80/24 Rule really enforced?

[RuralMedicine]

So true. There was a mix up in the beginning of the year that messed up our keys for our call rooms. To make the story short we don't have our keys to our call room yet. I thought that this would be a problem, however I haven't missed the darn key as of yet. If I had my key now, I still would not know what the inside of our call room looks like.

Hang in there---after some of my worst NICU call nights I often felt really bad for the poor OB residents. Often worse than I felt for myself.

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[8744]

You really are not understanding where I'm coming from. As I've pointed out several times I realize that I had a choice in coming here in the first place and I could certainly go elsewhere, work less, and make more. The point you are missing is that it isn't all about me. My departure (or any physician's departure) would have significant adverse effect on the community. If we had more physicians in this community (and more competent EM providers but that is another thread entirely) my colleagues and I would all work less. At the moment we are choosing to continue to practice in this community because don't believe that your right to health care should be dependent on living in a urban or suburban area, being affluent, or having connections. I enjoy what I do. I believe that health care is a right not a privilege and that there are more important things than how much money you can make.

Ah. So it's a calling for you and your suffering is self-inflicted.

Please do not be offended when I say that your career path has no influence on my life and is not a source of inspiration.

I was kidding.

 

[Faebinder]

Ah. So it's a calling for you and your suffering is self-inflicted.

I think that's pretty much it.... If you feel like you should do what you are doing at the rate that you are doing it.. that's great... but there are many out there who don't feel the same and shouldn't. The extreme should not be the norm.

Some us do have families and would like to maintain them and I'll quote a mentor of mine, "There is nothing that will ruin your career in medicine or put you out of steam faster than a divorce or a broken family."

 

[toxic-megacolon]

I think that's pretty much it.... If you feel like you should do what you are doing at the rate that you are doing it.. that's great... but there are many out there who don't feel the same and shouldn't. The extreme should not be the norm.

Some us do have families and would like to maintain them and I'll quote a mentor of mine, "There is nothing that will ruin your career in medicine or put you out of steam faster than a divorce or a broken family."

Getting back to the original topic, has anyone heard about any new changes in enforcement of the rules? The current system obviously doesn't work at many places. I wonder what would happen if the work hours were tied into JHACO. Everyone is scared of JHACO... they can even find a soda bottle in the 3rd drawer of a random nurses station.

 

[Faebinder]

Getting back to the original topic, has anyone heard about any new changes in enforcement of the rules? The current system obviously doesn't work at many places. I wonder what would happen if the work hours were tied into JHACO. Everyone is scared of JHACO... they can even find a soda bottle in the 3rd drawer of a random nurses station.

Are you saying they will increase the hour limit back or are they going to tighten up the hours a resident is in the hospital?

 

[RxnMan]

He's suggesting that the residency hour limit be tied in with JHACO accreditation status. Since nobody wants to lose JHACO status, program directors would have more motivation to be compliant with the rules (and therefore keep better track resident hours to back this up). It'd give the residency hour limit rules more bite because the entire hospital could be penalized by the actions of one malignant director. It's a good idea.

 

[docB]

I can't even tell you guys how much of a bad idea it would be to let JCAHO get involved with the residency programs. You're talking about the prototypical govt. agency that will never be satisfied with anything because it would lose its funding if it did. Residents would have to take 3 weeks of orientation lectures with titles like "The Open Beverage in a Work Area: Worse Than Nuclear War?." And you'd have to do it every year. And don't think that JCAHO would just address the work hours issue you guys are worried about and go no furthur. They will never respect those boundaries and they'll get so intwined into the system the whole thing will grind to a halt. Just look at what happens to a hospital when the inspection team shows up. You have to basically quit work for a week before they go away and you can get back to business. Don't look to JCAHO to solve this problem. It would be like curing a head ache with a decapitation.

 

[MirrorTodd]

Love the analogy. Never heard that one before.

 

[toxic-megacolon]

Out of curiousity, how do ACGME site reviews work? Basically they announce they are coming, the program cleans up their act for a few weeks, and then gets a license to go back to the same old system for the next 5 years? Or is there more to it?

 

[njbmd]

Out of curiousity, how do ACGME site reviews work? Basically they announce they are coming, the program cleans up their act for a few weeks, and then gets a license to go back to the same old system for the next 5 years? Or is there more to it?

Hi there,
There is a site-visit document that must be filled out by the Program Director. It's about 100 pages long and contains everything about the program. In this document, everything about the program must be documented like M & M conferences, teaching conferences, experiences of residents on various rotations, documentation of resident hours, credentials of teaching physicians, ABSITE scores, percentage of grads who pass ABS exam, residents who leave and why etc. It's a little difficult to clean up a program for a few weeks and then go back to same old mode.

The site inspectors also interview residents so you have to answer questions truthfully and honestly. This is not the time to air personality disagreements with a program but it is a time to discuss things that you feel ACGME needs to know like hours, teaching quality. Residents also have a survey that should be honestly filled out before the site visit. On that survey, you will be asked about things like hours, educational experience etc. If you tell the truth (if there are problems), the ACGME site inspectors will examine those things more closely.

Other things that the ACGME will review are the evaluation sheets that you should be filling out at the end of each rotation. Again, be honest and make comments if you feel that there is something lacking. We were able to change a couple of rotations that residents were getting less than a good educational experience by everyone filling out the rotation evals honestly and promptly.

If there are things about your program that you have honestly attempted to bring to the attention of the program director and chief residents and you have been dismissed, a site visit can provide a platform for change especially that survey that is done before the site visit.

The ACGME wants residency programs to adhere to their rules and provide the best educational experience for the residents possible. The site inspectors are not fools and are not fooled by a quick "whitewash" or a Program Directors document that is full of crap. They take these visits very seriously.

After a visit, a program can be placed on probation and given time to correct their problems, given two years accreditation or given a full five year accreditation.

Good luck
njbmd

 

[Annette]

Yeah, the residents will be honest and truthful. And they are terrified that they will lose the program. The PD gets to pick the residents the review team gets to speak to. And, as for residents leaving the program, that is so easily whitewashed, even Tom Sawyer wouldn't ask for help.

I agree about filling out evals to get better teaching. After years of one attending putting in a board review tape (and a bad one at that) instead of lecturing, poor teaching, and lack of patient care (having to beg a gastroenterologist to scope a LGIB???), we got three people to complain. She was taken off the teaching service that month.

 

[3dtp]

Hi there,
It's a little difficult to clean up a program for a few weeks and then go back to same old mode.

Operative words here. "a little difficult" But it can be done and according to one GME, "The ACGME will NEVER support a resident over a program. I've never seen it in twenty years."

The site inspectors also interview residents so you have to answer questions truthfully and honestly. This is not the time to air personality disagreements with a program but it is a time to discuss things that you feel ACGME needs to know like hours, teaching quality. Residents also have a survey that should be honestly filled out before the site visit. On that survey, you will be asked about things like hours, educational experience etc. If you tell the truth (if there are problems), the ACGME site inspectors will examine those things more closely.

This is indeed true. If a resident has engaged a malevolent program director, and make absolutely no mistake about this, they exist, truthful answers on the accreditation survey are relatively easy to trace. Life will be unbelievable hell for the truth-tellers, if not the end of their career. I have personally seen it happen.

Other things that the ACGME will review are the evaluation sheets that you should be filling out at the end of each rotation. Again, be honest and make comments if you feel that there is something lacking. We were able to change a couple of rotations that residents were getting less than a good educational experience by everyone filling out the rotation evals honestly and promptly.

I hope, and it has been my experience that the majority of program directors are relatively honest, are interested in having a good program, and in training excellent doctors. Sadly, there is a significant fraction who are interested in raw, unchecked power and its exercise, and there are institutions who give it to them. If you are in one of these programs, you fill this out at your peril.

If there are things about your program that you have honestly attempted to bring to the attention of the program director and chief residents and you have been dismissed, a site visit can provide a platform for change especially that survey that is done before the site visit.

You may be correct. Who, knowing the stakes (and I know that by writing this, I am giving ammo to the miscreants), would willingly place their heads on the guillotine block? Change will do the dismissed resident no good. It will not get their job back, it will give them a permanent and indelible mark on their record which will have to be explained.

If you have been dismissed, you are, unless you are exceptionally lucky, talented, or exeedingly persistent, finished in medicine.

The ACGME specifically says it will not arbitrate individual actions at hospitals. If the ACGME were to be truely interested in what has transpired, it would make a deliberate effort to contact recent ex-residents of the program. It would schedule its site visits in June rather than July-August-September when outgoing and presumably graduating residents could be candid without direct repercussions. Even so, they face the risk of a hospital creating an adverse unsupported (read false) comment on a licensing/credentialling document in retaliation. And there is very little one can do about it except explain it for the rest of their lives. If a resident has a legitimate complaint, as Annette said, even Tom Sawyer can do that whitewash. I have personally seen this happen.

The ACGME wants residency programs to adhere to their rules and provide the best educational experience for the residents possible. The site inspectors are not fools and are not fooled by a quick "whitewash" or a Program Directors document that is full of crap. They take these visits very seriously.

On this we agree. I do think the ACGME will ding a program for violations. It was not until very, very recently that the ACGME published a list of programs on probation. Prior to this, the only way a resident-candidate found out was to waste money on application, interview expenses and then the program had to tell applicants it was on probation. At the present, there is absolutely no information available to residents on RRC citations in any form, unless you ask the PD at the interview time or before what citations they have had.

My question to you then is, if you are an evil program and a potential resident asks if you are evil, would you tell the truth, knowing it cannot be verified and how would that affect your ranking of a potential resident? If you are not an evil program, and a resident-candidate asked about RRC citations would it affect how you rank an otherwise acceptable candidate?

I submit that unless and until we have full disclosure prior to the application process, we are blind mice wandering around a maze.

 

[Faebinder]

3dtp.... absolutely great reply... and I agree with it whole heartily and to be honest.... If I was in an evil program and someone asked me if I was... I unfortunately would be scared of stirring the pond and would never say a word... but I am glad to know there are people not like me out there.

 

[njbmd]

You may be correct. Who, knowing the stakes (and I know that by writing this, I am giving ammo to the miscreants), would willingly place their heads on the guillotine block? Change will do the dismissed resident no good. It will not get their job back, it will give them a permanent and indelible mark on their record which will have to be explained. If you have been dismissed, you are, unless you are exceptionally lucky, talented, or exeedingly persistent, finished in medicine.

Hi there,
By dismissed, I was referring to your attempts at effecting changed from within the program were dismissed as in ignored and not that the resident had been dismissed from the program.

I have run into residents who have been dismissed from programs and the picture is not a bleak as you point out. No, it is not a good thing to be dismissed/fired but some people make poor decisions in the choice of a specialty or program. They have been able to enter other programs or change specialties but they are not "finished in medicine". There are too many open slots in programs out there.

njbmd

 

[3dtp]

Hi there,
By dismissed, I was referring to your attempts at effecting changed from within the program were dismissed as in ignored and not that the resident had been dismissed from the program.

I have run into residents who have been dismissed from programs and the picture is not a bleak as you point out. No, it is not a good thing to be dismissed/fired but some people make poor decisions in the choice of a specialty or program. They have been able to enter other programs or change specialties but they are not "finished in medicine". There are too many open slots in programs out there.

njbmd

Boy, we need to have a long talk. I have known and helped a number of people get reestablished after they've run afoul of a malignant PD at a particular institution. Fortunately for most of them I've collected a group of PDs who either are well aware of their evil colleagues and are willing to do something about it or have been victims themselves. It usually costs them between 2 and 5 years of their lives. The personal devastation is astounding, from suicides to bankruptcy. Gotta agree with Annette here.

I have no doubt that there are a rare few that do get into the system that shouldn't be there, but at one program in 3 years, 6 were terminated, one because she pointed out major medicare fraud (for which the hospital was fined $38M years later). Of these 6, perhaps one was legit. I worked with these folks, watched it. It was awful.

PM me, man we gotta meet somewhere and have a beer and a long, long chat about some of the stuff I've seen that is sickening. Maybe at a national meeting we might both attend. Hey Annette, you want to join us? I think if the three of us sit down and have a burger and beer some of the stories I know and I'll bet Annette knows will curl your hair.

 

[toxic-megacolon]

The site inspectors are not fools and are not fooled by a quick "whitewash" or a Program Directors document that is full of crap.

Well if that were true all surgery programs would either be close to compliant or on probation, no? Actually playing devil's advocate a little bit... njbmd when you have something to say I always listen b/c you're usually right. But still.... makes me wonder about our whole system

 

[Annette]

PM me, man we gotta meet somewhere and have a beer and a long, long chat about some of the stuff I've seen that is sickening. Maybe at a national meeting we might both attend. Hey Annette, you want to join us? I think if the three of us sit down and have a burger and beer some of the stories I know and I'll bet Annette knows will curl your hair.

Name the place and time.