Accreditation group cites MGH on resident surgeons' workload - The Boston Globe

Accreditation group cites MGH on resident surgeons' workload - The Boston Globe

And yet Obama wants to burden the medical profession with more people by the millions.
Clearly the profession can not handle more patients and is overburdened already.

Junior surgeons at Massachusetts General Hospital have been working too many hours, in violation of patient safety rules, according to a national accrediting organization that is threatening to put the hospital’s surgery training program on probation.



The Accreditation Council for Graduate Medical Education cited the hospital because a significant number of its surgeons in training, known as residents, were exceeding hour limits and working seven days straight. The organization believes these workloads contribute to fatigue-related mistakes, and has given the hospital until Aug. 15 to fix the problem.

The hospital’s surgery chief, Dr. Andrew Warshaw, said that since learning of the violations in April, the hospital has reduced residents’ workload and it is now following the rules.

But five years after the hour restrictions were adopted, Warshaw and other surgeons said frustration is building at the nation’s teaching hospitals, because residents believe the rules interfere with their work and ultimately may harm, rather than help, patients.

The council acknowledged the tension in its April 13 letter to Mass. General, in which reviewers wrote: “The greatest challenge . . . has been getting the culture of the residents to change.’’

Many residents are conflicted over whether to stay with a complicated pa tient past their scheduled departure time and violate the rules, or hand the care to another doctor and go home.

“We develop a bond with that patient. We want to stay and finish the job,’’ said Dr. Parsia Vagefi, a fifth-year surgery resident at Mass. General.

Dr. Emily Christison-Lagay started her residency when there were no rules, and she often worked 100 to 120 hours a week, including “power weekends’’ that lasted from Saturday morning to Monday night. Sometimes “you felt sick to your stomach you were so tired,’’ she said.

Now, however, she must leave the hospital by around 6 p.m., leaving little or no time for conversations with patients about their postsurgical care. She said she would rather have no rules and endure the occasional “horrific’’ weekend so she could spend more time with patients.

Dr. Thomas Nasca, head of the accreditation council, lamented in a letter to training programs earlier this year that residents are placed in an “ethical quandary’’ because “we compel them to lie [about their hours] if they do the right thing for their patients.’’

Still, the council is stepping up enforcement, and 5 percent to 10 percent of surgery programs were cited last year, including many of the country’s most prestigious training programs. Beth Israel Deaconess Medical Center was threatened with probation last year, but has since reined in residents’ workloads.

The Institute of Medicine, which advises the US government on health policy, is pushing the council to limit residents’ hours even further. It recently recommended that nap time be mandated for residents who work 30-hour overnight shifts. The council is reviewing its rules and is expected to decide by next summer whether to make changes, which could include tightening or loosening the restrictions.

Surgeons are adamantly opposed to tougher limits, saying there is little evidence that sending residents home after a prescribed work shift has improved patient care and that the rules actually may be hurting residents’ education. General surgery residents need to complete at least 750 cases during their five-year training so they are ready to operate on their own once they finish.

Any change would also have financial implications for teaching hospitals, where the nation’s 107,000 residents provide the majority of care.

At Mass. General, Warshaw said last week that he has canceled certain clinical rotations and educational conferences for residents in order to reduce their hours, and he believes the hospital will avoid any penalties.

“We are trying very hard,’’ Warshaw said. “We patrol the hallways, sending people home, and we send them home from the OR before cases are done.’’ The hospital has also, he said, added extra staff at night to relieve the residents.

“But there are serious questions about whether we are all heading down the wrong road,’’ he added. “Would you rather have a tired surgeon who knows you? Or a fresh surgeon who doesn’t know you?’’

Surgery residents at Mass. General generally work from 6 a.m. to 6 p.m., plus occasional overnight shifts.

Accreditation council rules require residents to have at least 10 hours off between daily shifts and after overnight shifts. According to a 2007 survey of Mass. General surgery residents, nearly 20 percent said they weren’t always getting a 10-hour break, while another 20 percent reported working more than the 88 hours per week allowed on certain especially difficult rotations. During a site visit, the council confirmed this problem and found residents on other rotations were violating an 80-hour-a-week limit.

When the hour limits were first implemented five years ago, the council was up against a macho, hard-driving surgery culture where doctors often worked more than 100 hours a week. At the time, one unnamed Mass. General surgeon said of residents, “now they’re entitled to work less, to be less tough . . . now they’re softies,’’ according to a study about the impact of hour restrictions at Mass. General, published in 2006 in the Annals of Surgery.

But Dr. Matthew Hutter, a Mass. General surgeon and lead author of the study, said he believes that attitude has changed. “More attendings are telling residents to go home,’’ he said.

His study, which compared the experiences of 58 Mass. General surgery residents in the year before and the year after the rules were adopted, found they reported less burnout and emotional exhaustion, but found no impact on the quality of patient care.

An Institute of Medicine committee is calling for even stricter rules, including a five-hour nap for residents on overnight shifts.

“We do know that hospitals still are not safe places for patients,’’ said Maureen Bisognano, a member of the Institute of Medicine committee and executive vice president of the Institute for Healthcare Improvement in Cambridge, a patient-safety consulting organization. “We also know fatigue contributes to a less safe environment.’’

But Dr. Scott Johnson, director of the surgery residency program at Beth Israel Deaconess, called the new recommendations “crazy,’’ adding, “I don’t know how we can schedule a five-hour nap time while a resident is on call.’’

The council’s Nasca said naps would increase handoffs of patients to other doctors, which could potentially increase errors - though research has been inconclusive on whether the current rules have increased handoff mistakes caused by miscommunication. At the same time, he said, the organization is unlikely to allow residents to work more hours, although it may allow more flexibility for certain specialties like surgery. For example, the group could allow fifth-year residents to come back to the hospital during their 10-hour breaks for emergency surgery, because that is experience they need before going into practice.

“I don’t see us walking away from the expectation the public has for us making care the safest possible for them,’’ Nasca said.