Study: Trimming Residents' Hours Would Cost Teaching Hospitals $1.6 billion Annually

John Commins, for HealthLeaders Media , May 21, 2009

America's teaching hospitals would have to spend $1.6 billion each year to cover the costs of replacement workers if reduced work hours for medical residents are adopted, according to a new study by the RAND Corp. and the UCLA School of Medicine on Wednesday.

While patients would probably benefit from an expected reduction in medical errors, limiting trainee workloads would also create a substantial new expense for academic medical centers, according to the study published in the May 21 edition of the New England Journal of Medicine.

The study examines the implications of an Institute of Medicine report in December that calls for revisions to medical residents' workloads and schedules to decrease fatigue-related medical errors and improve the educational experience. The IOM didn't recommend further reducing residents' 80-hour work weeks. However, IOM recommended reducing to 16 hours the maximum time that residents can work without time for sleep, increasing the number of days residents must have off, and restricting moonlighting during residents' off-hours.

The RAND/UCLA study's authors say the issues raised by the IOM report are legitimate concerns, but addressing the recommendations won't come cheap. The IOM's recommendations would cost each major teaching hospital about $3.2 million annually on average, the report states.

"Adopting new restrictions on the work hours of physicians in training would impose a substantial new cost on the nation's 8,500 physician training programs," said lead author Teryl K. Nuckols, MD, an internist at the David Geffen School of Medicine at UCLA, a researcher at RAND, and the lead author of the NEJM report. "There is no obvious way to pay for these changes so that's one major issue that must be addressed."

Jay Bhattacharya, MD, an associate professor of medicine and a health economist at Stanford University, was a member of the IOM committee that issued the report. He also co-authored the NEJM study, which he says has left him fearful and hopeful. "The fear is that people will say it's too expensive," Bhattacharya says. "The hope is that it will cause people to think carefully about what they want. They want reduced medical errors for nothing, and that's not possible. I hope it causes some people to say this is a lot of money, but it's a good deal."

Joanne M. Conroy, MD, the Association of American Medical College's chief healthcare officer, says her group does not oppose a reduction in the working hours for medical residents, but would prefer to see "specialty specific" reductions rather than one-size-fits-all reductions now in place. She says some subspecialties, such as anesthesiologists, operate in teams and make it easier for residents to coordinate break times.

She says medical residents expressed concerns about restricting hours and the impact it will have on their training. "Surgery residents actually are very vocal that they don't feel prepared with the current restrictions" that include an 80-hour work week, Conroy says. "Residents as a group are not necessarily in favor of further restrictions. We can't forget that we are training the next generation of physicians."

Bhattacharya says trimming back medical residents' duty hours is a fine line. "If you work too much, you create a set of tired people making life-or-death decisions that could hurt people. If you do work too few hours, you get people who leave residency poorly trained," he says. "The only real right way to get yourself out of this mess is having adequate supervision during the residency process."

Conroy says hospitals will find a way to pay for whatever new restrictions are implemented. "We'll all moan and groan," she says. "But we will figure out how to get it done."

John Commins is a senior editor with HealthLeaders Media.

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