Friday, November 21, 2014

What's up with the residency programs at St. Elizabeth's?

I've written about the financial difficulties leading to the closure of Quincy Medical Center and have suggested that these almost inevitably resulted from the business model employed by the private equity firm that owns this hospital system.  But are there other somewhat hidden consequences of this style of ownership?  One worth reviewing might be the system's commitment to residency training programs.

St. Elizabeth's Medical Center is the major training hospital within the Steward Health Care System.  How is it doing with regard to the long-standing and clinically important graduate medical education program that resides there?

Not so good.

The ACGME is the governing body that accredits residency programs.  It has a public website on which the status of each program is listed.  As we go through the site, we see the following programmatic problems at St. Elizabeth's in three of its largest training programs.  (The fourth, Anesthesiology, is currently accredited but up for renewal soon.)


Internal Medicine


Getting a warning or probationary designation is a very big deal.  For example, of the 9,527 programs that were ACGME accredited in 2013-2014, only 279 programs (under 3%) received such designations.  Here's the chart:

A warning is serious, but probationary status is applied when the ACGME concludes, following a site visit and review, that a program or sponsoring institution has failed to demonstrate substantial compliance with ACGME requirements. 

What's behind the St. Elizabeth situation? While the details behind these designations are not published, in general, the largest number of such citations come from persistent violations of the ACGME duty hours requirements.  Recall that, several years ago, the ACGME imposed strict limits on the number of hours per week that residents were permitted to work. These rules came about from Congressional pressure and an acknowledgement that it was not healthy for the residents, patients, and members of the public for trainees to get too little sleep (resulting in "impaired neurocognitive performance, including reduced memory consolidation, and deterioration of waking performance marked by increased rates of attentional failures.")

I have a hypothesis that when a hospital like St. Elizabeth's suffers from financial distress, there is an inclination to use residents as low-cost labor (relative to nurse practitioners and physician assistants) and assign them to extra hours of work in taking care of patients.  I'd be happy to have this hypothesis disproved, but that would require disclosure by St. Elizabeth's of the reasons for the warning and probationary ACGME designations.  The hospital is very unlikely to provide that to me!

But is there any inclination on the part of the Attorney General, the state official with authority to monitor the performance of the Steward Health system, to look into this matter?  If residents are, in fact, violating duty hours, there is the potential for harm to the public.  If residents are being assigned to cover the work that would otherwise go to paid staff, is that consistent with the employment promises made during the take-over of the system from its previous owners?

(There is also another possible reason for poor reports from the ACGME--a lack of training opportunities.  For example, if the volume of patients is too low, surgical residents don't get enough cases on which to practice. Might that being going on at St. Elizabeth's, too?)

It is too late to save Quincy Medical Center, but it is not too late for the state to review these matters and intervene.


ScottyJ said...


Having been a residency director at BIDMC under your tenure I feel confidant in stating that duty hour violations have nothing to do with how Steward or BIDMC or any other institution uses their resident trainees. Residents are highly motivated individuals, not unlike any other young professional in the country. As such, they have a strong desire to learn their craft and doing so requires a 110% effort. But, unlike any other young professional, residents are restricted in their ability to give 110% by existing regulatory agencies. While duty hour implementation was done under the guise of patient safety, to date there have been few if any publications demonstrating improved patient safety and most demonstrate the contrary. Having been involved with residencies at BIDMC and Steward, I can assure you that duty hour violations at the former far exceeded anything that I have witnessed in my tenure at Steward.
No matter how hard you want to believe that the sky is falling, sometimes it really is just an acorn falling from a tree.

Kathy Day RN said...

Paul, this blog makes me sad. I graduated from St E's Hospital school of Nursing in 1970. It was a noble proud institution then. Cardinal Cushing officiated at my graduation. He had a designated suite with very plush decor at the oldest part of the Hospital. We were proud, of our program, our product, our doctors, and our leadership in that Hospital. To hear that the corporatization of this fine Hospital has caused such a decline, of any kind, is very disheartening. Sad indeed.

Unknown said...

I certainly believe there is truth to your suspicions here. The volume and acuity is indeed lower than most Boston area hospitals, leading med students in my day to refer to it as 'St Easy' for their rotations.
The coverage hours have also been an issue at other cash-strapped institutions: as a resident and chief resident at Tufts, I was all too aware that 'coverage' always trumped education planning. This was shortly after the 80-hr workweek regulations were put into place, so I can only imagine these poorer hospitals are struggling with the newer restrictions. At Tufts, rather than hiring more NPs, they just leaned on the attendings more, since they have no work hour caps and are salaried. Not a good time to be in (poor) academic medicine, unfortunately!

Paul Levy said...


1) As I said, I have happy to be corrected if my hypothesis is wrong. Why don't you now finish your comment and tell us the full story of why the St. E. programs have a warning or probationary status.

(2) By the way, other young professionals in other fields in which public safety is an issue ARE also restricted by duty hours (e.g., in the transportation field). So this is not "unlike any other young professionals."

Anonymous said...

Don't "residents" receive a stipend and often a housing allowance? I read recently that these kinds of payments in the San Francisco area can reach as high as $60K?

Paul Levy said...

Not all programs offer housing allowances. Residents' salaries are greatly supported by federal subsidies. Their payments are fixed for the year, regardless of how many hours they work. Not so for NPs and PAs.

Anonymous said...

Hi Paul,

Was curious about your persistent hostility toward Steward?

Is it only Steward you are concerned about?

Or because Steward is owned by a private equity firm - cerberus?

Or is it all medical firms that are private? For instance, how do you feel about Tenet Health Care [or previously Vanguard] owning Metrowest and St Vincents.?

I think BIDMC had relationships with both of those hospitals - Metrowest and St Vincents - in your tenure at BIDMC and since.

Aren't all private firms like Tenet out to maximize shareholder value. How is that different from what Steward or private equity firms in general?

And doesn't a private economy [competition] provide a good mix of quality and cost in other industries - electronics for instance?

The non-profits hospitals you seem to favor have provided the highest cost health care in the country in Massachusetts led by those beacons of public spirit Partners, who seem to have been profit maximizing better than the for profits like Steward. Steward has made no profit at all. Partners has literally made billions in the last decade alone.

So please explain.

Is it bad management at Steward?

Fear of private equity (and how is this different from all private industry).

Or fear of all private companies in health care? [If it is this option please explain why it's the non-profits that have the highest prices and by far the highest profits]

Paul Levy said...

Dear Anonymous,

In case you've missed several dozen blog posts here, you'll note that I have often made reference to the profit-maximizing behavior of Partners Healthcare System. So, this isn't an issue of non-profit versus private hospitals.

There are a number of very well run private hospital systems who are in it for the long run. Several have been leaders in patient quality and safety.

The issue here is a business plan that is based on extracting as much cash as possible from the system and then hoping to sell the remainder or go to the public market with an IPO.

I think it is legitimate to ask whether the quality of clinical care and, here, medical education is maintained when this business strategy is in force.

Anonymous said...

[Note: this message could also have been put added to the Quincy Medical Center post.]

Steward's quality of care in the last couple of years has mostly been quite good.

The Leapfrog Group has given all steward hospitals an A.

Cleverly and Associates ranks hospitals on quality and cost.

Cleverly ranks (for quality and cost) 20 hositals in the country chosen in five categories for a total of 100 hospitals in the country. The five categories range from small rural hospitals to large academic medical centers.

For 2014, three of the top 100 in the country ranked by Cleverly were Steward hospitals: Good Samaritan, Holy Family and St Ann's.

There is another ranking [Community Value five star] which is essentially the top 20% of all hospitals in the country ranked on quality and cost.

Seven more Steward hospitals were in this category. That means all ten Steward hospitals were ranked in the top 20% in the country in quality and cost.

To be fair there were many [43] Massachusetts hospitals in these two lists, which means most Massachusetts hospitals ranked highly nationally.

But the only major teaching hospitals in the 100 were Baystate, Lahey, and Tufts Medical. And St Elizabeth's in the larger category top 20% for quality and cost.

I would assume the other major teaching hospitals in Massachusetts were considered high cost at least by this evaluation.

I had not heard about St Elizabeth's problems with it's residency programs. I personally don't know the details so really can't comment on the true cause.

But Steward's business model is good for Massachusetts health care consumers. It provides good quality care for a good price.

It has also invested funds in things like new Emergency Rooms and technology that enhances quality of care.

I know you have criticized Partner's for its high prices and profit maximizing outlook.

What I don't understand is why Stewards efforts to profit good quality care at a good price doesn't deserve some praise?

happy to be retired said...

Anon----you must work for Steward, and if so, u would know that their business plan (although Paul put it more diplomatically) was always to "put lipstick on a pig and flip it" for big profits, especially for the execs involved. In addition, regardless of the surveys which questionably measure excellence of care do not seem to jibe with the opinion of folks who are avoiding Steward like the plague. To wit, the exodus of the flock of patients Steward hoped to hold in their system to fill Quincy who voted with their feet and went elsewhere. Ask where the Steward physicians receive their care and then come back looking for praise.

Anonymous said...

I have followed your recent (and not so recent) posts about Steward, including this latest one. While I agree with most of what you say, I feel that you are missing the most concerning sign that Steward will not exist in its current capacity for much longer. The "charistmatic", "ubiquitous", "deal maker" etc (only to mention a few of the Boston Globe accolades from the past five years) CEO Ralph de la Torre is nowhere to be found. A hospital is closed (oh, sorry, converted into an outpatient emergency center) and the CEO is not mentioned in any story as making any comments or taking questions.
We all know that in Steward's current state, with much real estate having been sold and leased back, Cerberus has made plenty of cash while Steward cannot be sold to anyone that wants to run it as a hospital system. That ship has sailed. You know very well, but probably cannot say it in public, that the two hospitals that are still making money (Norwood and Good Samaritan) will be sold as individual hospitals), Carney will shut down and St. Elizabeth's (which cannot run as an independent hospital since it does not serve the Brighton community but is rather fed by outside private groups that are getting tons of money from Steward to continue sending their patients there) will most likely become a mall, condos or something like that.
Cerberus will make a killing. De la Torre gave them access to this treasure trove and they took it and ran with it. He is well compensated for this but now he is out of the picture, thus no attempt for any media attention from a person who loves that kind of exposure.
With Martha Coakley and Thomas Menino not in the picture any more and with Cerberus paying lease fees on property it has cashed in, it is just a matter of time...

glad to be retired said...

Interesting post, Anonymous, for those of us sitting in amazement that Steward has not folded already and noticing too that Ralph is no where to be seen except at high profile fund raisers and roasts with such high fliers as Jack Connors. Though what a sharp business fellow as Connors would want with a blow hard like "Burn the boats on the beach baby Ralphie" I cannot fathom. Agreed with Carney and St. E's being dumped and with Norwood and Good Sam being salvageable, but still believe that Steward/Cerberus is still going to somehow fill the pockets of the Ralphs and other execs before they fold. These folks are simply robbers.

Anonymous said...

That's an important point about Ralph not being seen or heard from.... they have left the Quincy mess to Dr. Girard to explain when it should be Ralph out there explaining his broken promises re keeping Quincy open for the duration of his agreement with the Attorney General. Remember, he put his house up for sale last year and then quickly removed the listing when asked about it which makes you think he wasn't planning on sticking around for too long. Norwood and Good Sam do make some money as true community hospitals so another buyer might show interest although a place like Norwood still has quad rooms so very old infrastructure. Carney will be next to be closed as it continues to lose millions as well. They are trying to add family medicine PCPs at Carney but where are the patients going to come from? Nobody wants to go there if admitted. With Brighton real estate white hot you make an interesting point about St. Elizabeth's.... could be an attractive piece of land for a major developer. There are not that many land areas that big in Boston that might be available. I'm not sure how much debt they have accumulated at Steward overall but I think it's in the hundreds of millions of dollars. I guess only those consolidated financial statements would show what they are paying to Cerberus (probably in "management fees" for their business "expertise") and how bad the situation really is. You would think a reporter would seek out Ralph and ask him the truth. There are thousands of jobs at stake here and the CEO is not seen or heard from? Doesn't make any sense.

Paul Levy said...

Anon (just now),

While I appreciated your most recent submission and believe it to be true, it goes over the boundary of what I can properly publish. Sorry!