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Why medical safety isn't as easy as it seems

A critical part of medical training is the "residency", when medical students literally reside in the hospital, not too long ago putting in hours that put BigLaw junior associates to shame.

In the famous Libby Zion medical malpractice case, plaintiffs' lawyers alleged that resident fatigue caused Zion's death; while a jury believed the hospital's argument that Zion was responsible for her own death because of cocaine usage and limited damages to $375,000, Libby's father Sidney Zion continued fighting for medical safety. In 1989, in response to lobbying from Zion and other patient-safety advocates, New York state passed laws limiting the number of hours medical residents could work, and started enforcing those laws in earnest in 1997; in 2003, the Accreditation Council on Graduate Medical Education followed suit, an event recently commemorated in a glowing WaPo profile. This may be an improvement in medical care and medical safety: a 2004 NEJM study found that eliminating extended work shifts improved the attention span of interns; a Journal of the American College of Surgeons survey found a large majority of residents complain that sleep deprivation affects their work. But the resulting shortages of medical staff during night shifts might have offsetting tradeoffs that make care even worse:

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.�

New York Magazine tells a scary story of a patient almost killed by a resident's carelessness—and the resident wasn't allowed to learn about it for days because he wasn't allowed to have his beeper on:

�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.�

We also might be ending up with less-trained doctors:

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.

Doctors also complain that residents have a "shift mentality" that reduces their willingness to learn, and that the reduced hours are being used for social-life rather than for rest. As for the Dr. Bertrand Bell, who headed the Bell Commission?

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.

The problem is one of scarcity; we could certainly have more medical safety, getting the best of both reduced hours and extensive supervision, by devoting more social resources to health care, but in a world without free lunches, we as a society might rationally prefer to spend our money elsewhere: we can't devote 100% of GDP to rooting out the last medical error. There are cheap ways to improve medical safety, and there are expensive ways to improve medical safety, and increasing staffing levels falls in the latter category. It's too soon to tell whether the new hour rules will be a net gain or a net loss. But the ambiguity does show that medical safety and quality are issues not well handled by the medical malpractice system—or by politicians. But at least the politicians have to answer to voters. (Craig Horowitz, "The Doctor Is Out", New York Magazine, Nov. 3, 2003 (h/t)).



Rafael Mangual
Project Manager,
Legal Policy

Manhattan Institute


Published by the Manhattan Institute

The Manhattan Insitute's Center for Legal Policy.