Show Me the Money: Can We Afford Education-Oriented Residency Programs?

In the early 90s, I had the privilege of directing UCSF’s exceptional internal medicine residency program. It was a time of transition. A decade earlier, residency accreditation requirements (dictated by the Accreditation Council for Graduate Medical Education, ACGME) were fairly benign and largely ignored – marquee programs like ours were generally given carte blanche to organize our residents’ experience as we saw fit.

When I took over our residency in 1992, change was in the air. The ACGME began flexing its muscles, mandating that trainees spend at least one-quarter of their time in ambulatory practice, for example, and that we ensure that residents in VA-based clinics take care of women from time to time. While we residency directors weren’t thrilled with this challenge to our unfettered autonomy (truth be told, we were far more pissed at the ACGME’s maddening computer program), these early ACGME standards were perfectly reasonable and complying with them wasn’t a big deal.

But regulators and accreditors are like patients with Parkinson’s disease: they have a hard time getting started, but once they get started they tend not to stop. Soon there were more required rotations (geriatrics, adolescent medicine…) and a mandate to have at least one compensated residency leader for every 30-40 residents (today we have 5 Associate Residency Directors in addition to the director; back in my day, it was me vs. 150 residents, he says with envy). And, in 2003 came the Big Kahuna: the now-famous limits on housestaff duty hours.

While the duty hours limits have improved housestaff well being and have probably led to fewer shift-end traffic accidents, they have not had demonstrable effects on outcomes, patient safety, or resident education. We now understand that a “simple” mandate to reduce duty hours is actually an act of breathtaking complexity: raising questions of how to do effective handoffs, staff non-resident services, balance autonomy and supervision, ensure that our residents graduate ready to be independent practitioners, and more. Our learning curve has been steep, and it still feels like we’re constantly tweaking the model to get it right.

The ACGME is poised to announce its updated regulations in the next month, and the training world is holding its collective breath. (It’s worth reading my recent AHRQ WebM&M interview with Tom Nasca, ACGME’s CEO, for some insights into his thinking). The smart betting is that ACGME won’t cut the overall weekly hours again, but will mandate defined nap periods and overnight attending supervision (anticipating the latter, we are launching nocturnist coverage of our teaching service at UCSF in July – please contact me if you’re a hospitalist/insomniac looking for work).

While the duty hour limits and the requirement for constant attending supervision are forcing enormous changes, they may not be as disruptive as the changes that ultimately flow from a simple survey that ACGME now administers to all U.S. residents. On it, they ask residents to rate their program’s balance of service vs. education. What a concept!

Of course, this is a deceptively tricky question – service and education can be devilishly hard to tease apart. Sure, sometimes it’s easy: learning about TTP in residents’ report: education. Conversely, carrying the ever-squawking Medical Officer of the Day (the hospital’s air traffic controller) beeper: service. But how about admitting a septic patient at 3am: that’s both. So is participating in an M&M conference reviewing a bad outcome. I’m guessing that even the iconic act of holding the retractor has some educational value for the surgical trainee.

This service-education tension raises all sorts of issues that are colored by economics (housestaff remain the cheapest and most cost-effective labor force in healthcare), nostalgia and ego (“I went through hell, and look how good I turned out”), and even pedagogical theory. Is managing a simulated patient – even one with a “The Sims”-like look and feel – truly as educational as managing a real patient? I doubt it. Is doing a “social admission” on an 82-year old found at home hungry and lying in excrement education? It sure doesn’t feel that way at midnight, but it is how trainees learn about our tattered healthcare safety net and about empathy. The line between service and education is anything but sharp.

In this week’s issue of the New England Journal of Medicine, a group from the Brigham reports the results of an interesting experiment conducted at their affiliated Faulkner Hospital over the past few years. In a study that reminded me of our early test of the hospitalist model (dividing the service into two halves and running the old and new models simultaneously, measuring boatloads of outcomes), their study pitted a traditional team (one attending, a resident, two interns) against a new-fangled team, which they called the Integrated Teaching Unit (ITU). The latter team had two attendings (one hospitalist and one non-hospitalist, both handpicked for their “superior teaching ability”), two residents, three interns, and a reduced intern call schedule (every 6th night) that led to a patient volume about half of usual (3.5 vs. 6.6 patients). In addition to reorganizing the team structure, the investigators did everything else they could think of to enhance education and satisfaction: geographic location of ITU teams to a single nursing unit, multidisciplinary rounds, a faculty development program, and more.

The ITU achieved one of its key aims: improving the education life of the housestaff. Residents on experimental teams were far more satisfied than those on control teams (78 percent vs. 55 percent), and spent significantly more time in conferences and other learning and teaching activities (20% vs. 10% of total time). ITU-based faculty also characterized their ITU work as a much more satisfying teaching experience than their usual ward stint. Given the extent of the changes, these improvements in satisfaction (particularly for the residents) are hardly shocking (just imagine how the interns randomized to the control service felt, watching their colleagues on the ITU managing half the patient volume and being on call q 6 rather than q 4?).

What about patient-related quality outcomes? By and large, they were disappointing. Patient satisfaction was no different between the two groups, in part because the hope that decompressed housestaff would spend more time with patients was not realized. There were no differences in clinical or quality outcomes, belying the oft-made argument that our quality would be better if we just had more time.

But one patient-related outcome was seemingly affected: length of stay was significant shorter on the experimental service than on the control one: 4.1 vs. 4.6 days (p=0.002). To me, this may be the study’s most important finding, since this LOS reduction could help produce the dinero to pay for this kind of reorganization. In fact, a similar magnitude of LOS reduction fueled the growth of the hospitalist field: hospital CFOs became willing to help support the cost of hospitalists, since, under the DRG payment systems, lower hospital costs translate into more money in the hospital’s piggy bank. Remarkably, the authors of the Brigham study play down this LOS reduction (and don’t provide any data on costs) – not even mentioning it in the abstract (well, they mention it, but frame it, oddly, in the negative: “The experimental teams were not associated with a higher average length of patient stay”). They were similarly circumspect in the discussion section of the paper, where they pooh-poohed their LOS findings:

…patients assigned to our experimental teams did not have longer stays; indeed, the length of stay for these patients was shorter than that for the patients assigned to the traditional teams, but given the potential for bias in patient assignments, we cannot be sure of the validity of this finding.

I find all of this surprising, because the LOS reduction seemed fairly robust to me. After all, the patients were essentially randomly assigned and appeared well matched (see Table 1 in the paper), and the difference remained highly significant after adjustment for potential confounders.

I’m guessing that the submitted manuscript was more aggressive in touting the LOS finding, and that the reviewers or editors asked the authors to tone it down. To be sure, we don’t know that this finding will hold up in future studies, or whether it was due to a Hawthorne effect or careful cherry picking of the attendings. But the same could have been said of our original hospitalist study in JAMA, which showed a similar LOS reduction and helped launch the fastest growing specialty in medical history.

Why am I making a fuss over the LOS reduction – after all, it wasn’t the primary goal of the study? Because the question of whether people look at this study as an interesting academic exercise (which only Harvard, with its bottomless endowment, could fund) or as a national blueprint for residency redesign completely hinges on the economics. My friend, the medical historian Ken Ludmerer, makes this point in the article’s accompanying editorial:


Every measure that might be taken to improve the learning environment carries a cost — whether it be paying for teaching time, hiring other physicians to see patients that the resident staff once saw, or relieving residents from mundane chores by employing more phlebotomists and ward clerks. The critical issues become what value teaching hospitals will place on their educational mission and whether the requisite funds can be obtained.


The problem, of course, is the funding model for medical education, the lion’s share of which comes in the form of Medicare payments to hospitals to cover the direct (residents’ salaries) and indirect (sicker patients) costs of running a training program. Hospitals protect the information about the actual Medicare dollars they receive per resident the way Coca Cola protects its formula for soda. This means that the residency director or department chair interested in creating an environment in which housestaff are happier and better rested, with time to reflect on their patients, would somehow have to make the case to her medical center CEO that he should part with many more of his Medicare dollars for this purpose. 

Will the CEO see this – cutting each intern’s average volume from 7 to 4 to improve teaching and housestaff happiness – as a worthwhile investment? I doubt it. And if CEOs don’t support it, the model has no chance of catching on. Although the NEJM study didn’t describe the incremental cost of the ITU, my back-of-the-envelope calculations tell me that staffing the entire Faulkner medical service (4000 admissions per year) with the new model would cost about a million extra dollars – both because you’re paying two teaching attendings to do the work previously done by one, and because you’d need to create a non-teaching service with 24-hour coverage to care for the patients that the decompressed residents no longer cover. 

My hat goes off to our Harvard colleagues for carrying out, and funding, this provocative experiment. It certainly caused me to think (and fantasize) about how I’d reorganize my service if we had unlimited resources. But until we can demonstrate that this kind of reorganization improves hard outcomes that hospitals really care about (like length of stay, cost, readmission rates, quality measures, or mortality), I doubt many hospitals will be willing to ante up.

If they don’t – and if subsequent studies truly show improved educational outcomes (importantly, we need long term follow-up, since it remains an open question whether housestaff who care for half as many patients over their entire residency will come out as well prepared as their sleepier but more experienced forbears) – then it may fall on the ACGME to raise the bar on the education-to-service ratio, ultimately forcing hospitals and residency programs to implement changes designed to guarantee the optimal balance.

11 Responses to “Show Me the Money: Can We Afford Education-Oriented Residency Programs?”

  1. Unicorn April 9, 2010 at 4:43 pm #

    I am also agree wit you.

  2. menoalittle April 10, 2010 at 4:04 am #

    Bob,

    Your excellent post enlightened me about nuts and bolts of house staff training.

    The conclusions of the NEJM study was a reinvention of the wheel. Of course attending physicians are more efficient at shepherding patients through their illnesses, and house staff prefer to be spoon fed while sipping coffee and clicking the CPOE order sets from the on call room. How many of the IOM’s 98,000 annual death from mistakes are due to improperly supervised trainees and might this program be something Don Berwick would promote as an IHI safety program?

    “Service” exponentially drops when the trainees can click from afar and can avoid families while the attendings mingle. Education exponentially increases when attendings’ presence reduces stress and assume the accountability. Under this scenario, are the trainees developing sufficient clinical judgment, confidence, and equanimity to attend patients?

    Even if they were, there are two chances that penthouse c-suite hospital people will go for this program: slim and none (unless Berwick comes through). But for the wrong reasons. Why? For one thing, they need the cheap labor to maintain their standard of living while paying handsomely for government mandated HIT systems that neither reduce costs nor improve outcomes, and may have a propensity to increase unexpected deaths.

    Best regards,

    Menoalittle

  3. Brian Clay, MD April 11, 2010 at 1:07 am #

    I think it would be interesting to solicit the opinions of the community hospitalists here at the Society of Hospital Medicine annual meeting this week.

    As an associate program director of the internal medicine residency program at my own institution, I feel confident that we are generating skilled and competent residents at our program. However, I am finding myself asking every community hospitalist that I encounter (1) whether their program considers hiring new residency graduates for their hospitalist positions, and (2) what the experience has been in the last few years with new graduates who have trained under the auspices of the 2003 ACGME work hour rules.

    I get a fairly uniform response.

    Almost to a tee, my community hospitalist colleagues confirm that newly graduated residents have excellent to outstanding medical knowledge and clinical acumen. What they seem to lack, according to the input I’ve received, is adaptability: they have a limited ability to “ramp up” their work efficiency when faced with a higher-than-usual census or with multiple acute patients simultaneously.

    It is an interesting concept to think about. Rare is the training program that places even a senior medicine resident alone to care for patients without any supervision or “lifelines”; indeed, the RRC would likely come down hard on any program that established such a rotation. Even if the attending physician is at home and the resident is functioning “alone,” they are almost always granted limits on the amount of patient assigned to them, and they are almost always located in a hospital with other junior and senior residents present on other teams.

    None of these elements are maintained out in the “real world” of a community non-teaching hospital.

    In fact, one of the most interesting concepts that the ACGME is currently considering (and Dr. Nasca alluded to it in your interview with him) is the idea of varying the work hour rules by level of training. I suspect this is likely driven mostly by the testimony solicted by surgical residents, who made the very cogent point to the ACGME that their ability to learn from the perioperative courses of their patients was limited by the arbitrary limit on continuous hours worked. In any case, it sounds as if we should expect more stringent rules — if not an outright total-hour reduction — for first-year residents, with more liberal work hour parameters for junior and senior residents.

    (Quick aside: if this ends up being the case, most internal medicine programs are going to have trouble figuring out what to do with their preliminary medicine interns, who are only in the program for one year. Usually, they do a preponderance of inpatient call months, during which they work relatively more hours.)

    This could be an appealing concept, as it would allow program directors to provide much more autonomy and independence (and, truthfully, exposure to more stressful clinical workloads) in order to prevent that shock of transitioning from the highly regulated world of residency to the role of community hospitalist, where the work hours are only limited by the amount of work itself.

    We have night faculty at one of our two campuses; we will be rolling out night faculty at the main university hospital in the fall.

    (Quick aside #2: Take a moment to imagine night faculty at a teaching VA hospital.)

    The education-service tension is a whole separate discussion — one that remains challenging as long as that which constitutes “education” or “service” remains in the eyes of the beholders.

  4. Sam April 11, 2010 at 5:46 am #

    I agree with your post. The NEJM article this week did not go far enough in talking about the LOS data. I currently work at an academic teaching hospital with a residency program where the residents are not required to pre-round, and instead go to morning conference from 7:30-8:30am before attending rounds. How can we continue to teach residents in training that it is OK to round on your patients for the first time in the day after 9am? How would you feel if your mother or father was admitted to a teaching service, where the doctors may not see her or him until 10:00am? The day is half gone. Needless to say, I am always deeply concerned when I see that there is more time being spent in front of the computers than with the patients. Even worse, when I see an intern or resident pick up a phone and call into a patient’s room…because they do not want to get up and physically go talk with the patient. Hospitalist programs at teaching hospitals make the reduced work hours workable for the residents, but at what point do you transition resi-terns (residents who do their interns’ work for them when they go home early postcall) into senior residents who are ready to make the transition to attendings? Yes, the compressed workday for residents can be extremely stressful, with no time built into the day to decompress or “unpack” experiences with patients, but we do need to think about the balance between “service” and “education” and realize that almost any service for the patient is usually educational as well.

  5. Oskie April 12, 2010 at 12:50 am #

    Sam’s comments are pure B.S. What drives GME is money, money, money. House staff work the way they do because of the ROI for the hospital and the RVU’s they generate for their salaried, hospital employed, attendings. ITU’s are a sorely needed step in the right direction but will not likely see wide-spread implementation because of economic and financial reasons.

    In this day and age, every patient deserve a well-rested and reflective physician at their bedside.

  6. BrighamGrad April 12, 2010 at 5:26 pm #

    Having been a resident @ BWH/FH in the time window impacted by the ITU I think there are a couple of points that weren’t well captured in the paper…

    1) The “Pre-ITU” System @ Faulkner Hospital was a team structure based on 1 Resident, 1 Intern.  The change to 2 interns and 1 residents occurred at the same time as the introduction of the ITU.   This historical pattern was due in part to the time involved in tracking down the various/myriad attendings (one could easily have 4-5 attendings on a single team).

    2) I do not recall the patient allocation as being this discrete/randomized (although my memories are somewhat vague/imprecise) – some PCPs wanted to attend on their own patients which were then not eligible for ITU.   Additionally, at the housestaff level there was some level of triage/discussions/reallocations based on a patient being “ITU Appropriate”.  I suspect that this also introduced an element of non-randomized distribution that could impact LOS outside of the pure structural format of the team

  7. Sam April 13, 2010 at 5:04 pm #

    Oskie probably needs to graduate from residency before understanding that residents do not generate our salaries!

  8. mark thoelke April 15, 2010 at 3:01 am #

    Brigham grad addresses a question I had about the paper. The traditional model was described as having essentially a teaching attending who met thrice weekly, and who did not round with the team. Were these then patients who were managed by their PCPs? If so , LOS difference is answered.

    Enjoyed your SHM talk Bob.

  9. BrighamGrad April 19, 2010 at 5:11 pm #

    Mark – yes – managed by a mix of PCPs, HVMA Hospitalists, I think also a float hospitalist attending for “unassigned patients” – some mix along those lines (as opposed to simply 2 attendings for all patients on a team).

  10. T. Rose,M.D.,FACP May 14, 2010 at 5:20 pm #

    I interpreted the NEJM study a bit differently: for a huge investment in added Attending time, reduction in patient volume, less night call, etc the Harvard group showed ONLY a 10% increase in attendance at conferences, and no improvement in patient care. The high ratings for education/teaching were predetermined since the Attendings on the “experimental” team were chosen for their “superior” teaching skills.
    I doubt the LOS reduction reflects anything other than more efficient management of a 50% smaller service.
    I, too, wistfully dream about running a Department with unlimited funds…….

  11. asproegypt September 30, 2010 at 9:33 am #

    thanks for the subject ,all countries should apply the residency programs on it to facilitate all conditions for people about here in middle east we start to use residency programs in hospitals and universities to develop health care , and more information about residency education go to this link :
    king Saud Bin Abdulaziz University

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