“You have to remember,” says the avuncular Bell, “that you’re dealing with a firmly entrenched structure for graduate medical education that is essentially unchanged since it was invented at Johns Hopkins over 100 years ago. And if you know anything about these kinds of systems, you know how doggedly they resist change.”
The Bell Commission and the subsequent adoption of the 405 rules were the result of the infamous Libby Zion case. On a Sunday night in 1986, the 18-year-old college freshman was taken to New York Hospital by her parents. She was agitated and had a fever of 103. Assured by the doctors that she’d be well taken care of, her parents went home for the night.
By 6:30 the next morning, however, she was dead. Driven by grief and anger and the belief that the hospital had killed his daughter, Sidney Zion, the newspaper columnist, lawyer, and well-connected New York raconteur, fought an ugly, protracted, eleven-year battle with the hospital. He charged gross malpractice, and the hospital countered that Libby had died from cocaine poisoning.
The malpractice trial ended with something of a split verdict: The jury believed the doctors had made mistakes, but it also believed the cocaine allegations. Zion and his wife were awarded $375,000, but no punitive damages were assessed. And while exactly what happened to Libby Zion remains, even after all these years, the subject of dispute, a couple of things are clear.
The only people who saw and treated her that night were two residents: one who was nine months out of medical school and the other who’d been a resident for two years. A senior physician was at home and involved only by phone. One of the residents had been on about eighteen hours and the other nineteen.
Zion’s lawyer charged that inexperience and fatigue were a deadly combination. One of the residents admitted when he testified that he’d made mistakes that night but repeatedly denied he was too tired to exercise sound judgment. To this day, many doctors are incredulous when it comes to the fatigue issue.
Even Bell himself, who firmly believes that shorter hours have made things better for residents and patients, says that supervision was the real issue in the Libby Zion case, not the hours. It is ironic, then, that in practice so much of the focus has been on limiting residents’ hours, and that this effort has often resulted in less supervision, not more.
Everyone in medicine has a story about someone falling asleep at a patient’s bedside or in the middle of a blood draw. And the Journal of the American College of Surgeons’ recent survey found that 81 percent of residents said sleep deprivation had negatively affected their work.
But the impact of sleep deprivation on residents remains a subject of some dispute. There are those in medicine who believe that learning to treat patients and to get by on little or no sleep is more than just a hazing ritual that’s part of becoming a doctor. It is a legitimate crucible and a valued training tool, especially for surgeons.
“In the old system, there was no such thing as hours or time clocks,” says Maldonado, pointing out that it’s called a residency because in the system’s early days, students literally lived in the hospital.
“When I was a resident, you came to work much as you’d go to battle,” he says. “You didn’t know when, or if, the end of the day would come. You were there to take care of patients, and nothing else mattered. It was a shock to the system, but it honed your skills very quickly.”
There is also little dispute, among surgeons, at least, that the restrictions on hours have had a negative effect on training and patient care. “Look,” says one surgical director, “the rules are, overall, a good thing. It’s an absolute necessity to remove someone who’s stressed and exhausted. You wouldn’t want them taking care of you or your family. The problem is, everything was implemented in a bean-counter, bureaucratic kind of way that doesn’t allow for flexibility. It’d be much better if they let us follow the spirit of the law rather than the letter. But they don’t trust us to follow their rules, because they know if we had a choice, we wouldn’t.”
For the first ten years that the 405 regulations were in effect, they were essentially ignored by the hospitals. It was a kind of “don’t ask, don’t tell” situation.
However, in 1997, then–public advocate Mark Green released a report that exposed the defiance on the part of the hospitals and embarrassed the state Health Department. Since then, the state has cracked down with serious financial penalties for hospitals that don’t comply.
Nevertheless, following the rules continues to be a significant problem. An inspection report released by the state at the end of last year cited nearly two thirds of New York’s teaching hospitals for some failure to comply with the 405 regulations, even though they have to pay heavy fines for the violations. “If the overwhelming majority is out of compliance,” says Tom Gouge, director of the general-surgery program at NYU, “there are two possibilities: You either have a whole profession of bad actors or there’s things about the system you’ve set up that just aren’t workable.”
Another surgical chief bristles about being responsible for enforcement. “They’ve asked people like me,” he says, “to do things we’re not very good at, not equipped to manage, and find philosophically repugnant. We have to act as cops and chase people out of the hospital. It’s antithetical to everything being a doctor is about.”
He worries that the day is coming when American medicine will more closely resemble the European system, in which the workweek for residents and doctors is under 60 hours (in Scandinavia, it’s already under 40). “If I’ve got somebody doing an aneurysm repair, I don’t want my surgeon looking at the clock,” he says. “I worked in Denmark as an observer, and I actually saw a surgeon start a pancreaticoduodenectomy at eight in the morning, and when three o’clock in the afternoon came along, the surgeon took his gloves off and walked away. The operation was about three quarters done, but he didn’t finish. Another team was coming on at three.”
The struggle to remake the system and integrate the work rules is further complicated by the dramatic changes that have taken place, even since the 405 rules were adopted in 1989, in whom hospitals treat and how they treat them. Patients in the hospital tend to be much sicker than in the past, because everyone else is quickly sent home.
Technology has also made an enormous difference. Much of the equipment found in the emergency room and the OR didn’t exist ten years ago, and it has made training residents much more complicated than it used to be. “This is why having rested residents is more important than ever,” says Bell. “The number of chances I had to kill somebody as a resident were very limited. Today, with all of the technology available, it’s infinitely more complicated and dangerous.”
Logic would indicate that the surgeon who has performed a procedure 50 times is better trained and prepared than one who has done it 30 times. However, there is no actual way to measure this. Surgery, like sports or carpentry, requires the kind of coordination and dexterity that varies from person to person.
But it is not just fewer hours in the OR that’s at issue. Some surgeons complain that the attitude of many young residents has been negatively affected by the 405 rules. They are less hungry, more passive. Most young residents are thrilled with the 405 work rules, which enable them (unlike their predecessors) to actually have a life outside the hospital. However, the Journal of the American College of Surgeons reports that despite the personal benefits, only 21 percent of New York’s residents believe the 405 restrictions have had a positive impact on patient care.
And in fact, how the residents use their time off has become an irritant to some faculty. One professor who is angry about this is NYU vascular surgeon and professor Mark Adelman. “Some of them come back to the hospital with little or no rest after they’ve been off,” he says. “Instead of using the time to prepare or to rest, they use it to improve their social life. You can hear them in the hospital in the morning talking about where they went to dinner or who they hooked up with at a club. There are some residents, unfortunately, who look at this like an extension of college.”
Adelman is not alone in this view. Another surgeon complains that preparation can sometimes be a problem. It used to be, he says, that if you knew you were coming in to watch and learn how to do a hernia repair, you’d see the patient, talk to two other residents who’d done one in the past 48 hours, and go read the chart in the surgeon’s office to get the history and see what tests were done. You would also review films with the radiologist.
The hope, of course, was that once in the OR, the surgeon would let the resident take a crack at it. But with today’s shift mentality, the surgeon says, the residents often do little if any preparation for a case. Recently, for example, he was doing a colon resection, and the resident showed up without having reviewed the patient’s records. “He didn’t know anything about the patient,” the surgeon says. “He didn’t even see the patient without drapes on, because he went out to breakfast. I prepped and draped the patient, and the resident walked in and said, ‘So, what are we doing on this lady today?’ ”
As it turned out, the “lady” happened to be a man. “I’m convinced,” the annoyed surgeon says, “it’s a carryover of the shift mentality. He didn’t see the patient or review the films because he wasn’t in the hospital. He was off the day before. It’s pushing me to withdraw. I’ll be damned if I’m going to stand in the OR for an hour to teach a resident if he’s not putting anything into it.”
The impact of the changes in training probably won’t be felt for another couple of years. But one thing is certain. “The clock will not be turned back on this,” says Dr. Richard F. Daines, president of St. Luke’s–Roosevelt. “So we have to pay more attention to offering a high-quality teaching experience within a reasonable schedule.”
There are essentially two ways to address the problem. One would be to extend the length of a residency to ensure no training is lost. This clearly is not about to happen. In fact, there is a growing movement to go the opposite way—to shorten training time. It’s all about money. Most residents pile up huge personal debt to pay for their education—the average is about $150,000—and they are itching to get out and earn a living. In addition, the federal government, which foots most of the bill for doctor training, would also like to reduce costs.
The other alternative, then, is to use the time residents have more effectively. To accomplish this, hospitals need to hire more support personnel to handle what doctors refer to as scut work—wheeling patients to the OR, picking up film, drawing blood, and performing all of the other necessary but noncritical tasks. Relieved from these nonessential duties, residents could devote more of their time to education.
Hiring more physician’s extenders would alleviate much of the pressure on the patient-care front as well. But again, this takes money and the political will to make it happen—both of which are right now in very short supply.
This does not augur well for the immediate future of health care. “There’s a confidence I feel approaching sick patients because of all my training,” says Maldonado. “There’s still plenty of committed, ambitious residents. I just don’t think they’re getting the same level of training.”