Teaching Internal Medicine Residents in the New Era: Inpatient Attending with Duty-Hour Regulations

BACKGROUND: Little is known about the impact of resident duty-hour regulations on the inpatient teaching experience. OBJECTIVE: Provide descriptive information on the effect of resident duty-hour regulations on attendings and the educational environment. DESIGN: Qualitative analysis of attending focus groups and e-mail survey of residents in Internal Medicine. PARTICIPANTS: Inpatient attending physicians at 2 academic centers and residents at the affiliated university-based Internal Medicine residency program in Portland, OR. RESULTS: Seventy-two percent of eligible attendings participated in 2 focus groups. Three themes were generated: increased clinical role, altered time management, and altered teaching. Attending physicians report performing more clinical work, teaching less, using more focused teaching methods, and experiencing an increased perception of intensity. Forty percent of eligible residents completed our e-mail survey. We organized residents data using the same 3 themes as attending physician data. Residents observed attending physicians performing increased clinical work, being more time aware, delivering more focused teaching, and having less time to teach. Participants noted changes in autonomy and professionalism. Strategies to enhance teaching effectiveness in the new environment were described. CONCLUSION: Duty-hour regulations have increased attending clinical responsibility and decreased teaching time in 1 residency program, leading to the perception of a more intense attending experience. Duty-hour regulations encourage educators to determine what is critical to preserve in the educational experiences of learners and challenge us to reexamine autonomy and professionalism in training

Residency Work-Hours Reform: A Cost Analysis Including Preventable Adverse Events

BACKGROUND: In response to proposed federal legislation, the Accreditation Council for Graduate Medical Education limited resident work-hours in July 2003. The cost may be substantial but, if successful, the reform might lower preventable adverse event costs in hospital and after discharge. OBJECTIVES: This study sought to estimate the reform's net cost in 2001 dollars, and to determine the reduction in preventable adverse events needed to make reform cost neutral from teaching hospital and societal perspectives. DESIGN: Cost analysis using published literature and data. Net costs were determined for 4 reform strategies and over a range of potential effects on preventable adverse events. RESULTS: Nationwide, transferring excess work to task-tailored substitutes (the lowest-level providers appropriate for noneducational tasks) would cost $673 million; mid-level providers would cost$1.1 billion. Reform strategies promoting adverse events would increase net teaching hospital and societal costs as well as mortality. If task-tailored substitutes decrease events by 5.1% or mid-level providers decrease them by 8.5%, reform would be cost neutral for society. Events must fall by 18.5% and 30.9%, respectively, to be cost neutral for teaching hospitals. CONCLUSIONS: Because most preventable adverse event costs occur after discharge, a modest decline (5.1% to 8.5%) in them might make residency work-hours reform cost neutral for society but only a much larger drop (18.5% to 30.9%) would make it cost neutral for teaching hospitals, unless additional funds are allocated. Future research should evaluate which reform approaches prevent adverse events and at what cost