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Beth Israel cited for residents' long hours

Facing review for accreditation

By Liz Kowalczyk
Globe Staff / September 7, 2008
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Young surgeons at Beth Israel Deaconess Medical Center have regularly worked more hours than allowed by national safety limits, with some on the job seven days straight or up to 90 hours a week, according to an oversight organization and hospital officials.

The group that oversees training of new doctors, called residents, cited Beth Israel Deaconess for hours violations in a letter in January. The Accreditation Council for Graduate Medical Education said that the hospital would jeopardize its accreditation as a surgery training program if it does not correct the problems by Tuesday, when council staff plan to review the hospital again.

Hospital officials are optimistic that they are now in compliance but said it has not been easy.

"When your 80 hours are up on Friday and someone comes in with a ruptured aneurysm, we don't have the luxury of saying 'Sorry, I have to go home,' " said Dr. Scott Johnson, a transplant surgeon who has headed the hospital's surgery training program since November. "Every hospital in the country is struggling with this issue."

Johnson said that the hospital has spent months working to rein in residents' hours at Beth Israel Deaconess and the other hospitals where the residents do rotations, and that he believes the program has significantly reduced violations and will maintain its accreditation. The hospital has been sending data on residents' hours to the council every three months as part of a corrective action plan.

Because of concerns that exhausted residents are more prone to errors and do not learn well, the council adopted rules five years ago prohibiting residents from working more than 80 hours a week on average, and more than 24 to 30 hours in a shift. They also must have 10 hours off between shifts and one day off in every seven.

But many teaching hospitals, which not only educate residents but rely on them as inexpensive labor, have had trouble complying with the rules. The council cited 227 training programs for hours violations in the last academic year, or 9 percent of the total number of programs, including 19 surgery programs.

The council does not release the names of programs that are cited; Beth Israel Deaconess provided the council's letter and details of its violations to the Globe.

Residents, along with nurses, provide most of the round-the-clock care for patients in teaching hospitals. Massachusetts hospitals have more than 5,000 residents on the job.

Massachusetts General and Brigham and Women's hospitals, which have the largest training programs in the state, were cited in 2006 for hours violations, according to Dr. Debra Weinstein, vice president for graduate medical education for Partners HealthCare System, the parent organization of the two hospitals. She said she could not provide more details, but noted that the most difficult rule to comply with has been providing a 10-hour break between shifts.

Some policy makers now argue that even current limits are not strict enough. Congress has directed the Institute of Medicine to study whether residents' continuing long hours are a threat to patient safety, a report that will be completed soon. A number of previous studies have suggested that residents who work long hours are more likely to make errors, but many senior doctors argue that limiting hours also can lead to mistakes, because residents must hand off their cases to colleagues who are less familiar with the patients.

In Massachusetts, Senator Richard Moore, Democrat of Uxbridge, has filed legislation that would allow state public health officials to further limit the number of hours residents work, a bill that teaching hospitals oppose.

"The hours limits in place now are too long; it's perfectly acceptable to stay up 30 hours straight," said Sandy Shea, senior area director of the Committee of Interns and Residents, a union that represents residents at Boston Medical Center and Cambridge Hospital among other institutions. "There is a lot of pressure on residents not to blow the whistle on their program," she said, adding that problems are widespread among hospitals.

The accreditation council reviewed Beth Israel Deaconess's surgery training program last July because the hospital wanted to expand the number of residents in the program. It now has 65 surgery residents. As part of that visit, council staff reviewed information on how many hours residents were working.

In its January letter, the council cited the hospital for "substantial failure to comply" with the one-day-off-in-seven rule during every month of the 2006-07 academic year. "Violations of duty hour rules continue to persist," the council wrote. The council denied the hospital's request to expand the program because "duty hour compliance has, over a period of years, not occurred."

Johnson said residents also have violated the 80-hour-a-week limit, with some working up to 90 hours a week.

Others had violated the rule requiring 10 hours off between shifts. Many residents who violated this rule were working late and then coming in as early as 4 a.m. to prepare for early-morning patient conferences, called rounds, with senior doctors.

Johnson said that Beth Israel Deaconess prohibited "pre-rounding" three years ago, but that residents felt they were expected to do it at the hospital's affiliated institutions where they rotate, including Mount Auburn Hospital in Cambridge. Beth Israel Deaconess pulled residents out of that hospital for a week this July because residents were working too many hours. He said Mount Auburn has since hired a nurse practitioner to do some of the work residents were doing and plans to hire another to help with the heavy workload.

Aside from hiring more staff, Johnson and other surgery department administrators are reviewing residents' hours weekly, to see who is in danger of violating work hours rules, so he can send them home. Johnson also said he did not think the violations were as bad as they seemed because the hospital had incorrectly entered data into the computer tracking system.

"We had been asking residents to abide by the hours rules, but as an institution we weren't giving them the support they needed," Johnson said. "The residents want to be here and they want to learn. Someone has to police them."

Liz Kowalczyk can be reached at kowalczyk@globe.com.

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