No one could have predicted that Libby Zion’s admission to New York Hospital shortly before midnight on March 4, 1984, with a high fever and myriad other symptoms ultimately would result in radical changes to medical education and training nationwide. In 1989 New York became the first state to formally legislate resident work hour restrictions (commonly known as the 405 Regulations). Strong financial and professional penalties were instituted in 2000 to enforce compliance: $6,000 per violation on initial review, $25,000 per violation on next follow-up and $50,000 per violation on subsequent follow-up; also assessment of professional misconduct for any physician found falsifying, or verifying falsified reporting of resident work hours.
To date, the costs of New York’s 405 Regulations have not been reported. The decision by the Accreditation Council for Graduate Medical Education (ACGME) to implement similar limits on July 1, and the related federal legislation introduced in the 108th Congress make apparent the need for an accounting of the 405 Regulations’ impact.
The financial and educational impact of the 405 Regulations has been substantial for New York hospitals, academic departments, residents and all training programs. The specific costs include hiring of additional support personnel (physician extenders, fellows), expanded ancillary services, compliance administrators, and fines levied against hospitals or medical schools. The responsibility of meeting these costs may fall primarily to the hospitals because they have been designated as the legally responsible party; however, in the case where a hospital contracts its financial support, there remains significant potential for some or all of the costs to be transferred to individual departments or physician practices.
The Department of Neurosurgery at New York Medical College/Westchester Medical Center (NYMC/WMC) adopted policies and procedures that allow full compliance with 405 Regulations. To determine the direct and indirect costs of compliance, a review conducted for the period of 1998 to 2002 considered resident and staff schedules, cost of additional staff, and hours worked by both residents and staff at its primary hospital, WMC.
WMC, a level 1 trauma center and an American College of Surgeons-designated cancer center, is a 1,000-bed facility with 650 acute care beds. Three of NYMC/WMC’s five neurosurgery residents (and one rotating intern) staff WMC. During the 1998-2002 period, 750-1,000 major neurosurgical procedures were performed annually.
Our studies of WMC revealed the following impact of restricted resident work hours on the neurosurgical residency program:
- Direct instruction time to residents was reduced by 25 percent.
- Staff schedules were adjusted.
- Conference times were changed (post-call residents cannot stay for 5 p.m. conferences), and total conference time was reduced. (NYMC/WMC still requires conferences, but there are less of them.)
- There was a loss of 120 resident work hours per week.
- Total resident hours in the hospital decreased by 20 percent.
- Three additional physician extenders were hired to fill in for the reduction of residents’ hours at a cost of $375,000 to the hospital payroll.
The hospital-wide impact was proportionately greater. For example, the hospital budget for physician extenders increased by $3 million compared with the increase of $375,000 that the Department of Neurosurgery allocated for physician extenders to cover the hours previously worked by neurosurgical residents. In addition, more transport nurses were hired by the hospital along with other ancillary service providers at a cost of approximately $800,000 per year, and a compliance office was established with half-time employee at a cost of $44,500 per year.
Extrapolating these costs to nationwide application is, of course, impossible. Some large training programs may be able to make internal adjustments that obviate the need for hiring of additional staff. Programs may elect to lengthen training by one year and absorb the associated costs. Enforcement of ACGME or any federal rules that might be passed may differ significantly from the current enforcement of New York’s 405 Regulations.
Regardless, work hour restrictions come with a steep price tag, if only in educational time for residents. Careful analysis of the impact of these regulations on resident performance and satisfaction as well as patient outcome will be essential over the next few years.