Decrease In Work Hours Research Articles

Family life events in the first year of acute lymphoblastic leukemia therapy: a children's oncology group report.

Despite higher cure rates, childhood acute lymphoblastic leukemia (ALL) may continue to result in considerable family strain. We sought to (i) measure incidence of divorce, reduced career opportunities, changes to work hours, home relocation, and changes to family planning at one year after ALL diagnosis; and (ii) Identify family and patient factors associated with these events. We conducted a prospective cohort study of 159 children with average risk-ALL enrolled and treated on COG protocol AALL0331 at 31 selected sites. Eligibility criteria included age ≥2 years and English or Spanish comprehension. Parents completed surveys at three time points during the first 12 months of therapy. Parents were at significantly increased risk of loss of employment (46% vs. 9.1%, P ≤ 0.001) than peers nationally. 13% divorced/separated, 27% relocated homes, 22% decided not to have more children, 51% declined occupational opportunities, and 68% decreased work hours. In adjusted analyses, relocation correlated with less maternal education (OR: 4.27 [95% CI: 1.43-12.82]). Declining parental opportunities associated with family income <$50,000 (OR: 4.25 [95% CI: 1.50-12.02]) and child <5 years old (OR: 4.21 [95% CI: 1.73-10.25]). Deciding not to have more children correlated with smaller family size 2-3 versus 4-5 (OR: 3.62 [95% CI: 1.10-11.96]). Families experience a high incidence of major life changes in the first year of ALL treatment. Understanding these burdens helps health care providers to provide appropriate anticipatory guidance and support. No unifying factor was associated with the different family events. Ongoing follow-up is planned to measure long-term outcomes.

Optometry Services in Ontario: Supply- and Demand-Side Factors from 2011 to 2036

Optometric labour market projections are provided. First, population growth and ageing-based estimates of the rate of increase of eye-care services in Ontario from 2011 to 2$ are presented, holding the age-sex structure of utilization constant. Then, using data on the 2011 supply and working hours of Ontario's optometrists, the number of optometrists needed to keep the level of optometric services per age-sex-adjusted person comparable over time is estimated. The projections suggest that the number of Ontario optometrists should grow by approximately 30-40 full-time equivalents per year; to offset retirements and account for decreasing work hours, this suggests 77-90 new practitioners are required each year. However, in recent years, the number of Ontario optometrists has been growing faster than this, suggesting either that demand has exceeded supply and/or surpluses will accumulate if this trend continues.

Exploring Factors That Have Caused a Decrease in Surgical Manpower in Taiwan

The decreasing availability of surgical physicians is a concern in most countries. In the past decade, total physician manpower in Taiwan increased by 12%, but the number of surgical physicians decreased by 11%. Medical students are not inclined to choose surgery as a career--this study examines the factors involved in students' career choices. This study was conducted from January 2011 to April 2011. In total, 401 interns successfully completed questionnaires; this population makes up 34% of all interns in Taiwan. The structural questionnaire was designed to investigate factors affecting specialty decisions, with additional open-ended questions to investigate students' preferences in career specialty. Based on the research findings, the 3 most relevant factors in decreasing order of priority are personal interest, career-oriented lifestyle, and specialty characteristics (including workload and stress). For students likely to become surgical physicians, concerns about the work environment include the balance between work and family, wages that are incompatible with the workload, and the shortage of manpower on duty. Addressing the following concerns would increase medical students' likelihood of choosing a career in surgery: the need for a facilitator to help mitigate medical disputes and legal problems, decreased work hours, and decreased on-call duty hours. This study shows both motivating and discouraging factors affecting whether medical students choose surgery as a career. The purpose of this study is to strengthen the incentives for medical students to choose surgery as a career and to minimize the influence of factors that negatively affect such a choice.

Promoting successful diabetes management in the workplace

Purpose – The purpose of this paper is to learn from participants about their experiences managing type 1 and type 2 diabetes at work. Design/methodology/approach – Longitudinal, qualitative interviews with 45 individuals three times per year over three years focussed on views about disclosure; how they found or created support to manage their diabetes at work; and how they experienced the relationship between health and productivity. Findings – Among participants, the presence of secondary conditions, such as fibromyalgia or vision loss, typically overshadowed the effect of diabetes at work. These conditions were often mentioned as the reason why a participant changed jobs, stopped working, or decreased work hours. Perspectives on disclosure were affected by the perception of stigma and discrimination, as well as the need for workplace accommodations. Overall, participants believed that the routine of a job and feeling useful benefited their health. Research limitations/implications – The nature of the research was not medical and the paper did not collect participants’ medical records. The paper relied on self-report for diagnoses of diabetes and co-morbidities as well as unrelated health conditions. Although the participants lived in a variety of urban, suburban, and rural settings, the findings do not reflect the ways in which differences in geography may have influenced participants’ experience. A focus of future research might be the role played by geographic location in the experience of managing diabetes at work. Also, the majority of employed participants worked for small employers. Future research might include a focus on participants managing diabetes while working for larger employers, who may have greater resources and staffing to devote toward implementing changes in workplace policy. Originality/value – The paper considers the preference that many participants have for working and being productive rather than not working, including those with secondary conditions as well as diabetes. The number of participants (n=45) is relatively large for a qualitative interview study. The longitudinal nature of the study allowed for a follow-along opportunity that yielded a rich source of data.

Lean principles optimize on-time vascular surgery operating room starts and decrease resident work hours

Lean process improvement techniques are used in industry to improve efficiency and quality while controlling costs. These techniques are less commonly applied in health care. This study assessed the effectiveness of Lean principles on first case on-time operating room starts and quantified effects on resident work hours. Standard process improvement techniques (DMAIC methodology: define, measure, analyze, improve, control) were used to identify causes of delayed vascular surgery first case starts. Value stream maps and process flow diagrams were created. Process data were analyzed with Pareto and control charts. High-yield changes were identified and simulated in computer and live settings prior to implementation. The primary outcome measure was the proportion of on-time first case starts; secondary outcomes included hospital costs, resident rounding time, and work hours. Data were compared with existing benchmarks. Prior to implementation, 39% of first cases started on time. Process mapping identified late resident arrival in preoperative holding as a cause of delayed first case starts. Resident rounding process inefficiencies were identified and changed through the use of checklists, standardization, and elimination of nonvalue-added activity. Following implementation of process improvements, first case on-time starts improved to 71% at 6 weeks (P = .002). Improvement was sustained with an 86% on-time rate at 1 year (P < .001). Resident rounding time was reduced by 33% (from 70 to 47 minutes). At 9 weeks following implementation, these changes generated an opportunity cost potential of $12,582. Use of Lean principles allowed rapid identification and implementation of perioperative process changes that improved efficiency and resulted in significant cost savings. This improvement was sustained at 1 year. Downstream effects included improved resident efficiency with decreased work hours.

Racial and ethnic variation in employment and financial experiences of breast cancer survivors.

9601 Background: Concerns exist regarding the employment and financial experiences of cancer survivors and whether they differ by race/ethnicity. Methods: In a longitudinal survey of women reported to the Los Angeles and Detroit SEER registries for nonmetastatic breast cancer, we compared experiences of 4-year survivors by race/ethnicity. Results: Overall, 31% of 1,536 respondents (68% response rate) felt their financial status was worse since diagnosis (63% attributed this to breast cancer). This varied by race/ethnicity: 41% of Spanish-speaking Latinas (SSL), 33% English-speaking Latinas (ESL), 23% blacks (B), and 29% whites (W), p&lt;0.001. The median respondent had spent ≤$2000 on breast cancer medical expenses; 16% had spent &gt;$5000. 12% had medical debt 4 yrs post-diagnosis: 17% of ESL, 14% B, 10% SSL, and 9% W (p=0.01). Minority respondents were more likely to report foregoing medical care due to cost and other privations due to their medical expenses (Table). Overall, 14% felt their employment status was worse since diagnosis, and 61% of these attributed this to breast cancer. 755 worked for pay some time after diagnosis, of whom 56% said it was at least somewhat important to work to keep health insurance (55% of SSL, 65% ESL, 65% B, 50% W, p=0.03); 24% would look for a new job if assured of comparable benefits (45% of SSL, 29% ESL, 22% B, 17% W, p&lt;0.001); 7% had increased work hours to cover cancer-related expenses; 27% had decreased work hours due to cancer-related health issues; and 7% believed they had been denied job opportunities because of cancer. Conclusions: In this population-based sample of breast cancer survivors, job lock was common, and many women perceived being worse off with respect to finances and employment as a result of their breast cancer. Medical debt and privation varied significantly by race/ethnicity. [Table: see text]

From the Editors’ Desk: Physician Heal Thyself

Numerous studies have documented high rates of job dissatisfaction and burnout among physicians. Many factors have contributed to this trend including the rise of managed care and the concomitant increased paperwork and other administrative demands that sap time that could be spent with patients and leave physicians with a diminished sense of autonomy and control over their work. Physicians who work at academic medical centers face the additional challenge of a shrinking federal budget for research and increasing demands on their time for “unfunded mandates” such as teaching and mentoring. The end result has been unacceptably high rates of burnout, defined as a sense of emotional exhaustion, cynicism and a reduced sense of effectiveness, or as the pioneering researchers on burnout Maslach and Leiter pointedly write in their book The Truth About Burnout: “(Burnout) represents an erosion in values, dignity, spirit, and will—an erosion of the human soul.” The impact of physician burnout can be significant both for the individual and for the organization in which they work. Decreased productivity, poor retention, medical errors and negative patient interactions are just some of the documented potential consequences of burnout among physicians both for the individuals and for the organization. For the physicians themselves, depression, substance abuse and impaired relationships with family and friends may be the result of untreated stress and eventual burnout. But with these challenges come opportunities for physicians to enhance their well-being and avoid burnout. Well-being arises, in part, when we take the time to clarify our personal values and make career and personal choices that honor those values. Well-being is not just a personal endeavor, however; physician well-being is also an organizational and political issue. The personal commitment of physicians to healthy values and behaviors may be eroded in organizations that reward overwork and dissociation from human feelings and meaning at work. In this issue of JGIM, two articles address the issue of burnout and well-being among physicians and trainees from an organizational perspective. Sood et al. report on a small, randomized trial of a stress management and resiliency-training program (SMART) for department of medicine physicians. They found that compared with a wait-list control arm, physicians randomized to a single 90-minute one-on-one session focusing on meditation, relaxation and “attention and interpretation” had significantly decreased perceived stress, anxiety and improved overall quality of life at 8 weeks. While the data is limited, this pilot study suggests that introducing more stress management training programs into academic health centers could enhance resiliency and decrease burnout amongst academic physicians. One well-known contributor to physician stress and burnout is overwork. In this issue, a systematic review by Fletcher et al. examines the impact of the 2003 duty hour reform on resident burn-out and well-being (among other resident and patient centered outcomes). Overall, they found an improvement in resident well-being following the mandated decrease in work hours after the 2003 duty hour reform (but perhaps surprisingly, no impact on rates of depression). While duty hour reform has certainly helped to promote better self-care among residents, other studies have found that trainees are still susceptible to unacceptably high rates of burnout. Reducing work hours is a necessary first step to combat burnout among our trainees, but clearly it is not enough. We must teach the next generation of physicians to focus more on self-care including their physical, mental and emotional well-being. This is essential for the individual physicians and for the patients they serve.

Returning to work after treatment for breast cancer.

e11572 Background: Relatively few studies have assessed the association of cancer survivorship with unemployment, and return to work (RTW) after the diagnosis of breast cancer remind still a problem. Methods: In the present study the treating physician or psychoncologist recruited patients before the start of initial treatment, in the period from August 2007 to January 2008 at our institution. 76 of 112 consecutive patients with early breast cancer admitted to our outpatient medical oncology accepted to participate this study and to complete the interviews; all patients were interviewed at diagnosis and after 1, 3, 6, 9, 18 and 24 months. Clinical and psychological data including diagnosis, stage, age, anxiety, depression, treatment planned, job at diagnosis were recorded for each patient. Results: After 1 month from diagnosis, 45% of patients stopped work and after 3 to 9 months 55.3% of patients stopped work. In our group of patients, 77.9% of them had full RTW after a median delay of 10.3 months; anxiety and depression seem affect employment by decreasing work hours, and increasing absence. Age > 55 years, chemotherapy, physical and psychological status were the major factors affecting the return to work, while type of surgery, sentinel lymphnode biopsy or axillary dissection, radiation therapy and hormonal therapy did not negatively influence the return to work. Conclusions: People treated for cancer have reported a variety of problems at work. Also the importance of social support from the workplace in relation to sickness absence in general is well documented and more recently the importance of social support from the employer and coworkers for the return to work, was demonstred. Work is important for individual’s identity and provides also a social connection, however the experience of continuing or returning to work following cancer and related treatment is a largely unknown area of cancer research.

The Increased Financial Burden of Further Proposed Orthopaedic Resident Work-Hour Reductions

Increased funding for graduate medical education was not provided during implementation of the eighty-hour work week. Many teaching hospitals responded to decreased work hours by hiring physician extenders to maintain continuity of care. Recent proposals have included a further decrease in work hours to a total of fifty-six hours. The goal of this study was to determine the direct cost related to a further reduction in orthopaedic-resident work hours. A survey was delivered to 152 residency programs to determine the number of full-time equivalent (FTE) physician extenders hired after implementation of the eighty-hour work-week restriction. Thirty-six programs responded (twenty-nine university-based programs and seven community-based programs), encompassing 1021 residents. Previous published data were used to determine the change in resident work hours with implementation of the eighty-hour regulation. A ratio between change in full-time equivalent staff per resident and number of reduced hours was used to determine the cost of the proposed further decrease. After implementation of the eighty-hour work week, the average reduction among orthopaedic residents was approximately five work hours per week. One hundred and forty-three physician extenders (equal to 142 full-time equivalent units) were hired to meet compliance at a frequency-weighted average cost of $96,000 per full-time equivalent unit. A further reduction to fifty-six hours would increase the cost by $64,000 per resident. With approximately 3200 orthopaedic residents nationwide, sensitivity analyses (based on models of eighty and seventy-three-hour work weeks) demonstrate that the increased cost would be between $147 million and $208 million per fiscal year. For each hourly decrease in weekly work hours, the cost is $8 million to $12 million over the course of a fiscal year. Mandated reductions in resident work hours are a costly proposition, without a clear decrease in adverse events. The federal government should consider these data prior to initiating unfunded work-hour mandates, as further reductions in resident work hours may make resident education financially unsustainable.

Risks To The Health Of Wood Workers: What Can Be Done?

OBJECTIVE: To identify health problems of wood workers and suggest recommendations for its prevention. METHODS: Extensive online search was made for medical literature on it published in English from 1960’s to date.151 articles were retrieved which were tailored to 124 including books, reviews and epidemiological studies.53 of them were relevant and are included in this review. RESULTS: Wood workers are exposed to wood dust, fungi, bacteria, endotoxins, formaldehyde, phenol and various injuries in their working environment. This leads to impaired pulmonary functions; non-cancerous respiratory diseases like rhinitis, chronic bronchitis, hypersensitivity pneumonitis; occupational cancers like sino-nasal cancer, laryngeal carcinoma, lung cancer, mesothelioma, Hodgkin’s disease, bladder cancer, skin cancer, prostate and brain cancer. This can be prevented by decreasing exposure to wood fumes in air by proper ventilation and decreasing work hours by increasing shifts, personal protective equipment and regular nasal lavage. CONCLUSION: Wood workers are exposed to various biohazards at their work place which increases risk of occupational diseases which can be prevented by provision of healthy work environment. KEY WORDS: wood workers health, wood industry exposures, hazards of wood

The influence of demographics and work related goals on adaptive development for work related learning amongst private hospital employees

Contemporary lifespan development models of adaptive development have been applied to the workforce to examine characteristics of the ageing employee. Few studies have examined adaptive development in terms of worker perceptions of workplace, or their learning and development issues. This study used the recently developed Revised Learning and Development Survey to investigate employee selection and engagement of learning and development goals, opportunities for learning and development at work, and constraints to learning and development at work. Demographic and career goal variables were tested amongst a sample of private hospital employees, almost all of whom were nurses. Workers under 45 years of age perceived greater opportunities for training and development than more mature aged workers. Age and physical demands interacted such that physical demands of work were associated with lower engagement in learning and development goals in mature aged workers. The opposite was observed amongst younger workers. Engagement in learning and development goals at work predicted goals associated with an intention to decrease work hours or change jobs to a different industry when opportunities to learn via work tasks were limited. At the same time limited opportunities for training and development and perceptions of constraints to development at work predicted the intention to change jobs. Results indicate consideration must be paid to employee perceptions in the workplace in relation to goals. They may be important factors in designing strategies to retain workers.

Utilizing Information Technology to Mitigate the Handoff Risks Caused by Resident Work Hour Restrictions

Resident duty hours have been restricted to 80 per week, a limitation thought to increase patient safety by allowing adequate sleep. Yet decreasing work hours increases the number of patient exchanges (so-called "handoff") at the end of shifts. WHERE ARE WE NOW?: A greater frequency of handoff leads to an increased risk of physician error. Information technology can be used to minimize that risk. WHERE DO WE NEED TO GO?: A computer-based expert system can alleviate the problems of data omissions and data overload and minimize asynchrony and asymmetry. A smart system can further prompt departing physicians for information that improves their understanding of the patient's condition. Likewise, such a system can take full advantage of multimedia; generate a study record for self-improvement; and strengthen the interaction between specialists jointly managing patients. HOW DO WE GET THERE?: There are impediments to implementation, notably requirements of the Health Insurance Portability and Accountability Act; medical-legal ramifications, and computer programming costs. Nonetheless, the use of smart systems, not to supplant physicians' rational facilities but to supplement them, promises to mitigate the risks of frequent patient handoff and advance patient care. Thus, a concerted effort to promote such smart systems on the part of the Accreditation Council for Graduate Medical Education (the source of the duty hour restrictions) and the Association of American Medical Colleges (representing medical schools and teaching hospitals) may be effective. We propose that these organizations host a contest for the best smart handoff systems and vigorously promote the winners.

Simulation in surgical education

In recent years, simulation has come to the foreground as a method of teaching technical skills to surgical trainees. Rapid changes in health care systems underlie the shift to simulation-based education in many countries. Pressures include a decrease in work hours for residents, a shortening of

Changes in the number of resident publications after inception of the 80-hour work week.

Since the inception of resident work-hour regulations, there has been considerable concern regarding the influence of decreased work hours on graduate medical education. In particular, it is unclear whether implementation of work-hour restrictions has influenced resident academic performance as defined by quantity of peer-reviewed publications while participating in graduate medical education. We determined the impact of work-hour changes on resident involvement in the number of published clinical studies, laboratory research, case reports, and review articles. We conducted a PubMed literature search of 139 consecutive orthopaedic surgery residents (789 total resident-years) at one institution from academic years 1995-1996 to 2008-2009. This represented a continuous timeline before and after implementation of work-hour restrictions. The number of resident publications before and after implementation of work-hour changes was compared. There was a greater probability of peer review authorship in any given resident-year after work-hour changes than before. Average publications per resident-year increased for total articles, clinical articles, case reports, and reviews. There was an increased rate of publications in which the resident was the first author. Since implementation of work-hour changes, total resident publications and publications per resident-year have increased.

The Eighty-Hour Workweek: Surgical Attendings' Perspectives

The year 2008 was a sentinel year in resident education; this was the first graduating general surgery class trained entirely under the 80-hour workweek. The purpose of this study was to evaluate attending surgeon perceptions of surgical resident attitudes and performance before and after duty-hour restrictions. An electronic survey was sent to all surgical teaching institutions in North Carolina. Both surgeon and hospital characteristics were documented. The survey consisted of questions designed to assess residents' attitudes/performance before and after the implementation of the work-hour restriction. In all, 77 surveys were returned (33% response rate). The survey demonstrated that 92% of educators who responded to the survey recognized a difference between the restricted residents (RRs) and the nonrestricted residents (NRRs), and most respondents (67%) attributed this to both the work-hour restrictions and the work ethic of current residents. Most attending surgeons reported no difference between the RRs and the NRRs in most categories; however, they identified a negative change in the areas of work ethic, technical skills development, decision-making/critical-thinking skills, and patient ownership among the RR group. Most surgeons expressed less trust (55%) with patient care and less confidence (68%) in residents' ability to operate independently in the RR group. Eighty-nine percent indicated that additional decreases in work hours would continue to hamper the mission of timely and comprehensive resident education. The perception of surgical educators was that RRs are clearly different from the NRRs and that the primary difference is in work ethic and duty-hour restrictions. Although similar in most attributes, RRs are perceived as having a lower baseline work ethic and a less developed technical skill set, decision-making ability, and sense of patient ownership. Subsequent study is needed to evaluate these concerns.

Neurohospitalists: Challenges for the Integration of a New Field: A Neurointensivist's Perspective

A new field of Neurohospitalist medicine is developing. The roots of this field are firmly in the field of Neurology. The development of the field however, may follow the path of its predecessor hospitalist medicine. It is therefore important to study the history of Internal Medicine and hospitalist medicine in order to understand where the field may be headed. The field of Internal Medicine and medical education has undergone a metamorphosis over the past several decades. Historically, patients would be admitted to a hospital for medical evaluation. During this evaluation teams of residents with the attending physician would admit, evaluate, diagnose, and embark on an extensive treatment strategy. As average life expectancy increased, and newer technologies developed, the cost of caring for patients in an in-patient hospital setting became increasingly burdensome. Nationally, increasing health costs became a serious strain on the economic health of most industrial countries. Subsequently, the inpatient evaluation and treatment of most medical diseases became cost prohibitive and moved toward a more cost effective outpatient setting. The movement of medical evaluations to the outpatient setting provided a challenge to internal medicine education. Residencies needed to mirror practice to appropriately prepare residents for their eventual post training place in internal medicine. Subsequently, internal medicine residencies have increased their outpatient requirements over the past few decades. This, however, has occurred during a time of mandated decreasing residency work hours and increasing in-patient volume and acuity. A solution for many of these residencies was the development and implementation of medical hospitalist programs and fellowship. The development of Neurohospitalist programs appears to be following a similar path as internal medicine. Dr. Meschia has noted similar erosion in the in-patient experience of neurology residencies compared to changes that occurred in internal medicine programs (Meschia, 2010). Practice patterns have also shown parallels to Internal Medicine. Today many neurological diseases are evaluated and managed in the outpatient setting. Neurology inpatient services have also displayed a greater number of medical problems and complications. In addition to these findings, the development and expansion of “acute neurology” and more specifically, the use of intravenous tissue plasminogen activator and the development of interventional procedures has increased the need for immediate neurological expertise. This need has superseded financial models to compensate and accommodate the necessary people and resources to adequately treat this patient population. The development of the field of hospital neurology may provide a solution to this problem. The neurohospitalist can provide timely care for acutely ill neurological patients and can relieve neurology practices the need to cover an emergency room or a sick hospital population. Thus, there is a strong economic incentive for the development of the field. This rosy scenario for the neurohospitalists, however, has many potential pitfalls and questions. How will neurohospitalists be organized? What skills will be needed or required for practice? Dr. Likosky's survey of neurohospitalists found that the majority of these physicians do not see patients in an outpatient setting (Likosky et al., 2010). Who will follow the patient once they have left the hospital? How will neurohospitalists be reimbursed? These are only a few of the questions a young field will need to address as it develops. Each of these questions and issues has potential difficulties. One model for Neurohospitalist development is to have the neurohospitalist hired by a group practice. Reimbursement would be established by the group and patient follow up would be covered by the group. However, what if the neurohospitalists are hired and salaried by the hospital? as is the growing trend in medicine. Coordination with outside practices will take considerable skill. Inevitably “turf issues” will arise. Similarly what will happen when a neurologic emergency occurs when a patient is not covered by the neurohospitalists practice? Who will the emergency room physicians call when an outside neurologist or physician is unavailable or delayed? Most neurologists and physicians may be grateful for this help; however, so may patients who may wish to leave the outpatient neurologists practice to join the practice of the physician who cared for them during their crisis who may or may not have an outpatient practice. A majority of neurohospitalists in Likosky's survey came from either a stroke or neurocritical care background (Likosky et al., 2010). This may represent selection bias of the survey or of individuals who chose to spend their time in the hospital. However, neurohospitalists should be able to provide consultative roles in all areas of the hospital including the intensive care units (ICUs). The neurohospitalists may be able to complement both the general neurologists and neurointensivists by dividing services, procedures, or consultations when necessary. Again a certain level of political skill may be needed to navigate these areas.

Work Hour Regulations: Do We Need Further Changes Now? A Survey of Internal Medicine Faculty and Residents

In 2003, the Accreditation Council for Graduate Medical Education standardized and regulated work hours for physicians in training in the United States. In December 2008, the Institute of Medicine (IOM) recommended further reductions in duty hours to ensure safer conditions for patients and residents and fellows. Significantly, the IOM committee acknowledged that there are barriers to implementing its recommendations. IN THE WAKE OF THE IOM PROPOSALS, WE CHOSE TO SURVEY A REFERENCE CLOSER TO HOME: residency program directors, faculty, and residents. Our survey allowed them the opportunity to express their opinions regarding the IOM proposals. The majority of the faculty oppose the proposed IOM changes, arguing that there is no definite evidence to support the hypothesis that fewer work hours mean better outcomes in patient safety and education. First-year residents and residents who moonlight were more likely to experience stress and to support decreased work hours. The thoughts and opinions of faculty and residents collected through this survey, in combination with evidence-based studies from trial implementation of these standards, will contribute real answers to the challenging questions on resident work hours.

Mortality Among Patients in VA Hospitals in the First 2 Years Following ACGME Resident Duty Hour Reform

Conclusion: New duty hour regulations implemented by the Accreditation Council for Graduate Medical Education (ACGME) were associated with relative improvement in mortality in four common medical conditions in teaching-intensive Veterans Administration (VA) hospitals. No mortality changes were identified for surgical patients. Summary: On July 1, 2003, the ACGME instituted limitations in duty hours for United States resident physicians. The study sought to determine whether there was an associated change in mortality among hospitalized patients with duty hour reform. The authors determined whether there were associated relative changes in mortality in hospitals of different teaching intensity within the Department of Veterans Affairs health care system. This was an observational study of 318,636 acute care patients admitted to 131 VA hospitals from July 1, 2000, to June 30, 2005. Medical conditions studied were acute myocardial infarction, congestive heart failure, gastrointestinal bleeding, and stroke. Patient admissions that were determined by Diagnosis-Related Groups to be related to general, orthopedic, or vascular surgery were also studied. A logistic regression analysis examined changes in mortality in more- or less-intensive teaching hospitals before and after duty hour reform. Adjustments were made for time trends, hospital sites, and patient comorbidities. The main outcome measure was death ≤30 days of hospital admission. Changes in mortality rates were not significant in the first year after reform in either medical or surgical patients. In year 2 after reform, mortality decreased significantly in more teaching-intensive hospitals for medical patients only. When hospitals with a resident-to-bed ratio of 1 were compared with hospitals with a resident-to-bed ratio of 0, mortality odds were reduced for patients with acute myocardial infarctions (odds ratio [OR], 0.48; 95% confidence interval [CI], 0.33-0.71). For the medical conditions studied taken together, mortality in the hospitals with resident-to-bed ratio of 1 compared with those with resident-to-bed ratio of 0 was also less (OR, 0.74; 95% CI, 0.61-0.89). Similarly, mortality was improved in the three other medical conditions excluding acute myocardial infarction (OR, 0.79; 95% CI, 0.63-0.98). Compared with hospitals in the 25th percentile of teaching intensity, hospitals in the 75th percentile of teaching intensity had an 11.1% relative mortality decrease, and those in the 90th percentile of teaching intensity had a 15.9% relative decrease in mortality for all the combined medical conditions. Comment: This study raises a number of interesting questions about the impact of duty hour reform on in-hospital mortality. There are many possible explanations for the findings, including more attending involvement and more use of mid-level providers in response to the resident work hour restrictions. In addition, the failure of mortality rates to decrease in the surgical patients does not necessarily imply poor care of the surgical patients. Perhaps these patients were already getting excellent care, and this care was not affected by a decrease in work hours by the surgical residents. Nevertheless, surgical program directors must ask themselves whether they are doing well or whether they could be doing better, or perhaps both.

Who Will Do the Work? What Work Will They Do?

in the United States. 2 This first-pass determination was done during a time when the expense of oncology care was starting to become an issue, in an era of more rudimentary cancer treatments, and on a background of proposals to reduce oncologytraining slots by 40%. The then-estimated 3,600 full-time-equivalent oncologists were adequate, based on comparisons with staff model health maintenance organizations’ (HMOs) use of oncologists per 100,000 population. Though this estimate of the workforce size was almost certainly wrong, the earlier study’s two main conclusions are largely true: oncologists desired delivering less primary care, and the workforce was right-sized. Fifteen years on, most oncologists are as busy as they want to be, and they spend their professional time delivering specialty oncology care. The current study used many data sources (both existing and new data from four surveys) to provide a more reliable estimate of the current oncology workforce—the American Medical Association Masterfile of physicians—and a more robust estimate of the potential patient population and oncology practice patterns. The results indicate that we will be facing a shortage of 2,550 to 4,080 oncologists by 2020 —which could translate to 9.4 to 15 million fewer oncologist visits. The study used a combination of Medicare visit data and National Cancer Institute incidence and prevalence projections to determine the demand for services and capacity of the workforce to deliver those services. The authors performed sensitivity analyses, testing the effects of increasing oncology training slots, electronic medical record use, and midlevel provider use on visit capacity and workforce supply. Projections were also made on the effects of delaying retirement of current oncologists and potential for decreased work hours and thus productivity in younger oncologists. The model’s sensitivity to increases in the number of new cancer patients seen by an oncologist, to varying the intensity of oncologist interaction with each patient, and to truncation of oncologist interaction with each patient by use of hospice or primary care providers to manage various stages of the illness was tested. Making predictions, especially about the future, is difficult, as was observed by both the theoretical physicist Niels Bohr and the applied physicist Yogi Berra. The wildest swings in the predictive model for visit demand (Table 4) occur when the proportion of new cancer cases seen by an oncologist is varied. 1 Many other specialists manage early-stage colon, skin, and prostate cancers. Medical oncologists add little value to management of these early-stage tumors, but radical changes in the management of these conditions (effective adjuvant systemic therapy for early-stage, high-risk prostate and colon cancers for instance) could radically alter the demand forecast. On the contrary, simplification in the management of hormone receptor–positive early-stage breast cancer could lead to more management of this now-common condition by surgeons or other nononcologists. It is difficult to predict the changes in practice patterns that biomedical or information technology will bring 15 years from now. Market forces should be allowed to continue to guide adjustments of oncology care. The reason medical oncologists see less early-stage prostate and skin cancer is that we currently add little value to the care of these patients. As oncologists become relatively rarer and our time more dear, we will figure out ways to become more productive diagnosticians, innovators, and problem solvers. We will spend less professional time performing extensive documentation and other non–value-added tasks, and more time developing and leading our teams. We should develop and refine guideline-based care so that we can delegate more routine tasks to midlevel providers, experienced oncology nurses, and others who specialize in managing various aspects of the cancer care continuum. Information technology should be developed to allow us to spend more productive time with our patients. Those new associates who are identified and hired should add value to patient care and only do work for which a trained medical oncologist is required.

The Indirect Costs of Arthritis Resulting From Unemployment, Reduced Performance, and Occupational Changes While at Work

The objective of this study was to assess the cost attributable to lost productivity from arthritis and the association between the degree of loss and demographic, disease-related, occupational, and psychosocial variables for people. In a prospective study, 383 employed individuals with arthritis were recruited from southwestern Ontario, Canada. Respondents completed structured questionnaires assessing demographic, disease-related, workplace, and psychosocial variables as well as employment-related transitions at 2 time points 18 months apart. Indirect costs resulting from arthritis-related absences, reduced performance, decreased work hours, job change, and work disability were estimated. A proportional odds model was used to assess the impact of the various variables on lost productivity. The average cost attributable to arthritis was CAN Dollars 11,553(Dollars CAN = 0.75 Dollars US) per person per year. The largest component of the loss was the result of reduced performance at work, which accounted for 41% (Dollars 4724) of the total loss. This was followed by wage loss resulting from stopping working or changing jobs, which comprised 37% (Dollars 4309) of the total. Another 12% (Dollars 1398) and 10% (Dollars 1121) of the loss were the result of the decrease in hours of work and absenteeism, respectively. Four variables were associated with the productivity loss: greater symptom severity (odds ratio [OR] = 1.11), low or medium control over the work schedule (OR = 0.55 and 0.60, respectively), greater workspace limitation (OR = 1.10), and higher depression (OR = 1.04). Indirect arthritis-related costs are substantial. Our results show that not only the disease itself, but also psychosocial and work-related factors affect the magnitude of the costs.