Tag: Bob Wachter

Do We Have Any Clue How to Cut the Cost of Healthcare?

At the Society of Hospital Medicine’s annual meeting last week in Dallas, Lenny Feldman of Johns Hopkins presented the results of a neat little study. His hypothesis: physicians given information about the costs of their laboratory tests would order fewer of them.

Feldman randomized 62 tests either to be displayed per usual on the computerized order entry screen or to have the cost of the test appear next to the test’s name. Some of these were relatively inexpensive and frequently performed tests. After randomization, for example, the costs of hemoglobins ($3.46) and comprehensive metabolic panels ($15.44) were displayed, while TSHs ($24.53) and blood gases ($28.25) were not. He also randomized more expensive tests: the costs of BNPs ($49.56) were displayed, while hepatitis C genotypes ($238.62) were not.

The educational intervention was surprisingly powerful. Over the six-month study, the aggregate expenditures for each test whose costs were displayed went down by $15,692, while non-displayed tests had a mean increase of $1,718. Over the entire group of 31 tests whose costs were shown to physicians, costs fell by nearly $500,000.

Coincidentally, last week’s Archives of Surgery reported the results of an intervention aimed at decreasing lab ordering on the surgical services of Rhode Island Hospital. There, simply announcing the service’s overall expenditures on non-ICU laboratory tests for the prior week at a house staff conference led to significant savings: $55,000 over an 11-week study period.

Have we found the Holy Grail, the key to flattening the cost curve? A little physician education leads to increased awareness of the cost consequences of their choices and, voila, our economy is rescued from the brink of disaster. How nice.Continue reading…

The Hospitalist Field Turns 15: What The Past Says About The Future

I just returned from the Society of Hospital Medicine’s annual meeting in Dallas. Seeing more than 2,000 hospitalists in one place is remarkable, since I remember the days when we all fit into a mid-sized conference room at a Holiday Inn.

I have clearly assumed the mantle of elder statesman at these meetings. I find this odd, since my idea of an elder statesman is UCSF’s former chair of medicine, Lloyd Hollingsworth (“Holly”) Smith, a man of unbelievable accomplishment and grace. Holly is now in his late 80s, and every year we ask him to say a few words at our department’s annual faculty dinner. Holly is the best after-dinner speaker I know – his comments, always insightful and hilarious, are increasingly peppered with “old guy” references (my recent favorite: “I’ve now reached the age of – when I reach down to tie my shoes, I ask myself, ‘Is there anything else I need to do as long as I’m down here?’ before I get up.”)

I’m not complaining: for the past decade, I’ve had the honor of giving a closing keynote address at the annual hospital medicine meeting. In this week’s talk, I reflected on the history of the hospitalist field, in the 15 years since Lee Goldman and I coined the term in the New England Journal of Medicine.

This kind of reflection is useful because, in a world in which we’re all drinking out of a huge information hose, it’s easy to focus on the short term and lose track of the arc of history. Self-help guru Tony Robbins had it right when he said, “Most people overestimate what they can do in a year, and underestimate what they can do in a decade.” Our 15-year history proves that.Continue reading…

Can Berwick Be Saved? Here’s One Possible Scenario

We’ve all had the experience of hearing someone we know well say or write something totally out of character, and wondering, “what was that about?”

Don Berwick said such a thing last week, all-but-contradicting President Obama’s support for a strengthened, independent Medicare payment board. After a little head scratching, I began to wonder whether this might have been a harbinger of some good news regarding his tenure as Medicare czar.

This is one complicated political dance, so let me explain.

Berwick, as you know, received a recess appointment to lead the Centers for Medicare & Medicaid Services (CMS) last July, after his nomination had become hopelessly entangled in a web of partisan politics. I applauded President Obama for the appointment, and predicted that Don would do a great job in this crucial role, perhaps even wooing some of the Republican legislators who hijacked his nomination process to re-litigate the fracas over healthcare reform.

Then, in early March, Senate Republicans made it clear that they would not support Berwick’s continued tenure when his recess appointment expires later this year. The reasons include lingering concerns about Berwick’s politics (particularly his embrace of the British system of universal healthcare coverage), continued anger over the Affordable Care Act (ACA), and some peevishness over the recess appointment itself. In this space last month, I promoted a letter-writing campaign to try to save the Berwick appointment, though insiders told me it was “hopeless.”Continue reading…

The Science and Religion of Patient Safety

Earlier today, Secretary of Health and Human Services Kathleen Sebelius and Medicare chief Don Berwick announced the “Partnership for Patients,” a far-reaching federal initiative designed to take a big bite out of adverse events in American hospitals. The program – which aims to decrease preventable harm in U.S. hospitals by 40 percent and preventable readmissions by 20 percent by 2013 – marks a watershed moment in the patient safety movement. Here’s the scoop, along with a bit of back story (which includes a gratifying bit part for yours truly).

Last July, I attended the American Board of Internal Medicine’s Summer Forum in Vancouver. This confab has turned into medicine’s version of Davos, drawing a who’s who in healthcare policy. One of the attendees was an old friend, Peter Lee, a San Francisco lawyer and healthcare consumer advocate who had just been asked to lead a new Office of Delivery System Reform within the U.S. Department of Health and Human Services. Peter’s charge was to figure out how to transform the delivery of healthcare in America, challenging under any circumstances but Sisyphean given that he’d be pushing the rock up a mountain chock full of landmines comprised of endless legal and political threats to the recently-passed Affordable Care Act.

Fueled by the enthusiasm of being a new guy with a crucial task, Peter took advantage of some conference downtime to convene a small group – about 20 of us – to advise him on what he should focus on in his new role. After soliciting ideas from many of the participants around the table, he turned to me. I decided not to be shy.

I suggested that the topic of patient safety remained compelling and scary, and that it might be at a tipping point – with new success stories in reducing infections and improving surgical safety, more hospitals possessing the infrastructure to improve safety, and increasing penetration of IT systems due to federal support through the meaningful use standards. I also knew that Don Berwick, Peter’s new boss, would not be content to move around some bureaucratic chess pieces, or even a few hundred million dollars. Instead, he’d be looking to do Something Big – an initiative aimed at capturing hearts and minds, a federal version of his IHI 100,000 Lives and 5 Million Lives campaigns. What better target than patient safety?Continue reading…

The Speech: Could this have been what he planned all along?

A conventional look at The Speech: Obama over-learned the lessons of Hillary-care; he gave Congress too long a leash; he lost control of the message; the wacko’s attacked with a barrage of Socialist/Nazi/Plug-Pulling-on-Grandma-isms; not only was health reform on the ropes but the entire Obama Presidency was in danger of imploding (taking the Dems down with him in the mid-terms); Obama had his back against the wall, a make-or-break moment. Then last night, the President gave a great speech that staked out a thoughtful middle ground; Joe Wilson went rogue, horrifying nearly everyone; this led to real sympathy for Obama and the Dems and a shift in the political landscape. In the end, a mild version of health reform – with nearly-universal coverage, some regulatory protections against the most heinous insurance practices, fee hikes to pay for it all, and a little movement toward improving quality and efficiency – passes.

Another look at The Speech:

Obama, a student of history, realizes that health reform is a near-impossible sell since every special interest will come out swinging; he gives Congress the ball knowing that whatever plan emerges from their sausage factory will simply be red meat for demagoguing Republicans and special interests worried about preserving their Gravy Train; Congress obliges by developing plans that overpromise and under-resource, or that push predictable hot buttons (immigrant coverage, palliative care); the Right and its attack dogs go berserk throughout the Wacko Days of August; the left hunkers down, drawing a line in the sand on the Public Option, kyboshing malpractice reform, and avoiding the hard questions about financing.Continue reading…

Interview: Bob Wachter on reform, safety, primary care and everything


One of the best commentators around on the issues of patient safety, health care quality and basically everything to do with health care organizations is UCSF Professor Bob Wachter. Bob has been in the trenches as one of the leaders in the hospitalist movement, a major driver behind improving patient safety, and has also straddled the worlds of medical practice as a PCP, academia at UCSF, and been publicizing this all to a wider audience–particularly with his 2005 book Internal Bleeding and his more recent book Understanding Patient Safety. Then of course there are his occasional blog posts both on Wachter’s World and here on THCB.

This was a really fun conversation and somehow Bob remains an optimist. Here’s the interview.

A Brief History of the R Word

Joseph Stalin

Princeton ethicist Peter Singer’s article in this week’s NY Times Sunday Magazine is creating lots of buzz. It is a classic utilitarian description of the case for rationing – QALYs and all – and a plea for a mature national dialogue about the dreaded R-word.Don’t hold your breath. To understand why, remember the words of Joseph Stalin: “A single death is a tragedy, a million deaths is a statistic.”

A society of grown-ups would read Singer’s article and say,

“Gosh, he’s absolutely right. If we don’t make some hard choices about whether to cover $50,000 palliative chemotherapy to extend a life of an 80-year-old by a few months, then we are choosing not to have enough money to provide universal health insurance, or to ensure that everybody has their pap smears and generic Lipitor (or, while we’re at it, to house the homeless, provide decent public education, or have viable auto companies).”
Rationing is inevitable – as I recently mentioned, talking about whether we should ration is like talking about whether we should obey the laws of gravity. The only question is how we do it. And what better time than now to have this difficult national conversation, being that we’re in the middle of retooling our entire healthcare economy, the fundamental obstacle is finding the money to pay the bill, and we have a president who truly understands the dilemma and is smart and mature enough to lead the discussion.

Yet rationing remains a political Third Rail, the Lord Voldemort of the healthcare policy debate.

The issue is not new, nor are its political trappings. It’s worth understanding a bit of this history to frame today’s debate – and lack thereof.

In 1984, Colorado Governor Richard Lamm famously opined that the elderly had a “duty to die” in order to free up resources for the young. He was vilified.

In 1987, Oregon stepped into the mess that is healthcare rationing, and spent much of the next decade scraping off its metaphorical shoe. In the face of exploding Medicaid costs, the state legislature decided not to fund transplants (including bone marrow transplants) in order to preserve limited funds to cover other services.

This was in the early years of bone marrow transplant, when BMT had a 50-50 success rate for certain types of childhood leukemias (it’s better now), and cost about $100,000. The state did the math, and found that for the same $100K, several lives could be saved by plowing the money into other healthcare needs, including prenatal care. And so BMT became an uncovered service. A perfectly rational decision if you live in Utilitarian, Most-Good-for-the-Most-People, World.

But that’s not the world we live in.

What happened next was utterly predictable. A 7-year-old boy named Coby Howard developed acute leukemia, Oregon denied his BMT coverage under Medicaid, and his mom went ballistic (any parent, including this one, would have done precisely the same thing). The only question was which megaphone she would grab first to make her case: the media, her local congressman, or a lawyer (ultimately, of course, she used all three). Here’s how it sounded on ABC’s Nightline:

[Ted Koppel] began the program with footage of Coby Howard and said: “When the State of Oregon decided to stop funding organ transplants, it allowed this boy to die.” Koppel later asked: “Is the cost of modern medical technology forcing public officials to play God?”

In the end, Coby received his BMT, paid for by private donations, but sadly died later that year. Under the leadership of state senate president (later governor) John Kitzhaber, a former ER doc, and in the face of withering post-Coby criticism, Oregon developed a more explicit rationing plan – of course, it covered BMT. Kitzhaber and his staff later described the pressures they felt after they took on healthcare rationing,

“Our detractors consist mainly of uninformed members of threatened interest groups who delight in comparing the Oregon plan to a perfect world.”

Stalin could have predicted this, of course. The Oregon rationing plan (both the ad hoc decision to deny BMTs and the more explicit “prioritized list” that followed) depended on a hard-boiled tradeoff between a single identifiable life – in this case, a cute child with a determined mother – and many unidentified lives. We’ll never know which kids were saved by better prenatal care, or whose strokes were averted by primary care and hypertension control. These statistical lives make for a pretty dull interview on Nightline – and they don’t blog.

Where do docs fit into all of this? Our ethical model is to do everything we can for the patient in front of us – we are socialized from the first day of med school to believe that the single death is indeed a tragedy (the late Norman Levinsky made this point in a wonderful piece in the NEJM called “The Doctor’s Master”). Although as responsible citizens, we care about society and the unidentified lives outside our office or our ICU, it is not our job to weigh the impact of our choices on them. And, of course, we won’t be sued by society for plundering its resources, but might well be sued by the family of an individual patient who feels that we didn’t do everything possible to save their loved one.

I just finished a couple of weeks on the wards, and once again cared for several patients – cachectic, bedbound, sometimes stuck on ventilators – in the late stages of severe and unfixable chronic illnesses whose families wanted to “do everything.” As I wrote last year, there are limits (like chest compressions) on what I am willing to do in these circumstances, but they are mostly symbolic – basically, I am a bit player in this crazy house, with no choice but to flog the helpless patient at a cost of $10,000 a day in a system that is nearly broke and whose burn rate threatens to ruin our country. Go figure.

Is there anything we can do? The favored solution, a board resembling the UK’s National Institute for Health and Clinical Excellence (NICE) with the teeth to limit certain new drugs and technologies, is hard enough. But even if we were able to get a NICE-like organization in place (doubtful), that doesn’t really address the brutally tough issue: is our ethical model one in which we do everything possible, irrespective of cost, for every patient when there is any chance of benefit, or one in which we place limits on what we’ll do in order to do the most good for the most people. An American “NICE” isn’t going to limit ICU care for 80-year-olds with metastatic cancer. That will require a much broader public discussion, and even harder choices – since they will need to be made at the bedside.

As Singer notes, every society that rations provides a safety valve for the wealthy disaffected. In the UK, you can buy private insurance that allows you to jump the queue for your hip replacement. Canada’s safety valve is called the Cleveland Clinic. We don’t talk about the percent of our GNP we are spending on Starbucks lattes, or on iPods, or on vacations. People pay for these things out of pocket, and receive no tax advantages when doing so. Given the American ethos of self-determination and consumerism, any rationing plan will need to allow people who can afford care that isn’t covered by standard insurance to buy it with their own money (with absolutely no tax advantage). Two-tiered medicine, sure, but I see little problem with this as long as we are using the money in the communal pool to provide a reasonable set of benefits to the entire population.

How might a thoughtful structure to support rationing be organized in the U.S.? When considering new technologies and drugs, it will probably entail an independent board empowered to make coverage recommendations based on cost-effectiveness, just as NICE has done in the UK. But just as importantly, at the level of individual hospitals or healthcare organizations, there will need to be committees of providers, administrators, and patient advocates that can set and defend limits on care. Such decisions would not automatically mean that grandpa can’t stay on the ventilator, but would mean that ongoing care would no longer be fully covered by insurance. Of course, these decisions would have to be all-but-immune from litigation threat.

Will this happen? Probably not. Twenty years ago, the great Princeton healthcare economist Uwe Reinhardt observed that there are two kinds of rationing: “civics lesson rationing” and “muddling through elegantly.” In the former, a NICE-like federal board, or local panels such as the one I’ve described above, weighs the evidence and makes these tough rationing decisions algorithmically and prospectively. The muddling through option, which Reinhardt felt was far more likely, involves limiting the resources available – the number of ICU beds, or MRI scanners, or CT surgeons – and allowing docs, patients and administrators to duke it out at the bedside. The evidence is that they do a decent job at triaging to provide the most good for the most people.

Of course, these limits are naturally present when resources are truly scarce – like livers for transplantation – and in these circumstances we have developed thoughtful rationing approaches. The point is that health care dollars increasingly resemble livers.

I’m pleased Peter Singer and others have dared to speak of the R-word in public, because it is so central to today’s healthcare policy debate. But will the society that brings you Rush Limbaugh and Glenn Beck (or, I’m beginning to think, some of our Democratic representatives) deal with it in an effective, mature way? I truly doubt it.

Why not?

Joseph Stalin would know.

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As Medical Tourism Grows, Hold On We’re In For a Wild Ride

Until now, medical tourism has been a curiosity, iconic “Wow, Look How Flat the World Is Becoming,” fodder for stories on 60 Minutes. But as health insurers and employers get into the act, get ready for some Battles Royale.

Of course, it was only a matter of time. With surgeries costing tens of thousands of dollars less in India and Thailand than in Indiana and Tucson, and with companies ranging from GM to Citigroup desperately trying to shave health care costs to fend off bankruptcy, you knew it wouldn’t be long before insurers or employers began offering incentives – or forcing – patients to have their surgery overseas.

Starting this month, some employers working with WellPoint, the nation’s largest health insurer, will begin offering their employees substantial discounts if they choose to have their surgery in India. The Indian hospitals are accredited by Joint Commission International (JCI), the arm of the Joint Commission that’s in the business of blessing foreign hospitals. If they are like most of the foreign hospitals catering to international tourists, chances are that the quality of care is more-than-acceptable and the quality of service would make the concierge at the Ritz jealous.

The press release trumpeting WellPoint’s arrangement oozes with PC spin:

Members will now have more choices regarding where to receive care and a greater involvement in the care they receive.

Well, what could possibly be controversial about that?!

I’ve written two articles for the New England Journal of Medicine about international teleradiology and other digitally-facilitated outsourcing (here and here), another burgeoning piece of our newly flattened world. That phenomenon is far from fantasy: thousands of patients in American ERs will have their x-rays read tonight by physicians sitting in India, Zurich, Tel Aviv, and Sydney. But because this happens behind our professional curtain, the debate over tele-whatever has largely been Inside Baseball (Is the quality adequate?

Do the non-U.S. docs need American malpractice coverage? Can the foreign docs bill Medicare? [Answers to date: 1) Seems reasonable, a few anecdotal glitches, but no good studies; 2) At this point, yes; 3) Presently, no – the local docs bill Medicare for their “final read” in the morning and they or their hospitals compensate the foreign docs]). It’s all been back office and arcane enough that it hasn’t been terribly controversial.

While medical tourism seems poised to be more controversial, its limited niche thus far has attenuated the arguments. To date, most participants have been un- or under-insured people trying to control their out-of-pocket costs for elective surgeries that require large cash payments, such as plastic surgeries and elective hip replacements. So most surgeries have involved private arrangements between patients and international providers, sometimes facilitated by intermediaries that have sprouted up like weeds. (Since nobody needs a travel agent anymore to book a vacation to Paris, up pops a new tourism niche. Capitalism’s resiliency never ceases to amaze.)

As I said, as long as these were private choices, the potential reach of medical tourism was muted, as was the controversy. But every healthcare insurer and large employer is now actively scrutinizing the concept, and many find it quite appealing. Of course, sensitive to the politics, it is unlikely that any of them will flat-out force their customers/employees to travel to Thailand or Singapore. The pressure will be more subtle: with savings of tens-of-thousands of dollars per case at stake, there is enough money around to waive patient co-pays, give insurance discounts to employers, and cover travel expenses – including in-flight drinks and headphones – and still come out way ahead. As Brian Lindsay wrote in a terrific piece in Fast Company last March,

“They [patients] don’t – and we don’t – want to be in a situation where an insurer says, ‘You have to go,’ ” says Victor Lazzaro, CEO of the [medical tourism] packager BridgeHealth International and a former executive at Prudential… One solution is to be up front with patients about the true cost of their treatment and offer to share the savings with them. In light of what it costs for a fresh set of knees in the States – $45,000 and up for the uninsured – and the huge discounts overseas, it’s conceivable that patients might come out ahead if they let a Thai doctor install them. Of course, just because insurers won’t use a stick doesn’t necessarily mean the dangling carrot couldn’t be considered coercion in its own right.

The wars will be fascinating and the battles lines will be fluid and a bit unpredictable. Consider unions, for example. On the one hand, the cost savings for companies that insure their workers may help preserve union jobs or allow for cost savings to be passed on in the form of higher salaries or richer benefits. On the other hand, as local hospitals are hurt, unionized service and nursing jobs may take a hit. So should unions be for medical tourism or against it? Who knows?

But one set of losers seems clearer: domestic providers, particularly cardiac, plastic, and orthopedic surgeons. Again, from the Fast Company article,

In one fell swoop, [the surgeons] devolve from the rock stars of the OR to glorified mechanics, and they’d really only have themselves to blame. Overseas patients routinely return home raving about the personal attention shown by their Thai or Indian surgeons. Even before arriving, patients can trade phone calls and emails with doctors. (Nothing punctures the myth of American medical invincibility quite like the experience of having a doctor who actually speaks to you.)

I participated in a panel on medical tourism at last October’s American College of Surgeons meeting, and many of the docs in the audience were pissed. Using those computerized audience response gizmos, the surgeons in attendance were asked: If a patient returned from surgery abroad with a complication and came to see you, would you agree to care for the patient? A clear majority answered “No.” (Had there been a choice called “Hell, No!” I’d wager that it would have been the winner). Surely Hippocrates would be turning over in his grave, but I’m guessing that Hippocrates didn’t have to pay $100K/year in malpractice premiums or watch his 8 years of residency training become devalued by foreign competition.

How will all of this play out? It seems likely that medical tourism will continue to grow, as will the number of concerned responses from domestic providers (mostly guild behavior and protectionism clothed in the garb of patient safety and quality). I’m sympathetic to my colleagues’ reactions, but look, the status quo isn’t acceptable: We’re spending $2 trillion dollars per year on healthcare and still have nearly 50 million uninsured people, 100,000 yearly deaths from medical mistakes, huge and clinically indefensible variations in care, and outcome and performance measures that are as likely to be sources of shame as pride. If flattening our world improves value (quality divided by cost), either through the new internationalized care or by goosing our own system into action (the now-familiar disruptive innovation), that’s got to be a good thing.

But for domestic providers, it might not feel so good. Yes, foreign competition led the Big Three automakers to build better and more efficient cars – but they answered their wake-up call too late to save their hides. The risks to domestic healthcare are not as monumental as those playing out in Detroit (it is one heck of a lot easier to buy a Camry at San Francisco Toyota than to get a CABG in Bangkok, and every now and then a Bangkok airport shutdown or a Mumbai terrorist attack will make some Americans hesitate before getting on that plane). And there are hundreds of issues still to be worked out: can patients sue for medical malpractice, how do you ensure continuity of care for patients receiving care both domestically and internationally, will medical tourism compromise local care for Thais and Indians, will middlemen start siphoning off too much of the savings or acting unethically, and much more.

But in the end, the Flattening of Healthcare is inevitable. And, while it will be controversial, it may also represent the kind of shakeup our system requires if it is ever to deliver the value Americans need and deserve.

So hold on tight. We’re in for a wild ride.

Can the physical examination save us from the dehumanization of medicine?

In last week’s NEJM, physician-author Abraham Verghese paints a disturbing picture
of a medical world in which technology has morphed from tool to object,
the patient relegated to a supporting role. To me, Abraham has nailed
the diagnosis but not the treatment.

I had the distinct pleasure of getting to know Abraham when we both served on the board of the ABIM (actually I came to know his work 15 years earlier, when I reviewed his bestselling book, My Own Country, for the NEJM). Abraham is a romantic and a traditionalist, and in last week’s New England Journal
piece he poignantly lays out a problem he has fretted about for years:
namely, that information technology is dehumanizing the practice of
medicine. Describing rounds with his ward team at Stanford, his new
academic home (he was recently recruited there from the UT-San
Antonio), he recalls:

When I stroked a patient’s
palm and caused a twitch of the mentalis muscle under the chin — the
palmomental reflex — it was as if I were performing magic. Still, the
demands of charting in the electronic medical record (EMR), moving
patients through the system, and respecting work-hour limits led
residents to spend an astonishing amount of time in front of the
monitor; the EMR was their portal to consultative teams, the pharmacy,
the laboratory, and radiology. It was meant to serve them, but at times
the opposite seemed true.

Continue reading…

Resident Duty Hours and Patient Safety: Did The IOM Get It Right?

The Institute of Medicine just released its long-awaited report on trainee duty hours. It is well researched and balanced, and its recommendations appropriately reflect what we know vs. what we believe. Now the fun begins.

Let’s start with a little background, some of it drawn from my book Understanding Patient Safety:

Let’s be honest. Traditional resident schedules – on call every third night, staying up for 48 hours in a row, and working 120 hours per week – were both inhumane and immoral.

The “Days of the Giants” view that such training was needed to “turn boys into men” (before women became the majority of medical students) was machismo garbage. This was a hazing ritual formed when people believed that one should sacrifice one’s life on the Altar of Medicine, perpetuated because all of our egos are such that we said, “Well, that was brutal, but just look how great I turned out – so that must have been a good system!”

And, because housestaff labor is easily the cheapest in the building (what intern hasn’t done this math – my own 1983 internship salary of $17,600 translated into about $4.50/hour, less than I made caddying), what began as a rite of passage quickly morphed into an economic imperative. Having fallen asleep at the wheel once or twice driving home during my internship, I have little sympathy for those who wistfully long for the Days of Yore.

Beginning with the famous Libby Zion case at New York Hospital in 1984, the public and media have pressured “the system” to fix the problem of long trainee hours. A 1989 New York State regulation limiting duty hours to 80 per week was largely ignored, and no other state followed suit for over a decade. But the overarching pressure to improve patient safety, which began with the IOM’s 1999 report, To Err is Human, was enough to give the Accreditation Council for Graduate Medical Education (ACGME) the courage to gore this particular sacred cow, and to withstand the subsequent mooing.

In 2003, the ACGME, which accredits the nation’s 7,800 training programs, decreed that residents’ hours would be limited to 80 a week, with no shifts longer than 30 hours. Both numbers were completely arbitrary – there is no research that helps tell us the “right” number of hours per week or per shift. In fact, the research on sleep deprivation as it pertains to resident performance is surprisingly mixed. While it is well appreciated that 24 hours of sustained wakefulness results in performance equivalent to that of a person with a blood alcohol level of 0.1% – legally drunk in every state – studies have shown that tired radiology residents made no more mistakes reading x-rays than well-rested ones, and sleepy ER residents performed physical examinations and recorded patient histories with equal reliability in both tired and rested conditions.

That said, most folks find this to be one of those issues in which common sense trumps evidence-based medicine – pointing to the tongue-in-cheek BMJ piece challenging EBM zealots to participate in a randomized trial of jumping out of an airplane with and without parachutes (since the value of parachutes has never been subjected to evidence-based scrutiny). On this one, I agree: given the substantial evidence of the harms of sleep deprivation, the burden of proof should be on those defending the old schedules, not on those proposing more humane variations.

Several studies have examined the impact of the 2003 ACGME regs. It is fair to say that the jury remains out. The studies generally show no real effect on clinical outcomes or patient safety, and significant concerns have been voiced by both faculty and residents regarding unintended consequences. But the pressure to do more from a wary public remains, and there have been studies that have convincingly demonstrated that shorter shifts in the ICU environment lead to fewer errors.

When the ACGME regulations first came out, programs did what they always do with regulations they don’t like – they tried to skirt them. The ACGME did something clever in response – it fired two shots over the academic bow, placing two of the most prestigious programs in the country (Yale Surgery and Hopkins Medicine) on probation. The message was clear: we’re not screwing around. That said, this week’s IOM report was critical of what it deemed lax enforcement of the existing standards, calling for unannounced surveys, periodic audits, and stronger protections for whistleblowers. I think they were right to do so.

Programs responded to the 2003 duty hours regulations in a number of ways. When the rules hit, I was virtually certain that our residency at UCSF would go to a Night Float-on-Steroids system, sending the on-call team home at 10pm, having the nights covered by a fresh crew, and handing those patients back to a new team in the morning. But that’s not how it turned out.

One of the great things about UCSF is that our residents rotate through three separate hospitals, so we tried three different strategies to see what worked best. And the Night Float/Send The Primary Team Home idea proved to be a disaster – we couldn’t get housestaff to leave the hospital soon after admitting a desperately ill patient (that damn professionalism), so they were getting home in the wee hours of the morning, leaving them well over the hours limits and exhausted the next afternoon.

Surprisingly, the favored system was a robust Day Float system. In it, our teams continue to stay overnight, admitting all patients till about 2 am, after which a night float takes new non-ICU admissions. When I arrive for attending rounds in the morning, my team is there along with a freshly scrubbed day float resident. We hear about all the patients together, and then the team rushes for the doors, the goal being to be out by noon. The day float resident and the attending then spend the post-call afternoon finishing up the plan, notes, etc. It works pretty well.

With that background, let’s turn to this week’s IOM report. Although there was considerable trepidation that the IOM would recommend severe additional limits in duty hours (most other industrialized countries limit resident hours to 50-60 per week), the report recommends relatively mild modifications to the existing regulations (they’re summarized here). The biggest one is a requirement for a minimum sleep period of 5 hours in any 24-hour work period, with a maximum shift length of 16 hours. If we keep the scaffolding of our present UCSF system, this will mandate that the on-call team takes no new admissions and doesn’t cross-cover its own patients overnight; instead they’ll have to have a complete hand-off and a beeper-less interlude from about 2am-7am. That seems pretty do-able, especially considering the fact that we were girding for much more radical restrictions on hours.

What may prove to be a bigger deal is the new requirement that housestaff have “immediate access to an in-house supervising physician” – which I interpret to mean 24-hour in-house attending coverage, most likely by hospitalists. Although we have some moonlighters in the house overnight, we don’t yet have faculty hospitalists. But the tea leaves are clear: It is time to start planning for around-the-clock hospitalist coverage at teaching hospitals.

Efforts to cut duty hours raise a number of questions and concerns, which I’ll separate into five buckets: 1) handoffs, 2) costs, 3) do people really sleep when they’re off?, 4) practice makes perfect, and 5) the culture of medicine. Let’s tackle them each briefly.

First, handoffs. Until 2003, our handoffs were haphazard, on the fly, and completely unsystematized. Early on, we recognized that the 80-hour workweek was markedly increasing the number of handoffs – our own Arpana Vidyarthi found that resident handoffs increased by 40% after the 2003 regulations. Like so many other aspects of the safety field, we essentially had a squeezing balloon phenomenon: one fix (better rested residents) was traded for a new safety hazard (more handoffs).

In my own judgment, patient safety worsened in the first couple of years after the 2003 rules because the handoff hazards trumped the advantages of rested trainees. It was only after we developed standardized sign-out systems that the balance became more favorable, and the new IOM report calls for even more attention to such systems. That said, there are few days when I don’t hear our nurses complain about paging the resident and hearing, “I really don’t know that patient very well. I’m just covering.” (That’s assuming that they can figure out which resident is covering at that particular moment, an immense challenge unto itself.)

The second issue is cost. The new IOM report estimates that the cost of implementing the new standards will be $1.7 billion nationally – including the hiring of about 6000 mid-level providers (NPs, PAs) and 5000 hospitalists. I don’t doubt it. The 2003 regs were the Hospitalist Full Employment Act. At UCSF, while early efforts to deal with duty hour reductions focused on residents covering for themselves coming off non-call electives (didn’t work and was wildly unpopular), they soon shifted to using NPs and PAs (worked sometimes, but some patients were simply too complex and some providers were too expensive and inefficient) and ultimately to using hospitalists.

Of our 42 faculty hospitalists, I’d estimate that about 12 FTEs are here because of the need to replace resident bandwidth on a variety of services. The new restrictions are likely to increase the need for additional coverage, and thus the costs. The reason that the IOM blinked when it came to cutting the hours down to 60 must have been partly due to these cost considerations, especially in an era in which many teaching hospitals are struggling to break even.

The third concern is whether housestaff really sleep when they’re off. Remember, these are young people with significant others, hobbies, laundry, and debts. Not surprisingly, there is some evidence that they don’t use the time out of the hospital to sleep, and the IOM weighed this in choosing to keep the weekly hours at 80. As John Iglehart observes in his excellent editorial in this week’s NEJM, “Although some might propose further reductions in total duty hours, the report notes, ‘evidence suggests it is an indirect and inefficient approach given the moderate correlation that exists between resident duty hours and sleep time.’”

The fourth is Practice Makes Perfect. Particularly in surgery and other procedural specialties, there is real concern that trainees may not be handling enough cases to become fully competent. There are few data to support this concern, and one has to believe that some of the work that residents put in during hours 80-110 in the old days were not highly educational (not to mention safe). But I’ve met many surgical program directors who are quite convinced that their graduating trainees are not prepared to operate independently – both because trainees are doing fewer cases and because of the enhanced supervision that is chipping away at the trainee autonomy necessary to develop clinical instincts and judgment.

Which brings us to the final concern (and my greatest worry): the culture of training. When the 2003 ACGME regulations came out, New England Journal editor Jeff Drazen and Harvard policy maven Arnie Epstein wrote that that traditional residency schedules,

. . . have come with a cost, but they have allowed trainees to learn how the disease process modifies patients’ lives and how they cope with illness. Long hours have also taught a central professional lesson about personal responsibility to one’s patients, above and beyond work schedules and personal plans. Whether this method arose by design or was the fortuitous byproduct of an arduous training program designed primarily for economic reasons is not the point. Limits on hours on call will disrupt one of the ways we’ve taught young physicians these critical values . . . We risk exchanging our sleep-deprived healers for a cadre of wide-awake technicians.

Therein lies the tension: legitimate concerns that medical professionalism might be degraded by “shift work” and that excellence requires lots of practice and the ability to follow many patients from clinical presentation through work-up to denouement, balanced against concerns about the effects of fatigue on performance and morale. Getting this balance right will be the central challenge of medical education over the next decade.

In my view, the IOM is to be commended for thoughtfully reviewing the issues and developing a set of recommendations (likely to be embraced by the ACGME) that seem quite sensible and balanced.

So let us old fogies cast aside the warm afterglow of our residency experiences and admit that we’ve blocked out the memories of the bone-crushing fatigue, the errors caused by the immoral mantra of “see one, do one, teach one”, and the all-consuming fear that we would crash and burn, with nary a safety net in sight. Once we get over romanticizing the past, we can start figuring out how to work within these sensible limits on hours and supervision requirements to create a more perfect system for both our trainees and our patients.

Robert Wachter is widely regarded as a leading figure in the modern patient safety movement. Together with Dr. Lee Goldman, he coined the term “hospitalist” in an influential 1996 essay in The New England Journal of Medicine. His most recent book, Understanding Patient Safety, (McGraw-Hill, 2008) examines the factors that have contributed to what is often described as “an epidemic” facing American hospitals. His posts appear semi-regularly on THCB and on his own blog “Wachter’s World.”


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