Reporter’s Brief: Covering Medical Residencies

by May 2, 2019

There is limited transparency and accountability in medical residency programs. Local reporting can shine a light on it. (Image by Pixabay user Sasin Tipchai)

Before doctors with medical degrees can be licensed to practice independently, they must spend three to seven years completing an accredited residency program.

A 2017 article in the Atlantic, Why So Many Young Doctors Work Such Awful Hours, delved into the exceptionally long hours and low pay. Residents typically work up to 80 hours a week, with shifts as long as 28 hours around four times a month. This is in addition to other work responsibilities outside of hospitals or clinic.

For this, they are paid about half of what nurse practitioners earn while working twice as many hours, all while accumulating interest for hundreds of thousands of dollars in student loans for medical school.

Physicians have the highest rate of suicides of any profession. In an analysis of doctor suicides, family physician Pamela Wible wrote in the Washington Post that bullying, hazing, and sleep deprivation increase suicide risk.

Physicians report hallucinations, life-threatening seizures, depression and suicide due to sleep deprivation. Fatigued doctors have felt responsible for harming patients. Resident physicians are now ‘capped’ at 28-hour shifts and 80-hour workweeks. If they ‘violate’ work hours (by caring for patients), they can be forced to lie on their time cards or be written up as ‘inefficient’ and sent to a psychiatrist for stimulant medications. Some doctors kill themselves for fear of harming a patient as a result of their extreme sleep deprivation.”

Acquiring Data

The Accreditation Council for Graduate Medical Educations (ACGME), a non-profit council, is the body responsible for evaluating and accrediting medical residence and internship programs in the U.S. It can put programs on probation or revoke their accreditation.

In 2014, the Association of Health Care Journalists, an independent, nonprofit organization dedicated to advancing public understanding of health care issues, requested information from ACGME about the successes and failures of physician training programs across the country. ACGME refused.

Although ACGME does not share its accreditation decisions with journalists or the public, it’s possible that some programs and institutions may be more transparent and accountable. Additionally, some information is available at https://apps.acgme.org/ads/public/. This includes a list of programs, 24 as of press time, that are currently under probationary status. Although ACGME posts the decisions, it withholds crucial information about the reason for these decisions.

Further reporting might indicate what led to probation—poor training environments, violation of resident work hours, inadequate supervision, educational deficiencies, or something else entirely. If there are programs in your area that are on probation, it may be worth digging into. Additionally, it might be worth looking beyond these 24 programs. Anecdata suggests that there are programs no longer on probation (or that have never been on probation) continue to violate current ACGME requirements.

Residency programs under probation or at risk of losing accreditation are likely a very small percentage of those with problems. Although ACGME does have an Office of the Ombudsperson that accepts anonymously-submitted reports, its effectiveness is limited. It does not conduct formal investigations, make judgements in disputes between individuals and residency/fellowship programs/sponsoring institutions, participate in formal grievance process, render accreditation decisions, or even provide information to the ACGME Review Committee.

Beyond the Office of the Ombudsperson, it is possible to make a formal complaint. However, formal complainants must use their full names and run the risk of retaliation, or difficulty finding other residencies with the same specialties. On top of that, complaints could lead to residency programs losing certification. This would mean that residents wouldn’t be eligible for board certification in their specialties. They may even have difficulty obtaining medical licenses. Additionally, anecdotal information indicates that residents that leave one program may have difficulty continuing training in that specialty. And hospitals employing residents lose qualification for Medicare payments to offset their training costs if their residency loses accreditation.

Public Records

Medicare pays teaching hospitals a portion of the hospital’s “per resident amount.” Since teaching hospitals work with state-specific Medicaid programs, digging up state records may be possible if you can figure out which forms are filled out or reports are filed about these arrangements.

Centers for Medicare and Medicaid Services (CMS) has some open data available, and may also provide information listed by FOIAMapper, a site that compiles a centralized catalog of government records searchable by topic.

Another good starting point might be this list of general hospital financial reports.

CMS records include 15 years of Graduate Medical Education Agreements covering how Medicare calculates its share of grad education at each hospital, teaching hospital medical record audit files, Medicare program files, hospital cost reports, and other information.

If CMS does not provide public records requested in a way that may be in violation of public records laws, going to court for documents after 20 days may be quicker than the process of delays and appeals.

Paul Burke, who maintains a watchdog site about US healthcare issues, finding the best doctors and hospitals, and Medicare’s challenging relationship with hospitals, has also posted text from a FOIA request (which was denied by Medicare, and then released) along with his court case filings and settlement discussions.

It may also be possible to obtain records about public hospitals through state public records laws.

Putting it All Together

Cultivating sources requires boot-leather reporting, but advocacy groups, subReddits such as https://www.reddit.com/r/Residency/, resident unions (or people writing about them), and the forums on the Student-Doctor Network might be good starting points. Keep an eye out for screenings of Do No Harm, a new film about physician suicide, so you can speak with audience members if it is showing in your area.

For industry references, see the Institute of Medicine’s 2014 document, Graduate Medical Information that Meets the Nation’s Health Needs (2014) and the National Academies of Sciences, Engineering, and Medicine’s Graduate Medical Education Outcomes and Metrics: Proceedings of a Workshop (2018). Print versions are available for sale, but both PDFs can be downloaded for free.

Examples of Reporting

The Akron-Beacon Journal used unnamed sources to report on how a lack of teaching experience and academic credentials, along with a hostile work environment for students, led to loss of accreditation for Summa Health System’s emergency medicine residents program in 2017.

In 2009, the St. Louis Post-Dispatch wrote about the University of Missouri-Columbia’ residency training program receiving a two-year probation by speaking, quoting sources by name. And the State Journal-Register in Illinois covered an attempt by two former Springfield doctors to have a pediatrics residency training program disciplined for discrimination and federal work-hour limit violations.