New limits on resident work hours are still a year away from enforcement, but teaching hospitals are already beginning to grapple with a big question: Will there be enough work hours to get the work done?
Meanwhile, radiology residents are wondering how the new rules will impact them -- if at all. And an ongoing class action lawsuit charging illegal competition among medical groups and teaching hospitals could spell even bigger changes for physicians in training.
Under the new rules set by the Accreditation Council of Graduate Medical Education (ACMGE), residents can work a maximum of 80 hours a week with 10 hours off between shifts and one day off per week. A hospital’s accreditation can be jeopardized if it breaks the rules, which become effective July 2003.
The limits were introduced by the ACGME in June, and endorsed soon thereafter by the American Medical Association.
Radiology residents have responded with everything from skepticism to glee. Comments on the Residents Digital Community discussion group hosted by AuntMinnie.com ranged from "It’s about time" to "Don’t expect any big changes." Very few of the resident physicians contacted by AuntMinnie.com were willing to speak on the record, however.
"The new guidelines are a welcome change," said Dr. Tara Henrichsen, chief radiology resident at the Mayo Clinic in Rochester, MN. "Sleep deprivation is not healthy or conducive to learning, and these changes will make a resident’s time more productive."
The real-world impact is expected to vary from program to program, added Henrichsen, chairperson of the American Association of Academic Chief Residents in Radiology.
"Radiology has traditionally been a leader in using night float for radiology call," she said. "Therefore, the new regulations will not bring about drastic change to programs using night float systems. But there are many programs that will have to reevaluate and adjust their call schedules."
In New York state, where similar limitations on resident work hours have been in effect for several years, the new rules may have little impact, said Dr. Kevin Mennitt, chief resident at Columbia-Presbyterian Medical Center in New York City.
"In fact, I think some of the restrictions in the New York rule -- such as the amount of emergency room time -- are more strict than those imposed by the ACGME," he said. "We don’t expect too much impact within our residency."
Few generalizations can be made about the residency burden radiologists face compared to other specialists. Hours tend to be longest in surgery, obstetrics and gynecology, and family medicine, according to the Committee of Interns and Residents (CIR), a New York-based union that represents about 10% of the nation’s residents and is affiliated with the Service Employees International Union.
How hard radiologists work in any given residency program is largely a factor of program size, imaging exam volume, and the proportion of staff to residents, Henrichsen said.
Finding alternatives to coverage will likely be the biggest challenge hospitals face, noted Dr. Janet Strife, who is president-elect of the Association of Program Directors in Radiology. With Medicare funding frozen, no government monies are available to fund additional manpower.
In radiology in particular, managing subspecialist coverage will be difficult. There are often not enough faculty to cover the subspecialties, and the remaining faculty have not been trained in the specialty, she said.
"The guidelines may very well improve care, even if indirectly," she said. "There are services that typically are abusive to residents concerning their own lives and the demand of clinical service. It's hard to be kind, compassionate, and caring about patients when the ACGME program is not kind, considerate, or caring about the trainee."
As co-chair of the Internal Review Process of the ACGME, Strife also believes that an institution's internal review process should take the lead in monitoring physician hours and compliance with the new rules.
The guidelines may prompt a return to late-hour shifts by faculty, according to Dr. David Leach, executive director of the ACGME. In an article in American Medical News, he noted that in specialties such as surgery, faculty are already on site at all hours. That same sort of schedule may soon be mandatory for other specialties as well.
One of the biggest criticisms of the guidelines comes from the CIR, which has saluted the ACGME and the AMA’s actions but believes enforcement remains a problem. CIR cites a critical loophole in the guidelines that allows hospitals to request an increase in hours of up to 10% if they can provide a sound educational rationale.
Residents skeptical of the new rules say that it will be all too easy for programs to skirt the requirements without penalty. And fear of reprisal may prevent residents from lodging complaints with the ACGME about their program.
Federal legislation introduced in June, and endorsed by the CIR, could help. The Patient and Physician Safety and Protection Act of 2002 would make compliance a condition of Medicare participation and includes so-called "whistleblower protections" to encourage residents to report violations.
According to bill author Sen. Jon Corzine (D-NJ), such a law is needed to ensure that work hour limits are respected. Corzine’s law would also provide for additional funding to hospitals in order to increase staffing levels.
Parallel with these efforts is the ongoing class action antitrust lawsuit, filed in May against the National Residency Matching Program (NRMP), the Association of American Medical Colleges, the American Hospital Association, the American Board of Medical Specialties, the AMA, and all of the nation’s teaching hospitals.
The suit was filed on behalf of 200,000 U.S. resident physicians, and claims that the matching program is manipulated by medical organizations and private practices to consistently underpay and overwork residents. It charges that the named groups have illegally contracted and collaborated to eliminate competition in the recruitment, hiring, compensation, and employment of resident physicians.
Since the filing in May, little movement has occurred. Despite the actions by the AMA and the ACGME, the claim remains on the table.
The named defendants have accepted service of the complaint and are expected to file their response with the federal district court in Washington, DC, by September 11, said Michael Freed, a partner with Much Shelist Freed Denenberg Ament & Rubenstein who serves as class counsel.
In researching the issue prior to filing the claim, lead attorneys found that resident physicians are more vulnerable than other employees in terms of negotiating salaries and working conditions, Freed said.
But others believe the match program works well, assisting applicants in obtaining the best possible residency -- and helps institutions in recruiting the best possible residents.
"The system is fair and equally balanced," said Dr. N. Reed Dunnick, radiology chair and Fred Jenner Hodges Professor at the University of Michigan, Ann Arbor. "It has worked so well that we are trying to get the radiology fellowship program in match as well."
Furthermore, residency is more training than employment, Dunnick noted in an e-mail to AuntMinnie.com.
"Clearly, much of it is ‘on the job training,’ but the residency programs provide teaching conferences, formal lectures, and specialized training in medical physics, as well as teaching each subspecialty," he wrote. "Programs provide an average of two hours of formal conferences as well as innumerable informal conferences each day. Residents could not practice in their field without this training."
By Deborah R. DakinsAuntMinnie.com contributing writer
August 20, 2002
Related Reading
French junior doctors to get more rest, August 14, 2002
AMA approves new resident work hour rules, June 21, 2002
ACGME cuts residents' hours in the name of safety, June 13, 2002
Residents file suit against U.S. matching program, May 8, 2002
UK's junior doctors frequently misdiagnose wrist injuries', January 11, 2002
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