATIONAL AND WORK ENVIRONMENT 91 formance will be maintained at a satisfactory levelâ (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 H Â orvath, 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 patientâs 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 inpatientâs 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 patientâs progress before discharge (Gilsdorf, 2008). Teaching hospitals usually have a more complex inpatient case mix
92 RESIDENT DUTY HOURS TABLE 3-1â 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 ââ303 ââ 8.24 1.60 1.59 0.84 Other teaching ââ795 â 21.62 1.49 1.49 0.80 Non-teaching 2,579 â 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 institutionâs 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. 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 â Personal communication, Erika Steinmetz and Karen Fisher, Association of American Medi- cal Colleges, April 18, 2008.
RESIDENT EDUCATIONAL AND WORK ENVIRONMENT 93 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- dentsâ 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 institutionâs 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 âmust provide services and develop health care delivery systems to minimize residentsâ work that is extraneous to their GME [graduate medical education] pro- gramsâ educational goals and objectives.â 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
94 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 chapterâs 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 (âthatâs not my jobâ) 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 patientsâ 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 residentsâ 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
RESIDENT EDUCATIONAL AND WORK ENVIRONMENT 95 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 wantâgreater 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 residentsâ making an âinaccurate ini- tial clinical assessment or pushing workup activity onto subsequent days, leading to longer lengths of stay,â 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
96 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
RESIDENT EDUCATIONAL AND WORK ENVIRONMENT 97 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 patientâs 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
98 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). 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 todayâs 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- â Personal communication, D. Meltzer, University of Chicago, August 12, 2008.
RESIDENT EDUCATIONAL AND WORK ENVIRONMENT 99 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 residentsâ 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 âexperienced fre- quent interruptions and changes in focusâ; 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 programâs 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).
100 RESIDENT DUTY HOURS Organizational and Management Factors Although patient acuity is a factor in the number of patients that a resident can handle, organizational and management factors in the micro- system and macrosystem surrounding a resident can decrease or increase this number (Carayon and Gurses, 2008; Gurses and Carayon, 2007). Resident education is beginning to incorporate a greater understanding of the effect of system issues, not just science-based medical care, on patient outcomes through its focus on core competencies. Quality improvement is being viewed as an essential element of professional development (ACGME, 2007c; Batalden and Davidoff, 2007a,b). The term microsystem has been applied to âa small, organized patient care unit with a specific clinical purpose, set of patients, technologies and practitioners who work directly with these patientsâ (e.g., neonatal intensive care, surgical care team, outpatient clinic) (Mohr et al., 2004). Resident teams operate within an interdisciplinary microsystem on the front lines of the overall complex macrosystem of a hospital. Residents do not operate in isolation without affecting the work of others and vice versa. Effective microsystems have been characterized as having extensive cooperation and teamwork with better communication and interdepen- dence (e.g., use of multidisciplinary rounds, better use of information technology). Analyzing and mapping the processes within microsystems and the overall hospital are viewed as a way to reveal disorganization and inefficiencies that can compromise patient safety and contribute to wast- ing resources (IOM, 2001; Mohr et al., 2004). Chapter 8 examines ways to improve communication in handovers and teamwork with the aim of improving the conditions for safety through error prevention, detection, and feedback. Redesign of workflow, paging practices, and having residents treating inpatients that are in close geographic proximity are a few suggestions for facilitating higher caseloads and improving care: â¢ Having inpatients grouped in a geographically cohesive area re- duces the amount of time spent by residents traveling around the hospital (Bellini, 2008). â¢ Reliable, user-friendly computer order entry and electronic health records can reduce the time spent hunting for records, tracking down lab results, and deciphering illegible handwriting (saving 1-2 hours a day according to one report) and can reduce harmful drug interactions through e-prescribing (Armitage and Rathod, 2003; Henry Ford Health System, 2008). â¢ Health information systems can allow improved scheduling, faster utilization of laboratory and radiology tests (e.g., results obtained
RESIDENT EDUCATIONAL AND WORK ENVIRONMENT 101 more quickly, less duplication of testing), and access to electronic imaging in real time (Henry Ford Health System, 2008; Hillestad, 2008). These can enhance communication during team transitions and oversight by supervisors of resident activity. â¢ Services to handle transport, phlebotomy, intravenous (IV) services, and clerical support for appointments and discharges will free up resident time for educationally valuable patient care. â¢ Space and time set aside for residents to take naps help prevent or mitigate fatigue, reducing the propensity for error after many hours on duty (Arora et al., 2006; Flynn et al., 1999; Weinger et al., 2004). Performance obstacles that exist for residents (e.g., wasting time trying to locate supplies or track down charts, ineffective communications) are likely contributing to inefficiencies and errors of other staff as well (Gurses and Carayon, 2007). System redesign efforts made for other purposes can also help residents access desired educational opportunities during reduced duty hours. For example, MetroHealth in Cleveland and Denver Health have made strides in improving operating room efficiency in teaching set- tings by reducing the time spent on nonoperative tasks and reducing non- clinical delays and interruptions in shorter-duration surgeries (e.g., less than 2 hours) (Gabow, 2008; Harders et al., 2006). Denver Health increased its operating room efficiency from 70 percent to almost 85 percent. Such ef- ficiencies can allow residents to have the desired case experiences with less time wasted so that they can attend to their remaining duties. Organiza- tional factors can also have an effect on patient outcomes (Volpp, 2008). Understanding and resolving performance obstacles requires an in- vestment in time and resources, but removing barriers and streamlining practices can yield increased revenues and improve quality, while residents learn state-of-the-science evidence-based medicine and quality improvement strategies. Institutions should, to the extent possible, redesign their systems; for example, if patients can be admitted or discharged earlier in the day and other efficiencies are in place, there will be less pressure for residents to work long into the evenings and nights. REDESIGNING RESIDENT WORK AND WORKLOAD The 2003 reduction of duty hours did not always translate into a re- duced caseload for residents because of both perceived educational needs and institutional economic pressures for patient care and âthroughputâ (e.g., patients transferred and discharged per day), adding to work intensity due to compression of the same caseload into fewer hours and/or violation of duty hour limits. On the other hand, reports indicate that some resident
102 RESIDENT DUTY HOURS work is inefficient or has little or no educational value, which suggests that time was and is available during duty hours that could be used to greater advantage from a learning perspective. The committee maintains that ACGMEâs Residency Review Committees (RRCs), sponsoring institu- tions, and residency programs need to study and rectify the issue of resident workload so that residents are able to comply with desired duty hours. It is possible that a reduction in noneducational work (e.g., the 8 to 30 per- cent observed in recent studies; Brasel et al., 2004; Dola et al., 2006) and overall caseload will still accommodate the number of patient educational experiences necessary to achieve competence without extending training time although, for some specialties, additional time may be necessary. It is unlikely that reducing noneducational tasks alone will resolve issues related to having a sufficient resident workforce to provide 24-hour resident cover- age under further reduced duty hours, but removing these tasks could be a partial solution and could be achieved more quickly than the time required to generate additional medical school graduates (Jeon and Hurley, 2007). The committee also believes that the often high workload of residents and the compression of work into fewer hours are unrecognized contributors to risks for patient safety and resident well-being; for example, less informa- tion gets transferred during handovers when residents are rushed for time, and a workload that is overly heavy for the time allotted adds to stress. Chapter 4 includes information from studies examining the impact of excess workload on educational attainment and the importance of having adequate time for thorough evaluation of patients and reflection. There is a dearth of information on the resident caseload that pro- vides an optimal learning experience, promotes patient safety or enhances resident well-being. However, as clearly illustrated in Chapter 2, residents continue to violate duty hours and patient needs appear paramount in their decisions to do so, indicating that the current caseload combined with other required tasks exceeds the time available. Chapter 5 includes discussion of the effect of workload on residents. The committee could not obtain uni- form information across resident specialties on how many patients residents are admitting or how many patients they are following or cross-covering under current schedules. Such information is necessary to establish case- load guidelines by specialty and rotation. There is no transparency in the number of patients or their complexity that would allow judgment of the appropriate balance between service and education. Additionally, the com- mittee tried to obtain data from specialty certifying boards to determine the impact of the 2003 duty hour rules on educational outcomes, but data are just beginning to be analyzed systematically to determine whether the duty hours have had a significant impact on competency and preparation for board certification (ABMS, 2008). The committee believes that workload limits should reflect the practices
RESIDENT EDUCATIONAL AND WORK ENVIRONMENT 103 of each specialty, and this is its reason for recommending the ACGME RRCsâs role in determining the limits. Here is an opportunity for and a chal- lenge to the RRCs to determine the number and characteristics of patients that are optimal for both resident learning and patient safety on a day-to- day basis and for developing competence over the long term. ACGME al- ready has a process in place as part of its accreditation evaluation to collect information on institutions and residency programs through PIFs (program information forms). This vehicle could be adapted to collect information to make a determination of maximum caseload for residents by specialty (e.g., patient census, number of admissions, number of cases and time as a surgical assistant during the day, cross-coverage). Depending on specialty, some data are already available through this process (e.g., number of resi- dents, average annual caseload of operations, surgical volume, procedures as primary or assistant, admissions, average daily census, average number of patients per resident per shift). The committee believes that RRCs are in the best position to determine the appropriate guidance by training year for the specificity of data collection, maximum daily caseload and admissions, and overall census as well as the diversity of patient cases necessary. The committee suggests that RRCs do this in consultation with cer- tifying boards to ensure an adequate number and distribution of patient experiences for applicable board certification. RRCs may find specialty society databases (e.g., Society of Thoracic Surgeons national database on outcomes for cardiothoracic patients) (Society of Thoracic Surgeons, 2008) or research on physicians in practice that would inform workload guide- lines. For example, a survey of the members of the National Association of Inpatient Physicians (hospitalists) showed that the average daily patient census for these fully trained physicians most often fell between 11 and 15 patients, with an average of 6 admissions per admission period, and varied depending on case complexity (Lurie and Wachter, 1999). The authors note that these represent averages, not necessarily optimal workloads, and that caseloads will have to vary according to the complexity of cases managed (Lurie and Wachter, 1999). Currently, only the internal medicine (IM) RRC has established a caseload cap, and there are efforts through the Associa- tion of Program Directors in Internal Medicine to reduce the existing cap further and to take case complexity and other factors into account (APDIM, 2008). The current IM cap varies by training year and whether the resident is providing a supervisory function; first-year residents on an inpatient rota- tion are not to have more than five new patients per admitting day or eight new patients in a 48-hour period, although they may accept other patient transfers. For ongoing care they are not to be responsible for more than 12 patients (ACGME, 2007d). The committee believes there is a range in the number of patients that a resident may be able to manage depending on the supports available in the
104 RESIDENT DUTY HOURS training environment, the complexity of the cases, the number of patients needing treatment, and the capability of the individual resident. When establishing specialty-specific recommendations on caseloads, mitigating factors could allow an incremental raising or lowering of the number, such as patient severity and availability of electronic medical records. The com- plexity of the resident caseload should be monitored after implementation of the RRC guidance and the caseload adjusted accordingly, especially if all straightforward admissions go to non-resident teams leaving only the most complex cases for residents. The committee concludes that minimizing the time that residents spend in noneducational activities would help programs achieve compliance with duty hours by reducing unnecessary workload and would provide more time for sleep on long shifts and/or for enhancing educational content (Brasel et al., 2004; Schwartz et al., 1992). Knowledge of patient caseload metrics by specialty would have informed the committeeâs work, and the committee believes such data should be gathered by RRCs to establish guidelines. Residents are in training, and although having a sufficient vol- ume and diversity of patient experiences is necessary to develop compen- tence, time for daily reflection strengthens learning whether considering various diagnoses, choosing the right intervention, or examining patient outcomes after surgery. As a result of these findings and complementary findings in other chap- ters (4 and 5) on workload, the committee recommends the following: Recommendation 3-1: To ensure that residency programs fulfill their core educational mission, ACGME should require that institutions spon- soring residency programs appropriately adjust resident workload by â¢ Providing support services and redesigning healthcare delivery systems to minimize the current level of residentsâ work that is of limited or no educational value, is extraneous to their graduate medical education programâs educational goals and objectives, and can be done well by others; and â¢ Providing residents with adequate time to conduct thorough evaluations of patients and for reflective learning based on their clinical experiences. ACGME should require each Residency Review Committee to define and then require appropriate limits on the caseload (e.g., patient cen- sus, number of admissions, number of surgical cases to assist per day, cross-coverage) that can be assigned to a resident at a given time, taking into consideration the severity and complexity of patient illness and the level of residentsâ competency.
RESIDENT EDUCATIONAL AND WORK ENVIRONMENT 105 CHANGES IN RESPONSE TO DUTY HOUR LIMITS Programs use a mix of strategies to address the limits of the 2003 ACGME guidelines. Studies mainly document multiple layers of changes necessary to comply with the limits in an attempt to share best practices with others struggling with change. They also report that their first attempts did not always achieve their scheduling goal of being in compliance with the duty hour limits (e.g., Ogden et al., 2006; Yoon, 2007). Programs employed strategies such as making schedule changes, hiring individuals for certain routine support tasks, hiring midlevel providers and physicians to pick up clinical duties, adding residents or fellows to specific services, shifting work within the existing resident team and to faculty, and switching patients to non-teaching units. These reports give guidance on some options that resi- dency programs will have as duty hours are adjusted further. The frequency of using different strategies appears to vary both by specialty and by programs within specialties. Examples include the following: â¢ A survey of neurology programs found the following changes, in order of frequency: 75 percent reformed team structures; 42 per- cent increased staff, attending, or consultant responsibilities and/or coverage; 42 percent rescheduled educational activities; 25 percent added more residents; 25 percent eliminated some elective time and some previously required rotations; 17 percent added physician extenders (e.g., physician assistants, nurse practitioners); and 17 percent instituted night float (Watson, 2005). â¢ A neurosurgery program survey reported 68 percent of programs added ancillary healthcare professionals and that change did not limit residentsâ clinical exposure (Cohen-Gadol et al., 2005). â¢ Family medicine program directors reported that 50 percent of pro- grams increased the patient care responsibilities of attendings, 60 percent eliminated post-call clinics, about 40 percent added night float, and 20 percent added more staff (Peterson et al., 2006). â¢ A survey of orthopedic surgery residents indicated that 82 percent of their programs used physician assistants, night float systems, and/or home-call to comply (Kusuma et al., 2007). â¢ A survey of internal medicine chief residents found that 34 percent increased float time (night or day) and decreased elective time (Horwitz et al., 2006b). Overall 76 percent of programs had night float, with a mean of 2.4 months of night float during residency. Non-university-based teaching facilities used night float more often (Wallach et al., 2006).
106 RESIDENT DUTY HOURS Thus, depending on numbers of residents, patient complexity, and service needs of individual institutions or programs, various approaches have been implemented to seek to achieve compliance with duty hours and maintain educational quality. Few studies report patient outcomes, and those single-site studies that do tend to be underpowered statistically to determine changes in mortality. Changes to Scheduling Hospitals operate on a 24-hour basis and need staffing around the clock 7 days a week. In most training institutions, residents are the first medical doctors to be called to admit and monitor patients. So when resi- dency programs started to redraw their schedules, they sought to assess how and if they could continue to provide the same level of coverage. There are no national estimates of the frequency of specific scheduling strategies used, although some authors have commented that certain strategies (e.g., shift scheduling, night float) have become more common (Kaushal et al., 2004; Yoon, 2007). The purpose of reviewing these reports on scheduling is to examine the variations used in response to duty hour reform and to determine whether there is consensus on scheduling practices. One tradi- tional approach that has continued to be used to schedule resident teams has been to combine daily âshort callâ (e.g., an 8- to 10-hour day shift) with âlong callâ (the extended duty period of 24 + 6 hours) every third to fourth day. On short call, residents begin working in the morning and usually admit patients until some designated time in the afternoon; they do not stay overnight (ACGME, 2008). Residents have time during the day to hand over their patients to another team or to a member of their own team that will be on overnight (Carey and Fishburne, 1989). The benefits of this combination of short call and extended duty are seen as having the resident present for daytime educational experiences of rounds and formal didactics, combined with the learning experience of following patients continuously from the time of admission overnight until they have stabilized. A drawback of this approach is the acute sleep deprivation that residents experience if they obtain little or no sleep during the extended duty period. In order to meet the 80-hour limit, programs have generally scheduled extended duty periods every fourth night on average, rather than every third as allowed under ACGME rules (Barden et al., 2002; Mendoza, 2003; Steinbrook, 2002). Shift schedules (e.g., 8- to 16-hour day or night duty shifts) without using the extended 30-hour duty periods have been suggested as one way to reduce the acute sleep loss associated with extended duty periods, but there are other drawbacks. Regardless of whether using a shift schedule or a com- bination of short and long call, a period of overlap between schedules facili-
RESIDENT EDUCATIONAL AND WORK ENVIRONMENT 107 FIGURE 3-1â Representative work hours during a single week for the whole team of interns during the traditional schedule (Panel A) and the intervention schedule (Panel B). SOURCE:â Landrigan et al., 2004. Copyright Â© 2004 Massachusetts Medical Soci- ety. All rights reserved. tates handovers. A drawback of multiple consecutive nights of shift work is that it has negative effects on residentsâ well-being, alertness, and ability to function (Cavallo et al., 2002). The number of transfers of patient care increases as the number of shifts increase, as Figure 3-1 clearly illustrates (Landrigan et al., 2004). An increased risk of error has been associated with poor communication, and increased numbers of transfers offer a greater opportunity for communication errors (Afessa et al., 2005; Landrigan et al., 2004; Petersen et al., 1994). However, studies have shown that good handover procedures can mitigate communication problems and concerns about continuity of information (Goldstein et al., 2004). Chapter 8 exam- ines ways to improve handovers during these transitions in care. Examples of Schedule Changes Many schedule changes represent relatively no-cost strategies to meet duty hour rules. Schedule changes might include having fewer team mem-
108 RESIDENT DUTY HOURS bers on call at a given time, scheduling an extra day off, matching call to patient flow, increasing cross-coverage responsibilities, or shortening call length (Cockerham et al., 2004; Dillingham et al., 2004; Yoon, 2007). Usually, reports on schedule changes make statements about the programâs perceived ability or inability to maintain continuity of care, educational experience, and patient outcomes, rather than specific measures. Sometimes a programâs first attempt did not achieve compliance with duty hours or created problems that were not anticipated. For example, one IM program used to send its interns home early in the evening to come under the duty hour limits, but then found that interns were not getting enough exposure to admitting their own patients and following those cases. As a result, the hospital reinstated extended duty periods for interns (Yoon, 2007). Day-Night Shift Models Although 12-hour shift schedules are the norm in emergency medicine programs, it is only recently that such day-night shifts have been more widely embraced by other specialties as a way to conform to the 80-hour workweek limit. Working a shift at night increases fatigue levels and de- creases performance more quickly than working during the day, and be- cause of our innate circadian propensity to fall asleep at night, the night shift worker finds it more difficult to make up a sleep deficit during the day (Akerstedt, 2003; Rosa, 2001). To provide access to care 24 hours a day, some staff will have to work at night. The effects of night shift work and approaches to minimizing sleep deficit through appropriate scheduling are discussed more fully in Chapter 7. Several studies of limited duration or of small numbers of residents compared shift schedules to those incorporating extended duty periods and assessed compliance with duty hours, and improvements in patient and resident outcomes (Afessa et al., 2005; Goldstein et al., 2004; Landrigan et al., 2004). Each program had its own unique mix of hours and changes to staffing, but they all achieved fewer work hours per week under the 80-hour limit. Because of the increased transfers in care experienced, they scheduled an overlap in shifts to better conduct handovers, and the two programs based in an ICU setting each required the addition of more resi- dents (Afessa et al., 2005; Goldstein et al., 2004; Landrigan et al., 2004). With fewer resident hours available, some programs have chosen to have fewer residents on at night and thereby increased cross-coverage respon- sibilities (e.g., Cockerham et al., 2004). Otherwise, additional staff would have to be added.
RESIDENT EDUCATIONAL AND WORK ENVIRONMENT 109 Night Float Night float is a scheduling strategy that programs in different specialties have now embraced when they did not want to go to a straight shift sched- ule (ACGME, 2004; Bell, 2005; Calverley, 2003; Darosa et al., 2003; Lieu et al., 1992; Lin et al., 2006; Rosenfeld, 2003; Sanfey et al., 2003). Many internal medicine programs have used night float for years, while others had preferred to provide their own night coverage rather than sign out to another team. However, the limit on duty hours has induced its adoption (Horwitz et al., 2006a,b; Vaughn et al., 2008; Whang et al., 2003). The perceived benefits of the use of night float are that it improves con- tinuity of care at night for longer-stay patients, allows a more regular sleep cycle for residents rather than alternating days and nights, and gives them more autonomy to gain confidence in their skills. Its perceived drawbacks like any night shift are that it limits access to didactic teaching and rounds with attendings, decreases time with residentâs family, eliminates availability for daytime continuity clinics, and decreases operative experience for sur- geons (Bell, 2005; Calverley, 2003; Darosa et al., 2003; Lieu et al., 1992; Moore et al., 2000). Programs are working to increase the educational value of night float (Lefrak et al., 2005). Cavallo disputes the idea that weeks of night float or any night shift configuration are a safer option for residents or for patients than an ex- tended duty period, given the known consequences for workers of night shift work in disrupting the sleep-wake cycle: impaired alertness, more ir- ritability, greater risk of depressive symptoms (Cavallo, 2004; Cavallo et al., 2002, 2003). Since it is necessary to have 24/7 coverage, Cavallo advocates integrating changes to the physical environment, educating residents on the bodyâs adjustment to different work shifts, and encouraging the use of naps, including making sure that residents actually sleep and do not use the time to catch up on other work (Cavallo et al., 2002). Afessa et al. (2006) note that there should be limits to the consecutive nights that a resident works (e.g., four nights) to prevent fatigue. Such strategies are discussed further in Chapter 7. Day Float Day float is less controversial than night float. Residents enjoy the quality-of-life benefits of fewer hours during this rotation, but they do not necessarily have more time for conferences or teaching (Roey, 2006; Wong et al., 2004). Their duties might include independently admitting new pa- tients and completing work left from those who stayed overnight (checking on consults, arranging needed studies, writing progress notes, completing the discharge process) (Roey, 2006).
110 RESIDENT DUTY HOURS Preferred Scheduling Practices The committee finds that there is no comprehensive national informa- tion on how programs adjusted to the 2003 rules. The past 5 years have been a period of experimentation for programs. Models adopted in the ini- tial year have been replaced with different models and they continue to be refined to improve educational value, the quality of patient care delivered, and service coverage. One of the consequences of the 2003 duty hour rules may have been an increase in shift work schedules, and the number of days and months of night work in a year, but this is not documented nationally and should be part of the ACGME analysis of duty hours and monitoring compliance called for in Chapter 2. Based on the collective field experiences of programs adapting to the 2003 duty hour rules, the committee concludes that no single scheduling model appears to fit all training facilities or specialties, or even training programs within a particular program or specialty, and that some flexibility will have to be retained. There are advantages and disadvantages to each approach from the perspective of complying with duty hour limits, patient continuity, and potentially, patient safety. Studies tend to report on indi- vidual institution-specific adaptations, but there is little rigorous analysis of the effects of specific models across a wider spectrum of sites. The inter- national picture is the same; a variety of call schedules are utilized as noted in Appendix C. In making recommendations for adjustments to current duty hour rules that govern resident scheduling (Chapter 7), the committee draws on the scientific evidence that fatigue is an unsafe condition that can occur relative to the timing and duration of work and sleep opportunities. Transferring Resident Work to Other Personnel Earlier in this chapter, work within the resident day that is not edu- cationally valuable is discussed, as well as the need for someone else to substitute for them when residents are not available to provide patient care. Determining who should replace residents depends on the tasks that the substitutes will perform (i.e., task-tailored substitutes). Knickman estimated in 1988 that 20 percent of a medicine residentâs time could be replaced only by another physician, 35 percent by midlevel practitioners, 3.4 percent by nurses, 1.2 percent by laboratory technicians, and 6 percent by unskilled workers such as messengers and transporters. The remainder of the time was personal (13.4 percent) or education time (20.8 percent) (Knickman et al., 1992). This mix may be different for other specialties and may have changed in the intervening 20 years. In the New York City system where residents made up 13 percent of the total in the United States at that time, Green and Johnson (1995) projected that a 25 percent decrease in residents
RESIDENT EDUCATIONAL AND WORK ENVIRONMENT 111 would require 2,389 midlevel providers, 1,280 physician full-time equiva- lents (FTEs), 232 nurse FTEs, 82 laboratory technicians, and 410 unskilled workers (Green and Johnson, 1995). Besides making scheduling changes, in response to the 2003 duty hour limits, programs have added personnel from various categories. The committee commissioned a paper to develop an estimate of the cost of replacing resident hours under different future scenarios. A summary of this work is found in Chapter 9 (Nuckols and Escarce, 2008). Future changes in duty hours will likely require a mix of substitutes different from those used in the past. Since some of the more routine and less complex tasks and patient cases have already been ab- sorbed by others, more physician-level substitutes may be necessary. Support Services ACGME has encouraged institutions to transfer tasks such as patient transportation and blood drawing away from residents, as mentioned ear- lier for mitigating workload. A case can be made that by having someone who has supplies readily available for routine tasks such as blood drawing, electrocardiograms, or IV access, and whose skills are maintained through regular use, there will be efficiencies and perhaps patient safety benefits (Herbertson et al., 2007; Rogers et al., 2005). More recently, there has been a push to relieve residents of the time spent arranging appointments, scheduling tests and procedures, tracking down test results, or completing the paperwork associated with discharging patients. A few very preliminary studies with limited resident pools aim to make the business case as well as a quality argument for transferring these tasks to others; similar approaches warrant further follow-up studies. Moriarty and colleagues (2008) found that their internal medicine interns were spending an average of 187 min- utes a day on the phone performing tasks such as arranging for diagnostic tests, making discharge follow-up appointments, obtaining records, and so forth. Adding a medical team assistant reduced resident phone time to 41 minutes. Another program substituted a centralized inpatient appointment service to handle the post-discharge follow-up process to limit intern time on the phone; there were neither duty hour violations nor apparent differ- ences in no-shows, cancellations, readmission rates, or emergency depart- ment visits (Bellini, 2008). Last, a health technician on a surgical service picked up approximately 20 nonclinical tasks of interns per day, resulting in interns working 2 to 4 hours less each day and increasing their time in the operating room by 6.5 hours per week (Podnos et al., 2003). To ensure that residents maximize their patient care learning opportunities within their duty hours, the transfer of support service functions will continue to be required.
112 RESIDENT DUTY HOURS Physician Extenders Nurse practitioners (NPs) and physician assistants (PAs), like residents, work under the supervision of a physician. They replace residents in many places, particularly in surgical residencies (Buch et al., 2008; Kirton et al., 2007; Reines et al., 2006; Todd et al., 2004). These physician extenders, also known as âmidlevelâ providers, have been hired to relieve residents after overnight call so that they could adhere to duty hour limits, to reduce work- load by taking on more routine patients with little educational value for resi- dents, and to prevent excess resident work from shifting to faculty (Abrass et al., 2001; Lundberg et al., 2006; Schneider et al., 2007). Replacing residents with non-physician providers can be an expensive option, although not as expensive as replacing them with physicians (Pisetsky et al., 1998). These practitioners frequently know more than interns about day-to- day operational aspects of patient care, especially early in the academic year, by virtue of their experience and familiarity with the routines of the unit in which they work (Karlowicz and McMurray, 2000; Kirton et al., 2007; Silver and McAtee, 1988). However, if they are new to a unit themselves, these physician extenders may also be learning, and it may take 6 months to 1 year to understand the practices and procedures and develop the neces- sary skills (Mathur et al., 2005). Staff turnover becomes a key issue. Few studies give practical guidance on hiring physician extenders. A study by Rudy et al. (1998) in two academic medical centers illustrates some differences in how physician extenders are utilized, and these have implications for determining substitution ratios. NPs or PAs took on tradi- tional tasks of medicine, not nursing tasks, but they cared for 4.9 patients on average compared with 8.7 patients per resident. There were other dif- ferences: residentsâ patients were older and sicker, and residents did more invasive procedures (Kirton et al., 2007; Rudy et al., 1998). Thus, more than one midlevel practitioner would be needed to do the work of one resi- dent. Green and Johnson (1995) estimated that three midlevel practitioners would be required to replace one residentâs work hours. A more recent study looking at substitution strategies compared coverage of a pediatric intensive care unit (PICU) by four residents (two during the day and two at night) to a matched PICU with two residents (both on during the day; night call coverage by resident on a subspecialty rotation) paired with PAs. The PAs worked three to four 12-hour shifts per week. To have enough PAs available to replace the two full-time residents, the hospital had to hire 5.5 PAs. Recruitment, training, and turnover of the PAs in a competitive market have been continuing issues for the 5 years the program has been in operation (Mathur et al., 2005). Substitution of other clinical personnel for residents has cost implications as outlined in Chapter 9.
RESIDENT EDUCATIONAL AND WORK ENVIRONMENT 113 Hiring Additional Physician-Level Staff Not all resident tasks, especially those of more advanced residents, can be delegated to mid levels; at some point, attending-level physicians (e.g., fellows, faculty, other attendings) must be utilized. The hospitalist move- ment has grown at the same time that there were requirements for resident replacement (Meltzer et al., 2002; Wachter, 2006). This confluence has allowed some institutions to develop a non-teaching service to prevent the resident service from becoming overloaded (Bellini, 2008). Hiring these physicians is more costly as an initial investment than using residents, although these costs might be recouped since they may independently bill for services. Hiring moonlighting physicians is another stopgap measure to fill resident shoes, but these do not provide as much patient continuity (Horwitz et al., 2006a). To date, much of the physician-level burden has fallen on staff that is already present in the training facility, although the evidence is mixed on how much the workload of faculty has increased (Klingensmith et al., 2006; Ladd, 2006). When more work shifts to chief residents and to attendings, there is less time for these physicians to teach. The shift in workload to attending-level physician staff at teaching institutions has raised questions about the future attractiveness of becoming a faculty member in an aca- demic medical center (Reed et al., 2007). Having Additional Residents and Fellows The number of residency positions (including fellowship positions) in the country that qualifies for Medicare GME funding has not increased since the Balanced Budget Act of 1997 froze the number of positions at 1996 levels. This action was taken because of projections at that time of a physician surplus as well as pressure to reduce federal spending on gradu- ate medical education. Thus, adding more residents to fill in the gap left by reduced residency hours has not been a widely available option since 2003. Some programs added positions through other means such as private fund- ing, closure of another residency program, or transfer of positions among programs (Ladd, 2006). Duty hour reduction has also meant changes in relationships among institutions; for example, one teaching facility had to withdraw all of its medicine residents from the Department of Veterans Affairs hospital after a 35-year relationship in order to have a sufficient number of residents at its main facility (Daschbach, 2008). Even if a train- ing program wanted to add more residents to fill in hours left open due to duty hour constraints, it could not always do so because it had to have the â Personal communication, D. Meltzer, University of Chicago, August 12, 2008.
114 RESIDENT DUTY HOURS educational capacity (sufficient cases and faculty) and resources other than Medicare to fund the position. 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 â Personalcommunication, S. Hamlin, Cincinnati Childrenâs Hospital Medical Center, Febru- ary 20, 2008.
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