Out of Time
By Patrick Gilbert and Mary Ellen Miller
Mike Weisfeldt had just come in from the golf course when the phone call came. It was high August, and he and his wife, Linda, were two days into their annual vacation at their beach house in Delaware. Ever since Weisfeldt moved back to Hopkins three years ago from Columbia University to take the chairmanship of the huge Department of Medicine, he’s come to depend on these end-of-summer getaways to recharge him for the year that lies ahead. He was therefore surprised to hear his colleague Levi Watkins on the other end of the phone, calling from East Baltimore.
The news was not good. On July 1, the Accreditation Council for Graduate Medical Education (ACGME) had implemented new rules strictly limiting the number of hours that trainees in hospital residency programs can work. Now, Watkins, who is associate dean for postdoctoral studies, informed Weisfeldt that one week after the work rules went into effect, a resident rotating through the general medicine service had filed a complaint with the ACGME, saying that Hopkins wasn’t complying. As a result, the internal medicine residency program had received notice of ACGME’s intention to withdraw the residency’s accreditation, effective July 2004. Weisfeldt should come immediately back to campus to meet with his house staff.
“I felt like I’d been hit in the stomach,” Weisfeldt admits. Within minutes, he’d borrowed a friend’s car and, still in his golfing trousers and shirt, was driving the three hours to Baltimore. By early evening, he and Watkins, along with Paul Scheel, the department’s vice chair for clinical affairs, and David Nichols, vice dean for education, were standing in front of some 100 internal medicine residents, assuring them that their cherished program would survive.
Johns Hopkins’ residency in internal medicine is no run-of-the-mill program. Annually attracting more than 1,300 applications for its three dozen first-year slots, it is considered one of the premier training experiences in its field. It is also the living legacy of William Osler, arguably the greatest physician of the 20th century. By the time Osler arrived at The Johns Hopkins Hospital in 1889 as its first physician in chief, he already was recognized as America’s top physician and clinical educator. But it was here that Osler created one of his most lasting bequests—the postgraduate training system for doctors that would become the model emulated at teaching hospitals throughout the nation. Not only did he want all trainees to live at the hospital (thus the terms residents and house staff), he advocated the kind of hands-on teaching—once a radical idea—that’s been the standard here from the beginning. “Medicine,” Osler was fond of saying, “is learned at the bedside, not in the classroom.”
And so on this sultry evening in August, this group of residents had much to be concerned about as they listened in silence to the Hopkins leaders outlining the ACGME’s allegations and actions against their program. How would the historic residency be affected by this drastic action? Indeed, how would their own medical training now change?
The rules were clear: A resident cannot spend more than 80 hours a week on duty, averaged over four weeks, and may work no more than 30 hours at a stretch. Overnight on-call cannot occur more than every third night, and there must be at least 10 off-duty hours between shifts. One day in seven must be spent free of all hospital duties.
Weisfeldt explained what had happened: As soon as the ACGME had received the resident’s e-mail accusing Hopkins of breaking the rules, its internal medicine residency review committee (RRC) had convened to discuss the allegations. Then, on July 30, three site visitors had come to the department to determine for themselves if the program was in violation. It was the committee’s verdict resulting from that visit that Watkins had conveyed to Weisfeldt in his phone call. The program’s big violation, the committee had found, was that the frequency with which residents were on call in the medical intensive care unit had exceeded the guidelines. And it was that infraction that had led to the withdrawal of the program’s accreditation.
“It was,” says Weisfeldt, “rather like giving out a death sentence for possession of marijuana."
For Weisfeldt, the insult was especially searing. Johns Hopkins had in large part shaped him. He’d been an undergraduate at the University, earned his M.D. at the School of Medicine (SOM ’64) and as a young cardiologist in the 1970s taken his first faculty position here. Later, during 15 formative years as leader of the Division of Cardiology in the department he now leads, he’d learned the intricacies of administration. His ties to Johns Hopkins were long and deep.
Weisfeldt assured the residents that he and the entire medical leadership would act immediately to regain program certification. Three years ago, he reminded them, in anticipation of the new work rules, the Department of Medicine and Hopkins Hospital already had added 10 house staff positions to lighten the residents’ workload. The following year, it had created a 24-hour transport team to relieve residents from extraneous duties like moving patients from place to place. And last year, it had hired a group of hospitalist physicians to take over a portion of the patient load. Now, it would do more. In the meantime, Weisfeldt said, the residents must adhere to the letter of the law in following the new duty hours. If the clock told them their shift had come to an end, they must stop working.
The residents were uneasy. Would such a national humiliation affect the quality of their program’s applicant pool for next year? Weisfeldt doubted that. Two years ago, when Yale’s surgery residency had dealt with similar charges (the first major academic program to have faced such a penalty), its house staff had stood by the program and the quality of applicants had remained high.
But worrying the residents most was what such rigid rules would mean for their patients. What were they as physicians supposed to do if they were in the midst of treating a critically ill patient and suddenly they reached the end of their duty shift?
“Call any senior physician, including myself,” said Weisfeldt, “any time you need help in working through that kind of situation.”
There’s no doubt that faculty physicians are ready to jump in and help solve problems related to the ACGME guidelines. But much more will be needed to make the required adjustments. The new work-hour standards will unequivocally make for better-rested, clearer-thinking residents. But the physicians and administrators who run the nation’s 7,800 residency programs have discovered that restructuring a system that sometimes called for residents to work as much as 120 hours a week isn’t easy. The big question facing teaching hospitals is: How do we live within these mandates and still provide both the level of patient care and the educational experience that are the foundations for resident training?
At Hopkins, whose programs are known for training leaders, the challenges will be even greater. “I feel that substantive academic issues will need to be addressed,” Weisfeldt says. “Training residents at an academic medical center to become leaders in American medicine is not the same as training residents in clinical medicine at an excellent community hospital. To achieve our particular goals, our programs need the flexibility to offer substantive and integrative experiences.”
Vice Dean for Education David Nichols, who is leading the restructuring of all Hopkins’ residency programs, suggests the new model will have to be supplemented by simulated patient care and more classroom work. And the challenge will be to fit this structure into the work schedules.
“There’s a fine line between service and education,” Nichols worries, “because both involve patient care. It’s obvious now that the line is widening. The traditional model expected residents to learn at the bedside, at the elbow of experienced physicians. It’s been a valuable and stimulating way to teach doctoring. But the time residents spend on the job is becoming very precious, and can’t be extended under any circumstance.”
And it is this mandate that has left many young doctors-in-training worrying whether they’ll receive enough time at the bedside to gain the knowledge they’ll need to enter practice.
Chris Sonnenday, a fourth-year Johns Hopkins resident in general surgery, will be among those telling war stories. He finished the first three years of his residency in 2000 and moved into a three-year research fellowship. Then, on July 1, 2003, he shed his lab coat to once more put on the surgeon’s green scrubs.
“I left a very different residency than the one I came back to,” Sonnenday says. “You might expect that, as residents, we’d stand up and rejoice that these regulations have been passed. But I’ll tell you, if you’re the chief resident on the GI service and a case comes up that you may have one or two opportunities to do during your entire residency—well, many of us have to be dragged kicking and screaming out of the hospital.”
Sonnenday is hardly alone in missing the closeness with patients that was inevitable under the old system. “Yes, it’s hard to manage a life when you’re in the hospital every other night,” he says. “I totaled my car as an intern. But it was the best experience of my life and no one knew my patients better than I did.”
Still, there was a down side. “Like my peers, I worked 36 hours every third night for years,” says Jessica Bienstock, director of the Ob/Gyn residency program at Hopkins Hospital and Bayview Medical Center. “Did it make me a better doctor? I’m not sure it did.”
The incident that still sticks in her mind occurred 15 years ago while she was a senior resident at Manhattan’s Beth Israel Medical Center. At the time, New York had just become the only state in the country to regulate resident work hours.
A patient came in, and while Bienstock was doing her history and physical the woman suddenly exclaimed, “I remember you! Four years ago, you were here when I had my first baby. You had your head down on the desk. When I came in, you picked your head up and said, ‘Oh, no!’”
“That’s when the difference the new work-hour rules had made really hit home,” Bienstock says. “The second time I could be pleasant to the patient and happy to be taking care of her. But when I was an intern who’d been on call all day, she was just something else to disrupt the five minutes of rest I might be able to get.”
In mid-September, Hopkins sent the ACGME an official request to reconsider its withdrawal of accreditation from the residency program in internal medicine. Along with the request went piles of documentation showing the changes the Department of Medicine had implemented both before and after July 1 to comply with work-hour regulations for its 110 residents. Except for a few short-lived violations affecting a few residents, the documentation showed that the program had followed duty-hour rules. “We felt compelled to submit this evidence,” Nichols says, “to make clear just how strong our commitment to compliance had been all along.”
The records also listed the steps the department had taken since the ACGME’s action: It had increased the number of staff on the committee that oversees graduate medical education, appointed neurosurgeon John Rybock as a compliance officer, and put together a team to independently verify information provided by each residency program during an internal-review process. It had also addressed the concerns raised by the ACGME about the need to rid residents of such extra duties as transporting patients, doing emergency phlebotomies and picking up radiology results. Finally, the document showed that an independent team of auditors had now found the program in compliance.
Two weeks after receiving Hopkins’ request, the RRC sent word that it had changed its previous action. Instead of pulling the residency program’s certification on July 1, 2004, the committee would grant the residency probationary accreditation. It had been convinced to reduce its penalty because of the documented changes that had been submitted showing that the residency was now in compliance. It would, however, uphold the original 10 citations based on its July 30 site visit. And before taking the program off probation, it wanted to see ongoing compliance.
The softening of the August punishment had taken dozens of people countless hours, reams of documents and a considerable amount of soul searching, but the RRC’s response marked the first step toward a return to normalcy. Now, the task of making certain that every one of Hopkins’ 75 residency programs was strictly adhering to the ACGME’s rules fell to Levi Watkins.
As head of postgraduate programs, Watkins typically leads a review of each residency program every two years. The exercise involves gathering voluminous amounts of information about each program from the directors, including the numbers of hours that all residents work. In light of what happened to Internal Medicine, this largely self-reporting review would change. “We’ll be appointing a team to verify the information provided by each residency program to make sure we’re following the rules every day,” Watkins says.
On Oct. 15, the RRC made its second and last visit to campus to review the internal medicine residency program. Then, for two full months, the Department of Medicine waited to hear its fate. The ACGME would either keep the residency on probation, restore its full accreditation or withdraw its accreditation altogether.
On the morning of December 15, Mike Weisfeldt got the call he’d been waiting for since August. As a result of the October site visit, the ACGME had restored full certification without qualifications to the Johns Hopkins Hospital’s residency program in internal medicine. The committee, in fact, commended the institution for the significant changes it had made to the residency. While Hopkins would be required to submit a progress report in September, the next site visit for this program would not take place until February 2006.
A great sense of relief engulfed Weisfeldt as he heard the news. The committee’s verdict meant that for the first time in months he could feel easy. And now at last, he could turn his attention to all the other issues that consume a department like his. It had been a hard autumn—harder than he wants to see again. But Weisfeldt says he’s gratified the accreditation group gave the department a chance to press home its case for full certification.
Meanwhile, Weisfeldt’s colleague, Charlie Wiener, who directs the residency programs in the Department of Medicine, notes one bit of irony in the whole episode: All fall long, as Hopkins waited to hear the fate of its residency program, applications for slots in next year’s program kept rolling in.
“And as far as we can see,” Wiener says, “the number and the quality of those applying for the internship remained at exactly the same level they’ve always been.”
Despite all that had happened, applicants seem to go right on viewing Hopkins as a top place to train. “The ACGME’s actions seem to have had no impact whatsoever on our applicant pool,” Wiener says.