Sunday, September 07, 2008

Residency work hours

There is a good story by Liz Kowalczyk in today's Boston Globe about the difficulty we have had in enforcing the work hours rules for surgery residents. As in other areas of our hospital management, we have tried to be open and above-board about areas of deficiency and how we attempt to remediate those. So when the reporter called us on this issue, we disclosed all of our information, even though the Accreditation Council for Graduate Medical Education does not even release names of programs that are under review.

The fact that "9 percent of the total number of programs, including 19 surgery programs" around the country have faced similar programs is not an excuse for our failure to meet this national standard, and we believe we have taken actions now that will ensure our compliance.

Perhaps those of you involved in running residency programs who are reading this would like to comment on your successes and failures in meeting the ACGME standards. Perhaps, too, some residents out there would like to comment on how it feels from your side.

15 comments:

Lachlan Forrow, MD, FACP said...

Paul:

Once again BIDMC makes me proud, even when the news is about things we are not at all currently proud of!

I was of course initially concerned at today's front-page Globe headline -- "Beth Israel cited for residents' long hours: facing review for accreditation." Not the kind of thing the Director of Ethics Programs wants to read about his hospital, especially when I spend a lot of my life with our residents stressing how thoroughly BIDMC is a "values-rooted" institution!

But reading further my anxiety quickly flipped into pride once again at the exemplary openness/transparency and public accountability of my medical center: "The council does not release the names of programs that are cited; Beth Israel Deaconess provided the council's letter and details of its violations to the Globe..."

I felt especially grateful to Dr. Scott Johnson for the way he so openly and thoughtfully represented us and the openness with which we acknowledge our problems, and the seriousness with which we address them. I have known Scott for years as an extraordinarily skilled transplant surgeon, and a wonderfully reflective colleague during many difficult cases where we grappled with figuring out the right thing to do for a patient here. I often get copied on surgical notes where he or one of our other great surgeons has been up most or all of the night saving a patient's life. I didn't know that on top of all that Scott was responsible for leading our surgical residency training programs!

I actually feel increasingly sorry for people working in places still operating with a different, old-way ethos, where spokespeople so often (as in today's article) are in the position of "She said she could not provide more details..." I hope that in today's case that "could not" was only because the request for information came with the reporter "on deadline". Maybe in the future that will always be the case in health care??

Let's continue to hope that other institutions come to understand what all of us at BIDMC are coming to appreciate more and more each time we are in the news in this kind of way -- that this kind of transparency is not only simply the right way to be, but also has benefits for staff morale and pride, and helps drive improvements that will make us even better than we are already.

As Albert ("my life is my argument") Schweitzer taught -- "Example is not the main thing in influencing others; it is the ONLY thing."

Lachlan Forrow, MD
Director, Ethics Programs
BIDMC

Anonymous said...

Compliance with ACGME work hour rules is doable, but requires buy in from clinician leaders. Many chairs of clinical departments still believe physician training should resemble that of olympic gymnasts, as it did during their time. Residents are expected to perform the medical equivalent of a triple flip on the balance beam, and land on one foot- at 4 a.m., after 30 hours without sleep.
Hard work and ambition, no doubt, are virtues, but so is safety. Patients deserve not only heroic physicians, as disciplined as gymnasts, but also "guard rails", in the form of systems, including resident work rules, to ensure we don't fall flat on our faces.
It's ironic that BIDMC, with its audacious goals for patient safety, has experienced such a spate of high profile safety-related issues. BIDMC just may be more transparent than other academic medical centers, but could its clinician leaders, most giants in their fields, also be a source of vulnerability? Achilles' strength was his weakness.
Industries which champion safety identify "humble competency" as the key virtue in its leaders. When I trained at Harvard, I'm sorry to say, competency was easier to find than humble competency, a quirk shared by most great academic medical centers.
Could BIDMC better reach its audacious goals with less audacious clinical leaders?
A widely accepted axiom in business is that "culture eats strategy for lunch". The gap between the medical and safety cultures in academic medical centers is vast and poses the greatest threat to safety and quality. The issue is even bigger than it appears. Academic medical centers are training future generations of leaders, so selecting and training a new breed of clinician leader is the "gift that keeps giving" to the health care system.

nasov said...

Would it ease up on the surgeons if hospitalists could be trained to do more of the post-surgical care?

Anyway, well done on transparency -- you do put your media where your mouth is.

Anonymous said...

As a residency program director at BIDMC, I am fine with the transparency - but I just not sure the strategy on this with the Globe was the best for surgery and the other 38 ACGME programs at the hospital.

The Globe did not point out how many fantastic letters and reviews we have received from the ACGME. We have extraordinary results, with over 70% of our programs at maximal accreditation lengths. But the public did not get that information.

Paul Levy said...

Anon,

If you are looking for an accurate and full portrayal of an issue like this, you cannot expect it in the daily media. The good news you cite about our many residency programs is simply not newsworthy. It is a basic rule of journalism that stories are newsworthy when they present conflict, dispute, or lack or resolution, not when they are about happy or successful programs.

But to your major point, to some extent, we put ourselves at a disadvantage in the public eye when we are open about our flaws. Note in this story, for example, that the other organization cited simply chose not to provide comparable data, even though they obviously have to have it available under the ACGME rules.

But I know of no other effective way to get better as an organization that to hold ourselves accountable in a very public way -- even if others in the city and region choose not to.

After Dana Farber Cancer Institute had a serious patient error many years ago, it adopted this kind of policy, and it is now of the prime examples of clinical excellence. Jim Conway, who was instrumental in making that happen, has told me that he used to get questions from staff along this line: "Jim, do we have to be so open about everything... no one else is?" I believe, as Jim has taught me, that while it can be hard, lonely, and "attention getting," the approach being taken by the BIDMC is the right, ethical, and responsible thing to do.

Paul Levy said...

Anon 12:57,

You have many good points, to which I will only respond that they contribute to the reasons I have made changes in some of our clinical leadership lately.

storkdoc said...

Well,

I wish that I had the 80 hour work week when I was an OB/GYN resident. Would have been nice......but...

We just hired another associate fresh out of residency training and we were going over the call schedule.

And she looked up at me and said, "so you work after you've been on call?'

I merely shrugged my shoulders and said, "Welcome to the real world."

We are in a tiny town in the Midwest and do not have residents. If we didn't work the day after call there would be no coverage on some days and that just won't do.

Jill said...

While I don't agree with the old mentality of staying at the hospital all hours because that's how surgeons are trained, as a surgery intern, I don't think you can put an hour limit on the amount of time we should need to do our jobs. It takes however long it takes, and I need to be able to spend the time it takes to do a good job. The last thing I want to do is to hand off a task to someone who doesn't know the patient half as well as me, is not as invested in their care, and will take at least twice as long to get up to speed and finish a task I could do twice as well in half the time, simply because I'm up against an artificial hour limitation. It's completely counterproductive, and will likely have serious unintended consequences for the quality of surgical care in this country.

AND, I don't like being torn between having to lie to get the education I need, and sacrificing my education to retain my integrity.

Anonymous said...

i am surprised that your program directors did not raise this issue directly before. it strikes me that even if your surgical program director did not raise the issue, it should have been discovered internally by their boss.
don't ask, don't tell will not work in the era of transparency. it is refreshing to hear that you are changing things, but i wonder when you replace these people whether individuals of equal experience and skill are able to be found.

to storkdoc, what kind of person does not ask about the work schedule before accepting a job? it is unfortunate that we graduate such naive individuals. i hope the person doesn't run away to a larger practice in a big city where they can take the post call day off. we've had many such departures over the past few years, even though we have learned to make clear the schedule during the initial interviews.
i think in some ways it is an a result of salary gurantees. take away the guarantees and you will see the young docs eager to work instead of resenting the work.
anyhoo best of luck.

appreciate the honesty of the hospital, although i perceived the tone of the quote from the surgeon recalcitrant (who knows what it actually was), rather than apologetic.

Anonymous said...

I am an IM assistant residency program director who did residency before work hours regulations were in place. The fundamental problem in meeting work hours regulations is that residents still spend far too much time in non-educational tasks that should not be performed by a physician. Despite all the attention paid to work hours, this has changed little since I was a resident 10 years ago. It has always amazed me how seemingly simple things like ordering a CT scan requires filling out two forms and making three phone calls, while at a private hospital one order would suffice. My hospital would completely fall apart if it weren't for residents figuring out workarounds to compensate for inefficient systems (as I am reminded every time I see patients without a resident). But it's not possible to transform a teaching hospital into a private hospital--private hospital have to make systems efficient to satisfy their MD's, but teaching hospitals can always assume residents will be around to get things done, no matter how broken the system is.

Anonymous said...

All I know is that I don't want that doctor or surgeon working on me at any hospital that is on his 29th or more hour! Try staying up all night, which I had to do for a charity fund raiser recently, and it hard to focus on things like driving home and what not.

Scary

Anonymous said...

Read the statistics on how many residents fall asleep in the hospital parking lot after work! If I get the wrong medicine and die because my doctor was falling asleep on the job, do I get a refund? Will the chief of surgery pay for my funeral? Why does it fall to ACGME to police this?

The government limits how long a trucker can drive or a pilot can fly without sleep. Why do doctors consider themselves above simple human limits?

Anonymous said...

I am a Family med intern at a wonderful program and am truly enjoying residency so far, but my boyfriend is a surgery intern in the same city (different hospital) with a completely different experience. His program is blatantly violating work hours rules and having chief residents "talk" to lower level residents to make sure that they log "80" hours. There is no transparency and no support for he or his fellow interns. To see someone so passionate about medicine change into a tired, cynical and aged man in just three months is beyond discouraging. The ACGME needs to revamp how they look at programs with potential work hour violations. They are currently overlooking some pretty obvious lying and unethical work hour rules.

Anonymous said...

Just started my internship a few weeks ago. I used to get the comments, "Oh, you are so lucky you have work hour restrictions. 80 hours when I was a resident would have been fantastic." I can only speak for where I am training which is a big name institution but the work hour restrictions do not exist.

During orientation, we were told that the GME office was there to help and that they wanted us to be honest with our work hour input on the computer. Well first day on the rounds, we were told a different story: "You will log your hours 6 to 6 and the last intern that didn't got suspended for 1 week without pay."

It's ridiculous that physicians in our generation get crap about not working as hard as the generations before us because it's simply not true....but we must make it appear that we have only worked 81 hours one week and 79 the next when it was really 109!

Anonymous said...

people only do what they are forced via laws/regulations to do. otherwise, it is usually business as usual, status unproductive quo and people doing as little as possible to get to 5-6PM.