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The Increased Financial Burden of Further Proposed Orthopaedic Resident Work-Hour Reductions
Atul F. Kamath, MD1; Keith Baldwin, MD, MPH, MSPT1; Lauren K. Meade, MS2; Adam C. Powell, MA2; Samir Mehta, MD1
1 Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, 2 Silverstein Pavilion, Philadelphia, PA 19104. E-mail address for S. Mehta: samir.mehta@uphs.upenn.edu
2 Aresty Institute (L.K.M.) and Department of Health Care Management (A.C.P.), The Wharton School, University of Pennsylvania, Philadelphia, PA 19104
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Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. One or more of the authors, or a member of his or her immediate family, received, in any one year, payments or other benefits of less than $10,000 or a commitment or agreement to provide such benefits from commercial entities (Current Opinion in Orthopaedics [publisher support]; AO Foundation and Smith & Nephew [speaker's bureau]; Wolters Kluwer Health — Lippincott Williams & Wilkins [publisher support]).

Copyright © 2011 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2011 Apr 06;93(7):e31 1-8. doi: 10.2106/JBJS.I.01676
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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.

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    Atul F. Kamath, MD, Keith Baldwin, MD, MPH, MSPT, Lauren K. Meade, MS, Adam C. Powell, MA, and Samir Mehta, MD
    Posted on October 12, 2011
    Response to Mr. Cawley's Comment
    University of Pennsylvania

    We thank Mr. Cawley for his interest in our original research study, as the topic is as timely today as when it was first published in April 2011. However, we must disagree with the reader’s unsubstantiated generalized statement that Medicare Part B billing for physician extender services necessarily offsets the cost of hiring these additional physician extenders. Data from our study demonstrates that hiring additional ancillary staff is a costly undertaking: across the thirty-six surveyed programs, the frequency weighted average cost was $96,000 per full-time equivalent unit – up to $110,000 for a Registered Nurse First Assistant [1]. While nurse practitioners and physician assistants may generate ancillary revenue, it is not clear from the reader’s personal opinion the amount or the significance of these added revenues, especially as they relate to orthopedic surgery, a largely procedural-based field. What Mr. Cawley also fails to discuss are the added costs of employment and other benefits for these physician extenders, which would only increase the total cost. The reader does not highlight the fact that different states have different laws regarding the practice pattern of allied health professionals. Finally, variability exists in how institutions may be using these individuals; for example, in-house floor “call” coverage versus utilization in the clinic area managing only post-operative patients. It is unclear exactly what Mr. Cawley is defining as billable. Perhaps he is referring to a “Medicare rebate” system he cites in an article published in Advance for NPs and PAs, which discusses the parallel expanding role of physician extenders in Australia [2]?Our sensitivity analyses represent an estimated cost range for changing work hiring patterns; it is not meant to be an exhaustive model of all possible cost factors. Such a model quickly becomes complex, and it may be too cumbersome to draw generalized conclusions easily. While revenue generated by physician extenders stands as but one piece of a complex – and ever-changing – model, it is unclear without concrete data what role this revenue plays in the overall cost scheme. Jones and Cawley echo this, as they discuss the changing physician assistant employment patterns, including a declining use of PAs as intra-operative surgical assistants [3]. Jones and Cawley themselves cite a systematic review on the role of physician extenders in acute and critical care settings [4]: the report calls for more data and well-controlled studies with respect to the contributions of physician extenders with respect to patient outcomes and financial implications. Jones and Cawley go on to cite a study by Mathur et al [5], which details some of the potentially cost-additive problems associated with physician extenders, such as high turnover rates in intensive-care settings. Per Jones and Cawley, there is “a paucity of literature reporting negative experiences in the use of PAs in residency training settings, ” add that “Missing from the literature is a recent and thorough accounting of direct and indirect expenses and opportunity costs…for subsequently hiring (PAs) as supplements for residents lost” [3]. They also cite a number of studies examining the midlevel practitioner-to-resident replacement ratio and associated costs: one study estimates a “worst-case” practitioner-to-resident replacement ratio of 3:1 [6]; another study estimated 1.5 non-physician practitioners would be needed to replace the hours worked by one resident [7]. Clearly, these factors may only increase associated costs, and “sustaining the presence of PA–resident teams has been described as the next great challenge,” according to Jones and Cawley. In our study, we did attempt to control for the potential confounding factor of increased attending staff or increased resident complement leading to increased costs per full-time equivalent physician extender hired. While Mr. Cawley’s statements are hypothetical, he does raise the issue that more data is needed to further characterize the economics of the changing orthopedic surgery workforce. While we support physician extenders as vital contributors to healthcare provision, without clear data by Mr. Cawley regarding the “productivity benefits” of the supplemental revenue garnered by physician extenders in the field of orthopedics, our model as published in The Journal remains largely unchanged. Variations in regional and economic climates, billing structures, and compensation issues must be carefully examined in further analyses. Lastly, we would ask Mr. Cawley to confirm his academic affiliation, along with any personal or professional conflicts of interest with the subject of the commentary – neither of which explicitly appears in conjunction with his initial opinions. REFERENCES: (1) Kamath AF, Baldwin K, Meade LK, Powell AC, Mehta S. The increased financial burden of further proposed orthopaedic resident work-hour reductions. J Bone Joint Surg Am. 2011 Apr 6;93(7):e31.(2) Cawley JF. Ups and downs for NPs and PAs Down Under. Adv NPs PAs. 2011 Jan;2(1):20. (3) Jones PE, Cawley JF. Workweek restrictions and specialty-trained physician assistants: potential opportunities. J Surg Educ. 2009 May-Jun;66(3):152-7. (4) Kleinpell RM, Wesley E, Grabenkort R. Nurse practitioners and physician assistants in the intensive care unit: an evidence-based review. Crit Care Med. 2008;36:2888-2897.(5) Mathur M, Rampersad A, Howard K, Goldman GM. Physician assistants as physician extenders in the pediatric intensive care unit setting—a 5-year experience. Pediatr Crit Care Med. 2005;6:14-19. (6) Green BA, Johnson T. Replacing residents with midlevel providers: a New York City-area analysis. Health Aff. 1994;14:192-198.(7) Reines HD, Robinson L, Duggan M, O’Brien BM, Aulenbach K. Integrating midlevel practitioners into a teaching service. Am J Surg. 2006;192:119-124.

    James Cawley
    Posted on July 11, 2011

    With regard to the paper by Kamath, et.al. 'The increased Financial Burden of Further Proposed Orthopaedic Resident Work-Hour Restrictions' published in the April 6, 2011 issue of The Journal of Bone and joint Surgery, I write to point out what I would regard as a fairly significant flaw in their analysis of cost. The authors make a case that, due to work-hour restrictions for residents, and the necessitated employment of NPs and PAs to compensate for the loss of resident staffing, sponsoring teaching hospitals will likely bear a substantial additional financial burden, and they go on to note that this 'unfunded mandate' should warrant additional federal subsidies to such institutions. Nowhere in the analysis is the recognition that hospitals can bill Medicare part B for the services of either PAs or NPs. This could significantly offset the costs of employment of the nonphysician staff thus negating the central thesis of the author's paper. I would be happy to provide additional comments.

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