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Limiting Work Hours for Medical Residents Could Be Costly

And it may not lead to fewer medical errors, researchers suggest

WEDNESDAY, May 20 (HealthDay News) -- For years, legislators and patient advocates have called for less grueling hours for medical residents to reduce the chances of medical errors.

Now, new research shows that allowing doctors-in-training to work fewer hours and take longer naps during their shifts won't come cheap -- it will cost the nation's teaching hospitals an estimated $1.6 billion a year.

And there are no guarantees that shortening the shifts of medical residents will improve patient safety, according to the study in the May 21 issue of the New England Journal of Medicine.

Some studies have shown that less-fatigued residents make fewer errors, while other research suggests that more frequent patient hand-offs, which would come as a result of shorter shifts, could actually mean more errors.

Doctors whose shifts have ended may have to leave patients at a critical time, and new doctors who come on duty may not be familiar with the patient, explained Dr. Kenneth Polonsky, chairman of the department of medicine at Washington University and co-author of an accompanying editorial.

"When you make physicians work shorter shifts, there is a trade-off," Polonsky said. "The care becomes discontinuous. That's what we're worried about."

The hours of medical residents are legendary. Until recently, residents often worked 120 hours a week and shifts of up to 40 hours with little more than catnaps, said study author Dr. Teryl Nuckols, an assistant professor of medicine at University of California, Los Angeles and health services researcher at the RAND Corporation.

That began to change in 2003, when the Accreditation Council for Graduate Medical Education (ACGME) established rules for the nation's 1,200-plus teaching hospitals that limited residents to an 80-hour workweek, 30-hour shifts and lightened workloads.

But those rules are widely flouted, according to surveys of medical residents cited in this latest study.

In December, the influential Institute of Medicine (IOM) issued a report calling for greater adherence to the guidelines, increased supervision of residents, more attention to patient hand-offs and even shorter shifts. Among the most significant recommendations: shifts no longer than 16 hours or as long as 30 hours if residents were given five hours of protected nap time.

The IOM, however, can only make recommendations. It's up to the ACGME to enact the rules, which it has so far not done.

In the NEJM study, Nuckols and her colleagues estimated the cost of adopting the IOM recommendations at $3.2 million annually per major teaching hospital.

The total would range from $1.1 to $2.5 billion, depending on how much it cost to hire substitute providers such as physicians assistants, nurse practitioners or other physicians to cover shifts and how many costly patient injuries could be averted.

The increase in costs to hospitals would be substantial. The annual funding for U.S. graduate medical education was about $18.7 billion in 2006, according to a RAND study.

The stakes for society, which bears the costs of disability payments and lost productivity for patients injured by medical errors, are even higher, Nuckols said.

If patient errors declined by 10 percent as a result of adopting the recommendations, the additional cost for each patient admitted to the hospital would increase by only $17. If patient errors increased by 10 percent, cost per patient admission would rise $266.

Dr. Albert Wu, a professor of health policy and management at Johns Hopkins University, said research has suggested doctors who are tired have less patience, show less compassion and are more likely to discharge patients too soon.

Yet, there are also risks associated with handing off patients from one doctor to another. And no research has definitively shown which concern outweighs the other.

"There is no good data to show what almost everyone believes to be true. All things being equal, it's better to have a doctor that is not falling asleep in front of you or who is so groggy they are unable to think clearly," Wu said.

More information

Read more about the Institute of Medicine report on resident hours.

SOURCES: Teryl Nuckols, M.D., M.S.H.S., assistant professor, medicine, University of California, Los Angeles, and health services researcher, RAND Corp., Los Angeles; Kenneth Polonsky, M.D., chairman, department of medicine, Washington University, St. Louis; Albert Wu, M.D., professor, health policy and management, Johns Hopkins University, Baltimore; May 21, 2009, New England Journal of Medicine

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