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Sunday, September 27th 2009

The Hours

I’ve been working some hours of late as my fellow intern is taking vacation and there really wasn’t afforded anything in the schedule to mitigate that. Not to get all ‘I walked uphill in the snow both ways to get to school each day’. I know residency used to be something tougher. Maybe.

While I haven’t gotten into the operating room I’ve gotten some cool procedures, gotten pretty proficient at chest tubes and pigtails and generally had a pretty good weight towards actual patient care this rotation considering the bureaucracy of medicine that falls to residents at academic centers. So don’t number the above as a complaint.

[zdvideo height=400 width=500 theme=gray border=no]http://www.youtube.com/watch?v=qdH2hX0WmPU[/zdvideo]
One Way To Avoid All This…

But the amount of time I’ve spent at the hospital has got me thinking about the way the ACGME polices residency rules. So much centers on self reporting. And there’s huge pressure to not report violations. When residency programs get in trouble with the ACGME there are consequences for the residents. A residency program shutting down can be disaster for residents. You could be searching for a new program, leaving a program you love, maybe even switching specialties or moving across the country.

The medical community does some to help in situations when programs are lost. In many specialties other programs traditionally give preference to those residents who have lost their spots. And the ACGME and most RRCs are helpful in giving residency programs exceptions for extra residency spots when programs shut down. In reality those concessions and that assistance are small potatoes.

Scrambling for a new spot that has funding for you, moving, acclimating to a new environment is major trauma. That is assuming you even get ahold of a new position.

There are major incentives for residents to keep their programs in good standing, including to lie about their hours worked.

Some research indicates almost half of residents lie about their duty hours. And you have to believe that is a remarkable under reporting of the situation.

Now I’ve never lied about my duty hours. And I can’t say I know directly of anecdotal episodes of categorical residents lying about their duty hours to protect their programs but you have to believe it happens. It is just not something that will ever be spoken to. If the ACGME wants residents and others to self report violations; if truthful reporting is going to be the centerpiece of review then it needs to give residents more protections. I’m talking about an extreme shift. I’m talking about emergency funding for residency spots when programs run into trouble, about guaranteed spots for residents whose programs fail including about requiring all programs to agree to participate in helping to take on displaced residents, about relocation expenses.

I’m thinking program violations for all sorts of things must be vastly, vastly, vastly under reported. ACGME policies don’t have a lot of teeth when weighed against the future of your training.