Education before economics.(Letters)

Dr. Lawrence G. Smith appears to admit that limitations of resident work hours are necessary. He also "strongly oppose[s] micromanagement" of work hours ("Limiting Resident Work Hours," Guest Editorial, May 15, 2003, p. 6).

His objection was that these changes will create hardships for training programs and cause a shift in values among residents. I submit that it is the former that is his essential concern and that the latter is a positive. His suggestion that "residency directors should present residents with the workload and the workforce rules, and let them come up with the best schedule" is indicative of the entrenchment of the idea that residents are indentured servants to maximize the economic benefit to the institution.

The Accreditation Council for Graduate Medical Education (ACGME) / Residency Review Committee has had long-standing and unenforced constraints, as has New York. Hospitals and program directors, citing finance and workload, push the limits, then push them again until hours are in the 110-120 range, leaving less than 7 hours off duty per day for the activities of daily living. Program directors who, as mine did, stand in front of resident staff meetings and announce that the rules are merely guidelines, and that the needs of the institution come first, are clearly proclaiming the true priority: economics, not education.

That economics guide the misuse of residents and others by hospitals was illustrated by an article in Clinician News (7[3]:1, 13-15, 2003), a periodical aimed at physicians assistants and nurse practitioners: "PA and NP salaries are simply too high for these clinicians to fill all the work hours that will be lost. A medical resident receives a stipend salary of approximately $40,000 per year, while most NPs and ...