Johns Hopkins penalized for resident hour violations

Internal medicine residency is threatened with loss of accreditation.

By Myrle Croasdale, amednews staff. Sept. 15, 2003.

The Accreditation Council for Graduate Medical Education has disciplined its first resident program for work-hour violations since new rules went into effect for all programs July 1. Johns Hopkins Hospital's internal medicine program was cited for exceeding the 80-hour workweek and requiring call more than every third night in the intensive care, counter to ACGME work hour standards.

As a result, accreditation will be withdrawn July 1, 2004, unless Hopkins complies with duty-hour limits.

See related content

Health policy watchers say the severity of the penalty -- loss of accreditation instead of the more typical probation -- signals that the ACGME is serious about enforcing work-hour rules and is conscious that failure to do so invites government oversight.

While the ACGME said it wasn't attempting to make an example out of the prestigious Johns Hopkins program, several residents and program directors said that was the effect.

"This will get the word out there that if they won't make special favors for Johns Hopkins, they won't make special favors for anyone," said Maurice Sholas, MD, chair of the AMA Resident and Fellow Section.

Ingrid Philibert, vice president of field operations for the ACGME, said two other programs had faced summary withdrawals of accreditation in the past 18 months and that, while unusual, the action was not unprecedented. Philibert pointed out that although July 1 marked the day when work-hour standards became mandatory for all programs, internal medicine as a discipline has had work-hour limits since 1988.

Johns Hopkins received formal notice of the action Aug. 20 and was told it had 45 days to submit material for reconsideration. If it fails to meet this deadline, it may reapply for accreditation before the July 1, 2004, deadline.

Its internal medicine program has 106 residents and is one of 63 residency programs at Hopkins.

Officials at Hopkins were surprised at the severity of ACGME's response, attributing scheduling violations to their misinterpretation of ACGME standards. But others said the program had documented 90-hour workweeks the year before.

David Nichols, MD, vice dean of education at the medical school, said it already had made changes and was working to be in compliance. But one challenge has been dealing with residents who don't want to leave.

"Some residents felt the desire or need to stick by their patient and not turn him over to a physician who has not been involved with the patient as well. We've since become more insistent that they must leave the patient," he said.

In working out alternate schedules, residents have voiced concern that they won't be getting the volume of cases or continuity of patient care they expect from training. Dr. Nichols said in response that the start of the workday was moving to noon to mesh better with the flow of patients, who tend to arrive in the afternoon.

John Dooley, MD, a third-year internal medicine resident at Hopkins, said internal medicine residents just want to focus on practicing medicine, not deal with administration hassles.

But the ACGME was moved to act by a letter from an unidentified Johns Hopkins resident.

Dr. Dooley said that complaint was tied to the crush of hours demanded at the beginning of the residents' year, when new trainees require more supervision and it takes more time to treat patients. Once the first few months pass, schedules ease and doctors can take more calls from home.

Another recent recipient of ACGME discipline is the Martin Luther King Jr./Drew Medical Center in Los Angeles. It lost accreditation of its general surgery program in August because it had exceeded the number of residents it was allowed. The program was on probation the year before. Now it must find other programs for 24 of its surgical residents. The ACGME is scheduled to review all the training programs at the hospital in September.