The Doctor Is Out

Photo: Kevin Irby

At a little past 7:30 in the morning, a Manhattan doorman was wheeled into an operating room at one of New York City’s premier teaching hospitals. He wasn’t exactly relaxed, but he was resigned to what he was facing. His doctor had stopped by earlier to give him a pep talk and to recap one last time what had to be done. Repairing an abdominal aortic aneurysm was a complicated procedure. The operation would last at least four hours. But the doctor told him not to worry. He did this particular fix several times a week.

As it turned out, the surgery went pretty much as expected, and the doorman was in recovery around lunchtime. By late afternoon, he was doing well enough to be moved out of intensive care. The surgeon checked in on him at 5:30 and found no issues. His post-op progress was good. Everything was exactly as it should have been.

But by the next morning, barely thirteen hours later, something had gone terribly wrong. When the doctor came in to see the doorman at 6:30 a.m., he was in full respiratory distress and on the verge of acute cardiac arrest.

The surgeon shifted into crisis mode. He inserted a breathing tube in the doorman’s throat to get air into his lungs, which had filled with fluid. Quickly but with precision, he threaded a pulmonary-artery catheter through the patient’s neck and down into his heart and lungs. He gave him a shot of lasix and one of dobutamine to stimulate his heart, which had nearly stopped pumping. Then he began chest compressions.

The surgeon didn’t know it at that moment, but his patient’s reversal and near death were the result of two critical decisions made during the night by a resident: an overextended, underequipped junior resident, responsible for taking care of more than 50 patients. The problem was compounded by the resident’s unfamiliarity with those in his charge. To put it bluntly, he had never laid eyes on many of them before: not during office visits, in the operating room, or in the course of postsurgical care.

In fact, only half of them were actually his patients. He was covering for three surgical services, each of which had its own residents who, theoretically, were supposed to handle their own patients. And on some nights, the system worked according to plan. There would be one junior resident from each group watching over his own fifteen to twenty patients.

But because of New York State’s 405 law, which limits the number of hours residents can spend in the hospital, the situation is often more complicated. Once they reach the maximum number of hours, residents have to leave the hospital. No exceptions. And this means that hospitals are frequently left without enough medical staff to handle the caseload. On those nights, taking care of patients can get a little hairy. And at some New York hospitals, it’s a scramble just about every night.

With residents working fewer hours, hospitals have been forced to find ways to fill in the gaps. Most don’t have the money to hire more nurses or physician’s assistants. Even if they did, nurses and PAs willing to work the night shift are in extremely short supply. The well-intentioned 405 law, adopted to prevent exhausted residents from taking care of patients, has instead produced an often dangerous lack of supervision.

“We used to have two senior residents and three junior residents in the hospital at night to take care of surgical patients,” says one chief of surgery. “Now we have one and one. It’s really a very small number to take care of all the sick people in the building. And there may be no one in the hospital familiar with the nuances of particular patients. It’s really not so hot for continuity.”

The doorman’s surgeon is more direct: “From my perspective, it’s absolutely horrible patient care. We see at least one or two patients a month put at risk because of the work rules.”

Here’s what happened to the doorman. At one in the morning, a nurse reported to the covering resident that he had no urine output. If the resident had been familiar with the doorman and the kind of surgery he’d had only hours earlier, he would have immediately recognized this as an important post-op sign.

However, since he’d come to the patient cold, a quick, informed judgment wasn’t possible. He didn’t even have time, because of his patient load, to do more than skim the most recent chart entry to figure out what was going on—though, given the usual perfunctory nature of the ten to fifteen pages of chart notations, a more thorough reading might not have helped anyway.

A little background: An aneurysm is a ballooning of an artery, much like a bubble in the sidewall of a tire. It weakens the wall and is prone to rupture. If an aortic aneurysm bursts, it is almost always fatal. Fixing the aneurysm requires inserting a piece of tubing, in the doorman’s case a six-inch piece, into the blood vessel to strengthen the compromised area. In a case involving the aorta, the surgeon opens up the patient from the sternum down to the pelvic area. Then the aorta is clamped, which completely cuts off circulation to the lower part of the body—the kidneys, the intestines, the legs.

To get to the aorta, the surgeon has to move the intestines out of the way. When everything is put back in place, there is usually lots of fluid shift, meaning fluid normally in the bloodstream leaks into the tissues. Once the aorta is unclamped and the procedure is completed, normal circulation should resume. One potential problem following any major surgery is the patient can become intravascularly depleted. In lay terms, the body’s organs are not getting sufficient blood flow.

Surgeons monitor kidney function as a kind of early-warning system. When there’s not enough fluid in the body, the system tries to retain whatever it has, so the kidneys don’t produce urine. Which is exactly what happened in the doorman’s case.

Once the nurse alerted him, the resident had three options. He could choose a policy of benign neglect, hoping the patient’s condition wouldn’t worsen as the night wore on. He could call the surgeon’s senior resident—who was at home and easily reachable. This would seem to be the obvious and most prudent step.

Except that he knew that if he made this call, the senior resident almost certainly would have instructed him to move the patient to the ICU, run a battery of tests, and spend an hour making sure the problem was properly dealt with.

“When you’re taking care of so many patients,” says the doorman’s surgeon, “and you have no background on any of them and one guy’s having chest pains, someone else has shortness of breath, another guy’s got diarrhea, and somebody’s running a fever, and you multiply it times 50 or 60 patients, you quickly realize you can’t spend a lot of time on any one person. So you run around trying to put out fires and deal with everything as expeditiously as possible.”

Consequently, the resident opted to “buff the chart.” In doctor argot, this means he did something—not necessarily the right thing—so it would look like he responded to the patient’s needs. What he did was order an intravenous diuretic. This forced the patient’s kidneys to produce urine but actually worsened his condition by further depleting his body of fluids.

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.

“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.”

The Doctor Is Out