24/10/80 hour rules of ACGME

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Yesterday the ACGME issued its 24/10/80 hour rule for residents to take 
effect on July 2003.   I went to our last RRC review and to the hospital FTE 
assignments relating to both surgical house staff and faculty presence.  I 
then went to the last ACS COT VRC review for trauma centers.   The arithmetic 
Rubric cube of assignments and regulations make these many and varying 
"rules" absolutely IMPOSSIBLE to accomplish.   IMPOSSIBLE.   I spent the 
evening last night trying to work out some sort of schedule where we would:
       1.   Get the work done
       2.   Within an 80 hour week
       3.   Allowing a maximum of 24 hours on duty at any one stretch
       4.   10 hours off at the end of any work schedule
       5.   PGY 4 or 5 response within 15 minutes of arrival of any major 
trauma patient
       6.   Surgical faculty present for all major and significant portions 
of surgical cases
       7.   Minimal numbers of requirements for surgery residents applying 
for their boards

My department and hospital has "cut back" FTE resident positions in order to 
provide greater "educational" opportunities at the private hospitals, and 
because of budgetary cutbacks relating to constrained "schedule of benefits" 
as defined by HMO & RVU thinking administrators.   The public have spoken 
over the past 3 years and have stated repeatedly that they are fed up this 
this kind of health care financing and denial of access.  

I tried and tried and several things became obvious:

1.    It is now going to take at least 7 years for me to have surgical 
trainees exposed to the same degree of education and pathology and judgement 
making as it took 5 years ago.

2.    There is no way I can cover the many shifts in the hospital with the 
current allocation of staff and surgical residents without at least a 50-75% 
INCREASE in bodies and I have already been told there will be NO INCREASE, 
and expect a decrease.   By my calculations, with the new requirements and 
the current staffing numbers, we will be able to cover 3 and maybe 4 nights 
per 7 days if our clinic, elective, outpatient, and operating room 
responsibilites also remain level.  If anything, out elective and non trauma 
cases are increasing.   Therefore, we can be available to the community only 
57-63% of the time we are currently available.  

3.    Should we add years to the training program (beyond the 5 years), do we 
pay the residents at a PGY 6 and PGY 7 level and just how far do we slip the 
time when residents in the United States begin to operate.  

4.    I have just reread the ACS COT VRC reports of our last two site visits 
and reread the yellow book.   I have a prediction.   Most hospitals like 
Grady, Ben Taub General Hospital, LAC, Parkland, Charity, etc. will be OUT OF 
THE TRAUMA business in 1-3 years.  We simply cannot afford to jump through 
all of the JCAHO hoops and still take care of the other patients.   I am 
aware of several hospitals in the country where neurosurgeons and even 
orthopedic surgeons and even general surgeons are paid $1500.00 per 12 hour 
night call just to be on call from home, without seeing a single patient.   
Billing is then done separately and the surgeon keeps the collections.   For 
some of these programs the neurosurgeons (and even orthopedic surgeons and 
general surgeons) are coming in to operate on as few as 3 cases per month.   
This means $500,000.00 per specialist paid to be "on call" for only 36 
operative cases per year.   Something is wrong with this arithmetic.   

This is a very sad day for me.  I never thought I would see the day when 
regulatory agencies and governments would legislate morality, judgment, and 
work hours.   As I understand the Libby Zion case, it had NOTHING to do with 
work hours and fatigue, it had to do with continuity of care.  As I 
understand, the medical resident who had been on duty but a few hours 
(certainly within the new ACGME recommendations) gave a PHONE order regarding 
a patient she did not know and there was a complication to the order given on 
the phone.   This medical resident used fatigue in her defense, even though 
fatigue was not part of her lack of continuity of care.  It was a problem of 
TOO MANY cooks, TOO many practice guidelines, and too little attention to 
detail and a poor handoff.   

The regulations I read last evening from ACGME now make it impossible to do 
the quality patient care I have seen in this countries "county" hospitals for 
the past 40 years.   It is an end of an era and I do hope and pray that the 
students and residents who filed the class action suit, ACGME that published 
the regulations, and ALL organizations that have (politically) endorsed them 
recognize what they have done to graduate education, to trauma centers across 
the country, to indigent health care, and to quality.   Congratulations, you 
have accomplished a degree of federalization and control that the Clinton 
Health Care Reform (control) initiative did not accomplish, and what many 
countries which have introduced socialized federalized medical care have 
accomplished to the dissatisfaction of the patients.   You have destroyed the 
guild of medicine.    May God grant us grace to live through this and wisdom 
to develop some schema to provide quality health care to our patients.  In 
the end, it is the American patient that is the looser of this socialistic 
victory.    

k

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