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TIMES Of Trouble

By Edward D. Miller, M.D.

Edward D. Miller, M.D. and David Nichols, M.D.When I learned that Hopkins’ prestigious internal medicine residency program had been stripped of its accreditation, I was, quite frankly, shocked. The alleged offenses, quickly corrected, didn’t call for sanctions that could affect our 75 residency programs, Hopkins Hospital and, eventually, all 7,800 residency programs nationwide.

Academic medical centers are now in a period of transition away from the time-honored training regimen in which residents worked long hospital shifts to gain practical knowledge of disease treatment. This sort of bone-wearying learning experience is no longer appropriate, and the Accreditation Council for Graduate Medical Education (ACGME) has set 80 hours, on average, as the maximum any resident can spend in a hospital per week. This is reasonable. I am a big supporter of efforts to minimize residents’ fatigue.

Hopkins’ goal is to set a standard that is a national model. Yet this can only happen if the ACGME permits flexibility as residency programs make complicated adjustments in hospital routines and educational curriculum.

Let me run through the history of our troubling episode,* describe our response and tell you what we intend to do going forward.

 

The Situation

The ACGME’s Common Program Requirements commenced July 1. The following week, a brand new Hopkins resident filed a complaint with ACGME about his duty hours while rotating in the Department of Medicine. As soon as we were notified, the department changed the duty schedule in General Medicine and in the medical ICU where the violation had occurred. Levi Watkins, associate dean for professional programs, e-mailed ACGME that the complaint had been addressed, we were monitoring other areas and believed we were in compliance. Six days later, we were informed that an “Egregious Accreditation Violation Subcommittee” had been convened and would visit Hopkins in a week. The group met here for six hours, interviewing residents and program directors but never touring the MICU or other hospital areas.

In a letter, Charles Wiener, director of the department’s residency programs, addressed issues raised during the site visit: He reported changes in the MICU call schedule to bring it into compliance, clarified the work schedule, and described our ongoing compliance initiatives and our efforts to improve education and problems of fatigue.

On Aug. 20, we received a “death penalty” notice from ACGME alleging 10 areas of non-compliance. It summarily withdrew accreditation for both the residency program and the 12 internal medicine fellowships. The action would require 250 residents and fellows to leave their programs, force us to close community clinics and cripple delivery of hospital patient care. Curiously, Hopkins had no formal right to appeal. Still, we requested reconsideration and were allowed to submit new information.

 

The Response

I immediately called in the main players from Internal Medicine, the medical school and our internal review board. We already had conducted a thorough internal audit of work-rules compliance, but we combed through these data again and gathered every detail related to the citations. Our conclusion: We were not in violation. To make sure we weren’t fooling ourselves, we asked the foremost external review organization to conduct an exhaustive audit. Its independent judgment: Hopkins was in compliance. In anticipation of the new work rules, we’d added house staff and other staff to fill in for residents, and I’d approved a new center using computers and patient actors to round out residents’ bedside training.

In late September, we delivered to ACGME a binder of documents the size of the Manhattan telephone book in which we systematically refuted all charges and listed our improvements. Our message: None of the agency’s citations rose to the level of “egregious” as defined by ACGME, and the punishment did not fit the alleged crime.

 

The Resolution

On Oct. 13, ACGME rescinded its summary “death penalty” and gave Hopkins’ internal medicine residency “probationary accreditation.” An agency representative made a site visit the next day; on Dec. 15 the residency program’s full accreditation was restored.

Hopkins has adopted a zero-tolerance attitude on infractions of resident work rules because that’s what regulators expect. We will document our compliance at every step. I think this is the best approach.

We’d also like to resume a dialogue with ACGME. Our objectives are the same—a quality medical education that serves the interests of residents and patients. We remain committed to delivering superb training for future physicians while abiding by the rules set out for us.

*See Out of Time for more about this troubling episode.

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