Hopkins IM residency loses accred

[johnshopkins23]

That seems an unrealistic concern, and it's unfortunate that whoever is counseling your friend would circulate this rumor. Wherever you go, you will inevitably sign off to some residents who are not as dependable as others. Even at Hopkins, I know certain people with whom I have tended to take greater caution when signing out. I have seen nothing that would suggest that next year's Hopkins class will be any less competent than this year's intern class. Of course, the neurotics that we all are, we will always try to find some factor to distinguish between the very top programs, and, if that's the one, then so be it.

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[neglect]

There are two ways to which people respond to slavery other than the default of suicide. The first is to bow. The second is to fight. Most people respond with different combinations. Ny fighting, this ER resident is a hero to all slaves, everywhere, no matter what his motications, even if Linie (Guess which type) doesn't agree.

Do you say 'I am Spartacus' or do you just sit there - no matter what you're getting hung up on the cross. Every single day doctors just sit there, watching and waiting. Watching thier malpractice fees rise and compensation fall. Waiting so they can get into their little apartments and pay off another loan installment. Waiting to get out of residency and convincing themselves they're really learning by drawing that 100th abg, LP, line, tube.

Most other professional fields look at how hard we work, how we get paid (especially early on), and the business decisions we make - and laugh. The words 'stupid doctor' are redundant in most law and business circles.

But sometimes a general rule stubs a toe on an exception. This guy didn't just sit there watching and waiting it out. I say, next time you're sitting around having a beer with your resident buddies, raise a toast to the greatest one among us: pseudonym Toe Stubber, MD.

 

[boxdoc]

Well stated, Neglect!

Revolution, anyone?

 

[Dr. Lector]

"No, I'm Spartacus."

 

[boxdoc]

I couldn't agree with Neglect more. Why do we cower in the face of authority? Why do we hide out heads when facing the demands of a senior resident, a program director, a hospital administrator, an insurance company? Why do we shrink back, letting others make our decisions, directing our lives, and determining out future?

Medicine is full of intelligent, motivated people. It's also full of very large egos that pride themselves on getting ahead of the rest. They've gotten ahead by pleasing superiors. They've pleased undergrad chemistry teachers, pre-med advisers, supervising residents, program directors. It's why we are where we are. We are conformists, willing to conform to others' demands, willing to only ask, when told to jump, "How high?" We are told what to do to get where we want to go, and we do it, regardless of humiliation, regradless of injustice, regardless of sacrifice. We are the white collar slaves. We bow to demands, and we rarely stop to think about why we are doing the things demanded of us.

Those who do stop to ask "why?" are branded as troublemakers, as nonconformists, as unprofessional, as bad medical students or residents or physicians. Eventually, the residency system beats them down. It puts them in their place, it shapes their expectations, and it makes them submissive, accepting, powerless. It makes them a modern-day physician, or at least what insurance companies and HMO's envision a modern physician should be.

This time, though, someone asked "why?" Someone stood up to authority, and, in doing so, faced the wrath of Johns Hopkins Hospital. But, because of what this person did, the system may change, even just a little.

Hopefully others will stand up. Whether it be against malpractice coverage, against reimbursement, against residency abuses, against the millions of injustices plaguing today's medical practitioner. Because, as long as we continue jumping through hoops, pleasing authority--because that's what we've been trained to do--medicine will continue to spiral down to its impending crisis. And we--and only we--will be the ones to blame.

 

[Linie]

Linie, to say the person deserved it, well, I think I've heard that one before--in cases of domestic violence.

There are two ways to which people respond to slavery other than the default of suicide. The first is to bow. The second is to fight. Most people respond with different combinations. Ny fighting, this ER resident is a hero to all slaves, everywhere, no matter what his motications, even if Linie (Guess which type) doesn't agree.

It's very amusing that I'm being depicted as the flag-waver for unregulated work hours and all things bad, including demonizing the person who wrote the letter.

On The Letter-Writer: I NEVER participated in bashing this person. Not in conversation, laughing at jokes that were made, and I even refused to engage in naming names. And I discouraged other people from doing all of the above. Of course I heard what was being said. You can't stop 110 people from gossiping, esp when their program has been pulled out from under them. It's easy to understand their wrath. What you should do is lead by example, which is where our leadership fell down (big-time). I was not aware of conversations with the letter writer and the supervising residents, attending and EM PD prior to the writing of the letter. Until reading about it on this thread, I had never heard such a thing.

On Work-Hours: I AGREE WITH THE 80H RULE!!!! Okay? At least in theory. I just think that cracking down on a program for violations on July 9th is silly, counting hours is dumb too, and forcing people to leave before they have finished an adequate work up is ridiculous. But other than all that, working more than 80h is unlikely to add much to an education, provided that the time spent at work is on educational things.

What I haven't wasted time writing on this thread about is my frustration with the administration at Hopkins. Last Fall I put in a lot of effort to get the administration to work toward compliance. I was working informally with several other residents, interns, this years' ACSs (chiefs) to come up with solutions. My efforts were squashed by the PD and last years ACSs who showed little interest in trying out different systems, and a general lack of concern about what would happen if we weren't compliant. I even said to them, all you need is one unhappy person to complain and bring the whole thing crashing down... And guess what? I was all too right, but much earlier in the year than I expected.

Last May and June we discussed different solutions and made some changes. The math worked out to 80H, but it was never road-tested. It seems to me that if you are running a large program providing care to thousands of patients and education to over 100 people, you would want to make sure your system works.

When the letter to the ACGME came out, I was on vacation, which was a very good thing, bc I was furious. "I TOLD YOU SO" was what I was screaming inside.

I'm not two-dimensional. Please stop depicting me that way. You all are as bad as the people who bashed the letter writer.

Someone is my class who is applying to internal medicine has been told to think twice about hopkins.

This is my biggest fear. This is why I wrote into this thread in the first place: to provide at least one voice from Hopkins, and to dispell some rumors. I'm terrified of what will happen during recruitment. Hopkins is not flawless, but it is an excellent place to train. I hope it stays that way.

 

[johnshopkins23]

Unfortunately, Linie, we're in the same boat. We're the victims of this whole thing.

We're their victims because the JH administration (specifically, the PD and ACS's) was unwilling to prepare for the work hours regs. I'm aware of everything you've stated. I know all that. I was there, too. The administration looked at proposals and basically laughed. We tried. We knew what would happen.

We're the victims, as well, of the spin they've put on this whole thing. You didn't know about the whistleblower talking with residents, attending, EM PD because the JH administration didn't want you to know that. The larger medical community doesn't know the nature of the violations because Hopkins didn't want them to know that. It's all spin and PR, and that's what this whole reaction has been about--image, power, and finding a scapegoat. The whistle blower became that scapegoat.

I've never wanted to imply that you were involved in bashing this resident. It's just that so many of our colleagues were, and they felt they were justified in doing so. You simply alluded to that--that the reaction was to be expected. I'm not saying you were part of that reaction.

I stand by what I said before. I wish the administration would now recognize their errors, both before and after the report, and try to make some sort of reconciliation. Do they think we're *****s? We're pawns in their PR games? We've been threatened with loss of accreditation--with loss of our futures, our incomes, of everything we've worked for over the past 10 years--but we're seeing that those threats won't materialize. Still, those threats keep us quiet. And, of note, it's been the administration making those threats; as Linie noted, the ACGME never intended for news of the "loss of accreditation" to even reach us. It was, most likely, a means of slapping the administration on the hands, but was never meant to hurt us, as residents.

What has happened at Johns Hopkins Hospital is wrong. Residents have been caught in the middle. The administration needs to recognize their errors. Up to this point, they have not done so.

 

[boxdoc]

"Last Fall I put in a lot of effort to get the administration to work toward compliance. I was working informally with several other residents, interns, this years' ACSs (chiefs) to come up with solutions. My efforts were squashed by the PD and last years ACSs who showed little interest in trying out different systems, and a general lack of concern about what would happen if we weren't compliant."

That's pretty serious. I'm guessing if JH residents are at all hurt by this, they will have quite a few legal options available. Just a guess.

 

[smf]

girl whose father and mother loved very much. As much as all of your parents do or should do.

That young lady, a little girl, got admitted at a prestigious medical centre. A full on academic centre with residents, fellows, students.

That little girl died. A long investigation followed, top officials, academia, experts from several fields. After an exhaustive process it was determined that sleep deprivation and exhaustion significantly contributed to her death, which incidently was thought to be needless by impartial experts.

If that girl's (which could have been your sister your daughter, or you) father had not been a journalist and attorney the incident would have simply faded.

As a result work hours rules were initiated. Supervision rules were initiated. The rules try to protect the well being of patients and can also secondarily effect the safety of your medical license. You are less likely to lose it or lose a court battle if such cases can be prevented before they can begin.

Who believes learning only takes place after not sleeping for 36 hours? Eventually we all "sign out" and thus continuity of care is lost. Perhaps we need to stay up for the length of the entire admission as to not miss learning?


Yours truly,

Ms. Libby Zion

 

[droliver]

SMF,

actually if you review the case, the fact that the patient was not forthright about which medications & narcotics she was was taking was likely the sentinal event in the chain & delayed her diagnosis. The role of supervision (rather then fatigue) was the other most glaring series of events, and was also fingered in the recent sanctions on Mt. Sinai's transplant program. Both of these conclusions, I might add, have been refuted by the people in the know @ the programs. These two cases represent political solutions to bad outcome (rather then malpractice)

 

[smf]

Was that the effort to villafy the dead girl. If what you say is true then why would this case have led to the hours limitations and supervision rules?

The courts would have found that the care involved in the case met the "standard of care" because the patient withheld information.

Can you honestly say that you are 100% certain that at some point in time after not having slept for 30 or more hours, running around, doing admissions, doing scut, checking I/O's, following vent settings, abg's, chasing lab results on foot (pre-computer era), wheeling patients to and from studies, feeling like "night of the living dead" is less a fictional movie and more reality; that you have made an error that did or could have harmed a patient? I personally cannot say that. I have fallen asleep while driving post call and had it not been for hitting the curb of the highway, I might not be here now having this discussion.

I recall that feeling of being half alive/half dead, sort of like being in a "twilight zone"

This issue has been debated year after year. Funny, as the folks involved in post graduate education seem to make the continuity of care argument.

Simply put I say all those opposed to hours limitations should be regularly scheduled to fly on commercial aircraft maintained by, piloted by, and air traffic controlled by those who havn't slept for 30 or more hours.

PS; I did my training in the good old days when residents were real doctors and didn't sleep.

 

[droliver]

Originally posted by smf
Was that the effort to villafy the dead girl. If what you say is true then why would this case have led to the hours limitations and supervision rules?

The courts would have found that the care involved in the case met the "standard of care" because the patient withheld information.

PS; I did my training in the good old days when residents were real doctors and didn't sleep.

This case led to the work hours rules because of the bully pulpit her father has as a prominent journalist. It was a reactionary change to a very sensationalized case. There was in fact (I believe) no malpractice charge ever achieved in a verdict as I think the hospital settled the case.

PS- so did I

 

[neglect]

You know what has to be the biggest medical myth other than telling undergrads that being a doctor is great because you get to take care of people (nurses do that)? It is this entire idea of possibly learning ANYTHING about patient outcomes from continuity of care.

Take cards. PVCs are bad. Lets give heart attack patients lidocaine to stop the PVCs they always get - that'll make them better because less PVCs (bad) are better. And it worked: less PVCs. So everyone is giving their patients lidocaine with their MIs, and they have less PVCs.

But problem: someone follows something called the scientific method, only recently applied to our field of medicine and does something called an experiment. He looks at tons of patients and finds that although many individual patients do well with or without lidocaine, there are more in the lidocaine group that die - without PVCs.

So that's been done over and over, proving that aspirin is good for MIs and lidocain is not. And ALSO proving that doctors are blind to outcomes unless they are heading up big trials with big numbers.

I would also add that its probably dangerous to think that by observing outcomes one can learn anything while on the floor. Some of the patients on lidocaine do really really well. Just like some of the people with leaches do really really well.

In the haze of what we do, we miss the big numbers from which you can get significance and meaning. Probably 90% of what we do has no basis in science, we just infer it does because we think we know some physiology.

Continuity of care: nonsense. Its a myth designed by really smart people to make residents feel bad when we go home after call. And idiots believe it. I say, there is no spoon. Signing out,

the benign neglect

 

[boxdoc]

Yes, the Libby Zion case was most likely a springboard for residency reform, although investigators never proved that the death of Libby Zion resulted from resident fatigue.

From Kenneth Ludmerer's "Time to Heal:"

"Despite the years of review by various medical and legal groups, the cause of Libby Zion's death was never determined. The house officers in the main acted appropriately. They were not fatigued... Nevertheless, the grand jury did indict the system of residency training in the United States, and the case became a cause celebre for reforming graduate medical education."

The Libby Zion case most likely forced the public to scrutinize the medical education system, and, through that scrutiny, its problems became apparent.

"Robert G. Petersdorf, president of the [AMA], later expressed his regret that 'long-overdue changes in restructuring residency training were not initiated within our community prior to the serendipitous stimulus of the Zion case.' My wish, he said, would be 'that the profession had been more perceptive in recognizing the issue and making appropriate changes in training prior to its becoming a cause celebre.'"

Ludmerer continues:

"Overwork and exhausion did perverse things to caring individuals who entered medicine to serve....Not surprisingly, stress-related depression, emotional impairment, and alcohol and substance abuse were all well-documented phenomena among house officers....
"The residency had been created in an era when stable patients lingered in the hospital for long periods of time. By the 1980s, hospitalized patients were much sicker, the turnover of patients was much greater, and there was much more for house officers to do during a night on call....
"One problem with the regulations was that the arbitrary limitation of hours did not resolve the issue of house staff stress....The limitation of working hours, in short, said nothing about the larger issue of working conditions."

Libby Zion did not necessarily die because of resident fatigue, but the ensuing investigation exposed the glaring shortcomings of resident training--shortcomings that, for years, medical educators had failed to address. Fifteen years later, we're still struggling with this work hours issue. It seems there's much more to address. The medical community would be wise to comply with these work hours regs and move forward to address the larger issues facing resident training. Who knows when the next "Libby Zion" will come along and, once again, we'll be caught unprepared-- and with little progress since the 1989 investigation?

 

[droliver]

Originally posted by boxdoc
Who knows when the next "Libby Zion" will come along and, once again, we'll be caught unprepared-- and with little progress since the 1989 investigation?

There won't be another singular "Libby Zion" case that ensures change, rather its going to be the series of inevitable lawsuits that start to filter in on any death or bad outcome that occurs at a teaching hospital where work hours are called into question with the new ACGME rules now on the books. Institutional liability is going to push programs into punch-clock monitoring of work hours to insulate them from these issues.

 

[smf]

Originally posted by droliver
This case led to the work hours rules because of the bully pulpit her father has as a prominent journalist. It was a reactionary change to a very sensationalized case. There was in fact (I believe) no malpractice charge ever achieved in a verdict as I think the hospital settled the case.

PS- so did I

Are you saying (feeling) it would have been better had her father been a "nobody", had no "pulpit" nor ability to be outspoken, so the case probably would have been swept under the carpet like we all know NEVER happens.

Do you have children?

 

[Apollyon]

Originally posted by johnshopkins23
And, after all, the person's an ER intern. How much can we really expect from those people?

I was looking at this thread for another reason, and ran across this (so, sorry for bumping it up). There are two ways to interpret this: 1. The EM person is an outsider, not attuned to the intricacies and politics of IM or 2. EM physicians are inherently and intrinsically intellectually and morally inferior. If it is #2, we certainly don't have a monopoly on it; I was given evidence of same this week on an off-service rotation at a pretty high-powered place.

Character is often in short supply; I remain much more willing to be right than popular.

 

[njbmd]

Originally posted by droliver
There won't be another singular "Libby Zion" case that ensures change, rather its going to be the series of inevitable lawsuits that start to filter in on any death or bad outcome that occurs at a teaching hospital where work hours are called into question with the new ACGME rules now on the books. Institutional liability is going to push programs into punch-clock monitoring of work hours to insulate them from these issues.

Hi there,
We are already punching the clock and in compliance with the 80-hour work week here at UVa. Surgical education, especially for the interns, is really suffering because they just don't get into the OR. As the program continues to shift in order to stay in compliance, some of the scutwork things are going to be shifted to the mid-level practictioners. This has to happen or the folks who came in this year and the years to follow, will have a difficult time meeting their caseloads. This will get worse and not better as folks go up the ladder.

We try to keep one member of the team around for late cases and that member will come in later in the morning on the next day. We also give extra days off when the caseloads are light. All in all, we are staying in compliance with the hours but don't kid yourself, this is shift-work. If you spend 16 hours in the hospital doing a liver transplant, you are out the next day without exception. Other folks will cover your cases. We also go home during the day if things get slow so that we have the option of returning to work on late cases. A good day of incoming traumas can shift our entire surgical schedule to cases running late so we just adjust our times.

Since the RRC placed a mandate with little instruction as to how this mandate would be carried out, programs have been adjusting. For those who are out on the interview trail, you need to see just how your prospective programs are making the adjustment.

Post-graduate medical education has changed and we knew that it would. It will fall to the individual resident to insure that you are getting the best training possible. You have to be very pro-active about your education and make sure that you are getting the experiences that you need. With any change comes a degree of discomfort but with any change comes adjustment. Just make sure you are getting what you need to meet your requirements and get the best post-graduate training. Often the best solution is the one that you develop yourself. You can't always look to some of the program directors to provide solutions. You can work them out yourselves even if you are punching a clock.


njbmd

 

[smf]

Originally posted by neglect
You know what has to be the biggest medical myth other than telling undergrads that being a doctor is great because you get to take care of people (nurses do that)? It is this entire idea of possibly learning ANYTHING about patient outcomes from continuity of care.

Take cards. PVCs are bad. Lets give heart attack patients lidocaine to stop the PVCs they always get - that'll make them better because less PVCs (bad) are better. And it worked: less PVCs. So everyone is giving their patients lidocaine with their MIs, and they have less PVCs.

But problem: someone follows something called the scientific method, only recently applied to our field of medicine and does something called an experiment. He looks at tons of patients and finds that although many individual patients do well with or without lidocaine, there are more in the lidocaine group that die - without PVCs.

So that's been done over and over, proving that aspirin is good for MIs and lidocain is not. And ALSO proving that doctors are blind to outcomes unless they are heading up big trials with big numbers.

I would also add that its probably dangerous to think that by observing outcomes one can learn anything while on the floor. Some of the patients on lidocaine do really really well. Just like some of the people with leaches do really really well.

In the haze of what we do, we miss the big numbers from which you can get significance and meaning. Probably 90% of what we do has no basis in science, we just infer it does because we think we know some physiology.

Continuity of care: nonsense. Its a myth designed by really smart people to make residents feel bad when we go home after call. And idiots believe it. I say, there is no spoon. Signing out,

the benign neglect

Nice post!