Hopkins IM residency loses accred

[Linie]

With due respect to the current Hopkins residents who are pawns in this issue, does anyone seriously believe July 2004 will come without Hopkins regaining its accreditation?

I wouldn't be surprised if JHU was picked to be punished out of a few non-compliant programs b/c ACGME wanted to make an example of a well known program. However, since all JHU has to do is re-apply next year, their punishment is effectively nothing but a warning / probation. If they fail again to comply with the work hours, then there will be consequences other then bad publicity. But ofcourse, that won't happen.

All this may turn out to be a tempest in a teapot- actually the ACGME advised Hopkins not to tell the IM residents about the loss of certification, leading me to believe that they fully intended to re-certify us as of July 1, 2004. So it may indeed have been a paper tiger after all. But of course it's still very nerve-wracking. We have intern recruitment coming up this Fall, and you can imagine how nervous it makes us. If I were applying for residency right now I might think twice (or more) about ranking Hopkins highly given the current situation. Fortunately, the whole thing should be concluded by the start of the interview season.

Come on thats absolute BS and you know it. The person who wrote the letter was just the starting point. The ACGME didnt just read the letter, say "OK they must be breaking the rules, their accred is revoked and thats that"

Actually, it's true that we were never before cited for work hours violations. Please contact them yourself and ask them about our past citations. And also, please tone it down a bit, you've been very rude with almost every posting. Try to think if you would be as comfortable speaking to our faces in the tone you are using as you are in this anonymous format.

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[DALABROKA]

Originally posted by edfig99
Then there is all this BS about "what about my personal life...." That does not play into residency. Residency is like the military -- you sign up for it, and you do as you are told and you follow their schedule. It's for a short time and after that you can do whatever the hell you want.

I think that the central point of the work hour limit is being lost amongst all of the hot tempers and rhetoric. What happened to the governing clause of "first, do no harm." It is admirable when residents want to stay with their patients through the course of the illness/trauma/post-op period. I'm quite sure that the continuity of care is very good when one is willing to sacrifice his or her own personal life, and sometimes health/sanity, to see a case through. However, if I?m not mistaken, the New York state resident work hour regs were enacted to lessen the occurrence of MEDICAL ERRORS that are associated with sleep deprivation following several high profile cases of exactly that. While I look forward to getting the best possible education I am able to, I have to remember that my personal gains cannot come at the cost of harm being done to a patient. We are all human and therefore ALL make mistakes. If working a few less hours means that the risk of injury to a patient via a mistake is less, then I?m all for it.

Originally posted by edfig99
What this system is creating is a bunch unknowledgable and unprepared (as well as unmotivated) yet well-rested and socially comfortable physicians.

If given the choice, I would take the well rested, socially comfortable physician over the stressed-out, wired, punch drunk resident that has been up for 36 hours straight. What good is all the knowledge you have acquired if you can't think clearly enough to apply it. I certainly hope that this argument isn't one of those "I did it so you should have to too" type things.

In regard to Hopkins, the ACGME may have done them a favor. Think of the alternative situation in which federal legislation is passed regarding the work hours. The fed's plan is MUCH more rigid and unforgiving and has many whistle blower protections built in. Think how hard it would be to work within that bureaucracy. If the ACGME doesn't "put-up" the fed's are going to take over. At any rate, the next couple years should be interesting!

DALA

 

[Linie]

If given the choice, I would take the well rested, socially comfortable physician over the stressed-out, wired, punch drunk resident that has been up for 36 hours straight.

I'm curious what you mean by "socially comfortable".

While I look forward to getting the best possible education I am able to, I have to remember that my personal gains cannot come at the cost of harm being done to a patient. We are all human and therefore ALL make mistakes. If working a few less hours means that the risk of injury to a patient via a mistake is less, then I?m all for it.

For the most part, after 36 hours, if your patient is circling the drain or someone else's patient is sick and they need help, adrenaline kicks in and you would swear you felt very energetic and well-rested. At that point, other residents (unit team) should be contacted, or the person you are signing out to should come see the patient with you so you don't have to stay for the next 12 hours, and so there is a thorough, relevent sign-out that allows a smooth transition of care and you can go home.

Most mistakes in medicine that I have seen have had to go through several steps before they are acted upon. For example I write an order for an inappropriate dose of heparin. The nurse checks the order, and the pharmacy reviews the order. Most often, someone catches the mistake before the heparin is given to the patient. When two other check systems fail, then the patient gets the wrong dose.

There's a line that is crossed somewhere with work hours. The old practice of making residents take in-house call for an entire weekend is too much (that's the weekend call that the Plastics resident had just completed when she quit on "Hopkins 24/7"). I'm not sure exactly where the line is (for me), but I know I have not crossed it when I'm told to leave no matter what's going on with my team or my patients at 30 hours.

There's also a line that programs have routinely crossed in the area of non-patient care duties of housestaff. It should not be the housestaff's job to transport patients who are not critically ill, make outpatient appointments, do routine blood draws, admit to and cover services on which there is no teaching, etc (these are other things that the ACGME looks at). At least at Hopkins, these non-work hour problems have largely been solved. I think that THIS is a very worthwhile area for the ACGME to regulate strictly. The work hours though should have guidelines, but not strict regulations.

The problem is that hospitals are financially strapped, so making the cheap form of skilled labor work more hours makes financial sense. Also the attendings trained with much longer work hours than us (but also with a very different patient load), so it may be hard for some of them to relate to what it's like in 2003 to take call. Because of the conflicting pressures on hospitals, work hours rules are necessary. What I'm not sure of is how to effectively regulate "guidelines" without it turning into strict and unbending rules.

Another issue that has not been discussed much (if at all) on this post is the purpose of the ACGME's involvement in the work hours issue. The federal government is very hot on this issue and would love to make the rules for us. The ACGME's purpose in this area is to make sure that the rules are made by physicians rather than by an outside, non-physician body. Physicians have dropped the ball in so many other areas (HMOs/insurance, malpractice insurance, etc). The work hours thing is one shining example of physicians taking charge of the situation and coming up with a system that works for us.

What is happening at Hopkins right now is that we have been made an example of. All programs are struggling to comply with the 80-hr week, and by shutting down the big guy, the ACGME is able to leverage a lot of pressure on the other big guys and the littler guys. And thus show everyone that they have clout and mean business. Hopefully with the end result of the Fed Gov does not get involved.

By mid-October, the result of Hopkins' "appeal" (not exactly an appeal) should be known. If the appeal is not successful, the "new program" that Hopkins will be applying for will be decided upon for certification by Dec15th.

 

[ERMudPhud]

Originally posted by Linie
And also, please tone it down a bit, you've been very rude with almost every posting. Try to think if you would be as comfortable speaking to our faces in the tone you are using as you are in this anonymous format.

I guess you've never met Macgyver before. He's typically loud, rude, and opinionated. The opinionated part is actually the worst since his opinions are frequently as poorly supported as those of the people he is yelling at. As for his opinions on clinical work hours its not clear that he has done any clinical work so his opinion on that probably should be taken with a grain of salt. My personal opinion (after a residency that included plenty of q2-3 >100hr weeks) is that decreased work hours is the wave of the future so we might as well learn how to make it work. Yes shift work and sign out can create a mentallity of just do the minimum until it becomes someone elses problem. We've all seen that. The challenge is to create a system that allows people a reasonable work schedule without teaching them to just keep passing the buck along.

 

[ckent]

Originally posted by ERMudPhud
I guess you've never met Macgyver before. He's typically loud, rude, and opinionated. The opinionated part is actually the worst since his opinions are frequently as poorly supported as those of the people he is yelling at. As for his opinions on clinical work hours its not clear that he has done any clinical work so his opinion on that probably should be taken with a grain of salt.

Agree with that assessment. He has reported in the past that he is a medical student, but even if he is, I doubt he has reached his clinical years or even second year given the content of some of his recent posts that I have read and responded to. He seems to harbor a lot of resentment towards doctors in general, which is confusing if he is a medical student. Anywho, I agree with the Hopkins suspension simply because I doubt that there would have been any other way to get them to comply with the new rules. I don't think that they decided to suspend Hopkins solely based on that one letter, I suspect that they did interview other residents/interns who, in a confidential manner, confirmed that they were not working anywhere close to 80 hr weeks. Remember that the 80 hr work week rule was not a rule made to protect residents (nobody cares about them), but a rule to protect patients from residents. Whether or not is effective at doing that is arguable, but I'm not going to argue against it as 80 hrs seems like a loong work week for me already. I'm not against working hard, I could live in the hospital and work every day if it were required (have nothing better to do), I just don't function as well when I lack sleep which I know that an 80 hr work week already requires you to occasionally do.

 

[IMRES03]

Where is the data to support the 80 hour work rule leading to fewer medical errors? Show me one good study that compares directly an 80 hour week versus pre-80 hour week and the outcome of more medical errors, worse medical care, etc. Not one study has been done thus far to support the ACGME's new regulations other than studies showing tired people make more mistakes. But how do we know that tired people make more mistakes than those made when shift work is forced in which multiple signouts are required? This is what bothers many people in academic medicine, if we are going to start enforcing these type of rules in the era of evidence based medicine lets first get some evidence. Not just some poorly designed study showing people who lack sleep make errors in some non-clinical scenario. I for one would rather have a Hopkins resident up for 30 hours reporting to an acute event on my mother versus someone who knows a one-liner on her any day.

 

[Mirror Form]

Originally posted by IMRES03
I for one would rather have a Hopkins resident up for 30 hours reporting to an acute event on my mother versus someone who knows a one-liner on her any day.

Having a Hopkins medicine resident who's only been up for a little over 30 hours reporting on you isn't that unreasonable; it's just a minor violation of the rules. I can sympathize w/ the JHU residents finding it frustrating to not to be able to bend the rules a bit. However, the scenario you described isn't why the rules had to be made.

I may only be a 3rd yr med student, but half the surgeons I work with talk about how they used to have to take call multiple nights in a row, and then be operating with virtually no sleep over the past 50+ hours (sometimes even much more). It doesn't take a randomized control trial to prove that will cause errors. In fact, it's really only common sense that sleep deprivation in general will cause lots of medical errors. Whereas, I haven't seen any reason other then speculation to indicate that shift-work causes medical errors (and shift work has been going on in in NY for awhile).

When the team members I'ved worked with sign out, they do a pretty good job detailing all the major problems and what has to be done. Not surprisingly, it gets done by their fellow team members everytime! Sure, maybe one resident will delay dis-impacting someone when it isn't urgent so the next guy has to do it. But, having non-urgent tasks delayed a few hours is nothing new to medicine, and it's far better than having more important things done wrong.

Furthermore, I find it hard to believe this idea that most residents will just adopt a "pass on the buck attitude," due to the 80 hr work week. The ones I've worked with so far sure as heck haven't, yet they only work 80 hrs per week! Maybe a few residents will adopt that attitude, but I doubt those types would have been anymore motivated to care about their patients if they were more sleep deprived and not allowed to ever go home.

The simple fact is that medical mistakes have been shown to be A MAJOR CAUSE OF MORBIDITY in medicine, and sleep deprivation has been linked as a significant cause. Shift work definitely hasn't been linked as a major cause of medical mistakes, and to assume that it's just as bad as sleep deprivation sounds kind of like a stretch to me. But ofcourse, as a 3rd year med student, my opinions are probably being clouded by what ACGME and the objective data says, as opposed to "just knowing what it's really like" from my own personal experience in one or two hospitals.

 

[droliver]

Originally posted by Sledge2005
The simple fact is that medical mistakes have been shown to be A MAJOR CAUSE OF MORBIDITY in medicine, and sleep deprivation has been linked as a significant cause. Shift work definitely hasn't been linked as a major cause of medical mistakes, and to assume that it's just as bad as sleep deprivation sounds kind of like a stretch to me.

You have it a little confused with this I think. It has been proposed in a very publicized article that medical errors are responsible for a very large # of deaths in America. The conclusions of that article (in re. to the magnitude of the problem) have been disputed as it was retrospective & very subjective on what they felt were decisions that caused a death. Many of the deaths involved pharmocologic issues & not procedural related deaths. There is to date I believe nothing that can point to sleep deprivation as an independent risk factor in this issue on a systemic basis. Its one of those seemingly intuitive things that has just kind of assumed a mantle of fact. There have been some prospective studies focusing on surgical trainees that showed some advanced laparoscopic skills lagged from fatigue on standarized skill testing, but this is not the same thing as saying "You kill people when you operate tired".

There have however been a number of papers over the years that do identify shift changes (be it Physian, Nurse, etc...)as sentinal events in deaths & bad outcomes. Witness this for yourself any day in the hospital with nurses ending shifts, any month as residents change services, sign outs b/w partners, changing ER shifts, new residents starting in July...you name it. My chairman of surgery used to pose the dilemma like this: Do you want a Doctor who is tired and knows you well or someone fresh who is unfamiliar with your care? There's a delicate balance between the real dangers of fatigued doctors & the inherant problems trying to effectively communicate what others need to know about patients. Inflexible ACGME mandates with the hours exagerate the former and downplay the later. There are a lot of very experienced people who feel this will not serve our patients well.

 

[neutropeniaboy]

Originally posted by droliver
There is to date I believe nothing that can point to sleep deprivation as an independent risk factor in this issue on a systemic basis. Its one of those seemingly intuitive things that has just kind of assumed a mantle of fact.

That's a loaded statement, fairly though.

I consider myself somewhat of an expert on sleep (given my past research in the field of sleep deprivation and OSA). Try these. They're interesting articles:

Richardson, et al. Sleep. 19:718,1996
Marcus, et al. Sleep 19:763, 1996
Steel, et al. Acad Emer Med 6:1050, 1999
Gaba, et al. Anesth 1998
Taffinder, et al. Lancet 1998
Friedman, et al. NEJM 1971

I'll let you draw your own conclusions, but it's not just "open to interpretation" whether sleep deprivation in post-call residents impairs their abilities to perform routine medical tasks, perform operative procedures, intubate patients, and run common algorithms.

On a related note, however, I wonder how many of these "go getters" who aren't complaining about the 100+ hours per week and its great educational value have actually done a surgical residency. Let's talk about on-the-job fatigue...

 

[IMRES03]

Originally posted by neutropeniaboy
That's a loaded statement, fairly though.

I consider myself somewhat of an expert on sleep (given my past research in the field of sleep deprivation and OSA). Try these. They're interesting articles:

Richardson, et al. Sleep. 19:718,1996
Marcus, et al. Sleep 19:763, 1996
Steel, et al. Acad Emer Med 6:1050, 1999
Gaba, et al. Anesth 1998
Taffinder, et al. Lancet 1998
Friedman, et al. NEJM 1971

I'll let you draw your own conclusions, but it's not just "open to interpretation" whether sleep deprivation in post-call residents impairs their abilities to perform routine medical tasks, perform operative procedures, intubate patients, and run common algorithms.

On a related note, however, I wonder how many of these "go getters" who aren't complaining about the 100+ hours per week and its great educational value have actually done a surgical residency. Let's talk about on-the-job fatigue...

Again show me a study that compares the restricted work hours with multiple signouts versus a system such as that at Hopkins that did not restrict work hours. You can make all kinds of assumptions that fatigue lead to medical errors but just the same not knowing the patient as well as the primary intern/resident leads to mistakes. A well designed study must be done to make sure that the changes we are making are justified as far as patient care is concerned.

 

[ckent]

I agree that studies need to be done in order to judge the quality of care given at institutions with better work hours and more sign out versus more work hours and less sign out, and I suspect that the writers of these new work policies were actually not physicians but rather the lay public administrators that thought that they were doing everyone a favor. I do not think that your anecdotal stories prove anything though, as I can offer my own anecdote. Who would you rather have taking care of you or in the OR operating on you, a resident who has been up for the last 30 hrs got 5 hrs of sleep before that, and was up for another 24 hours before that, and got 4 hours of sleep the night before that, etc., or someone who went home at a reasonable hour last night and the night before, and is feeling well rested after 8 hrs of sleep? Keep in mind that we are talking about the same resident, that knows you just as well in each situation. You have to remember that residents cannot be awake and working in the hospital 24/7; eventually, all residents, whether they work 100 hrs vs 80 hrs, must sign out to someone. Also remember that even with an 80 hr work week, when most of the tests/procedures are being done (high risk times), the resident that knows the patient the best is present. Why not have that resident be alert and awake during those high risk times, rather then having the resident be groggy, and careless during the high risk times plus times when doctors are just sitting around in the call room waiting to see if nurse will call them if something happens to their patient. I haven't worked in an ICU setting yet and I'm sure that it's different there, but on a general medicine floor, I noticed that even though I felt much more uncomfortable when I would be called about patients that weren't mine but I was covering for, most of the times, having a one liner was really all I needed to make appropriate decisions (ie the same decision the person who knew the patient best would make). With things like CP, hyper or hypoglycemia, fever, hypoxia, you don't need to know the whole hpi to know what to do here 99% of the time. Just knowing the basics should let you do the appropriate steps to get the patient through the night until the resident who knows the patient the best comes back, well rested, ready to figure out what needs to be done next. Even during general surgery, 90% of the surgeries done on patients who were admitted (not patients from the ER or trauma, as no one knows those patients who need to go to the OR except the person who is on that night) that I observed were being done were being done 7am -4 pm. I'd much rather that the surgeons be wide awake for the part in the OR, and they can just call the person covering for my surgeon while he is sleeping if I start experiencing chest pain.

 

[Annette]

CK, the voice of reason!

I did night float last month- covering for residents so they could go home, sleep, and have somewhat of a normal life. Very rarely was there anything I needed to do for patient care. The most complex thing was if a patient comes back from xray with a bowel obstruction, order an NG tube and a surgery consult. If at anytime I had a question, I could call an attending (and did! No one complained about the call, either). The only tricky bit was handing over admissions, and for the complex ones, the night float team went over the h+p, orders and plans with the team that was picking up the patient.

Thanks, neutropenia boy for posting those studies. I can't believe that some people are still arguing that they should work 100+ hours a week to be properly trained.

 

[neutropeniaboy]

Originally posted by IMRES03
Again show me a study that compares the restricted work hours with multiple signouts versus a system such as that at Hopkins that did not restrict work hours. You can make all kinds of assumptions that fatigue lead to medical errors but just the same not knowing the patient as well as the primary intern/resident leads to mistakes. A well designed study must be done to make sure that the changes we are making are justified as far as patient care is concerned.

Don't be obtuse; I know where you're going with this statement. You know no one can disprove you, because no such study will ever be performed. It's clear that you didn't even read what I offered up. We're not talking about assumptions here.

Your line of argument is that since there is evidence that what is present now is known to have flaws; therefore, until we have something that is proven to be better, we're going to keep the flawed system. Dumb.

I'll agree with you that at least I feel out of the loop when I have a weekend off, and when I come back, it's almost like the patients are entirely new entities. But when my complex base of skull resection patient has urinary retention or a fever in the middle of the night, I'd say a night float could handle that just fine...

On the other hand, I've done some emergent airway surgeries in the middle of the night, and I've felt my timing and depth perception to be off. And when you're doing a power weekend on facial trauma...forget it...you just get no sleep. One just doesn't have the fine motor skills and capability to concentrate in general after a sleep dept has been accumulated. This has been studied time and time again.

I don't know why you think that residents are somehow above this certainty.

 

[neutropeniaboy]

Originally posted by IMRES03
This is what bothers many people in academic medicine, if we are going to start enforcing these type of rules in the era of evidence based medicine lets first get some evidence.

That's a non-sequitur. How can one get evidence on a model that is never first put into action. You're declaring it ineffective before it has truly been assessed.

On this note, why don't you be the first to design such a study since you're eager to disprove it.

But, oh, how can we study this post-80 hr world if it's never instated. Ah. Oh. Hmmm.

 

[vuillaume]

Foxxy makes an excellent point. I do still think that there are major continuity issues, but these could well shrink to nothingness if all the time lost tracking down X-rays, filling out discharge paperwork, triple-checking that a study that was ordered and entered properly was actually going to happen, or phlebotomizing in a major medical center because it's not available after 3pm on weekends went away.

In the old days where we generally worked over 100 hours, how much of that time was actually spent taking care of patients rather making up for the inefficiencies of the hospital?

I confess that I dislike the 80h work week more for the visceral reaction I have that it makes being a physician feel more like shift-work job than a calling.

On the other hand, this is our reality; and I think we can make large strides closing the continuity gap if hospital administrators will help us do so by reconfiguring information systems so that inane, time-consuming paperwork could be automatically generated (is there any reason that any effort other than writing your signature should be expended on a discharge?). And I should not have to double check that a critical lab was properly entered, actually drawn, and processed.

On "light days", I find myself looking in on my patients all through the day--it just feels right. Every day should feel like these "light" days. Ninety-percent of what burns up my hours could be minimized if the hospital were willing to burn processor time rather than burn resident work hours.

 

[MacGyver]

foxxy,

if you know your program is violating the rules and yet you do nothing to notify the ACGME, then you have officially lost your right to complain otherwise.

 

[MacGyver]

Originally posted by Foxxy Cleopatra
It should make the opponents to the rule happy to know that there are many programs that could care less about abiding to the rules. I just finished a service where I never worked less than 120 hours a week and never left post-call before 6 the next evening. Honestly, I don't see things ever changing, either.

Things WILL change if the ACGME strips their accred and basically pulls the plug on their program.

I'd like to talk to smug fatcats who are in charge of your program--I bet they wouldnt be quite so cavalier about it if they knew that in the future only IMGs would be applying to their programs because they are not accredited.

things WILL change if residents would start doing the right thing and reporting violations. Look at Yale surgery--one of their residents complained and now Yale is at the forefront of hospitals in sticking to the regs and hiring PAs/NPs to do all the clerical/scut crap.

Your post is EXACTLY why the ACGME needs to be very harsh and severe in dealing with hospitals. Any other approach, by your own admission, would do nothing to solve hte problem and get these programs in line.

 

[Foxxy Cleopatra]

Originally posted by MacGyver
foxxy,

if you know your program is violating the rules and yet you do nothing to notify the ACGME, then you have officially lost your right to complain otherwise.

LOL- glad it's now "official."

Seriously, when I am needed (a.k.a, a patient is crashing, very challenging/elaborate cases) time is not a problem.

My issue is that if the system was more efficient (like vuillaume said, orders being carried out, the presence of efficient ancillary services) it would take a huge chunk out of the challenges we have now with compliance. It would also free our minds and hands up so that we could be more attentive to the subtle (and not so subtle) problems that come up with our patients.

At least that is how it would work in my idealistic, slightly jaded world.

 

[Jim Picotte]

Foxxy, I think if you're really working that many hours then something needs to be done. Someone will eventually report your program, perhaps a rotator through surgery or another resident when they hear about this. I did a surgery month last year before the rules went into effect and the program at my hospital was in compliance with all surgery residents and rotators leaving by noon the day after call with 4 days off a month. They started last January with the new rules to make sure they had everything worked out in time to be in compliance by July 1st. Whether people agree with the spirit of the new rules or not, programs will need to be in compliance...we do not want federal legislation. If the programs still don't comply even with the new rules there will be federal legislation. If we continue to be so arrogant and scoff at the rules there will be consequences that are worse than what we have now. Patients do not care about our education, they are worried that we're working over 80 hours a week and having so much responsibility in their care. They do not care that there are multiple checks for mistakes or that there may be more mistakes with sign outs (sign outs must happen eventually, we can't work constantly...so get better at doing them).

Here's the proposed federal regulations:

Sen. Jon Corzine's bill would limit resident work hours to:

24-hour maximum per shift
80-hour total per week
10 hours off between shifts, minimum
One day off out of every seven
On-call duty no more than every third night
The measure also includes:

A maximum penalty of $100,000 per program for violations
Protections for those reporting violations
Unspecified funding for compliance costs

You can see there is no "averaging" per the federal rules, it's absolute and instead of 30 hours we'll only have 24 hours a shift nothing longer. Of course the federal rules would give some money for additional PA/NP's which would be nice.

 

[IMRES03]

One big problem about averaging is that it directly affects our lifestyle. I don't know about you but to have a golden weekend is really nice. If the programs cannot average that means that you have off maybe one weekend day per week instead of having at least one golden weekend per month with the payback of working one complete weekend. It is hard to do much with one day off but with two in a row at least you can head out of town for a couple days.

 

[IMRES03]

Originally posted by Jim Picotte

24-hour maximum per shift
80-hour total per week
10 hours off between shifts, minimum
One day off out of every seven
On-call duty no more than every third night
The measure also includes:

.

These references are one of the major problems here. We are not or I would hope working SHIFTS. This is not a job but a profession.

 

[WatchingWaiting]

Re: We are not or I would hope working SHIFTS. This is not a job but a profession.

I'm sorry to break this to you, but 24 hours would not be termed a "SHIFT" by any person in any other profession. Would you be happier if the phrasing were, "No more than 24 hours of consecutive work so you're not functioning with the same level of performance as a person with a .1% blood alcohol level?"

 

[dr.evil]

I think THE BIGGEST problem with reporting your own program of work hour regulations is that you are absolutely screwing yourself and your fellow residents.

Who wants to be an internal med resident at Hopkins right now? It sucks. These guys are working their tails off and now their program is not even freakin' accredited because someone inside the program ratted out the program. That just sucks.

How does that help you personally in your career? I know it's selfish to think about yourself when reporting the failure of your program to comply but let's face it, we're all in this to finish our goal. Reporting your program could put a dent in that plan. The reporting system sucks. The RRC needs to give people a little time on the inside to adjust prior to making it public that they are pulling someone's accreditation. Maybe they did and I just don't know. Either way, I'll just put my head down and power through, right or wrong.

 

[daddymd]

Even worse than screwing your program, is screwing yourself. After the whistle blower at Hopkins complained to the ACGME, the medicine folks at Hopkins were berserk trying to figure out who did it. It didn't take long since the ACGME had returned the whistle blower's letter of complaint to the program director (minus the person's name) but the description of the work conditions was such that it didn't take long to deduce who it was. The letter was sent to all the medicine housestaff by the medicine pd. The work place became so hostile once the identity of the whistle blower was known, that the person resigned from their residency position within a few weeks.

Despite Linnie's assertion that Hopkins doesn't have problems with work hours, Hopkins was cited both in 1996 and 2000 for violations. Furthermore, I'd like to hear her response regarding the whistle blower's assertion that the schedule for the medicine service this intern was on was Q2 the entire month, having worked nearly 130 hours for two weeks with the same schedule planned for the next two. How is that even close to the ACGME's limits?

 

[MacGyver]

Furthermore, I'd like to hear her response regarding the whistle blower's assertion that the schedule for the medicine service this intern was on was Q2 the entire month, having worked nearly 130 hours for two weeks with the same schedule planned for the next two. How is that even close to the ACGME's limits?

Good point. This makes it crystal clear that not only was Hopkins ignoring the regs, they were flagrantly violating them.

Clearly they have no respect for the regs, and need to be punished severely.

If there was a way to punish the program without punishing the residents, then I'm all for it. Unfortunately, thats impossible.

 

[Z]

Having just finished a surgery residency with 2 years for research I feel I have some legitimate perspective on the work hours issue. In my view, reducing the amount of non-educational work that residents do to make the hospitals run efficiently is the first thing that should be done to reduce the workload. As several people have alluded too, this is a real and almost universal problem.

Also, I think it is unreasonable to MANDATE duty hour restrictions. We do not work shifts. Patients get sick at all hours of the day and night. If I know the patient then I should be taking care of them in their hour of need. Maybe I am the one who knows that the patient does best with a PCWP=16 and CI=3.4. Sometimes it is not numbers at all. Sometimes it is just looking at Mr/Ms so and so and knowing that they just do not look right. Instead of limiting work hours and potentially compromising continuity of care I believe that we should look at the issue from a protected time off vantage point. A mandate for a weekend off a month or 2 weekends or 4 days/month or whatever would be more practical and the regulation would be easier for programs to implement. This is more like the real world anyway (at least as far as surgeons are concerned). Just my two cents.

 

[Linie]

It didn't take long since the ACGME had returned the whistle blower's letter of complaint to the program director (minus the person's name) but the description of the work conditions was such that it didn't take long to deduce who it was. The letter was sent to all the medicine housestaff by the medicine pd. The work place became so hostile once the identity of the whistle blower was known, that the person resigned from their residency position within a few weeks.

My response is to ask you why do you think the workplace became so hostile?

This is taken from the ACGME website- http://www.acgme.org/ResInfo/complaint.asp
Persons making such complaints should be aware of the options available to them, either as an individual or as a member of a group, for expressing concerns. These options are listed below in the recommended order in which they should be utilized depending on the complainant's relationship to the program. The options are as follows:

1. contact the program director;
2. contact the institutional graduate medical education committee or similar oversight body;
3. contact a) the institutional resident organization, or appropriate peer review group, if one exists; or b) contact the resident physicians' section of the AMA, if appropriate;
4. contact the appropriate Residency Review Committee (RRC).

In the section on confidentiality of complaints (same website):
Complaints related to non-compliance with a standard, are brought to the attention of the Residency Review Committee without revealing the name of the complainant unless the person has specifically stated in writing that it is permissible to reveal his/her identity. If confidentiality is appropriate, all communication with the Residency Review Committee, the program director or site visitor will maintain this confidentiality. If the criticisms are vague as to the situation that is in alleged non-compliance, the Executive Director will ask the complainant to provide more specific information before bringing the matter to the RRC.

My point is that this person had other options available to him/her, but chose to write a nasty letter to the ACGME. I guess you can blame the ACGME for sending a version of the letter to Hopkins that did an inadequate job of hiding the person's identity.

Furthermore, I'd like to hear her response regarding the whistle blower's assertion that the schedule for the medicine service this intern was on was Q2 the entire month, having worked nearly 130 hours for two weeks with the same schedule planned for the next two.

The intern most certainly was not on a Q2 schedule. All interns are Q4 on inpatient (non-unit) services. Period. The residents were Q2, as they have been for umpteen years during the first 2 weeks of residency, to provide one-on-one supervision of the new interns. During this time, the residents do not admit patients themselves at all, nor do they cross-cover. They are there as back-up when the intern needs help. The second two weeks of July, the residents go to Q4. I'm not saying the first two weeks of Q2 are a breeze for the residents, but I slept 7 hours straight in-house on at least one occasion because my actual patient duties were limited.

Despite Linnie's assertion that Hopkins doesn't have problems with work hours, Hopkins was cited both in 1996 and 2000 for violations.

Sorry- I did get that one wrong. Hopkins was cited in 2000 for not having 4 days off in the CCU. That was changed after the citation. That was the ONLY work hours citation from the RRC review. I'm not aware of any citations in 1996, please enlighten me.

A lot of postings on this thread have described absolutely miserable work circumstances with excessive hours (120+), little educational value to the time spent at work because of clerical duties, transport, etc. If there's a role for strict enforcement of the rules, it's at places like that.

 

[Linie]

Furthermore, I'd like to hear her response...

How do you know I'm female? Are you at Hopkins?

 

[MacGyver]

Originally posted by Linie
How do you know I'm female? Are you at Hopkins?

Uhh... I think its quite obvious from your name. I dont know you at all but from your posting I knew that you had to be a woman (or either a very confused gay man)

 

[pathdr2b]

Originally posted by MacGyver
I knew that you had to be a woman (or either a very confused gay man)

This from the guy that thought I was a guy. So now let me see how this works, post on SDN in a "sympathetic" way and you're a woman or a gay man. Post with "balls" ( as I must have done before since you thought I was a guy), and you must be a man or should I add, a gay female?

FYI, I agree with you on the Hopkins issue but I'm on the fence when it comes to surgical residents. How can you train to be a good surgeon working only 80 hours/week?

 

[buggymd]

You can train to be anything in 80 hours a week period. You just need to be actually doing surgery, not all the other crap that we residents have to do, as has been talked about previously.

I would report my program, we have to, or nothing will change. If your program is violating the rules, then you shouldn't be there. There are places that are doing the right thing, in terms of hours, you just have to find them.

For many years residents have just been cheap labor for hospitals and the work hours have been legitimized by saying that we are being educated and trained, I am sure that this is all just a bunch of crap. There are few people out there who are committed to education. I personally think that it's all about the money!

 

[Linie]

Yes, I guess my name does sound female.

 

[soon2bdoc2003]

just thought i would add my 2 cents... at my IM prelim an average week on the floor gets me in at about 60-65 hours. We have night float covering 9pm - 7am 5 nights a week so we only do overnights fri. and sat. nights. we cap at 5 h&p's and 8 new admissions total per call, 12 pts max per intern and and these caps are strictly enforced. Regular day for me right now is 8am-4pm, and until 9pm on short call. So out of my 8 hour regular day 4.5 full hours of it is dedicated to teaching and this is also strictly enforced by the PD. I just cant imagine how getting scutted to death putting in an additional 50 hours a week would improve my training over what I am getting now.

 

[hndrx1a]

HEY, SOON2B...SOUNDS LIKE YOU PICKED GREAT PROGRAM; MIND SAYING WHERE YOU GOT IN?

 

[chef]

i understand 4th yrs medstudents can still apply to hopkins IM this yr, but what about graduating 4th yr IM hopkins residents? can they apply to IM subspecialties this yr?

 

[Linie]

i understand 4th yrs medstudents can still apply to hopkins IM this yr, but what about graduating 4th yr IM hopkins residents? can they apply to IM subspecialties this yr?

I assume you mean people applying for IM subspecialty fellowships? (Which by the way happens during second year residency, 18 months before the fellowship would start. Also IM residency is a 3 year, not 4 year stint, although there's talk of making it 4 years...)

I'm sorry for being so dense, but I don't understand if you're asking if people currently in the Hopkins IM residency can apply for fellowships because they may be losing their certified program, or can people apply for fellowships at Hopkins to start 7/04 because the fellowship programs would lose certification too. I'll answer both questions!

Junior residents at Hopkins can apply (and are applying) for fellowships at Hopkins and elsewhere. However, if the decertification goes through as of 7/1/04, and there's not another certified program in it's place (which is unlikely to happen) those residents won't have completed a certified residency by 7/05 (when their fellowships would be starting), and therefore they won't be eligible to do fellowship. I heard a rumor that if Hopkins IM residency is decertified, Hopkins would have to pay for all the people who lose their program part way through to finish residency at another institution. I don't know if that's true though.

As for applying to the Hopkins IM subspecialty fellowships, as long as there's a certified IM residency on 7/1/04, there are fellowships on 7/1/04. No IM residency, no fellowships. For now, the plan is to procede with the fellowship recruitment process, accepting applications according to the usual schedule. The final decision about Hopkins' appeal will be made in late October. If the appeal is denied, the application for the new residency program will be reviewed before fellowship applicants are making their decisions.

 

[johnshopkins23]

Much seems to have been made of the original complaint submitted to the ACGME. Dr. Charlie Wiener, JH IM PD, directed the distribution of the original email to the IM housestaff one week before the ACGME site visit. Here is a copy of that email, with email addresses and extraneous information removed:

Sent: Wednesday, July 23, 2003
Subject: FW: Duty Hour Complaint to ACGME

Sherelle, can you forward this to the housestaff? Charlie wanted us to let the housestaff see this finally. Phil

This is a copy of the original email and letter to us from the ACGME that we received the day before implementing the changes in the current call schedule. After letting the ?new system? settle in for a bit, we thought it was time that you guys and girls all have the same information that we have.

I just want to thank you all for trying to make this system work. We all know that it has its faults and will someday be modified, but this letter will clue you in to the necessity and the urgency that we felt upon first receiving it. Phil

----Original message----
From: David Leach
Sent: Thursday, July 10, 2003


Levi Watkins Jr., MD
Associate Dean of Postdoctoral Programs
Johns Hopkins University School of Medicine

Dear Dr. Watkins:

The Accreditation Council for Graduate Medical Education (ACGME) has received several complaints over the past several days through the ACGME Complaint Procedure available on our Website. These complaints detail allegations of failure of the Johns Hopkins University School of Medicine and its Program in Internal Medicine to comply with the ACGME requirements on resident duty hours.

This is an issue that ACGME takes very seriously. I am attaching a copy of one of the complaints with the name of the sender and any other identifiers removed. Because of the seriousness of the allegations I am asking you to provide ACGME with a detailed response for each of the infractions alleged. We will need your response by close of business on Wednesday, July 16, 2003.

To avoid delays we would prefer your response by e-mail. Please call or email if you have questions.

Cordially, David

David C. Leach
Executive Director
ACGME

Sent: Wednesday, July 09, 2003 2:52 PM
To: Marsha Miller
Subject: Johns Hopkins Violations

Dear Ms. Miller-

I am writing to outline the Johns Hopkins Hospital Department of Internal Medicine violations of the new ACGME work hours violations.

The violations are as follows:

-Junior and senior residents are on a q2 call schedule (every other night) this month. Residents typically work between 30 and 36 of every 48 hours. During the first week after the July 1 deadline, residents work upwards of 130 hours. The schedule has continued this week. In order to comply with ACGME requirements (based on averages over a 4 week period), residents will have to go to a q 4 call schedule and work 30 hours per week during the second two weeks of the month. Obviously, this is not going to happen. Residents do not have any days off this month.

-Medical ICU residents take call every second night. Residents take call for a twenty-four hour period, beginning at 8 a.m., round with the second team the following morning, leave close to 12 noon, and return the following day for call again.

-Interns regularly work 32 to 36 hours on call. Interns have been informed that pre-rounding does not count toward hour requirements; although an intern may arrive at 6 a.m. to preround on patients, the administration begins counting work time at 8 a.m. Interns are then supposed to leave the hospital the following day by 2 p.m. Rarely has this happened. Following a call day, interns typically leave the following day at 4 p.m., or even later, essentially making for 34 consecutive work hours. Interns have been guaranteed two days off this month, with a potential for two additional days off, workload permitting. On floor services, the administration seems to have placed most of its emphasis on at least approaching compliance with interns, while completely ignoring compliance requirements for work hours among second and third year residents.

My colleagues have expressed a sort of hopeless frustration with the work hour requirements; they are in awe at how the program can so blatantly ignore the regulations, yet their position does not allow them to speak out about the violations. I have spoken with my attending physician about the violations, but I have yet to see any changes to assure compliance, particularly among junior and senior residents,. From my own perspective, I certainly have been frustrated by the work hour demands; during my first week, I worked over 100 hours and spent 32 and 34 working consecutively during my call periods.

The violations are extensive. I am hoping this letter is helpful in outlining the violations. I know the ACGME regulations have been hailed as the greatest change in medical education in decades. At Johns Hopkins Hospital, very little has changed.

 

[johnshopkins23]

bump

 

[P Diddy]

so who do you think they'll go after next?

will it be west coast, since the east coast has already been hammered?

will it be FP, for if an FP program goes down then no one is safe?

or will it be you, Clarice, listening to the awful wailings of the slaughtered lambs?

 

[boxdoc]

My guess is that they'll "go after" a program in violation of the regs (as this program obviously was) with someone willing to report those violations (and who, hopefully, doesn't have to face what this whistle blower apparently faced).

 

[johnshopkins23]

I, for one, hope other programs can respond with more maturity than we have. I've watched the things that have gone on here, and I've just been amazed. Of course, like everyone else, I'm stuck with venting on this thread, anonymously, because I depend on these guys for my recommendations. Let's face it, we're all scared to death. Best to just put your head down and put up with it and get out.

I've talked to a number of medicine and ER people, though, and think I have a pretty good idea of what happened. First, I don't agree with the person writing the letter, and, like everyone else, I think the ACGME is just trying to make an example of us. But is there any question we were in violation? We were all there. We knew the talk around the hospital: surgery's in compliance, but medicine isn't even close? And DATO? Come on. One guy to cover scut for the O and try to get interns out by 2. And that doesn't even address the q2 stuff.

You can't blame the ER intern, either. I don't know where people came up with this idea that s/he didn't follow the "ladder," but a number of people with whom I've spoken tell me that s/he spoke with his/her supervising residents, attending, and PD before contacting the ACGME. I think the letter alludes to that. One of his/her residents was apparently very vocal with his/her disgust with the whole situation at that time, with the hours and failure to prepare, etc. And, after all, the person's an ER intern. How much can we really expect from those people?

The bottom line is this: someone was going to report us. We all heard the PD's sighs of relief: "Thank God it wasn't one of ours." So this person becomes the scapegoat.

The blame needs to go where the blame is deserved: on the administration. Enough of this "the rules are complex and subtle" s@#t. So what if the ACGME hadn't cited the MICU q2 schedule before? I travel 80 down 83 every day. Just because I haven't gotten a ticket yet, does that mean I wasn't speeding? Let's get real.

I hope, in the long run, the program is better for this. The sad thing is that it could have been better without all this mess. Hopkins is a great place. Let's face it. They could have done things last year to make things more efficient. It's obvious that compliance just took a little effort. After all, we're compliant now, aren't we (OK, close, anyway, but who's going to say anything?). Just put a little fire under their feet, and they move.

Why did the PD go after the whistleblower? Why did we do it, too? Linie, to say the person deserved it, well, I think I've heard that one before--in cases of domestic violence. The person had a right to report. S/he was the only one willing to do so. We all knew what was going on.

Maybe now that things have calmed down a bit, and we're pretty sure we're not all going to be on the street, panhandling in Patterson Park, we can give this some rational thought. What went on at Hopkins was immature, unprofessional, and wrong. And I know I'm not the only one who thinks that.

 

[MacGyver]

hopkins23,

thanks for posting the email. I think that makes it obvious that all of the claims are false:

1. Hopkins was "almost" in compliance
2. The rules are too complex and confusing
3. It was just a one time violation
4. Hopkins was making a good-faith effort to comply

Clearly, Hopkins KNEW what the rules were, and had NO intention of following the rules.

 

[johnshopkins23]

Oh, and another thing (sorry to ramble on here). It seems to me we've all been taking issue with the legitimacy of the work hours regs. I'm not a big fan, personally, but something has to be done to bring this system under control. Residents have been abused for too long, and, while conditions have improved at Hopkins, we're not called "Osler's Marines" for nothing. If people had issues with the regs themselves, these should have been addressed long ago, not after the regs went into effect. Again, Hopkins has always been a leader in medical education. Why were we so reactionary on this one?

 

[droliver]

The blame for this fall squarely on the program director as I see it. Everyone had plenty of warning about the new rules & had the oppurtunity to work things out prior. We started renovating our surgery schedule more then 2& a half years before this to get the kinks out before this July. It's not as if Hopkins doesn't have the endowment to cover some of the costs associated with hiring new allied health professionals to be in compliance, a luxury I might add which is not feasible to all but a few other places with that institutions wealth.

I do feel however, that the letter from this ER resident was pretty inappropriate & they have paid the professional costs of their poor judgement with a predictable backlash. They should have gone thru their E.R. program director to have things addressed via those channels then go running to the RRC. She should have also made sure she was going to get backup from her peers on this. Note: with none of these observations do I mean to blame the victim here. I just think it was a pretty bad political decision!

 

[johnshopkins23]

Predictable backlash? Unfortunately, yes. Appropriate, professional, and ethical? No.

We're all bound to make moves that are politically unsavvy, particularly as first-month interns. Such a move, though, does not justify the reaction this resident received (which, I might add, was more than a few dirty looks while running scut).

The reaction was not only from residents, either; the administration played a role in this. After all, why send the whistle blower's letter out in the first place? It revealed his/her identity (based on the conditions the individual reported-- it was no secret the service s/he was on), and this was only one step in several of which I am aware.

As I understand it, as well, the whistle blower had a very frank discussion with the ER PD before s/he wrote the letter, and was basically told that ER had no influence over what happens in medicine. Such is the nature of the very decentralized structure of the Hopkins system.

And, yes, the blame should be placed where appropriate. Fair warning was given. The PD should accept that blame, try to make some sort of reconciliation, and move forward.

Okay, I think I've said enough. Deep breath. Glad to get that off my chest.

 

[boxdoc]

Some very interesting points made by all. Maybe the truly politically unsavvy thing is in talking to ANYONE at the institution. If you know others have already addressed the issue, and they're not doing anything about it, what's the use in bringing it up with them? By doing so, you're just setting yourself up (as I would imagine this individual did). "Hmmm, this intern recently spoke to me about her issues with the work hours violations. Now the ACGME is sending me a letter that sounds a helluva lot like what she said. I wonder who wrote this?" No, not a very politically savvy move. Sounds like this person tried to talk to some people, hit dead ends, went to the top, then got nailed because they tried to folllow the ladder initially. That's my take on the whole thing, anyway.

 

[Idiopathic]

The whistle-blower had to know that s/he would get roasted over this. And s/he still did it. Bad political move, bad career move...maybe. But we should all strive to have this kind of sac, if it truly is a case of standing up for one's self, rather than an issue of revenge or bitterness.

 

[droliver]

Less then 2 months into a residency, I would suspect the later....

 

[boxdoc]

Maybe it was the latter (bitterness and revenge). Let's suppose for a moment, though, that this individual believed strongly in the importance of work hours regulations, that s/he saw his/her internal medicine colleagues getting slaughtered, that s/he heard their bitching, and s/he stuck his/her neck out for them by reporting to the ACGME (and knowing, despite the rumors that may have been circulated about loss of accreditation, that, in the end, the program would be better for it, and residents would not be hurt). Maybe this is assuming too much, but, if this were the case, such action would be truly noble.

 

[Thewonderer]

Someone is my class who is applying to internal medicine has been told to think twice about hopkins. It is not that the program will not be good but if it comes down to Hopkins v.s. B&W or even Wash U in St. Louis, why go to Hopkins when your intern class might be weaker than usual and your work hours/efficiency might be affected by the weaker interns who sign off to you?