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http://www.nytimes.com/2002/06/14/health/14HOSP.html

Limits on Residents' Hours Worry Teaching Hospitals

By REED ABELSON

any of the nation's teaching hospitals, already under financial pressure, are raising concerns about the effect of new rules that will limit the number of hours worked by medical residents.

"For academic medical centers, the impact is going to be profound," said Dr. Peter Herbert, the chief of staff for Yale-New Haven Hospital, a teaching affiliate of the Yale School of Medicine, who estimates that the cost for some hospitals could run into the millions of dollars.

The rules, which are being imposed by the group that accredits teaching hospitals, will limit the average workweek to 80 hours and restrict a resident's duty to no more than 24 hours at a time.

Some hospitals consider residents an inexpensive source of labor. Some residents say they work 100 hours or more a week. Having significantly cut back on nurses and other staff, hospitals rely heavily on these new doctors, who spend several years training at a hospital after earning their medical degrees.

In addition to caring for patients, particularly the poor and uninsured, these doctors often handle paperwork, transport patients and perform tasks once delegated to others.

The new rules, which are aimed at reducing the risk of dangerous errors by inexperienced doctors who are sleep deprived, will take effect in July 2003. They are being applied by the Accreditation Council for Graduate Medical Education, which oversees the training of 100,000 residents in the nation's 7,800 programs.

While some specialties already limit residents' workweeks, the new rules will apply to all training programs and could require many hospitals to change how they staff.

Yale-New Haven Hospital, whose surgery program was threatened with a loss of accreditation because of the long hours residents worked, is hiring 12 physician associates to reduce the residents' workload, Dr. Herbert said.

"There is a huge financial hit," said Dr. Jon Cohen, the chief medical officer for the North Shore-Long Island Jewish Health System, which, like other New York hospitals, has had to adapt to a law that already limits residents' hours.

The cost of two to three physician assistants can run as high as $200,000 a year, compared with $50,000 to pay a medical resident, Dr. Cohen said. "No one knows where that money is going to come from," he said.

Many hospitals acknowledge that the new rules will require significant changes in how they do things and how they view residents.

"The big cultural change is the institutions have to recognize and treat residents as students," Dr. Cohen of North Shore said.

Some say this will force teaching hospitals to think seriously about the best way to deliver care and educate residents.

"The real challenge for us is to redesign the health care delivery model," said Dr. Thomas J. Nasca, dean of the Jefferson Medical College at Thomas Jefferson University.

In New York, the cost of adopting the law limiting residents' hours was estimated by the state at $220 million a year, some of which the hospitals recovered through higher reimbursements.

The New York law took effect in 1989, and a study done in the late 1990's suggested that many hospitals, particularly in New York City, were still asking residents to work longer hours than the law required. In recent years, however, enforcement of the law has been increased, and many hospitals have made more significant changes in their staffing.

New York hospitals are not likely to feel much impact from the new rules, said Kenneth Raske, the president of the Greater New York Hospital Association, with the exception of some surgical programs where hospitals are still allowed to ask their residents to work longer hours. "The surgical programs need to have some flexibility," Mr. Raske said.

Depending on how the hospital uses residents and the services they provide, the cost of complying will vary widely, the American Hospital Association said. "We really don't understand the cost or the adaptions," said James Bentley, the group's senior vice president for strategic policy planning.

While some hospitals will hire senior nurses or physician assistants, others may rely more on other doctors and may curtail some of the areas where residents provide care, Mr. Bentley said.

But hiring nurses or physician assistants may not add significantly to costs, others say. "The financial impact won't be catastrophic," said Mark V. Pauly, a professor of health care at the Wharton School at the University of Pennsylvania.

Still, the new rules are an example of rising costs for hospitals, said Mr. Bentley, who said the association was working to prevent cuts in federal and state payments that would further weaken the financial condition of many of its members.

Even specialities like internal medicine that already adhere to 80-hour workweek will have to adjust. At the University of Chicago hospitals many residents work 36 or 38 hours at a time to be able to provide follow-up care and attend educational programs, said Dr. Holly Humphrey, who oversees the residents in internal medicine. The 24-hour limit, even with a possible additional six hours for handing off patients or attending lectures, "is a big, big change," Dr. Humphrey said.

She is concerned that residency programs will "take on a mentality of shift work," she said.

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