Legislation is one thing; enforcement is another.

[Castro Viejo]

The longing for residents across the country of a shortened work week by way of legislation is something that New York State, since 1989 at least, has had for quite some time. In New York we have what the other 49 states want: 80-hour work week with no more than 24 consecutive hours on call/on duty in a clinical setting, making decisions on patient care.

Enforcement of these famous "Bell Commission" rules is an entirely different area that has only been touched upon superficially in all the rhetoric slung about by AMSA. Ask the residents of New York how many of them actually have an 80-hour week, and according to information from the AMSA website, about 60% have a workweek exceeding 95 hours and only approximately 10% actually maintain an 80-hour week.

Ways certain institutions in New York State have gotten around Bell Commission regulations is by scheduling 80-hours of clinical responsibility for residents, but not taking into account the 10 or so hours of lecture residents also have to take in addition to added hours of nonclinical responsibility. Other institutions have simply told residents to lie about the number of hours they've worked when surveyors come around asking. From a purely psychological standpoint I suppose the Bell Commission rules do give residents and patients in New York State a fair amount of comfort that legislation exists to protect the two parties, but enforcement has been quite a challenge and I don't think that this pursuit of legislation is the silver bullet for the problem.

Has anyone thought of ways to enforce these regulations? And if you have, could you please forward them to the NYS Department of Health? Your New York colleagues would be thankful.

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[MacGyver]

Well, first off the residents need to stop being complicit in the deceit and dishonesty that hospitals in NY are perpetuating.

Until they are willing to step up and not lie to ther officials, and notify the powers that be that hospitals are not doing what they are supposed to, nothing will change.

I think this needs to be tied to accreditation with the RRC. Every hospital should use standard timekeeping logs which keep track of all hours spent there, whether in academic conferences or out on the wards.

there should be a random auditing process of all timelogs, and independent consultation with residents about approx how many hours they work. If the logbook does not agree with the residents, then a full scale investigation should be launched.

After that period, if it is determined that they are not following the statute, then they are given a warning to clean up their program in, say, 2 months time. Then another investigation will occur. If they dont meet it this time, their accreditation is pulled for 6 months, and another investigation is scheduled.

If it is determined that any resident has made false statements to the authorities regarding work hours in an attempt to protect the hospital, they are given a warning. If they continue to lie to the officials, they are placed on probation.

Its time to put some bite into the system and eliminate the corruption. In my opinion, any resident who would make false statements public record about these regulations has disgraced their hippocratic oath.

 

[drusso]

Just pull the accreditation and shut down **ONE** major medical center (Hopkins, Mass General, Wash U?) for failure to comply with new federal resident physician work rules and watch the system change virtually overnight...

 

[hankhill]

Maybe it would make a difference if residents could somehow push to be payed by the hour. If they had to clock in each day when they arrive and clock out each day when they leave, it would be easy for regulatory agencies to come in and check up on the program. On top of that, programs would be required to pay residents 1.5 for overtime. I'm sure that the programs would make adjustments so that residents would still get payed the same amount that they do now, but maybe this would provide a way of legally and accurately documenting resident work hours.

On the other hand, programs might try to get around this by just telling their residents not to clock in when they are on call or otherwise. I don't know. What do you think?

 

[Castro Viejo]

According to information posted by AMSA, the Bell Commission regulations were initially not enforced and it wasn't really until about 1998 when someone in the NYS Department of Health discovered this. The penalty at the time was a mere $2,000 for each violation (i.e., for each resident found to be non-compliant with Bell Commission regulations). That's not that stiff a penalty, but eventually rules were changed to make it possible for penalties to reach over $50,000.

I'm sure the vast majority of residents in New York State realize that by lying on time cards used for inspection, they're not helping their case of being overworked, but in the realm of medicine, he who is labelled a "whistle-blower" would be so black-balled he might as well pack up and move down to Mexico to practice. On some level I'm sure everyone right down to first-year medical students understands that unless you have something on the order of a "class-action" type of case (where AMSA claims to have generated the support of over 200,000 residents, physicians, and medical students), you're gonna get squashed.

 

[edmadison]

I have a quick question for tim, based on his first post:

I was under the impression that educational time such as lectures, et al. was included in the work hour restrictions of the Bell Commision, is this not the case? Here in Rochester, the departments count that time towards the 80 hours (very begrudgingly)!

Ed

 

[Castro Viejo]

I've got a shelf exam in Psych on Friday, so I'll have a little more to write then, but I remember distinctly reading that the Bell regs (405 regs) apply to number of hours "on-duty" in direct patient care. Thus it would stand to reason that academic conferences, didactic hours, and other such time not in direct patient care would not count toward the 80-hour work week requirement.

Well, let's be honest, I believe that most programs would just make it 80-hours per week whether you're on the floor or in the classroom. It's just those especially malignant programs that would follow the letter of the law so closely.

 

[AMSA LAD]

•••quote:•••Originally posted by ******:
•According to information posted by AMSA, the Bell Commission regulations were initially not enforced and it wasn't really until about 1998 when someone in the NYS Department of Health discovered this. The penalty at the time was a mere $2,000 for each violation (i.e., for each resident found to be non-compliant with Bell Commission regulations). That's not that stiff a penalty, but eventually rules were changed to make it possible for penalties to reach over $50,000.

I'm sure the vast majority of residents in New York State realize that by lying on time cards used for inspection, they're not helping their case of being overworked, but in the realm of medicine, he who is labelled a "whistle-blower" would be so black-balled he might as well pack up and move down to Mexico to practice. On some level I'm sure everyone right down to first-year medical students understands that unless you have something on the order of a "class-action" type of case (where AMSA claims to have generated the support of over 200,000 residents, physicians, and medical students), you're gonna get squashed.•••••Hello,

I am the AMSA Legislative Affairs Director and also a med student in New York. As such, I have quite a bit of information to offer on enforcement issues, etc...

First of all, AMSA is not involved with, nor has it taken a position on the lawsuit against the match and we have not attempted to put together a class action lawsuit solely based on resident work hours.

As for actual enforcement, the Bell regulations were passed in 1989 but not actually enforced until this past October. The first real survey of hospital compliance with the Bell regulations didn't take place until 1998. 12 Hospitals were subjected to a surprise survey byt he NYS Dept. of Health and all 12 were found in violation of some part of the Bell rules. As was mentioned, in response to this survey and its findings, the NYS legislation upped the fines through HCRA 2000, the Health Care Reform Act of 2000.

The survey also led NYS to hire an investigative agency to survey all teaching hospitals on a surprise basis each year. This did not take palce until October 2001. The agency, named IPro, investiagtes the number of hours worked by residents by correlatingphysicians orders, charting, etc... with the times residents say they have actually been working. Not surprisingly, many residents flat out lie about the nubmer of hours worked. Anecdoatally, a number of residents have told me their attendings require them to make up false data...hence the need for an agency to do actual investigations rather than rely on testimonials.

IPro files quarterly reports with the NYS DOH and beginning next October, the DOH will publish annual reports absed on these findings.

AMSA strongly believes that public disclosure is the only real means of enforcement. Unless public accountability is required, people don;t change their behavior.

It is absurd that a program like Yale can lose its accreditation, but no one is allowed to know why. AMSA was responsible for breaking that story and yet no one in the ACGME or the Yale program would initially tell us why. If the program was was placing residents and aptients in harm's way, then the public has a right to know why.

Public disclosure is an absolute necessity in governing the medical community's dealings with the resident work hour issue.

--Rob

 

[Winged Scapula]

•••quote:•••Originally posted by edmadison:
•I have a quick question for tim, based on his first post:

I was under the impression that educational time such as lectures, et al. was included in the work hour restrictions of the Bell Commision, is this not the case? Here in Rochester, the departments count that time towards the 80 hours (very begrudgingly)!

Ed•••••While I am not in NY, the above scenario is very common. A friend of mine is working at a community surgery program which has been "ordered" to restrict its working hours to 80 per week. The residents thought this impossible until they realized that the program took 1 hour out of each day for lunch (whether or not they got it), 30 minutes for breaks, deducted all meeting, lecture and tutorial time, time traveling to outside clinics, hospitals, etc. Anything where you aren't directly involved in patient care is deducted from the total.

 

[Castro Viejo]

Yes, I apologize. The class-action lawsuit against the NRMP has nothing to do with AMSA's efforts, although the two are dangerously close in their timing.

Although one of the residents filing the lawsuit, Dr. Paul Jung, is the former Legislative Affairs director for AMSA (this was back around 1996/1997, I believe).

 

[Hopkins2010]

Tim,

the scenario you described of residents getting shunned for not being complicit in deceit and lying is very simple to solve.

My solution: give stiff fines or otherwise punish RESIDENTS who are found to be lying about their work hours. Once you do this, then the hospital cant expect residents to lie in complicity, because the residents will then have a very good reason not to do so. The hospital wont be able to kick you out, because the next resident to take your place is exactly under the same pressure not to falsify records.

 

[focker]

•••quote:•••Originally posted by Hopkins2010:
•Tim,

the scenario you described of residents getting shunned for not being complicit in deceit and lying is very simple to solve.

My solution: give stiff fines or otherwise punish RESIDENTS who are found to be lying about their work hours. Once you do this, then the hospital cant expect residents to lie in complicity, because the residents will then have a very good reason not to do so. The hospital wont be able to kick you out, because the next resident to take your place is exactly under the same pressure not to falsify records.•••••<img border="0" alt="[Laughy]" title="" src="graemlins/laughy.gif" />

Well, you've figured out the problem! Residents just aren't under enough pressure!

 

[neutropeniaboy]

My friend (PGY-2 in radiology) who works at Downstate got an interesting letter once during his employment there. When the committee reviewed his work hours, they sent him a letter stating that he had exceeded the maximum allowable work hours. They further stated that any additional hours accumulated beyond the regulated hours were considered "voluntary" on the part of the resident.

Hmmm. I wonder what would happen if he said he no longer wanted to work these "voluntary" hours.

 

[Ryo-Ohki]

AMSA LAD, why isn't AMSA supporting Jung's lawsuit?

 

[Hopkins2010]

focker,

you think just abiding by simple rules and regulations is "pressure"?

How else are you going to ensure that residents accurately report the hours? At least with this scenario, the resident has a very valid excuse as to why he/she cant lie to protect the program.

 

[neutropeniaboy]

•••quote:•••Originally posted by Ryo-Ohki:
•AMSA LAD, why isn't AMSA supporting Jung's lawsuit?•••••Probably because the lawsuit is ridiculous...

 

[Ryo-Ohki]

Care to elaborate?

Have you even read the brief of the lawsuit?
<a href="http://www.usatoday.com/news/nation/2002/05/07/residents-brief.htm" target="_blank">http://www.usatoday.com/news/nation/2002/05/07/residents-brief.htm</a>

 

[focker]

•••quote:•••Originally posted by Hopkins2010:
•focker,

you think just abiding by simple rules and regulations is "pressure"?

How else are you going to ensure that residents accurately report the hours? At least with this scenario, the resident has a very valid excuse as to why he/she cant lie to protect the program.•••••Right now residents are worried about negative consequences from employers if they tell the truth about hours. You want them to also have to worry about getting in trouble with some regulatory agency for lying about them? Talk about being put between a rock and a hard place.

I think independent investigation of work hours, as AMSA LAD described above, is the best solution. This would allow collection of accurate results without putting residents in such a difficult position.

 

[neutropeniaboy]

•••quote:•••Originally posted by Ryo-Ohki:
•Care to elaborate?

Have you even read the brief of the lawsuit?
<a href="http://www.usatoday.com/news/nation/2002/05/07/residents-brief.htm" target="_blank">http://www.usatoday.com/news/nation/2002/05/07/residents-brief.htm</a>•••••Well, the suit names the NRMP. I don't see that it names the San Francisco Matching Program or the Urology matching program. Yet, we all end up with similar regionally-dependent salaries and hours.

I think the notion that these organizations have "contracted, combined and conspired" to circumvent competition is unfounded.

While I think salaries are low, they are distinctly not adjusted to subjugate residents. Honestly, we're training physicians who pay no liability insurance, few medical fees, have no costs that maintain practices, etc.

Would I like to be paid more? Yes. The market, however, cannot bear the raise in salary, however.

I don't think the salary is a problem. I think the hours residents work is the problem. Not because there's a mismatch between salary and hours worked, rather the risks these long hours present to the physician health and patient health.

Whatever the problems may be with residency, I don't believe they are generated by the NRMP and participating hospitals.