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A Whistleblower’s Story

REFLECTIONS ON MAKING THAT REPORT

The New Physician May-June 2004
Yes, I blew the whistle on Johns Hopkins Hospital’s internal medicine residency for work-hours violations. Yes, I would do it again. But first, let me clarify a few things.


It was early July 2003. I had just graduated from Johns Hopkins University School of Medicine and was starting my residency in emergency medicine there. For my first month, I was to rotate in the internal medicine program. Now, I’m not sure that was such a good idea.


I had always been somewhat outspoken on residency work-hours issues, talking about it regularly with classmates and even authoring a letter about it in the Annals of Internal Medicine the year before. And, if it hadn’t been for the Accreditation Council for Graduate Medical Education’s (ACGME) new work-hours regulations, I probably wouldn’t have done a residency.


Maybe I was too idealistic. I tried to hold onto this concept of “true medicine,” of compassionate medicine, of seeing patients as more than obstacles to a few hours of sleep. But as a Hopkins medical student, I saw the dehumanization of patients, and I felt residents’ work conditions played a significant role in their desensitization and cynicism. The Hopkins residents with whom I had been as a student regularly worked 120 to 140 hours a week. When the ACGME regulations were proposed in the summer of 2002, I changed my mind about residency. I figured I could do 80 hours and hopefully maintain some humanity.


Yet the internal medicine program had little, if any, intention of changing things. I don’t say this to be dramatic. I say it because before I contacted the ACGME, some internal medicine residents openly shared their disgust with me concerning Hopkins’ disregard for the rules. After my first four days—during which the required 10 hours off between shifts meant nothing, throughout which we, as interns, had been informed we might have two days off during the month and during which our senior residents emphasized they would not have any days off—some medicine interns approached me and asked me to speak up.


“Troy, we’ve got too much to lose,” they said.
Little did I know....


So I said something. I spoke openly with my supervising residents, my attending physician and my emergency medicine program director. I have been criticized within the Hopkins community for not following the “chain of command.” I’m not sure what more I could have done. This much, though, I didn’t do: I didn’t talk with the internal medicine program director. I’ve known Dr. Charles Wiener for quite some time, and, admittedly, I was intimidated by him. So I didn’t see the value in talking with him.


Some internal medicine residents told me they had formed a committee the previous year to propose how Hopkins could adhere to the regulations. They came up with a number of proposals, all of which were rejected. When residents proposed bringing internal medicine residents in from off-site rotations to provide adequate coverage, the response, according to these residents, was, “Do you have $50,000? That’s what they pay us to have you rotate there. Do you have that kind of money?”


In the end, that’s what I believe it was about—money. Sure, I was under the impression that the department hadn’t put a lot of effort into compliance, but it didn’t have much money to work with either. An administration official later told me that the hospital’s residency programs had received no additional funding to assist in ACGME compliance measures and had been told simply to make it work by the July 1 deadline.


With this in mind, then, I couldn’t imagine my weak appeals to one administrator after another would have made much of a difference. And, with this in mind, I wrote “the letter.”


It was a five-minute e-mail. I sat at a computer in the physicians’ lounge, and I wrote to the ACGME. I stated the facts: Residents had worked more than 120 hours during that first week; we had been told we would have only two days off that month; the medical intensive care unit (MICU) residents were on an every-other-night call schedule; on-call periods had reached 40 consecutive hours in some cases; and time off post-call had been far less than 10 hours. I wrote that e-mail on July 7. Early? Absolutely. But I wrote it at that point for a number of reasons.


First, I was angry. The department had promised new interns during residency interviews that they would be in compliance by July 1. Resident proposals for compliance had been rejected. The administration’s efforts at compliance had been anemic and practically nonexistent, amounting to little more than a senior resident assigned to four interns to help them get their scutwork done and get out by hour 30.


Second, I had climbed the chain-of-command ladder in seeking help and had nowhere else to go. Realistically, I had spoken to all of the relevant individuals a resident should approach. The response was, “There’s nothing we can do about it.”


And finally, the work-hours situation hit a very personal note. I almost hurt a patient. It was the first patient who remembered my name, who called me Dr. Madsen through his sleepy-eyed grin. That was what pushed me over the edge. I forgot to order a second set of cardiac enzymes on him. Post-call, on hour 32, the test had not been done. I had ordered it earlier, but at that point I should have drawn it myself. And I just plain forgot. Fortunately, the test was performed sometime later that day.


When I returned the next day, though, my attending physician said they had been preparing “end-of-life issues” for the patient the previous night, and I was to blame. That’s what made me write to the ACGME. I blamed myself for the mistake but couldn’t help but question, at least for the millionth time: How can inexperienced residents be expected to function and take care of patients after being awake for 30 consecutive hours? I couldn’t help but think, “The system’s just messed up.” And so I wrote that e-mail.


Reporters and friends have asked me: “Would you do it again?” To reporters, I say, “Yes.” To friends, I give a qualified “yes.”


Under those same conditions, yes, I would report again. But I was somewhat naïve. I assumed these regulations meant something, yet residencies continue to violate them. Sure, they’re close. Maybe residents work 85 hours a week, and 32 or 34 hours on call. But I thought the rules were supposed to be fixed—a threshold not to be crossed.


I’ve also learned that, unfortunately, residency is about survival. Most residents just want to get through, and they want to do nothing to rock the boat in the process. I saw evidence of this when the knowledge of my e-mail became public. Residents knew fairly quickly who authored the e-mail; my supervising residents said they had seen it and that Wiener had asked them if I might have been the one who had written it. The ACGME had sent the e-mail to the hospital with my name and certain details removed, but the letter was so specific that no amount of omissions could have masked my identity.


Wiener also called my program director and said he felt I had written the letter and that, because of this, I would not be allowed to work in the MICU when my time came—a rotation required for my completion of the emergency medicine residency program.


Within a few short weeks, all residents in the internal medicine department had received a copy of my letter. One resident, who had warned me to “watch your back,” suggested I might want to consider transferring.


Some were vocal in their criticism of the whistleblower and the ACGME. A few said they wanted to “kill” the author. And in that environment, wouldn’t you want to keep your mouth shut? I didn’t expect to get a bullet in my back, but, yeah, I was scared.


Finally, I learned that it’s easy to make an outsider emergency medicine intern a scapegoat. I became the scapegoat for the institution’s failure to prepare for the ACGME regulations. I became the scapegoat for the threatened loss of accreditation.


And whistleblower protection? It doesn’t exist. There are no statutes to protect someone who reports to an accrediting body. I was exposed to the elements, whatever those may be.


So, yes, I made the report, but I spoke not just for myself. I spoke on behalf of the residents who asked me to speak up for them. I said what they were unwilling to say. I expressed their anger and their disillusionment. So, no, I wasn’t the only one who made that report.


Under those same circumstances, yes, I would report again. But knowing what I know now? No, I wouldn’t make that report. Maybe I’m wrong in saying that, but knowing what I know about the lack of protection, I would have kept quiet. I would not encourage anyone to make that report. Or, if you make a report, go into it knowing what you may face. I had no idea.


Is the system better off for it? I don’t know. Sometimes I think nobody cares much. We’re all just surviving. Sure, work me those 34 hours; I’m not going to say anything. At least it’s not 40 hours. We’ve gotten to where we are by jumping through hoops. Premed courses, the Medical College Admission Test, medical school, boards….


We’re asked to jump, and we ask, “How high?” Perhaps, though, that can change. Maybe future whistleblowers won’t have to worry about retaliation, because residents will stand behind them. Maybe, as a profession, we will question the years-long abusive practices of residency training. Maybe we’ll stop asking “How high?” and simply ask “Why?” I hope so, because I believe the premed idealistic desire to “just help people” doesn’t have to get lost in residency’s hours and demands. I believe that compassionate medicine is far more important than medicine’s machismo. I believe that the practice of “true medicine” is possible, even in residency.


And I believe that continued work-hours reform is one of the most important steps toward bringing compassion, toward bringing the practice of “true medicine” to residency training. I believe things can be different. Still.


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RESPONSE FROM JOHNS HOPKINS


Editor’s note: TNP asked Johns Hopkins if it wanted to comment on Madsen’s story and was provided with these words from Dr. John Dooley, a senior internal medicine resident at Hopkins.


The Hopkins internal medicine program drew a lot of attention last summer, and it is true that residents sometimes spent longer hours caring for patients than was permitted under the regulations. However, after a lot of thought and effort, Hopkins fashioned a new system that is fully compliant with the ACGME, and we were granted reaccreditation.


This much is widely known. What is less appreciated is the phenomenal character of the Hopkins environment—something I have been privileged to experience. I would like to blow the whistle on the inner workings of my residency and expose the reasons why I have no regrets about training there.


Hopkins residents are known for the intensity of their work, and our approach has nothing to do with testing endurance limits or being victims of abuse. Rather it is a reflection of our commitment. We believe shift work to be antithetical to the responsible practice of internal medicine and that nothing dehumanizes patient care more than abdicating responsibility for a patient at an arbitrary hour. Aside from what the ACGME mandates, we would never seek to constrain the time we spend at patients’ bedsides.


I have found the faculty and program leadership approachable as well as deferential to our needs and concerns. Faced with the ACGME challenge, our chairman and program director promised that a solution would be in place as soon as possible. Working closely with the entire institution, they committed time and money to the restructuring process. When residents said they needed “stat” phlebotomy services 24-hours-a-day to improve care of critically ill patients, we got it. I have never felt any less than fully supported by our program and hospital leadership.


In other forums, some have indicted Hopkins residents as “toxic,” but it is an insult to equate frustration with the obstacles to patient care with cynicism toward patient care itself. It is more telling about the program’s character to ask: What makes Hopkins residents “toxic”? The answers include: distraction from our patient-care mission by threats of loss of accreditation; the logistical glitches inherent in complex medical care; and our seemingly futile struggle with a health-care system that often neglects the needs of the poor.


Our program’s spirit is characterized by the word aequanimitas, from the title of an essay by the physician Sir William Osler. To us, it means being composed and competent even in the face of severe illness and medical emergencies. I confess that my aequanimitas faltered after the ACGME investigation. I was discouraged by the negative press and concerned that medical students might never learn our perspective on training and medical practice. I hope, however, that word will spread that we do practice the truest form of medicine at Hopkins, and that will never change.
Troy Madsen is an emergency medicine resident at Ohio State University Medical Center. Direct comments and questions about this article to tnp@amsa.org.