The Accreditation Council for Graduate Medical Education has placed the surgery residency program at Duke University Medical Center on indefinite probation after a June 2003 evaluation found numerous problems with Duke's compliance.
The Accreditation Council for Graduate Medical Education has placed the surgery residency program at Duke University Medical Center on indefinite probation after a June 2003 evaluation found numerous problems with Duke’s compliance.
Even though Duke may continue to train doctors while under probation, the diminished status may threaten its reputation as a top surgery school. In order for Duke to instruct surgeons, its program must earn the official stamp of approval because residents cannot take their certification exams unless they have completed an ACGME-accredited program.
The department of surgery has already addressed the seven problems detailed in the ACGME report, and Dr. Danny Jacobs, chair of surgery, said he expects to request a re-evaluation later this year to upgrade the program’s status. The accreditation body regularly evaluates all residency programs every two to five years, and surgery’s next scheduled review is in June 2006.
Most of the citations Duke received are related to paperwork and record keeping; Duke officials emphasized that patient safety was never directly at risk.
“I think as people have gotten busier and the demand for documentation has increased, we didn’t keep pace with the amount of administrative support to make sure the amount of documentation is sufficient,” Jacobs said.
ACGME first officially informed Duke in December 2003 that its surgery department would be subject to some kind of “adverse action.” Last year 6.5 percent of programs the ACGME scrutinized received some kind of warning, probation or suspension, said Julie Jacob, a spokesperson for ACGME.
When Duke’s surgery program received its initial censure detailing 10 areas of non-compliance, it filed a report explaining the measures the Medical Center had already taken to alleviate the issues. Many of the corrections had been in planning stages before the review, but ACGME is required to evaluate schools based on the daily operations at the time of the assessment.
Jacobs took over the surgery department from Dr. Robert Anderson in February 2003, and some of his first changes were directed at improving documentation and addressing issues ACGME raised.
In the ACGME report, Duke was found deficient in not having official training in the basic and clinical science fundamental to surgery. ACGME also found that faculty did not hold a proper annual meeting to evaluate the program, and residents were not documenting their surgeries sufficiently.
“It turns out that our residents didn’t understand how to code some of their cases,” Jacobs said. “We take credit for this. This is where we should be faulted.”
The strict enforcement of ACGME guidelines came at the same time that legislation limiting the maximum work week for residents to 80 hours went into effect. Particularly at Duke, where residents have been notorious work-a-holics, the guidelines have proven a difficult adjustment.
At least one of Duke’s initial citations—which are kept confidential—from ACGME regarded the 80-hour work week, but DUMC had already established a staff position to force students into restricting their hours. Several residents noted that they receive frequent e-mails warning them that they are too close to the limit.
“It’s somewhat frustrating that you can’t do the things that you probably need to be doing,” said Dr. Ed Rampersaud, a first-year resident at Duke. “The frustrating thing is not that you have to go home; it’s that that work still has to get done.”
DUMC has hired more than a dozen physician assistants to help accommodate the workload that residents can no longer perform with the restricted hours—a move that puts the Medical Center in a better position than many other less wealthy schools.
The surgery department also made several technological upgrades in the past few years. First-year resident Dr. Vanessa Olcese said all the residents now carry wireless electronic devices that can synch up with the hospital-wide system.
Given the adjustments that the surgery program has already made, Jacobs said he is not worried that the probational status will affect its ability to attract the top residents. Duke chooses about six surgery residents each year from a pool of hundreds, and it expects to pull from the same group this year.
Steve Veres contributed to this story.
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