In early July, days after new rules were supposed to limit the number of hours he and other new doctors could work, Dr. Troy Madsen almost made a fatal mistake.
A first-year resident at Baltimore’s Johns Hopkins Hospital, Madsen was on hour 32 of a 34-hour shift when he failed to make sure a crucial blood test was given to a heart patient.
Complications related to that mistake led to a setback that could have killed the patient, Madsen later learned. The man ultimately recovered, but Madsen was horrified at what his mistake almost meant.
The 28-year-old doctor’s work shift violated new rules limiting residents to no more than 30 hours straight and no more than 80 hours a week on average.
“It was my first week in residency, and the whole thing was just overwhelming,” he said.
Violating work rules
He e-mailed outside authorities, and Johns Hopkins — ranked by U.S. News & World Report as America’s top hospital for 13 years running — was temporarily threatened with losing accreditation for its internal medicine residency program, an earthquake that rocked the medical community.
Today, medical experts say Johns Hopkins and most other programs comply with the new residents’ work rules adopted last July. But the medical community almost universally acknowledges that some programs still overwork young doctors.
Two resident organizations, which believe the rules should become law, say they’ve gotten dozens of reports that programs are violating the work rules.
Justin Wood, a spokesman for the union Committee for Residents and Interns, said a common story he hears is residents are told “more or less explicitly” to falsify time sheets.
Sometimes residents, particularly those in difficult specialties, work long hours by choice.
“The kind of people who are attracted to surgery ... want to stay. It’s hard to push people out the door sometimes,” said Dr. Larry Kaiser, the surgery department chair at the Hospital of the University of Pennsylvania.
A resident in Philadelphia, who asked not to be identified for fear of the retaliation, said she worked a 34-hour shift last week because she didn’t want to dump work on her colleagues.
Dr. Lauren Oshman, president of the American Medical Student Association, said there are too many disincentives for reporting violations: no whistle-blower protection, resentment from peers, and the risk of getting one’s own program disaccredited.
Still, the overall atmosphere is very different from when residents regularly worked 120 hours and studies showed sleep deprivation was leading to mistakes. A death in New York in 1984 caused in part by weary residents led to stricter laws there.
Dr. Elliot Sussman, chief executive of Pennsylvania’s Lehigh Valley Hospital who also chairs a board of teaching hospitals for the Association of American Medical Colleges, said when he was a resident in 1977 he had to work “black weekends,” from 7:30 a.m. Saturday until Monday evening — 60 hours.
“That doesn’t happen anymore,” he said. “We want (trained) professionals, but we also want humanistic physicians.”
Hospital executives say they’ve complied with the new rules by hiring extra help and making schedules more efficient.
But limiting residents’ hours cut off a cheap labor supply, and many hospitals have had to hire extra help. National figures aren’t yet available, but Sussman said his hospital has already spent an extra $1 million. At Penn, Kaiser said, the figure is $6.5 million.
But there’s also a marketplace incentive for compliance, Philbert said. Medical students now ask if residencies follow the rules. David Buchanan, a fourth-year student doing a rotation in Wheeling, W.Va., said most residents say their programs are in compliance.
“Nobody seems to be really upset about their call (overnight) schedule anymore,” he said. “They’re saying call might be once a week and I’m thinking, ’Wow, that sounds pretty good.”’
The ACGME found that some Johns Hopkins residents in July worked call every other night. Many believe the hospital’s punishment was a warning for other programs.
Madsen, meanwhile, suffered a common whistle-blower’s fate. “People I worked with, people I knew very well, would not look at me, would not talk to me,” he said. He left the program and eventually wound up at Ohio State University Medical Center where he says he is happy.
What made him angriest, he said, was Johns Hopkins’ “blatant disregard” for the new regulations. He said the hospital made no schedule changes even as the new rules deadline loomed last summer. “They said, ’Hey, we’re Hopkins. We’re going to do anything we want.”’
Johns Hopkins Medicine spokeswoman Joann Rodgers said the institution did make changes to comply before July 1 and continued to do so afterward. She also said that “serious efforts” were made to retain Madsen. “People here certainly did not want to see him leave,” Rodgers said.
Four months after the threat to their accreditation, Johns Hopkins was found to be in full compliance by ACGME in December.
Today, Madsen says he doesn’t regret his actions.
“I felt like what I had done was in the interest of patient care and resident well-being,” he said.