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OCR for page 295
9
Resources to Implement Improvements
for Patient Safety and Resident Training
Improved residency training conditions for patient safety, enhanced resi-
dent well-being, and excellent educational outcomes are the committee’s
goals. Recommendations for duty hour adjustments, enhanced supervi-
sion, and workload reduction will best achieve the targeted goals when
implemented in concert, and implementation of all the committee’s recom-
mendations will require a significant investment in personnel to substitute
for the hours that residents are no longer available. To cover some of the
excess resident hours with substitute personnel would cost an estimated
$. billion dollars, the equivalent of about percent of direct and indi-
rect graduate medical education payments made to teaching facilities from
public and private sources. To help institutions implement the changes, the
committee recommends that additional funding be provided by all sup-
porters of graduate medical education. Systematic collection of pertinent
data would help monitor and evaluate the effects of implementing the
recommendations, and research would provide an evidence base for future
changes to duty hours or educational strategies.
As the preceding chapters demonstrate, this Institute of Medicine
(IOM) committee found the issues of patient safety, resident safety, duty
hours, and schedules closely related to broader issues of how graduate
medical education is structured, including the work environment, the super-
vision of residents, and safety practices throughout the training institutions.
While recommendations on a particular topic are embedded in the scientific
evidence of its corresponding chapter and presented serially in this report,
the committee intends the report and all of its recommendations to be
considered as a whole. This chapter discusses the possible consequences of
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RESIDENT DUTY HOURS
implementing a single recommendation (e.g., duty hour limits) in isolation
and an approach to phase-in the recommendations in a practical fashion.
Thus, the committee presents first a preamble to the recommendations:
Preamble to Recommendations
To promote conditions for safe medical care, improve the education
of doctors in training, and increase the safety of residents and the general
public, the committee offers the (previous and) following recommenda-
tions, which should be implemented with all deliberate speed. While some
recommendations should be implemented immediately, changes to duty
hours, adjustments in workload, and the funding needed for these changes
might require an integrated phase-in. The recommendations will require
additional resources—both financial and human. Without the necessary
restructuring in resource allocation, attempts to implement the recommen-
dations will fail to have the desired benefits and could even reduce patient
safety. The committee believes that the Accreditation Council for Gradu-
ate Medical Education and the other organizations charged to implement
aspects of the recommendations should begin their work with urgency, and
that action on all recommendations should be taken within 24 months.
The committee took a broader perspective than just the duty hours and
schedules, looking at related aspects of the work and learning environment
of residents. It found little detailed information available on the educational
outcomes of training programs since the 2003 limits because many of the
first cohort of doctors fully trained under the 2003 limits are just complet-
ing their training. Supervision and workload were not addressed when duty
hours were set in 2003, and lack of supervision at critical junctures, excess
workload, and fatigue can all contribute to error and to reduced learning.
Thus, the committee believes that to minimize unintended consequences,
recommendations to prevent and mitigate fatigue through adjusting resi-
dent duty hours, enhancing supervision, and reducing workload should be
implemented in concert. Implementing the duty hour adjustments without
the others could prevent achievement of important goals identified by the
committee. Recommendations by the committee reflect the best ways to
achieve performance and learning goals based on sleep science, learning
theory, and the close observations of medical educators.
In designing its recommendations to achieve the targeted goals outlined
in the preamble, the committee considered strong evidence from the litera-
ture concerning the impact of sleep and fatigue on human performance
and the occurrence of error, and based several recommendations on this
evidence. Although fatigue creates an unsafe condition in the work environ-
ment, there is insufficient evidence to determine the degree to which resident
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RESOURCES TO IMPLEMENT IMPROVEMENTS
hours of work translates into patient harm. For this reason, the committee
did not change the current weekly duty hour limit of 80 hours or the limit
of 30 hours for extended duty periods. Rather, it chose to create better
opportunities for fatigue prevention and mitigation within the basic duty
hour structure and to focus on supervision, handovers, and other systemic
changes to enhance learning and safety.
The intent in adjusting the 2003 Accreditation Council for Graduate
Medical Education (ACGME) duty hour limits is to:
• Prevent fatigue whenever possible;
• Recognize that some fatigue is inevitable and provide measures
to relieve both acute and chronic sleep deprivation and reduce its
negative effects;
• Be practical to schedule;
• Be feasible to monitor;
• Enhance the learning experience;
• Preserve the ability of residency programs of various sizes and dif-
ferent specialties to adapt the changes to their circumstances by
not mandating a single schedule for all and by allowing limited
opportunities for exceptions based on patient need and unusual
learning opportunities; and
• Maintain the spirit of residency and the excitement of being a
doctor.
The committee was also asked to consider the potential cost impact of
its recommendations, and it is the estimated cost and the limited availability
of the healthcare workforce that the committee believes are the greatest bar-
riers to further changing resident duty hours. Having an adequate workforce
of physician extenders, residents, and physicians alike takes planning to
develop incentives and remove disincentives to grow the labor force that the
country and individual labor markets require to support reductions in resi-
dent hours and serve other healthcare needs. Based on a commissioned cost
model, an estimate of the personnel substitution costs associated with several
duty hour and workload limits shows that the costs would be substantial, in
the ballpark of $1.7 billion in 2008, with variations in that amount depend-
ing on who substitutes for residents and how programs choose to schedule
residents. Other recommendations of the committee could require additional
funds. The committee, while recognizing that funds for health care are in
great demand, recommends adequate support by all funders of graduate
medical education (GME) and related research so that the recommendations
can be fully implemented and have the desired impact.
The committee acknowledges that there are objections from some
members of the graduate medical training community to any changes to the
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RESIDENT DUTY HOURS
2003 duty hour limits and related aspects of GME, just as there were objec-
tions to those limits initially (see Chapters 1 and 2). A crucial objective of
graduate medical training is to ensure that the country will produce increas-
ingly competent physicians for independent practice—a long-term patient
safety goal. With this in mind, the committee found that there are good
reasons to take a deliberate approach to changing resident duty hours.
This chapter reviews current funding for GME and projections for
the costs and workforce needs associated with the committee’s proposed
adjustments to hours and workload. The chapter concludes with a phased
implementation strategy and addresses the necessity of further research,
data collection, and evaluation that would allow consideration of the ap-
propriateness of resident duty hours in the future.
COST IMPLICATIONS OF CHANGES TO DUTY HOURS
Implementing workload reductions and adjustments to the 2003 duty
hour limits will require replacing residents’ time with that of other workers
and entails substantial costs for society but also potential benefits to patient
and resident safety. This section first looks at what the United States invests
in graduate medical training and then examines projected estimates of per-
sonnel costs to implement the committee’s recommendations on hours and
workload adjustments.
Funding for Graduate Medical Education
GME is paid for largely through insurance premiums and payroll
taxes. A number of parties specifically contribute to GME: the Centers for
Medicare and Medicaid Services (CMS), the Department of Veterans Af-
fairs (VA), the Department of Defense (DOD), the Health Resources and
Services Administration (HRSA) of the U.S. Public Health Service, states,
and private funders. Available data on the level of funding for GME over
the past few years is limited. Medicare is the largest single payer of GME
($8.5 billion in 2007), and its funds come in two forms (see Table 9-1).
Some of the other funds, particularly from private and state sources, are
harder to identify and estimate at the national level. Wynn and colleagues
estimate that for all sources of support, direct and indirect expenditures as-
sociated with training residents were approximately $18.7 billion in 2003
(Wynn et al., 2006).
Some of this funding comes indirectly through payments for patient
care in teaching institutions (e.g., from Medicare indirect medical educa-
tion [IME] payments, state Medicaid, private payers) to cover the increased
costs of care associated with resident training in teaching hospitals. The
Medicare IME funds ($5.7 billion in 2007) are provided through higher
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RESOURCES TO IMPLEMENT IMPROVEMENTS
TABLE 9-1 Sources of GME Funding
FY 2007
Funding Source (billion dollars)
CMS
Medicare 8.50
IME (5.70)
DGME (2.80)
VA 1.0
Direct (0.50)
Indirect (0.50)
DOD NA
HRSA
Children’s Hospital 0.28
GME
Training in primary care, Medicare, and dentistry 0.05
3.20a
States—Medicaid
Private payer (not direct payments, but imputed from higher Unknown
reimbursement to teaching hospital)
NOTE: CMS = Centers for Medicare and Medicaid Services; DGME = Direct graduate medi-
cal education payment; GME = Graduate Medical Education; HRSA = Health Resources and
Services Administration; IME = Indirect medical education payment; NA = Not available;
VA = U.S. Department of Veterans Affairs.
aEstimated spending in 2005 (Henderson, 2006).
SOURCES: CBO, 2008; Chang, 2007; HRSA, 2008a,b.
hospital payments. The size of the operating adjustment to a hospital’s
payment rate is based on teaching intensity and the number of residents per
bed, with limits on the rate of increase. It is included in inpatient operat-
ing and capital payments under the Medicare inpatient hospital payment
system and includes subsidies to hospitals treating patients of the Medical
Advantage Program (MedPAC, 2008).
Other funding, such as direct GME (DGME) payments are made to the
training institution for support of training such as the residents’ stipends,
teaching physicians’ salaries and benefits, and administrative overhead of
GME offices. The DGME payment is based on historic, hospital-specific
costs per trainee, with maximum limits on the number of trainees. Some
teaching hospitals receive very little, if any, support from the Medicare
GME funding stream, even though they train many residents, because they
do not serve a large Medicare population (Opas, 2008).
Other federal financial sources of support for GME include the VA and
DOD (which both also provide sites for residency training), and HRSA.
The VA has approximately 9,500 residency slots in its healthcare facili-
ties (9 percent of U.S. medical resident slots) and, with multiple residents
rotating through each slot, participates in the instruction of approximately
one-third of U.S. doctors in training (about 34,000 medical residents) per
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00 RESIDENT DUTY HOURS
year.1 The DOD supports approximately 3,000 residency positions in mili-
tary facilities accredited by the ACGME. HRSA manages the Children’s
Hospital Graduate Medical Education program, authorized to support the
training of stand-alone children’s hospitals that do not receive Medicare
reimbursements (and therefore do not receive the DGME and IME pay-
ments described earlier).
States may voluntarily provide GME funding through their Medicaid
programs. Up until at least 2005, all but three states (Illinois, North Da-
kota, and Texas) did so (Henderson, 2006). However, there has been a
debate in recent years about whether the use of federally matched dollars
for GME reimbursements is an appropriate use of Medicaid funds. In June
2008, Congress placed a moratorium on a proposed rule until April 1,
2009, to block CMS’s prohibition of GME payments from these matched
funds (P.L. 110-252, June 30, 2008).
Private payers’ contributions are difficult to determine. These pay-
ments compensate GME providers for the care received by their benefi-
ciaries rather than paying for GME directly. This is similar in concept to
Medicare IME. Private sector sources and the federal government provide
the preponderance of funds for GME (Knapp, 2002; Wynn et al., 2006).
Finally, economists consider that residents support some of the cost of their
education through their own efforts. By providing service in hospitals at a
relatively low hourly wage rate, residents, in effect, subsidize the institu-
tion for some of the costs of their education. Given the cost of replacing
residents with other personnel, they are not a trivial source of support for
their own graduate medical training although they pay no tuition.
The committee considered the impact of its recommendations on the fi-
nancial status of hospitals. Figure 9-1 compares the median margins of total
income and patient revenues of hospitals by teaching or non-teaching status
as well as whether they are safety net hospitals (Andrews et al., 2007).2
While there is not a consensus on what constitutes a safety net hospital
(Siegel et al., 2004), the study by Andrews and colleagues bases its definition
on the proportion of uncompensated care that a hospital provides. For most
hospitals, except the category of safety net teaching hospitals, the negative
patient revenue margin is smaller than the positive total income margin.
Safety net teaching hospitals, however, have a substantial negative patient
revenue margin (–9.6 percent), in part because of the uncompensated care
they deliver, and a positive total income margin of only 1.2 percent. It is
a positive total income margin only because safety net teaching hospitals,
1 Personal communication, J. P. Bagian, National Center for Patient Safety, July 31, 2008.
2 “The total income margin is the total income for a hospital (i.e., net patient revenue plus
contributions, government appropriations, and other income), divided by the total expenses
(i.e., operating costs and other expenses)” (Andrews et al., 2007, p. 13).
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6 .0
4.0 3. 2 %
3.1%
2.9 %
2.5%
1.9 %
2 .0 1. 2%
0.0
– 0.4%
– 0.7%
– 2 .0 –1.3 %
–1.6 %
– 2 .0 %
Patient Revenue
– 4.0
Total Income
– 6 .0
M e d i a n M ar g i n s ( p e r c e n t )
landscape
– 8 .0
Figure 9-1.eps
–10.0 – 9.6 %
–12.0
N o n - S a fe t y - N e t Secondar y S a fe t y- N e t N o n - S a fe t y - N e t Secondar y S a fe t y- N e t
S a fe t y - N e t S a f e t y- N e t
N o n -t e a c h i n g H o s p i t a l s Teaching Hospitals
Type of Hospital
FIGURE 9-1 Median margins of hospitals by teaching status.
SOURCE: Andrews et al., 2007.
0
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0 RESIDENT DUTY HOURS
on average, successfully obtain sufficient other revenue such as government
allocations and other subsidies. Approximately one-third of safety net hos-
pitals, whether teaching or not, have a negative total income margin, and
20 percent of all safety net hospitals are teaching hospitals (Andrews et al.,
2007). Teaching hospitals offer a substantial amount of charity care—care
provided without expectation of payment. Major teaching hospitals make
up only 6 percent of the acute hospitals in the country, yet they deliver 41
percent of all hospital-based charity care, and all teaching facilities provide
71 percent of that charity care. In 2006, the 274 members of the Council
of Teaching Hospitals and Health Systems (COTH) provided an estimated
$6.3 billion in uncompensated charity care, non-COTH teaching hospitals
an estimated $4.5 billion, and non-teaching hospitals $4.5 billion, totaling
about $15.3 billion in hospital charity care (COTH, 2008).
The committee is concerned that some safety net teaching hospitals
may not have the resources under current funding mechanisms to provide
the additional supports necessary to allow residents recommended oppor-
tunities to rest, transfer noneducational tasks to others, or offer residents
sufficient supervision because their resources already are spread too thinly
(Werner et al., 2008).
Cost Model
As previously mentioned, to implement the recommendations of this
report, some of the work presently performed by residents will have to be
done by others. The committee commissioned a health services researcher,
Teryl Nuckols, M.D., MSHS, and a health economist, José Escarce, M.D.,
Ph.D., both at the David Geffen School of Medicine at the University of
California–Los Angeles as well as the RAND Corporation, to construct a
model that would provide an estimate of the costs and workforce that would
be needed to replace resident work under various duty hour scenarios. This
section of the chapter is based on their methods and results. The complete pa-
per is published on the following websites: www.iom.edu/residenthours and
www.iom.edu/hcs. A committee member, economist Jayanta Bhattacharya,
M.D., Ph.D., performed sensitivity analyses on some of the main assumptions
of this model. His discussion and figures are posted with the main paper.
The model, based on existing literature and explicit assumptions, de-
rives estimates from four scenarios, called “components,” related to resi-
dent hours and workload, which were specified before the committee had
formulated its final recommendations. The model provides an indication of
the level of expected substitution costs based on 2006 data—approximately
$1.6 billion dollars ($1.7 billion when inflated to 2008 dollars)—if all four
components are adopted. The costs are reasonably similar whether excess
hours of residents’ time are replaced by hiring other healthcare providers
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RESOURCES TO IMPLEMENT IMPROVEMENTS
or additional residents. The simplified components of the model related to
the committee’s recommendations are:
1. Bringing all residency programs into compliance with the existing
2003 ACGME 80-hour duty limit, since not all programs and resi-
dents now comply.
2. Having any extended duty period beyond 21 hours incorporate a
5-hour undisturbed sleep period.
3. Reducing the workload of postgraduate year 1 (PGY-1) residents
by 10 percent.
4. Limiting shifts to a maximum of 16 hours for residents beyond
PGY-1. The model assumed that after hospitals achieved compli-
ance with the previous three components, they might choose to
reduce all shifts to 16 hours. Since they would have to include a
5-hour rest period for shifts lasting longer than 16 hours, eliminat-
ing shifts of 16 to 21 hours would require no more substitute hours
than would limiting the shifts to 16 hours. Available literature
reports that most PGY-1 extended duty shifts exceed 21 hours, so
the model assumed hospitals would not limit the shifts of PGY-1s
to 16 hours.
Implementing these reforms with the substitution of personnel tailored
to the tasks that residents currently perform would require the following
increases nationally in full-time equivalents (FTEs): nursing aides, 229; lab-
oratory technicians, 45; licensed vocational nurses, 320; midlevel providers,
such as physicians assistants and nurse practitioners, 5,984; and attending
physicians, 5,001. Given that there are 1,206 teaching hospitals across the
country, less than one FTE would be needed on average per hospital for
several of these provider types. If instead more residents were to be added,
this would require approximately 8,247 new residents (specialty and sub-
specialty) in addition to the existing pool of more than 105,000 residents.
Please note that the cost model calculates the economic costs of only
certain aspects of the committee’s recommendations and does not attempt
to predict which elements of the recommendations will be adopted (e.g.,
keep extended duty periods with protected sleep periods or use only shorter
shift schedules). Precise cost estimates of every recommendation were not
feasible given time and data constraints and were beyond the committee’s
statement of task, but the four components do reflect the likely magnitude
of costs for a number of the report’s major recommendations. Lack of
comprehensive nationwide data on the actual hours residents now work,
the frequency of their overnight work, and other factors required some as-
sumptions in the model’s design based on the existing literature. Sensitivity
analyses of selected assumptions allow for a range of estimates to address
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04 RESIDENT DUTY HOURS
these assumptions (e.g., different substitution ratios, call frequency dur-
ing residents’ inpatient months, current compliance levels). In addition,
the model could not anticipate fully programs’ choices of implementation
strategies (e.g., if the programs shifted workload from residents with longer
hours to those with shorter ones), which could possibly produce lower cost
estimates.
Estimating Baseline of Resident Duty Hours,
Rate of Violation, and Workload
To estimate the direct annual costs of the proposed reforms, the differ-
ence between what residents work at baseline and what they would work
under the proposed changes is calculated and called “excess resident work”
hours. As discussed in Chapter 2, there has been no recent rigorous or reli-
able collection of data on the total duty hours of residents in all specialties
across the country. The economic model uses the best available data on
mean weekly duty hours (66.6 hours) and the hours worked by PGY-1s in
excess of 80 hours from the first year of implementation: 29.0 percent of
the workweeks were longer than 80 hours, 12.1 percent were 90 or more
hours, and 3.9 percent were 100 or more hours (Landrigan et al., 2006). The
study did not give details on workweeks that fell below the 80-hour limit.
Other more recent studies have found relatively similar rates of duty hours
and degree of violations (AMA Division of Market Research and Analysis,
2005; Jagsi et al., 2008). The baseline calculation makes accommodation
for the portion of the year that residents spend on inpatient months (e.g.,
50.6 percent of PGY-1 residents’ months in the Landrigan paper), the num-
ber of nights that a resident might be on extended duty, how long residents
are staying over the 30-hour limit, and differences between PGY-1s and
other years (Nuckols and Escarce, 2008). The values for these assumptions
are detailed in the paper describing the model.
Hierarchical Nature of the Model
The costs of the four reform components are estimated in a sequential,
hierarchical fashion to prevent counting excess hours twice. Several basic
assumptions are built into this hierarchy:
• That achieving compliance with the 80-hour workweek would
make it possible to achieve the 30-hour duty period limit at no ad-
ditional cost because violations of the 30-hour limit are generally
what push residents over 80 hours;
• That residency programs would choose to implement a nap only
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RESOURCES TO IMPLEMENT IMPROVEMENTS
for residents already working more than 21-hour duty periods at
baseline; and
• That reducing average workload by 10 percent would be equivalent
to reducing weekly duty hours by the same amount; there are no
widely accepted measures or estimates of the workload of residents
across specialties (e.g., average daily census, number of admissions
or procedures per call day) available.
PGY-1 residents are more likely to violate duty hour limits than more se-
nior residents or fellows because PGY-1s tend to have more inpatient months,
more frequent extended duty periods, and more direct patient care respon-
sibilities. Reducing the workload of only first-year residents is factored into
the cost model, but the committee recognizes that it may become necessary
in some or all of the specialties for workload to be reduced in other years of
residency as well. The final component of the hierarchy for cost estimating is
a 16-hour shift maximum for residents beyond their intern year.
Substitution Scenarios
As discussed in Chapter 4, many training programs hired replacements
to assume “excess resident work” in response to the 2003 limits. This
model builds on substitution ratios available in the published literature.
Each step, or component, in the hierarchy of hours reduction has its own
combination of resident substitutes (Table 9-2). Alternatively, the model
estimates having each resident hour replaced by additional residents with
no work transferred to other types of personnel. Here the term “resident
substitution” means transferring residents’ clinical care-related work to
other providers or sharing it among a larger population of residents. Mid-
level providers (nurse practitioners and physician assistants) have often
been considered the prototypical resident substitutes (Stoddard et al., 1994;
Whang et al., 2003), but publications following the 2003 ACGME reform
and recent testimony from hospital administrators suggest that there are a
few basic strategies for reducing resident duty hours or workload:
• Task-tailored substitutes: Transferring noneducational patient care
tasks to the lowest-level personnel qualified to perform them.
• Midlevel substitutes: Transferring work to midlevel providers.
• Midlevel and attending substitutes: Transferring work to a mixture
of midlevels and attending physicians.
• Attending substitutes: Transferring work to attending physicians.
• Resident substitutes: Hiring new residents to share the work of
existing ones.
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RESIDENT DUTY HOURS
and that MedPAC3 has recommended reductions in IME funding. It also
recognizes that there are many payers that support GME, various places
other than health care where the federal budget could be cut, and many pa-
tients who want to receive safer hospital care and have better-trained phy-
sicians. The committee has responsibly interpreted the available evidence
and reached clear conclusions that implementing its recommendations will
require additional funds. It urges Congress and other supporters of GME to
carefully consider this report and to seek funds to help hospitals implement
the duty hour changes.
Recommendation 9-1: All financial stakeholders in graduate medical
education, such as the Centers for Medicare and Medicaid Services, De-
partment of Veterans Affairs, Department of Defense, Health Resources
and Services Administration, states and local governments, private
insurers, and sponsoring institutions, should financially support the
changes necessitated by the committee’s recommendations to promote
patient safety and resident safety and education, with special attention
to safety net hospitals.
• An independent convening body should bring together all the
major funders of graduate medical education to examine current
financing methodologies and develop a coordinated approach to
generate needed resources.
WORKFORCE IMPLICATIONS
Resident duty hour and workload adjustments, as well as the greater
degree of supervision by attending physicians recommended by this com-
mittee, will create demand for more residents, midlevel providers, and
trained physicians to provide 24-hour coverage in training facilities. This
demand for staff will come at a time when other national trends are driv-
ing demand for hospital services and personnel to staff these facilities.
Technology changes, increasing numbers of patients being hospitalized,
and an aging population in the United States are primary contributors to
the demand for inpatient services (IOM, 2008; Kozak et al., 2006). Calls
for patient safety improvements will also create more demand for hospital-
based staff (Shulkin, 2008). For example, some hospitals are recognizing
the need to increase staff in hospitals on nights and weekends when there
is greater mortality, but currently less comprehensive staffing. In addition,
calls for residencies to incorporate more diverse settings than hospitals into
3 Medicare Payment Advisory Commission, 2008 Report to Congress: Medicare Payment
Policy, Washington, DC, March 2008.
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RESOURCES TO IMPLEMENT IMPROVEMENTS
training programs (e.g., ambulatory care settings) would leave less resident
time for inpatient coverage and require more personnel to cover existing
inpatient facilities (COGME, 2007). Shifting workload to existing team
personnel does not appear to be a solution in many settings because of the
workload pressures already experienced in hospitals by all staff (Weissman
et al., 2007).
The issue of the proper size of the physician workforce and the ad-
equacy of the supply of particular specialists is a controversial one, lacking
consensus (Iglehart, 2008). Many professional organizations, panels of ex-
perts, and researchers have identified current and projected workforce short-
ages for nurses, nurse practitioners, and physicians (AAMC, 2006, 2007b,
2008a,d; American Association of Colleges of Nursing, 2004; ANSR, 2008;
Colwill et al., 2008; Larson and Hart, 2007; National League of Nursing,
2005; Salsberg, 2008). There are projections of a physician shortage across
the United States by 2020, especially in certain geographic areas and cer-
tain specialties, and calls for increasing the size of medical school classes
and residency positions to replace an aging physician workforce and serve
the greater care needs of an aging population (AAMC, 2007b, 2008a;
COGME, 2007; Colwill et al., 2008; IOM, 2008).
On the other hand, a body of evidence indicates that there may be
a surplus or at least not a shortage of physicians. Researchers who have
analyzed geographic and hospital-specific resource data find that there are
vast variations in the size of the physician workforce among geographic
regions that are not associated with improved health outcomes and better-
quality care (Fisher, 2004; Wennberg et al., 2004). These studies indicate
that health care over a period of time beyond just an inpatient stay could
be made more efficient, and that effective systems of care provide higher-
quality care over the course of a patient’s chronic illness. This longitudinal
efficiency relates particularly to the lower use of supply-sensitive services
such as inpatient hospital days, imaging and diagnostic tests, and physician
visits. Studies also show that solely increasing the total supply of physicians
is an inefficient way to benefit the specialties and geographic areas that may
need more doctors (Goodman, 2004). The reforms necessary to achieve the
improvements identified in these studies are beyond the scope of this report
and the work of doctors in training.
The pipeline to produce physicians is a long one: a minimum of 4 years
of medical school and 3 to 7 or more years of residency. The Association
of American Medical Colleges recommends a 30 percent increase in medi-
cal school enrollment from 2002 levels by 2015, an increase of 5,000 new
positions annually (AAMC, 2008b). The Council on Graduate Medical
Education (COGME) has recommended an increase in the number of CMS-
funded residency positions by at least 15 percent by 2015, about 3,000
new positions yearly, as well as diversification of training sites based on an
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0 RESIDENT DUTY HOURS
Institute of Medicine model of care delivery (COGME, 2007; IOM, 2003).
This 15 percent increase in residency positions would absorb about half of
the expanded number of medical school graduates. The remainder would
offset the enrollment of international medical graduates who now compose
approximately 27 percent of all residents (Brotherton and Etzel, 2007).
The 8,247 additional residents projected by the Nuckols and Escarce
economic model, if a larger pool of residents were to cover the excess
hours of resident work, is a total incorporating both specialty (7,639) and
subspecialty (608) residents (Table 9-5); it is not equivalent to the yearly
increase in medical students or residency positions mentioned above. Ad-
ditional residency positions are one approach to filling the gap in covered
hours. Since the Medicare funding cap on residency positions was put in
place, only training programs with access to alternative sources of funding
(e.g., private resources) have been able to expand their programs to ad-
dress reduced hours. The committee strongly urges that all possible funding
mechanisms be considered, including increasing or eliminating the cap on
residency positions. At the same time, the committee recognizes that each
institution will have to assess its local labor market, educational capacity,
and unique circumstances to determine the most effective way to achieve
adherence to the proposed requirements for duty hours, workload, and su-
pervision. Individual institutions may or may not find additional residents
to be the preferred approach.
A PHASED IMPLEMENTATION OF DUTY HOURS,
ITS EVALUATION, AND FURTHER RESEARCH
Phase-in of Recommendations
To promote safe medical care, improve the education of doctors in
training, and increase the safety of residents and the general public, the
committee offers its recommendations, which should be implemented with
all deliberate speed. The committee believes action is needed urgently be-
cause U.S. hospitals still have a too-high error rate and too many patients
are harmed during their stay. The committee realizes that its recommenda-
tions will not prevent all patient harm and that residents are not responsible
for the whole problem. However, resident duty hours and schedules is a risk
that can be ameliorated. Fatigue contributes to unsafe conditions and can
increase the risk of errors. Fatigue among residents is something that can
be reduced through a judicious use of periods for rest and sleep between
duty periods and by limits on extended long duty periods. Other benefits
are likely to result from the recommendations, including fewer automo-
bile accidents caused by tired residents, a better environment for learning
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RESOURCES TO IMPLEMENT IMPROVEMENTS
and working that enhances the acquisition of needed competencies, and a
greater participation by residents in the hospital’s culture of safety.
While some recommendations could and should be implemented im-
mediately, changed duty hours, workload, and funding issues might require
an integrated phase-in. The recommendations will require additional re-
sources—both financial and human. Without the necessary restructuring
in resource allocation, attempts to implement certain recommendations
will fail to have the desired benefit and could even produce conditions
that are less favorable to patient safety. The committee believes that the
ACGME and the other organizations charged to implement aspects of the
recommendations should undertake their work with urgency and that all
institutions with residency programs take action to begin implementation
of all recommendations within 24 months.
The committee proposes several recommendations that should be con-
sidered as a package and implemented in concert. The recommended pa-
rameters concerning the reduction in duty hours and fatigue mitigation are
particularly intertwined. Although the 80-hour week and the 30-hour limit
on extended duty are unchanged from the current rules, the recommended
length and scheduling of rest periods during the month are crucial to mak-
ing those duty hour limits supportable. The recommended periods for rest
during extended duty and periods away from the hospital to allow for
rest and sleep recovery are intended to establish safer working conditions,
to protect residents from excessive fatigue, and to protect patients from
fatigue-induced errors. The recommended duty hour parameters are also
closely linked to the recommendations concerning workload, supervision,
and funding. Supervision enhancements and workload reductions, however,
could be put in place before duty hours are changed. Some institutions will
probably be able to implement the recommended changes independently,
but others would need outside funds to help support the hiring of additional
staff to assume the excess duties (workload and hours) of residents.
Not only would the benefits of these duty hour parameters be less
likely to materialize if they are implemented piecemeal and in a disjointed
fashion, but also unintended and potentially harmful consequences could
result without the accompanying committee recommendations on workload
and funding. For example, if duty hours are reduced again but workload re-
mains at current levels, residents will be under greater stress as they rush to
complete work, which increases the likelihood of making errors and could
further reduce the amount of time they have for educational activities; this
could negatively impact the safety of both current and future patients. The
potential benefits to society of well-trained physicians and fewer people suf-
fering from PAEs argue for all funders of GME to contribute appropriately
to support these GME reforms.
Some recommendations should be implemented immediately, such as
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RESIDENT DUTY HOURS
limits on moonlighting, enhanced supervision, improved handovers, error
reporting, and the provision of transportation to residents finishing a long
duty period and those too tired to drive safely. Also, programs should quickly
enhance their formal education efforts on sleep to include the latest scientific
research on fatigue, sleep deprivation, and methods to mitigate fatigue.
Research and Evaluation Plans
The lack of systematic data collection before and after the 2003 rules
hampered the committee’s ability to determine their impact fully and to as-
sess how much of the complaints about duty hour reform represent rhetoric
and resistance to change rather than valid criticisms. The literature that
exists too often comes from single-institution studies with insufficient sta-
tistical power to determine effects on patient outcomes and is often specific
to one specialty, making findings difficult to generalize.
Collecting baseline information now on the current situation concerning
residents’ duty hours and workload would permit evaluations of the impact
of this report’s recommendations once they are implemented. When design-
ing evaluation studies, it will be important to include a sufficient number
of programs so that the studies can produce a national picture across all
programs as well as evaluations targeted to individual specialties.
Ongoing data collection at the national level will be useful for moni-
toring the full impact of the committee’s recommendations. Because major
policy changes cannot be tested in the laboratory and it is impossible to
predict all the effects of those changes on the healthcare system, there could
be some unintended and unanticipated reactions to the recommendations.
For example, some specialties might find that programs reduce hours and
workloads without accompanying redesign of education, causing fewer
opportunities for residents to achieve procedural or medical competency
or requiring a longer residency. Or the less continuous care provided by
residents could increase their detachment and reduce their commitment to
their patients if work is not adequately restructured to permit enhanced
team coverage. While the committee certainly does not want to increase
workload or hours for residents, some programs might try to meet the rec-
ommended parameters of rest and work periods by increasing the frequency
of overnight duty periods and reducing the current amount of time off duty.
When Residency Review Committees (RRCs) implement specialty-specific
workload caps, it would be useful for them to monitor the impact of the
caps on both residents and their learning as well as on the costs, coverage,
and access to services at training institutions.
Similarly, when designing and evaluating innovative projects to test
creative ways to meet the intent of the committee’s recommendations while
allowing for alternative approaches that might better suit a type of program
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RESOURCES TO IMPLEMENT IMPROVEMENTS
or specialty, researchers must take care to include a sufficient number of
sites to generate statistically powerful findings and a design that will sup-
port comparisons of the impact of the recommendations as implemented.
While many experts have told the committee that one rule does not fit all
and that every specialty has different characteristics and needs, it is difficult
to have a realistic understanding of their differences and similarities without
reliable data.
Some of the ideas for the types of data that would be useful have been
detailed in the preceding chapters. Below are some key research topics
that the committee recommends for future consideration. These and other
research issues have been discussed throughout the report. It is important
for all the stakeholders in GME, contributors of ideas as well as funds, to
be included in a discussion of an evaluation and research agenda, and in-
volved in the necessary priority setting. It will be a challenge to researchers
to tease apart the various and overlapping contributing factors to patient
safety to determine the extent of their individual impacts, but the results
will have widespread benefits and would be of use well beyond the scope
of the current study.
• The relationship between improved processes for handovers and
shorter and longer duty hours. This report has discussed many of
the multiple factors in the resident work and learning environment
that contribute to error and potential patient harm. Understanding
the handover process and the risks and benefits it poses for pa-
tients is an important aspect of the issue that is ripe for systematic
research, primarily to learn ways to improve on current methods,
but also to assess whether the risks to patients from handovers are
greater than the risks of being cared for by a fatigued resident who
has more familiarity with the patient.
• Resident fatigue and patient harm, as well as residents’ own safety
within various scheduling and fatigue mitigation approaches. On
the assumption that there will be considerable variation in the way
individual programs choose to meet the parameters of the duty
hour recommendation, further examination of scheduling effects
on PAEs and resident safety for specialties and program sizes is im-
portant, along with analysis of the buffering effect of enhanced su-
pervision and teamwork. Research could investigate whether duty
hours can be further reduced from current recommendations.
• Resident workload and its impact on patient safety. Resident work-
load has been understudied for its effect on short-term and long-
term patient safety. The workload of residents also needs to be
assessed for its educational value.
• Measuring and achieving competence by specialty within reduced
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4 RESIDENT DUTY HOURS
duty hours and workload. Although competency-based education
is a broader topic than could be covered by this committee and
relates to the restructuring of GME more generally, it is of concern
to this study as a method for assessing the impact of the reduction
of duty hours and workload on resident attainment. More efficient
methods of teaching and conveying information and procedural
skills, as well as the assessment of residents’ knowledge and skills
would contribute to the positive impact of the committee’s recom-
mendations. Achieving competence also means that residents need
sufficient exposure to an appropriate range of patient experiences
including, depending on specialty, outpatient exposure.
• Opportunities for and limitations to substitution of other provid-
ers for residents. Better workforce data are needed to assess the
impact of implementing the recommendations on both the existing
workforce and future workforce needs nationally and in specific
geographic areas. Researchers should also assess whether and the
extent to which additional residents are needed.
• Impact of the IOM recommendations after implementation. Clearly
the impact of implementation on patient safety is the overriding
concern; however, other impacts, such as resident safety, are also
important. The variations in impacts based on different approaches
to implementation by different programs and specialties are also
key to the fine-tuning of the rules in the future.
The committee believes that it is essential to build an information base
to evaluate what happens going forward. With mechanisms to monitor
and evaluate the ongoing implementation of the committee’s recommenda-
tions, as well as innovative experiments, it should be possible to adjust the
rules periodically as needed. For example, grounds for ACGME’s granting
exceptions might have to be tightened or expanded; or further measures
might be necessary after workloads are reduced through the elimination
of noneducational activities, if the work remaining is consistently of too
high an intensity. Additionally, such information, as previously mentioned,
could also help to avoid major problems or unintended consequences, such
as an aspect of the duty hour parameters producing insurmountable chal-
lenges to certain specialties more than others that cannot be handled on an
exceptions basis; or residents not sleeping during the prescribed 5-hour rest
period who may choose to catch up on paperwork instead of mitigating
their fatigue; or some small residency programs having to close because of
insufficient staff to cover the excess hours of residents.
Recommendation 9-2: To gather the data necessary to monitor imple-
mentation of these recommendations and to prepare for future adjust-
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RESOURCES TO IMPLEMENT IMPROVEMENTS
ments as needed to achieve the desired objectives, ACGME should
convene a meeting of stakeholders and potential funders to set pri-
orities for research and evaluation projects. The Centers for Medicare
and Medicaid Services, Agency for Healthcare Research and Quality,
National Institutes of Health, Department of Defense, Department of
Veterans Affairs, and other funders should support this work as a high
priority.
Because so many individuals and organizations have strong economic
and professional interests in GME, and resident duty hours in particular,
it will be a challenge to come up with an agenda for research projects. It
will be even more challenging to design research projects that can produce
sound scientific evidence of use to policy makers. Given the likelihood that
research and evaluation funds will be quite limited, it is especially impor-
tant that they be spent wisely to focus on priority issues and to do so in a
methodologically sound manner that is acceptable to the key organizations
that will have to be involved in implementation of future policy changes.
The results of these research, monitoring, and evaluation projects should,
in the future, indicate areas for further refinement of the rules and alterna-
tives that could better enhance the goals of patient safety, resident safety,
and training.
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