Think Broad, Act Lean: Implications of Residency Training and Duty Hour Changes on Health Care Costs

To the Editor: I read with great interest the articles by Antiel et al1 and McCoy et al2 in the March issue of Mayo Clinic Proceedings. Among the key findings were that US program directors anticipate a decrease in residents' ability to meet 5 of 6 ACGME core competencies with the recent residency training duty hour recommendations and that residents themselves rated a work schedule compliant with said recommendations inferior both in quality of education and overall compared to a traditional overnight call model. The body of literature on this important subject continues to grow (and reveal substantial concerns), but to date there is little to no discussion of a key area wherein residency training duty hours intersect with another vital issue—health care costs. That is, in the current era of US health care reform and limited resources, should residents be expected and taught to balance learning to become competent medical specialists with how to provide cost-conscious, individualized care? The practice of medicine has been referred to by some as “the art of the differential diagnosis.” As residents, our training teaches us to think broadly and compile expansive differential diagnoses, but it does relatively little to emphasize the next step, the true art of the specialty—focusing on the individual patient and tailoring the work-up and management accordingly. For example, a 39-year-old woman with a history of allergic rhinitis who uses inhaled corticosteroids presents to the emergency department with a fever and cough. She is admitted to the medicine ward with what seems, based on her history, examination, and portable chest radiographic findings, to be right middle lobe pneumonia. In addition to standard tests, I have witnessed (and once been one of) countless residents, especially those at prominent academic centers, ordering tests in a front-loaded “shotgun” approach: Two sets of blood cultures (to be thorough, despite no signs or symptoms of bacteremia or sepsis)—$168.12 Serum acid-fast bacilli culture (in case this could be Lady Windemere syndrome)—$126.07 Histoplasma urine antigen—$84.06, Cryptococcus serum antigen—$54.54, and Aspergillus (galactomannan) serum antigen—$47.89 (to rule out a fungal process) Induced sputum for bacteria—$126.08, fungi —$47.89, acid-fast bacilli—$210.13, Pneumocystis jiroveci—$115.57, and Legionella—$84.06 (while getting sputum for one, might as well send the others; after all, the patient is taking corticosteroids [albeit not systemically]) Legionella urine antigen—$52.54 (although the patient has no diarrhea and the infiltrate is focal, she may be at risk due to corticosteroid use, and it is an easy test to perform) Mycoplasma pneumoniae antibody—$42.02 and cold agglutinin screen—$27.32 (despite the non-atypical pneumonia radiographic appearance, this is a common infection that, if identified, could help narrow down antibacterial coverage) Human immunodeficiency virus (HIV) polymerase chain reaction—$210.13 (hospitalized patients should be screened for HIV with an HIV antibody; since it is possible that this patient is a new converter or one of few documented antibody-negative cases, polymerase chain reaction may be ordered) Angiotensin-converting enzyme—$42.02 (to help rule out sarcoidosis) Lactate dehydrogenase—$8.42 (use as a screen for lymphoma) Antinuclear antibodies—$31.53, antineutrophil cytoplasmic antibodies—$31.53, and rheumatoid factor—$16.81 (to assess for an underlying autoimmune etiology) Computed tomographic angiogram of the chest (to make certain the dyspnea and chest radiographic radiodensity are due to pneumonia and not pulmonary embolism with Hampton sign)—$1175 Total = $27003 With this differential and work-up, the admitting resident may well be credited on rounds the following morning for working hard and thinking “academically.” However, there are approximately 24,000 internal medicine residents in a total of 400 residency programs across the United States,4 and if we estimate that each resident similarly thinks and acts big (as opposed to acting in a stepwise, patient-tailored manner) in just 5 of the many pneumonia cases seen annually, the total extra cost across the United States would be $324,000,000. If this is multiplied by the number of problems commonly encountered in medicine, be it elevated liver enzymes, chest pain, or diarrhea, among a myriad of others, and if we include residents in family medicine, emergency medicine, and other specialties, we can see that the magnitude of incremental cost is not trivial. Despite the important drawbacks to a shotgun testing approach, some beneficial aspects may exist (Table). Good or bad, residents may ostensibly have no choice but to abide by this approach when working in a melting pot of insecurity, a desire to appear academic, a broad array and increasing complexity of patients, inadequate knowledge of costs, and the ability to order limitless tests with the click of a button.5,6 If such is the case, then one may see the shotgun approach as an inevitable rite of passage to becoming competent, evidence-based practitioners who can think broadly but act lean. Table. Pros and Cons Associated With Front-Loaded, Shotgun Approach Testing If the answer to the initial question of whether we should indeed be better taught to find a balance between being trainees and providing individualized, cost-sensitive care is “Yes,” and if we are not to believe that we are exempt from the dynamics and financial strains of the health care system, how can we make this happen sooner in our training? This is the more difficult question. Duty hours certainly play a role; a decade ago, the aforementioned rite of passage may have occurred earlier in one's training simply as a result of hitting the 10,000 hour mark sooner.7 With the upcoming duty hour changes, it is possible that this passage will be even further delayed. However, this matter is also driven qualitatively, not just by the number of hours worked. The time we invest in residency, regardless of how it is diced, must not consist of labor alone; we need to be allotted sufficient time to develop, as do attending physicians, to help inculcate a sense of medical logic, analytic ability, and judicious (as opposed to shotgun approach) diagnostic and management skills. We also very much need interventions, curricular as well as administrative, on comparative- and cost-effectiveness and “lean thinking,” and these interventions should be reinforced by working alongside attending physicians who value and practice such in addition to having a passion for patient care and teaching.6,8-12 These elements must be delicately integrated into our training while not jeopardizing the corner-stone of our growth and security—our autonomy. So what can be expected on this front from the upcoming ACGME duty hour changes?13 I find reassuring potential in the recommendation that, “the learning objectives of the program must (1) be accomplished through an appropriate blend of supervised patient care responsibilities, clinical teaching, and didactic educational events and (2) not be compromised by excessive reliance on residents to fulfill nonphysician service obligations.” I am also delighted to see that residents will be “expected to incorporate considerations of cost awareness.” Although these recommendations represent progressive priorities, they are likely much easier said than done; adjusting residents' schedules to conform with such marked duty hour regulations and ensuring that all work shifts and gaps in patient care are covered will alone be challenging enough for many programs, especially in the first few months to years after implementation. A vast majority of residency program directors share this sentiment, as suggested by the findings of Antiel et al. Having said that, I fully agree with McCoy et al that new paradigms of education (and supervision) will likely be necessary to ensure that resident learning is optimized. However, I have considerable concern that the development of such paradigms and the implementation of the aforementioned qualitative interventions will, at least initially, be highly vulnerable to the impending duty hour changes; it would seem that residency programs would benefit from either (1) more time to acclimate to and plan around the upcoming changes or (2) a data-driven, practical blueprint of how to simultaneously uphold the highest in patient care, resident learning, and sensitivity to medical societal strains while operating in tight confines. In conclusion, it is our duty, as residents, to understand that we are in fact members of the greater US health care system. We should learn how to provide medical care in a way that is tailored to the individual patient and also financially sensitive. Translating this into practice depends fundamentally on the nature of residency training, which sets the stage for how today's physician trainees will soon practice and steer medicine. Having recently gone through residency, I cannot help but wonder: How efficiently is this translation actually taking place? Is residency training and education keeping up with and adapting appropriately to the ever-changing face of medicine, and how will the new duty hour recommendations affect this process?