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The Doctor Is Out

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Several hours later, when the nurse again reported to the resident that the doorman wasn’t producing urine, he repeated his mistake. The resident ordered another diuretic—this one leading to the doorman’s early-morning near-death experience.

But here’s the kicker: By the time the surgeon finally got the doorman stabilized and out of danger, it was a little after eight o’clock. The first thing he wanted to do was find the resident: “I wanted to beat the crap out of him for nearly killing my patient.” Of course the surgeon also wanted him to witness and to understand the results of his bad decisions, to learn from the episode, which, of course, is the whole point of a residency in the first place.

But since the resident had been on all night and it was now after eight in the morning, he was gone. Under New York’s 405 regulations he had maxed out his time. And now his beeper was turned off, because if he were reachable, then technically he’d still be on call.

It would be days before the surgeon tracked the resident down, long after the episode’s shock value might have scared him into being more careful. “So in essence,” the surgeon says, clearly exasperated, “he doesn’t bear any responsibility for what he’s done, and he doesn’t learn anything from it, either.”

Though the hospital does have conferences several days a week to review cases and monitor the quality of care, residents cannot attend if they are compelled by law to leave the building. Attempts are made to have the meetings between seven and eight in the morning, during the changeover time, but this is not always possible.

“When I was a resident,” says the surgeon, “the whole team was together all the time except from 10 p.m. to 5 a.m. And even then, there were never more than one or two of us off. All of the issues were discussed in real time because the whole team was there and available. And if you were taking care of a patient, that was your patient. You were responsible for whatever happened, and if you made a mistake, you had to deal with it.”

He says that as a result of the work rules, the team concept has evolved into a tag-team concept. There is a diffusion of responsibility, he argues, because patients are always getting handed off to someone else. “I understand why the regulations were put into effect,” he says, “but if we’re going to follow them, we need to think about this and make some serious adjustments. Because right now, a lot of things have gotten worse instead of better.”

What is stunning about the surgeon’s statement is that New York State’s 405 regulations, which spell out the resident work rules, were adopted as law in 1989—fourteen years ago. And while it is the most significant change in decades in the way doctors are educated and trained, you would still think that in all this time the new system would have been modified to solve any problems. Yet the 405 rules remain a festering sore spot for both doctors and hospital administrators.

“When you’re taking care of so many patients, and one guy’s having chest pains, another has shortness of breath, another has a fever, you realize you can’t spend much time on any one person. You put out fires.”

The rules themselves are so simple and so rooted in what appears to be unassailable common sense that it is tough, at first, to understand why they’ve caused so much trouble. The essential idea is, learning to be a doctor shouldn’t require the medical equivalent of boot camp. Doctor trainees are human, and in order for them to make life-and-death decisions, it is critical that they not be exhausted.

The rules limit residents to an 80-hour workweek; prohibit any single stretch on duty of more than 24 hours, which must be followed by a full 24 hours off; and require at least 10 hours between shifts and at least one full day off a week.

To most people, this still sounds like an extreme workload. But a recent survey in the Journal of the American College of Surgeons reported that the average workweek for residents where there were no restrictions was 105 hours.

So when you do the math, the magnitude of the change becomes more obvious. The 405 regulations mean residents spend at least 25 percent less time in the hospital. As one doctor who just completed his training put it to me, a five-year surgical residency has suddenly become the equivalent of a three-year one.

No one knows at this point what impact the lost hospital time will have on the next generation of doctors, but there is no shortage of gut reactions. “You can’t replace patient contact,” says Tom Maldonado, who just completed a fellowship in vascular surgery and whose residency began in 1995, back far enough to straddle the old and new eras. “Medicine is about imprinting. You see something and you remember that patient. When confronted with a problem, a doctor looks back in his mind to find a reference point, and you’ll remember patient X had similar symptoms and this is what happened. You learn by experience.”

Since residents are hospital employees as well as students—employees who barely make minimum wage—the lost man-hours have had a noticeable impact on patient care. Take, for example, the tragic and widely publicized death last year at Mount Sinai in its transplant program. An apparently healthy 57-year-old man donated part of his liver to his brother and died three days after the surgery. He choked on his own blood. At the time, he was one of 34 patients in the transplant unit who were being taken care of by one first-year resident. Though the Health Department did not indicate in its report that the restrictions on hours played any role in the tragedy, several doctors not affiliated with Mount Sinai told me the junior resident was on duty alone because the more experienced senior resident had maxed out his hours and had to leave the hospital.

Despite the problems, discussion of rethinking the rules is a political nonstarter. What hospital wants to take the position that it is having trouble maintaining the level of patient care because it’s understaffed? Or that people ought to put their lives in the hands of overworked, bleary-eyed, totally fatigued residents? Or, that its residents are not being trained properly? Similarly, the New York State Health Department has taken the position that the rules are the rules and it is their job to enforce them, not rewrite them. Any member of the Pataki administration who called for change would immediately be vulnerable. You can almost hear the charges: “Those anti-regulatory Republicans want to put your sick grandmother at risk.”

This absence of real debate is even more critical now that a version of the 405 rules has been adopted nationally. For years, New York was the only state that limited the number of hours residents could work. But this past July, the Accreditation Council for Graduate Medical Education (ACGME), the accrediting body for 7,800 residency programs across the country, implemented a set of work rules that are nearly identical to New York’s 405 regulations.

Given that New York’s law has been on the books for so long, it is surprising how little the ACGME was able to learn from the experience here. In its report on the decision to adopt the new work rules, the ACGME essentially discounts New York as a model to learn from. “What has been lacking from the New York experience,” the report says, “is comprehensive data on the effect of the regulations, and information on what constituted effective, broadly applicable models for how to respond to limits on residency duty hours.”

In other words, no one seems to have invested much in the way of time or energy to definitively determine how the new setup is working.

As shocking as this is, Bertrand Bell hardly seems surprised. Back in 1987, the now-74-year-old doctor headed what came to be known as the Bell Commission, the blue-ribbon panel responsible for recommending the changes that were eventually adopted as the 405 rules.


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