Young doctors' long hours again at issue in patient safety

Posted on Tue, Jun. 11, 2002

Young doctors' long hours again at issue in patient safety

By Josh Goldstein

Inquirer Staff Writer

Posted on Tue, Jun. 11, 2002

Young doctors' long hours again at issue in patient safety

By Josh Goldstein

Inquirer Staff Writer

Nearly two decades after the death of 18-year-old Libby Zion in a Manhattan hospital while under the care of a poorly supervised and tired young doctor, the issue of fatigued resident physicians is again at the center of a national debate on patient safety.

And with more than 4,000 young doctors working long hours to complete their training in area hospitals from South Jersey to Wilmington, the potential link between exhausted residents and medical mistakes is a particular concern here.

Residents, especially those training as surgeons, regularly work 36 straight hours or more with little or no sleep. They often work 100 hours a week.

"We know there are a lot of errors in hospitals; and we know that when people are awake for a long time, there is a decline in cognitive function," said David Grande, a resident at the Hospital of the University of Pennsylvania. "At some point, logic prevails, and you can easily link the two."

The issue has regained attention for several reasons:

A bill pending in Congress would establish federal guidelines limiting residents to working 80 hours a week.

The prestigious Yale-New Haven Medical Center recently lost accreditation for its general surgery residency program, and the residents' work hours were a major reason.

The Accreditation Council for Graduate Medical Education, which oversees residency programs, is expected to issue new guidelines this week on work hours for residents in all medical specialties.

An Institute of Medicine study in 2000 found that as many as 98,000 hospital patients die each year because of medical mistakes.

In this region, six major academic medical centers run the bulk of residency programs for doctors who have just graduated from medical school but require years of additional training. These centers, as well as the community hospitals with smaller programs, are scrambling to reduce residents' hours while watching the bottom line and maintaining the quality of their training programs.

"We walk a fine line here," said Thomas J. Nasca, dean of Jefferson Medical College. "At the same time we are trying to make sure that residents are not asked to work longer than they should, we are also trying to inculcate into them a strong sense of duty to patients."

Most area teaching hospitals say they are seeking to limit residents to 80-hour weeks, with no more than one in three nights on call and at least one day off in seven.

"This will be an evolving process," said Amy Goldberg, a Temple University Hospital surgeon and associate director of its surgical residency program. "It is on everyone's radar screen now, and we are working to find the right balance."

Leaders in academic medicine here said they hoped the new guidelines of the Accreditation Council for Graduate Medical Education would head off congressional action.

The new guidelines are expected to establish 80-hour weeks for all residency programs, but provide flexibility to allow for continuity in patient care and in the education of residents.

The local residency program leaders said the federal law would impose too rigid a schedule, which could endanger patients by breaking up the team of doctors providing care, and hurt the residents' education by limiting their experiences.

Flexible schedules are needed, said Daniel T. Dempsey, chairman of surgery at Temple. "Provided that it doesn't go too far... it is entirely possible that the education and training will be better," he said.

"If you don't have surgeons who have seen these diseases evolve... it is not good for patient safety" either, he said.

The American Medical Student Association in Washington has pushed for a federal law to mandate fewer hours.

"We are turning to federal legislation in hopes that the system that is broken can be fixed," said Makeba Williams, a medical student in Tennessee who is the association's legislative affairs director this year. "We are not satisfied with the rules and guidelines that are in place, because they have not been enforced."

U.S. Rep. Robert A. Borski (D., Pa.) is a cosponsor of the bill that would limit residents to 80 work hours a week and provide for other limits to ensure they are less fatigued.

"If somebody is working 130 hours a week, they are obviously not going to be at the top of their game," Borski said. "It is just pure common sense... . There is only so much the human body can sustain before errors are going to mount."

New York State enacted similar work restrictions, known as the "Libby Zion" laws after the teenage daughter of a prominent journalist died in 1984.

A surgical resident in a Philadelphia hospital said last week that he regularly works 40 straight hours with no more than 60 minutes of sleep.

"To do the best possible job, to take care of patients around the clock, means you have to sacrifice things," said the resident, who asked not to be identified.

Things like eating, sleeping and even going to the bathroom, he said, adding: "At some point, you begin to see the patient as an adversary."

And after weeks and months of such a grueling schedule, there is a cumulative toll.

"If a patient is in trouble, the quick way to find out whether there is a need to operate is a CT scan," the resident said. "But if you are looking at the scan and you are tired, are you going to miss something? Yes."

Fixing the problem is not without cost.

"From a purely economic standpoint, if we remove residents from certain care situations, we have to replace them with other [skilled] employees... and there is a cost," Nasca, the Jefferson Medical College dean, said.

--------------------------------------------------------------------------------

Contact Josh Goldstein at 215-854-4733 or [e-mail].

Nearly two decades after the death of 18-year-old Libby Zion in a Manhattan hospital while under the care of a poorly supervised and tired young doctor, the issue of fatigued resident physicians is again at the center of a national debate on patient safety.

And with more than 4,000 young doctors working long hours to complete their training in area hospitals from South Jersey to Wilmington, the potential link between exhausted residents and medical mistakes is a particular concern here.

Residents, especially those training as surgeons, regularly work 36 straight hours or more with little or no sleep. They often work 100 hours a week.

"We know there are a lot of errors in hospitals; and we know that when people are awake for a long time, there is a decline in cognitive function," said David Grande, a resident at the Hospital of the University of Pennsylvania. "At some point, logic prevails, and you can easily link the two."

The issue has regained attention for several reasons:

A bill pending in Congress would establish federal guidelines limiting residents to working 80 hours a week.

The prestigious Yale-New Haven Medical Center recently lost accreditation for its general surgery residency program, and the residents' work hours were a major reason.

The Accreditation Council for Graduate Medical Education, which oversees residency programs, is expected to issue new guidelines this week on work hours for residents in all medical specialties.

An Institute of Medicine study in 2000 found that as many as 98,000 hospital patients die each year because of medical mistakes.

In this region, six major academic medical centers run the bulk of residency programs for doctors who have just graduated from medical school but require years of additional training. These centers, as well as the community hospitals with smaller programs, are scrambling to reduce residents' hours while watching the bottom line and maintaining the quality of their training programs.

"We walk a fine line here," said Thomas J. Nasca, dean of Jefferson Medical College. "At the same time we are trying to make sure that residents are not asked to work longer than they should, we are also trying to inculcate into them a strong sense of duty to patients."

Most area teaching hospitals say they are seeking to limit residents to 80-hour weeks, with no more than one in three nights on call and at least one day off in seven.

"This will be an evolving process," said Amy Goldberg, a Temple University Hospital surgeon and associate director of its surgical residency program. "It is on everyone's radar screen now, and we are working to find the right balance."

Leaders in academic medicine here said they hoped the new guidelines of the Accreditation Council for Graduate Medical Education would head off congressional action.

The new guidelines are expected to establish 80-hour weeks for all residency programs, but provide flexibility to allow for continuity in patient care and in the education of residents.

The local residency program leaders said the federal law would impose too rigid a schedule, which could endanger patients by breaking up the team of doctors providing care, and hurt the residents' education by limiting their experiences.

Flexible schedules are needed, said Daniel T. Dempsey, chairman of surgery at Temple. "Provided that it doesn't go too far... it is entirely possible that the education and training will be better," he said.

"If you don't have surgeons who have seen these diseases evolve... it is not good for patient safety" either, he said.

The American Medical Student Association in Washington has pushed for a federal law to mandate fewer hours.

"We are turning to federal legislation in hopes that the system that is broken can be fixed," said Makeba Williams, a medical student in Tennessee who is the association's legislative affairs director this year. "We are not satisfied with the rules and guidelines that are in place, because they have not been enforced."

U.S. Rep. Robert A. Borski (D., Pa.) is a cosponsor of the bill that would limit residents to 80 work hours a week and provide for other limits to ensure they are less fatigued.

"If somebody is working 130 hours a week, they are obviously not going to be at the top of their game," Borski said. "It is just pure common sense... . There is only so much the human body can sustain before errors are going to mount."

New York State enacted similar work restrictions, known as the "Libby Zion" laws after the teenage daughter of a prominent journalist died in 1984.

A surgical resident in a Philadelphia hospital said last week that he regularly works 40 straight hours with no more than 60 minutes of sleep.

"To do the best possible job, to take care of patients around the clock, means you have to sacrifice things," said the resident, who asked not to be identified.

Things like eating, sleeping and even going to the bathroom, he said, adding: "At some point, you begin to see the patient as an adversary."

And after weeks and months of such a grueling schedule, there is a cumulative toll.

"If a patient is in trouble, the quick way to find out whether there is a need to operate is a CT scan," the resident said. "But if you are looking at the scan and you are tired, are you going to miss something? Yes."

Fixing the problem is not without cost.

"From a purely economic standpoint, if we remove residents from certain care situations, we have to replace them with other [skilled] employees... and there is a cost," Nasca, the Jefferson Medical College dean, said.

--------------------------------------------------------------------------------

Contact Josh Goldstein at 215-854-4733 or [e-mail].