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3 Adapting the Resident Educational and Work Environment to Duty Hour Limits Numerous factors in the learning and work environments contribute to the content of work and the caseload that residents can manage. Trends over time have shown that patients admitted to the hospital are less stable and have more complex diagnostic and treatment needs than in past decades, yet their hospital stays are shorter. These changes have compressed the time residents have available to complete work and to learn from indi- vidual patients. The intensity of resident work appears to have increased for some specialties and rotations since the 00 duty hour limits when they are expected to admit and manage the same caseload in fewer hours on duty. The committee recommends the development of specialty-specific workload guidelines by Residency Review Committees and continued reduction of noneducational work to support both learning and patient safety goals. The committee also concludes, based on a review of adapta- tions since 00, that there is not a single approach to scheduling duty hours that fits all training facilities or specialties. The Accreditation Council for Graduate Medical Education (ACGME) announced new duty hour limits in February 2003, with a required start date of July 1, 2003 (ACGME, 2003). Many programs anticipated the changes and had started to adapt a year or two prior to ACGME’s an- nouncement. Sponsoring institutions and their program directors responded by redesigning schedules, strengthening duty hour monitoring practices, assigning some tasks usually performed by residents to other health pro- fessionals and support staff, trying new educational approaches, and alter- ing the work environment. No national funding allocation was dedicated to these program adaptations, and teaching institutions report that the changes were costly. 

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0 RESIDENT DUTY HOURS First, this chapter looks at how residents fit within a complex and changing work and learning environment, with particular attention to the influence of the content of residents’ work and workload on their ability to meet duty hour limits. The committee makes recommendations with respect to the content of resident work and caseload. Next, the chapter provides examples of how programs responded to the challenges of the 2003 duty hour limits, the variety of scheduling practices adopted, and the committee’s comments on scheduling preferences. Finally, the chapter examines how duty hour changes have required hiring substitutes for lost resident time, resulting in additional costs. RESIDENT EDUCATIONAL AND WORK SYSTEMS Resident education takes place on a daily basis through the delivery of direct care to patients, supplemented by lectures, conferences, and daily review of their patients with attending physicians. Most of the education occurs through the many conversations about their patients that residents have with attending physicians, consultants, and fellow residents. Resi- dency can be thought of as on-the-job training since very little is detached from direct patient care. Yet educationally valuable work has not always been given priority over the service needs of institutions (Cohen, 1999; Ludmerer, 1999). The 2003 reduction in duty hours reemphasized the need to find the right balance between education and service because compressing unaltered workload into fewer hours can put pressure on residents to violate duty hour limits or rush through their work, perhaps leading to patient harm (e.g., forgetting to order a test, which delays the diagnosis and care a patient receives, or forgetting to convey critical information during handovers). Residency programs and their sponsoring institutions needed to take many workplace factors into account when they redesigned resident work schedules in response to the 2003 limits, and these will remain consider- ations as additional duty hour adjustments are implemented. Ideally, the redesign took into account the ultimate outcomes of patient safety, resident safety, and educational attainment not just compliance with duty hours. A useful framework when redesigning healthcare operations in the context of patient safety is an adaptation by Vincent and colleagues of Reason’s tax- onomy of factors that contribute to accidents and adverse events in clinical environments. These include patient characteristics, task factors (includ- ing the content of work and workload), team factors, work and learning environment, and organizational and management factors (Reason, 1990; Vincent et al., 1998). Change in one area is not without repercussions in others, because change in the “work situation can alter substantially the individual’s level of performance or decrease the probability that the per-

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 RESIDENT EDUCATIONAL AND WORK ENVIRONMENT formance will be maintained at a satisfactory level” (Chiles, 1982). These other factors affect whether residents can comply with duty hour limits, maximize their learning, and care for patients under the safest conditions. Duty hours are not the only factor driving resident performance. Patient Characteristics The growing number of admissions to hospitals of complex patients, and the availability of ever-expanding advanced technologies for diagnosis and treatment have increased the intensity of the inpatient care experience in hospitals in general and thus for residents in training (Anderson and Horvath, 2004; Bodenheimer, 2005; Lawler et al., 2001; Vogeli et al., 2007). A declining overall number of acute care beds due to cost containment mea- sures, the shifting of many formerly hospitalized patients to outpatient care (e.g., increased use of ambulatory surgery), and reduced length of stay have meant that the inpatient population that residents care for today is sicker and more equivalent to the patients in intensive care units (ICUs) 20 to 30 years ago (Carayon and Gurses, 2005; Ludmerer, 1999; Oransky, 2003). As the U.S. population ages, some experts have advocated for new bed ca- pacity; if demand increases without growth in beds, or better management of existing beds, there will be pressure to turn over beds sooner increasing throughput (Bazzoli et al., 2003; The Chartis Group, 2007). The average length of stay over the past 25 years has decreased dra- matically: 7.3 days in 1980, 6.4 in 1990, 4.9 in 2000, and 4.8 in 2004 (Kozak et al., 2006). In fact, many hospital stays are shorter than 4.8 days. One university-teaching hospital reported that patients with 29 of their 88 most frequent diagnostic codes in 1986 were out of the hospital in less than 2 days, and if residents were to obtain the same breadth of experience as 1980, they would need more ambulatory care experiences (Rosevear and Gary, 1989). Brief intense patient stays in the hospital today also mean that residents have less time to get to know their patients and observe the progression of a patient’s illness or injury and recovery than they did 25 years ago. Duty hour limits implemented in 2003 may have further eroded the time for interacting with individual hospitalized patients. For example, Horwitz et al. (2006a) reported that the primary admitting resident team covers ap- proximately 47 percent of an average inpatient’s 4-day hospitalization on an internal medicine service compared with 70 percent reported prior to the 2003 duty hour limits (Petersen et al., 1998). Depending on how training programs schedule their residents under duty hour limits, a resident who admits a patient may or may not be available the next day to evaluate the patient’s progress before discharge (Gilsdorf, 2008). Teaching hospitals usually have a more complex inpatient case mix

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 RESIDENT DUTY HOURS TABLE 3-1 Case Mix Index by Teaching Status for FY 2007 Case Mix Index (CMI) FY 2007 Number of Teaching Status Hospitals % of Total Mean Median Minimum Major teaching 303 8.24 1.60 1.59 0.84 Other teaching 795 21.62 1.49 1.49 0.80 Non-teaching 2,579 70.14 1.28 1.24 0.41 All 3,677 100.00 1.36 1.31 0.41 NOTE: CMIs are transfer adjusted and based on Medicare Grouper Version 24. Major teaching is defined as having an intern and resident-to-bed ratio greater than or equal to 0.25. SOURCE: Inpatient Prospective Payment System (IPPS) Final Rule FY 2007; data analyzed and provided by AAMC (September 30, 2008). than other hospitals, and the case mix index (CMI) is often used as a proxy for the relative severity of illness. The CMI measures the amount of services provided to patients with different diagnoses. The higher the case mix aver- age, the greater the severity of illness in that institution’s patient population tends to be, and therefore, more resources are used, on average, to care for them (Andrews et al., 2007). The Centers for Medicare and Medicaid Ser- vices (CMS) takes this more complex caseload and the greater number of services that may be delivered in the course of teaching into account when determining payments for teaching hospitals through its indirect medical expenditure payment for graduate medical education. As illustrated in Table 3-1, the mean and the median CMIs for teaching hospitals are higher than for non-teaching hospitals, although there is considerable variation within each category, reflecting the diversity of specialized services (e.g., transplantation, burn units) offered to their patient populations (COTH, 2008). The mean and median CMIs have not changed much from fiscal year 2000 to the present. Comparisons of the CMI over a longer period of time to assess changes in the severity of patients and the services provided are of questionable validity because there have been changes in the classifica- tion of certain illnesses within the relative diagnosis-related group weights established by CMS, on which the CMI is based.1 Since patients differ in terms of severity of illness and length of stay from specialty to specialty (e.g., obstetrics vs. other types of surgery) and even among rotations within specialties (e.g., ICU rotation vs. ambulatory care), patient factors must be considered when determining what type of resident work schedule will best provide continuity of patient care and 1 Personalcommunication, Erika Steinmetz and Karen Fisher, Association of American Medi- cal Colleges, April 18, 2008.

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 RESIDENT EDUCATIONAL AND WORK ENVIRONMENT high-quality learning experiences. Patient severity is a key factor in deter- mining the number of cases that a resident might manage within his or her duty hours. Task Factors Noneducational Activities With reduced duty hours, it is critical to assess not only the number of hours that residents spend in the hospital but also the educational value of that time. A review of the literature on how residents spend their time, covering studies from the time of the Bell Commission to 2003, found that residents spent up to 36 percent of their time learning while delivering pa- tient care services, an additional 15 percent was spent in formalized teach- ing activities (e.g., conferences, grand rounds), but up to 35 percent of the day was spent in non- or marginally educational patient-related activities (Boex and Leahy, 2003). Although more limited duty hours and ACGME guidance have encouraged the transfer of some tasks with marginal edu- cational value (e.g., transport, phlebotomy) to others, residents typically still spend a substantial amount of time searching for test results and sup- plies, completing paperwork, obtaining and transporting specimens for laboratory tests, moving patients, making appointments, and completing paperwork for patient discharges (Gabow et al., 2006). The content of resi- dents’ work and the amount of time residents spend on different tasks have received little analysis since the 2003 change in duty hour regulations, but a few limited studies indicate that a considerable amount of noneducational work remains: from 8 to 24 percent for residents in one surgical program, with the highest values for PGY-1s, -2s, and -5s (Brasel et al., 2004), and 10 to 30 percent for another institution’s residents across multiple special- ties and training years (Dola et al., 2006). In a national survey of internal medicine programs, only 9 percent reported that ancillary services were more available now to help with these tasks than prior to duty hour reduc- tion (Horwitz et al., 2006b). Addressing this issue now is a way to add to the number of resident hours available for direct patient care, enhancing both their ability to meet patient care needs and their learning. Currently, ACGME requires that sponsoring institutions “must provide services and develop health care delivery systems to minimize residents’ work that is extraneous to their GME [graduate medical education] pro- grams’ educational goals and objectives.” These services and systems must include patient support services: Peripheral intravenous access placement, phlebotomy, and laboratory and transporter services must be provided in a manner appropriate to and consistent with educational objectives and quality patient care (ACGME, 2007b). As noted, such practices are not

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4 RESIDENT DUTY HOURS always followed. The committee concludes that ACGME should expand the protections for residents by monitoring and assessing these practices as well as broadening the current definition of support services to include administrative and secretarial support in order to reduce resident time unnecessarily spent on those tasks (e.g., making appointments, tracking down paperwork). Later, in this chapter’s discussion of support services adaptations, the experiences of several programs in transferring these tasks to others are illustrated. Reducing the amount of time residents spend on these marginally edu- cational activities is not meant to undermine multidisciplinary team-based approaches to medical care or to establish silos of work effort (“that’s not my job”) and cause delays in care delivery. There may be times when a resident might be able to do such tasks in a manner that is more timely, accurate, and complete, than others can, thereby accelerating care delivery to the patient or better coordinating care by assisting in the navigation of hospital systems. Resident Caseload The reduction of duty hours in 2003 was not typically accompanied by a reduction in the caseload that residents manage. Workload has been implicated as a factor in resident error, delays in patient care, and possible effects on patient outcomes (Jagsi et al., 2008; Ong et al., 2007; Vidyarthi et al., 2007). Working beyond shift length because of workload contributes to violations in duty hour limits and is observed in the practice of residents as noted in Chapter 2 and of nurses as well (Rogers et al., 2004; Scott et al., 2006; Tucker and Spear, 2006). Reports on nurses find that heavy work- load (e.g., nurse-patient ratios), time pressures due to work system factors (e.g., patient severity, having to perform nonnursing tasks; spending time tracking down patients’ charts), and reduced supervision can contribute to poorer patient care (e.g., delays in care, complications), increased mortal- ity, and a climate for error (Aiken et al., 2001; Carayon and Gurses, 2008; Lang et al., 2004; Tarnow-Mordi et al., 2000; Tibby et al., 2004). These are of concern in the resident work and learning environment as well. Specialty-specific and rotation-specific workload guidelines should take into account the number and severity of patients as well as the number of procedures required to determine the intensity of the experience and its ef- fect on promoting safe conditions for residents and patients. The contribu- tion of residents’ workload to error and patient safety has not received the same investigative or public attention as their duty hours (Parshuram et al., 2004). Common sense indicates that an excessive workload might result in cutting corners that could affect patient safety (e.g., forgetting to transmit vital information during a handover or to order a needed diagnostic test

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 RESIDENT EDUCATIONAL AND WORK ENVIRONMENT leading to delays in care). Additionally, Chapter 4 examines the impact of excessive workload on learning. Although the daily patient census for residents may have remained the same or even decreased over the past 20 to 30 years, the number of admissions and discharges has increased due to shorter lengths of stay. For example, one institution reported that although its average length of stay decreased by 13 percent and daily census decreased by 5 percent, the daily number of admissions and discharges for residents increased by 15 percent (Dellit et al., 2001). From a financial perspective, this is just what hospitals want—greater productivity, higher throughput, and faster turnover of beds, all of which maximize hospital revenues to ad- dress their costs (The Chartis Group, 2007; Gregory et al., 2003; Larson, 2003). After the 2003 reduction in duty hours, it appears that there has not been a significant reduction in the number of patients a resident admits, manages, or cross-covers based on reports across a variety of residency specialties. Maintenance of the same caseload may lead to increased work compression or intensity during work hours (Bellini, 2008; Dawson and Zee, 2005; Horwitz et al., 2006b; Jagsi et al., 2008). A national survey of ACGME-accredited programs in internal medicine found that only 28 per- cent reduced the average daily census for interns in response to duty hour limits (Horwitz et al., 2006b). Numerous reports from general and other surgical programs report that they also have maintained pre-2003 surgical volume despite the reduction in duty hours (e.g., Baskies et al., 2008; Bland et al., 2005; Ferguson et al., 2005; Shin et al., 2008). Admissions and discharges are among the most time-consuming and complex tasks that residents must complete (Dellit et al., 2001), and for many specialties these activities are limiting factors in the caseload that can be managed thoroughly within allotted duty hours. For example, Ong et al. (2007) found that increased resident workload for an internal medicine service on admission days (i.e., each additional team admission) was as- sociated with increases in average length of stay, total costs, and risk of mortality, with the risk even higher when more than nine patients were admitted to a team on their admitting day. The authors suggested that the increased workload may have led to residents’ making an “inaccurate ini- tial clinical assessment or pushing workup activity onto subsequent days, leading to longer lengths of stay,” thereby increasing the costs per patient and potentially having a detrimental impact on patient mortality. This study examined the care experiences of more than 5,000 patients over 3 years, but the authors recommend additional trials to increase the statistical power to detect changes in mortality (Ong et al., 2007). Teams were able to make some short-term adjustments to respond to increasing workload; the authors suggest that these short-term adjustments might mean that

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 RESIDENT DUTY HOURS residents skip offered didactics or stay overtime to catch up on work in order to reduce the overall patient census. However, it appears that fatigue may accumulate as the team once again becomes less efficient if the census remains high over the month-long rotation. Ong et al. (2007) also make a business case for reducing workload per team and using the savings to support additional physician-level staff or midlevel providers. Earlier studies have also found effects for the number and timing of admissions on length of stay and total charges (Griffith et al., 1997; Hillson et al., 1992). An additional approach to workload management is having teams admit a few patients each day rather than in boluses of a large number of cases every third to fourth night (Volpp and Landrigan, 2008). Maintenance of the same caseload can affect the time available for conference attendance, educational activities other than direct patient care, adherence to duty hour limits, and on-call sleep (Arora et al., 2008a; Horwitz et al., 2006b). These effects may not be static over the training year and may differ according to various measures of caseload (e.g., new admissions vs. overall census). For example, Arora et al. (2008a) found that interns early in the training year (July-October) had 10.5 minutes less sleep for each additional on-call admission, and this declined to 1.9 min- utes less sleep per admission later in the year (March-June) on extended duty periods (30-hour shifts). Thus, workload measures should recognize the growth in competence of residents over time. The study also showed that each additional patient added extra time to shift duration (e.g., 13.2 and 15.5 minutes per patient, respectively); approximately 30 percent of extended duty periods on this internal medicine service were found to be noncompliant (i.e., more than 30.5 hours in length). Reduction in workload can assist in greater adherence to duty hours. It appears that efforts to maintain caseload have not been supported by sufficient reductions in noneducational tasks that consume large amounts of resident time. This likely leads to a smaller proportion of available time for educational activity as throughput increases and sacrifices depth of learning for greater exposure to learning episodes that are more brief and may be less rich depending on the specialty and resident rotation. A well-designed caseload of the right variety and number of patients can enhance learn- ing, while too much work can overwhelm cognitive processing and lessen learning (Chewning and Harrell, 1990; Choo, 1995; Wiener et al., 1984). A reduction in duty hours suggests that the number of patients a resident can care for at one time, especially in the first year of residency, and the amount of noneducational work need to be reduced so that resident time and workload are maximally attuned to the higher-yield learning events of a patient stay. The amount of time spent in daily care of patients varies from specialty to specialty, necessitating specialty-specific workload guid- ance; for example, the most time-demanding portion of the work day for

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 RESIDENT EDUCATIONAL AND WORK ENVIRONMENT surgical residents may be the time spent in preparation and performance of procedures rather than admissions and discharges. Team Factors One of the key elements of the residency experience is working as part of teams, both resident teams and a larger interprofessional team (e.g., nurses, physicians, pharmacists). Each resident team is made up of several levels of residents and medical students, with those in each advancing year of training having increasing levels of responsibility. Even when working in teams, the ultimate responsibility for patient care resides with each in- dividual patient’s attending physician. Reducing resident duty hours has meant changing team dynamics and potentially affecting teaching, learning, and performance. A few studies indicate that some work has shifted within existing team structures, particularly from interns to more senior residents and from residents to faculty; the volume of work and/or its intensity, as noted above, appears to have remained the same or even increased for some training years but not others (Coverdill et al., 2006a,b; Hutter et al., 2006; Parekh et al., 2005). Reorganization of team structures has been necessary to enhance patient continuity (Mathis et al., 2006) and provide coverage of services around the clock. The effects of reduced hours on resident team dynamics vary according to specialty and the size of programs. Neurosurgery programs that often only have one resident per training year, very long operations, and patients who need close observation after surgery have had difficulty meeting the 80-hour limit (ACGME, 2007a; Cohen-Gadol et al., 2005). Having to cover duty hours with just a few residents per year makes it difficult to sustain traditional hierarchical relationships and progressively increasing training and experience from intern to second year to third year and up until the attending; these programs may have to match individual residents with attending physicians. This diminishes the traditional involvement of senior residents in teaching junior residents (Cohen-Gadol et al., 2005). Training programs, regardless of specialty, that have just a few residents will have a harder time adapting to reduced duty hours than those with more residents; these programs will need to find alternatives to resident coverage and redesign their approaches to care, or they might be unable to maintain accreditation. Under duty hour restrictions, an excessive workload (i.e., numbers of patients, complexity of caseload, amount of noneducational work) for the given time is one of the obstacles that residents, their mentors, and other professionals must overcome in providing quality care to patients. There is extensive research in other fields that indicates the detrimental effects on individual performance of excessive workload (Gonzalez, 2005; Hancock

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 RESIDENT DUTY HOURS et al., 1995; Rahman and Haque, 1992), but teams can help buffer these detrimental effects and even increase productivity by distributing work and workload among team members (Jung et al., 2002). Individuals in teams that work as a unit have a shared idea of how to accomplish a task and therefore provide assistance to one another (e.g., by providing backup or monitoring the situation for work to be done or to prevent errors). Team- work has been shown to improve performance even under conditions of sleep deprivation (Baranski et al., 2007; Vander Wood et al., 2007). In some programs, staff members have been added to the care team to help complete the work formerly done by residents; these include hospital- ists, physician assistants, and nurse practitioners. This is discussed in more detail later in the chapter. Sometimes these additional staff members are well integrated into the resident team with good communication to provide continuity of care; for example, they might all have rounds together. How- ever, others have more of a stopgap function to fill uncovered hours (e.g., moonlighting physicians) (Horwitz et al., 2006a).2 Work and Learning Environment The philosophy of the sponsoring organization and the residency pro- gram director determines whether the balance of resident work is tilted toward service or education. The size and scope of residency programs vary greatly from site to site. Sponsoring institutions may have a handful of spe- cialty residency programs, while others might have more than 100 different programs; medical school sponsors tend to have the most programs, an average of 35.5. There are numerous types of sponsoring organization (e.g., for-profit and nonprofit groups including government, church, or private ownership) with the majority being nonprofit (ACGME, 2007d). Some organizations, regardless of philosophy, have limited resources and thus may have trouble providing supplementary services or hiring replacements for residents even if they would like to do so. The commit- tee is cognizant of this and in Chapter 9 recommends additional funding to implement changes in workload and hours, with special consideration for safety net teaching hospitals so that they can maintain robust training programs while providing desirable community service. Some educators and residents have expressed concern that educational opportunities are diminished for today’s residents. Studies report decreased attendance at formal didactics, less availability for ambulatory care clinics, less opportunity for residents to discuss their cases thoroughly with attend- ings, and fewer other educational opportunities since 2003 (Arora et al., 2008b; Parekh et al., 2005; Reed et al., 2007). On the other hand, orga- 2 Personal communication, D. Meltzer, University of Chicago, August 12, 2008.

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 RESIDENT EDUCATIONAL AND WORK ENVIRONMENT nizations report on how they redesigned their programs to preserve these elements and how they maintained or even improved educational outcomes (Basu et al., 2004; de Virgilio et al., 2006; Horwitz et al., 2007). More information from reports on education after resident duty hours reform is contained in Chapter 4. Many of the work processes in the system as a whole are inefficient, affect residents’ performance, and inhibit their ability to complete their work in a timely fashion. Gabow and others have found that the workflow of residents is fragmented by frequent interruptions and changes in focus that interfere with task completion and cognitive processing, and that often (e.g., 25-26 percent) these interruptions are rated as being for unimportant reasons (Blum and Lieu, 1992; Gabow et al., 2006). Specifically, Gabow and her colleagues (2006) found that residents performed 5.0 to 11.3 dif- ferent activities per hour of non-sleeping time. Residents “experienced fre- quent interruptions and changes in focus”; interruptions can lead to errors, and sleepy residents will have more trouble recovering from interruptions to focus on their tasks (Gabow et al., 2006). Research in other environments finds that as interruptions increase, the frequency of error also increases (Hirst and Kalmar, 1987; Speier et al., 1997). Such interruptions have been implicated as contributing to pilot error (Dismukes et al., 1998) and to medication-dispensing errors by nurses and pharmacists (Flynn et al., 1994; Gladstone, 1995; Peterson et al., 1999). Human factors and systems engineering approaches help programs analyze their current work practices to determine the amount of time residents spend on key activities and how they interact with others in the work environment (Barach and Johnson, 2006). These could reveal ways to reorganize work processes and resident work time to increase efficiency and decrease interruptions (Chung and Ahmed, 2007; Gabow et al., 2006). For example, one surgical program’s self-study revealed a need to reorganize morning and evening rounds to make them more efficient. These activi- ties designed to improve both time and team management also resulted in other improvements (e.g., greater punctuality at conferences, clinics, and operations). Resident satisfaction improved as well because they did not perceive that time was wasted when they were on duty (Chung and Ahmed, 2007). Other programs have drawn up schedules and shift changes to match patient admission flow, thus reducing the amount of time residents spend waiting for patients to arrive (Levin et al., 2007; Ogden et al., 2006). Rethinking and reengineering how residents spend their time might help reduce the hours needed to complete the desired tasks; with increased effi- ciency, they could spend more time at the bedside caring for patients and in other learning activities, and when on night call they would have additional time for sleep (Lamberg, 2004; Morton et al., 2004; Viney, 2008).

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4 RESIDENT DUTY HOURS educational capacity (sufficient cases and faculty) and resources other than Medicare to fund the position.4 COSTS OF ADAPTING TO THE 2003 DUTY HOUR LIMITS The replacement of resident duties and coverage of hours of work by other personnel required as a result of the 2003 ACGME rules came with no dedicated funding from outside sources. Such help for transition fund- ing had been included in House and Senate legislative proposals to regulate resident duty hours; these proposals have not been called up for a vote in either body (GovTrack.us, 2005a,b). Individual Program Costs A few programs have reported in the literature and in testimony to the committee that adjusting to duty hours has carried substantial annual recurring costs. These estimates run from $1 million for a single specialty program to $7 million for all residencies across several hospitals (Knapp, 2002; Liekweg, 2008; Noah, 2008; Opas, 2008; Oransky, 2003). These funds primarily went to pay for hiring physician extenders, moonlight- ing physicians, and hospitalists and to privately fund additional residency positions. Teasing apart the costs associated with duty hour reduction is difficult. The addition of personnel is the most visible component. Other expenses might include costs of monitoring such as electronic duty hour verification, capital investment in rooms for napping, additional office space for the resi- dents to work in, and hidden costs of additional faculty work (Daschbach, 2008; Opas, 2008). Medicare is a principal source of payments for graduate medical edu- cation, about $8.5 billion in 2007. For graduate medical training facilities without a Medicare population, other sources must suffice. For example, the Los Angeles hospital system received little of its funding from a dedi- cated source for graduate medical training (e.g., 0.6 percent of its funds came from Medicare because it does not have a large Medicare popula- tion). The hospital system and its graduate medical education programs must compete with other county and state needs for appropriations; 70.8 percent of their support comes from state and other federal funds (e.g., Medicaid), 25 percent from county taxes, and 0.6 percent from the DSH (disproportionate share hospital) program (Opas, 2008). There is a clear need to address the costs of supplementing reduced 4 Personal communication, S. Hamlin, Cincinnati Children’s Hospital Medical Center, Febru- ary 20, 2008.

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