Last July, leaders of Johns Hopkins Medicine's Internal
Medicine residency program received a complaint that the
program had violated newly enforced labor rules limiting
resident work hours. Program leaders "acted vigorously and
immediately" to adjust resident work schedules so as to
comply with the standards, according to Mike Weisfeldt,
chair of the Department of Medicine. Nevertheless, in
August the Accreditation Council for Graduate Medical
Education (ACGME) issued a summary withdrawal of
accreditation for the Internal Medicine residency program.
The action put Internal Medicine at risk of losing its
accreditation effective June 30, 2004. But Hopkins has
officially applied to the ACGME for a reconsideration of
certification withdrawal. At press time, on October 5, the
ACGME's Residency Review Committee for Internal Medicine
ruled after further investigation that Hopkins be granted
probationary accreditation. ACGME said the case would be
further considered by mid-December. Currently, the
department trains some 110 residents.
On July 1, new work hour standards adopted by the ACGME
went into effect, limiting residents to working no more
than 80 hours per week, averaged over four weeks. The
regulations also mandated that residents be on call in the
hospital no more than every third night; have at least 10
hours off between work periods; and have at least one day
off out of every seven.
Nine days into the new enforcement period, a new Hopkins
intern sent an e-mail to ACGME officials stating that some
Internal Medicine residents were working more than 100
hours per week. That complaint was forwarded to Medicine in
edited form. "The only work hour violation was in the
[Medical Intensive Care Unit], affecting four residents who
had worked every second night rather than every third
night," according to Estelle Fishbein, Johns Hopkins vice
president and general counsel.
Following a site visit, the ACGME announced its plans to
subsequently withdraw accreditation. That move came "after
a highly irregular telephone conference call that did not
comply with ACGME's own procedural rules," Fishbein points
out.
The ACGME's action surprised many Hopkins officials, who
countered that program leaders had rectified work hours
issues as soon as they were informed of the violations and
that they had so informed ACGME. An intensive independent
audit conducted September 8-10 concluded that Hopkins'
Internal Medicine program was in full compliance with the
duty hour rules.
The charges also pertained entirely to scheduling issues,
not to the quality of Internal Medicine's educational
program, which has always received stellar ratings, says
Levi Watkins, associate dean for postdoctoral programs and
chair of the committee that reviews Hopkins' residency
programs. Hopkins officials further note that there had
been no finding that the quality of resident education had
been seriously compromised; in fact, close to 100 percent
of Internal Medicine residents at Hopkins pass their Board
exams on their first attempt. The ACGME has received
allegations of work hour rules at several other residency
training programs across the country and is investigating
at least six of those, according to ACGME officials.
As Hopkins awaits further consideration of its
accreditation standing, residents and experienced doctors
across Johns Hopkins are still coming to terms with the
ACGME's new work hour rules, which were established to
prevent overtired residents from harming their patients or
themselves. Many people in the 9-to-5 workday world would
wonder why any resident would object to rules that limit
doctors in training to a maximum average work week of 80
hours. But many residents say the work restrictions run
counter to the culture of doctoring, where physicians are
accustomed to going home when their patients are
stabilized, not when the shift is up. "The hours have
generally been demanding," says John Dooley, a third-year
resident in Internal Medicine at Johns Hopkins. "But at the
same time they allow us to experience what we can and to
maximize our time. The long hours are what make us good
doctors."
"I think it's very reasonable to put some limit on work
hours," says Sigrid Berg, a second-year resident in
Internal Medicine. "The problem is that you [have to] set
an arbitrary limit. But if a patient gets sick with chest
pains [when I'm done with my work hours], do I transfer the
patient to another doctor who doesn't know them, or stay
and work 84 hours instead of the 80-hour limit?" Since the
task of a resident is to learn, as well as to practice,
medicine, some residents are concerned that the new work
hour limits will not give them enough time to experience
the variety and depth of cases and procedures they will
need to pass their certification exams.
Even before the ACGME work rules went into effect in July,
Johns Hopkins over the past decade has made many
adjustments to lighten residents' workload and hours.
Internal Medicine for example, introduced a hospitalist
service, in which teams of attending physicians and nurses
("hospitalists") take responsibility for the care of some
patients without requiring the help of residents. Medicine
also added 10 new resident positions. Cardiac surgery,
Watkins' department, is now sharing a fellow with George
Washington University, enabling an every-fourth-night
on-call schedule.
These measures have not been without added cost, notes
Watkins. The annual bill for the hospitalist service is
about $1 million.
Residency programs have also introduced a variety of
scheduling innovations to comply with the strictly enforced
ACGME work hour rules. Pediatrics has changed from a
schedule in which residents were on call in the hospital
every fourth night to one in which resident teams work
consecutive weeks of days only or nights only and do not
work both days and nights within the same week.
Program leaders are also introducing new technologies to
help residents provide continuous patient care and stay in
compliance with ACGME rules. Each resident will now be
provided a two-way pager to relay patient information as
they sign on and off from a work shift. In the next two
years, Hopkins is also planning to introduce a simulation
center to be used for a portion of residents' training.
Residents will learn aspects of medicine through videos,
computer programs, and simulations performed by patient
actors. The center is being developed, in part, to
compensate for restrictions on residents' duty hours.
Such technologies for learning medicine might appear
strange to William Osler, the first physician-in-chief at
Johns Hopkins, who developed the medical residency system
in which young doctors learn at the patient's bedside and
at the side of physician mentors.
Then again, so too might the notion of restricting
residents to 80 hours. — Melissa Hendricks