Posted on: Sunday, July 6, 2003
Doctors split over cut in training hours
By Justin Pope
Associated Press
BOSTON — For the nation's bleary-eyed doctors-in-training, life got a little easier last week, when new regulations went into effect to limit their hours to 80 per week.
The new rules — a response to growing evidence that exhausted young doctors burn out and make too many mistakes — will help them get some much-needed shuteye. But the regulations could prove burdensome to the nation's 1,100 teaching hospitals, many of which are already on the financial precipice.
To absorb the costs of training young doctors, teaching hospitals have come to depend on cheap labor from residents, or doctors fresh out of medical school. Residents handle a variety of tasks, from scut work to surgery.
But now, those 100,000 residents will be working millions of hours less, while the workload for hospitals will stay the same.
The new standards, issued by the Accreditation Council for Graduate Medical Education, generally cap shifts at 24 consecutive hours and require a 10-hour break between them. Previously, residents sometimes worked 110 hours per week or more, particularly in fields like surgery.
Previous reform attempts have flopped, but this time hospitals could lose their accreditation if they break the rules.
Hospitals have been preparing for the guidelines for more than a year, so no sudden changes are expected. The guidelines have already changed how teaching hospitals operate. Hospital officials insist the rules have not hurt patient care so far.
Some hospitals, like Baylor University Medical Center in Dallas, have reduced the nights residents are on call (when they work two straight days and the night in between) from every third night to every fourth. Georgetown University, University of Iowa Health Care and Boston's Beth Israel Deaconess Medical Center are among those to implement or expand "float" systems, where a team of doctors arrives at night so others can leave.
Beth Israel and Massachusetts General, also in Boston, are hiring more nurses and physician assistants. Around the country, older doctors are expected to be asked to take up some of the slack.
Many hospitals say they support the changes, but they are not without consequences. Physician assistants are expensive, commanding salaries of $80,000 plus benefits in Boston.
Night floats, meanwhile, ensure patients see fresher doctors, but those doctors may not be familiar with the patients' cases.
"Any way you do it, there is some disruption in continuity of care," said Dr. Ronald Jones, who heads the surgical residency program at Baylor.
Dr. Andrew Lehmann, chief resident in internal medicine at Georgetown University Hospital in Washington, said his fellow residents mostly welcome the changes. But telling doctors it's time to "punch out" teaches bad habits, Lehmann said.
"Once they go out into the real world, they're not going to be able to just sign out at noon if their patients are doing poorly," he said. "That's part of the deal you accepted when you signed up to be a doctor."
But Dr. Alex Molnar, who just finished her first year of residency — usually the most grueling — at Brigham & Women's Hospital in Boston, enthusiastically supports the guidelines.
"We can go ahead and spend more time thinking about the medicine, and less time monitoring ourselves for sleep and deciding whether we need extra help," she said.
At some hospitals, the guidelines may have inspired new efficiency measures.
Massachusetts General, for instance, now uses wireless technology to monitor patients' vital information, freeing up residents from doing "pre-rounds" — spending an hour collecting data before their real work began.
Dr. Debra Weinstein, who oversees 1,400 residents at Massachusetts General and other area hospitals, is reserving judgment until she sees the results of an extensive study the hospital is doing on how the hours affect patient care and medical education. But she said she is confident that, in a pinch, patients will still come first.
"Doctors 100 percent of the time will take care of the patient before they follow a rule that says their shift is over," she said.
Hospitals insist the limit on residents' hours do not mean lesser care, since doctors hand off patients to colleagues all the time. Besides, the guidelines have some flexibility; for example, in some instances, residents can stay at work to see a case through if necessary.
"We're not talking about a factory floor here where people put down their tools and go home," Dr. Jordan Cohen, president of the American Association of Medical Colleges. "There are patient needs that need to be attended to, and that's going to trump anything."
