In a wake-up call to hospitals across the country, a national oversight board has withdrawn certification from the Johns Hopkins University's largest medical residency program.
Hopkins' internal medicine program, which has 106 residents, was stripped of accreditation for several violations, including failure to limit residents' work schedule to fewer than 80 hours per week.
"We were very surprised," said Dr. David Nichols, vice dean of education at the medical school.
Hopkins officials learned of the decision last week by the Accreditation Council For Graduate Medical Education, a private group that certifies all medical residency programs in the country.
The university is the first institution cited for violating new work restrictions, which went into effect July 1. They were intended to address long-standing concerns about exploitation of doctors-in-training and putting patients at risk of being treated by sleep-deprived physicians.
While acknowledging that the internal medicine program had violated the rules, Hopkins officials said that the problems were minor and had been fixed as soon as the school learned of the ACGME investigation. According to Hopkins, the primary complaint was that several first-year residents worked close to 90-hour weeks in early July.
Because the violations did not involve educational deficiencies, but problems with "scheduling structure," Nichols said he expected a less-severe punishment.
The certification withdrawal will likely have no practical impact on the internal medicine program, one of 75 residency programs at the school. The penalty will not take effect until July 1, the beginning of the next residency year. Hopkins can reapply immediately and could be reaccredited before next July. And Hopkins officials said they are negotiating with the ACGME to come up with a compromise that would allow the program to remain accredited.
Making an example?
But the episode is embarrassing to the elite institution. Some observers suggested that the accreditation group wanted to make an example of the school and forestall federal or state legislation by showing it could be tough on medical institutions.
Dr. Robert Udelsman, chairman of the surgery department at the Yale University School of Medicine, said: "They look at premier programs like Yale and Hopkins and say, "If we can take them down, we can take anybody down. And all these other programs will see that.'"
Last year, the council threatened to withdraw accreditation from Yale's surgery department for overworking residents. After making significant scheduling changes, the department kept its accreditation.
An ACGME official would not describe the violations at Hopkins other than to say that they were not minor. Ingrid Philibert, director of field operations, pointed out that the 80-hour rule has been in effect for internal medicine since 1988.
"It isn't as if this just started on July 1, 2003," she said. "We've had this standard in internal medicine for a long time."
She added that the group was not singling out Hopkins.
"We would have held any program in the country to that standard," she said.
Student groups pleased
Medical student groups praised the council's decision.
"We're pleased that the ACGME is standing behind the new regulations and enforcing resident work hours," said Nicholas Rudikoff, a research analyst for the Committee On Interns and Residents, a union with 12,000 members on the East Coast and in California. The group has no members at Hopkins.
For years, critics have said that long hours put in by many residents were unfair and potentially dangerous to patients. In some specialties such as surgery, residents typically worked 120 hours or more a week. Among other things, the new rules limit residents to an average of 80 hours a week over a given month.
Soon after the rules took effect, a Hopkins resident reported violations to the ACGME. In late July, the group sent a team of investigators to look into the allegations.
Nichols said the internal medicine program had passed regular accreditation reviews several times since 1988, and had received only two minor citations for work schedule violations, in 1997 and 2001. He described the new rules as "extremely complex and subtle."
Others echoed Nichols' opinion.
"Everybody's struggling with [the new rules]. I think there will be a number of these cases," said John Weinerth, dean of graduate medical education at Duke University Medical School.
Since the new rules took effect July 1, the ACGME has received five to 10 other complaints about violations, Philibert said. The board is beginning to investigate several of them.
Lauren Oshman, president of the American Medical Student Association (AMSA), said she suspects that many of the nation's 100,000 residents are still working more than 80 hours a week. She said that since July 1, the AMSA had received many calls from residents who said their programs were not complying with the new rules.
An opposing view
Not all medical students praised the board's decision.
"I think it's absurd," said John Dooley, 28, a third-year resident in Hopkins' internal medicine program.
Over a year, Dooley said, internal medicine residents probably work an average of 70 hours a week. But in a given week, they might work up to 100 hours, he said. Especially in July - the first month of the yearly program- residents tend to work more than 80 hours a week, Dooley said. New residents are learning the ropes, and more experienced ones are spending extra time teaching their newer colleagues.
While the new rules will curb the most egregious cases of overwork, Dooley said, the ACGME should realize that medicine is a demanding profession, particularly at a top institution such as Hopkins.
"The intensity of the training is what attracts people here," he said. "That intensity builds outstanding doctors."