From William Osler to Libby Zion

The topic of residents’ work hours restrictions is still very much discussed in U.S. hospitals, and conversation often comes back to the case of Libby Zion. So, this post is not strictly about medgadgets, unless you consider interns and residents to be medical devices (which, we’re told, some people do).
A well-written overview of the situation can be found online, from the pages of Johns Hopkins Magazine in 2001. Since that article went to press, a residency accreditation often depends on compliance with standards similar to New York’s Bell Commission laws. One wonders what Osler would think:

The residency system in the United States began at Hopkins in 1889 under William Osler, first director of the Department of Medicine and first physician-in-chief of Johns Hopkins Hospital. Following the German model of postgraduate medical training, Osler established a plan in which young physicians trained under an experienced mentor. Residents learned by doing clinical work, taking on increasing responsibilities as they gained more experience, and graduated from intern to junior resident to senior resident to chief. Over the years, other hospitals adopted the Hopkins model, and it became the norm for training doctors.
Osler, who once wrote an essay on the medical profession titled “The Master-word is Work,” expected residents to be fully committed to the role of doctoring. Residents lived at the hospital and were not allowed to marry–rules that continued until the end of World War II. Most residents were so caught up in the intellectually charged atmosphere of the time that they put up with the sacrifices.
“It was an even more grueling job, even more absorbing in the past than now,” says 80-year-old Victor McKusick, University Professor of Medical Genetics. After an internship and junior residency at Johns Hopkins Hospital in the late 1940s, McKusick in 1951 became chief resident on the Osler Medical Service.
“There was very little scheduled off-time,” says McKusick. Interns were on call every other night. Residents worked all through the week and all day Saturday. On Sunday morning, they performed rounds, and then, if they could arrange to leave their patients in the care of a fellow intern or resident, took the rest of the day off.
“We didn’t feel put upon or enslaved,” adds McKusick. “This was just the way it was.”

Those sentiments are echoed in physician memoirs from that period — we fondly recall the writing style of Lewis Thomas.
But some things have changed in hospitals since Osler’s time. Patients are sicker, yet are admitted and discharged much faster. Hospitals and health care are more complex, requiring residents to do more paperwork to get patients connected with appropriate services.

[A] law governing the work hours and supervision of residents arose as a result of outrage caused by the 1984 death of 18-year-old Libby Zion. The teenager was admitted to New York Hospital at midnight with fever and minor flu symptoms. She died seven hours later.

The immediate cause of Libby Zion’s death is still debated. One factor may have been the potentially lethal combination of the drugs Nardil, which Zion had been taking, and Demerol, which she was given in the hospital. But her father, Sidney Zion [pictured right], a journalist and former federal prosecutor, blamed severe flaws in the residency training system as the underlying cause. He launched a passionate campaign, arguing that lack of sleep on the part of the intern and resident, and inadequate supervision by the attending physician, contributed to this medical blunder.
A grand jury in New York heard the case but did not indict the doctors involved. Instead, it implicated the residency system as a whole.
The case prompted the New York state health commissioner, David Axelrod, to form a committee to investigate issues in emergency care, including the training of physicians. It was headed by Bertrand Bell, a Distinguished University Professor and professor of medicine at Albert Einstein College of Medicine. After 19 months of testimony, the Bell Commission issued a report recommending specific limits on residents’ work hours and stricter rules regarding their supervision.
In 1989, New York enacted changes in its health code that roughly followed the Bell Commission’s recommendations. According to Code 405, residents may work no more than an average of 80 hours per week. They must have off at least one 24-hour period per week and at least eight hours between shifts. The law also requires that an experienced supervising physician be in the hospital at all times or, in certain cases, no more than 30 minutes away from the hospital.

These changes were not entirely popular among established physicians — published comparisons were made to clock-punchers and those who chose sleep over care.
Bell responds:

“Here’s what the story really is,” says Bell. “Graduate residents are in an educational program. The person who gets paid to take care of the patients in the hospital is the attending doctor; he’s responsible.” He also adds that the Bell Commission focused more on supervision of residents than on work hours, although the latter issue has attracted far more attention.
“Not only can’t you expect people who are chronically sleep-deprived to do well, you can’t expect people like that to learn and be empathetic,” he says, noting some studies that suggest residents have higher rates of depression, drug abuse, divorce, and early labor. “You want to have people who are lovely and pleasant and want to help the world, and at the same time have the support to do it,” he says.

Administrators and the public largely agree, and starting in 2003, an 80-hour work week was required for most programs to maintain accreditation, with federal legislation to follow. A collection of data on the adverse affects of long work hours is at AMSA’s site — including medical errors on hospital floors, and even physician car accidents post-call.
So, it remains to be seen whether the bond between physicians and patients has been fundamentally altered by adopting clock-punching rules. But we can take heart that improved safety means more patients (and doctors) will survive the hospital encounter.
That does it for this week. Have a great weekend and we’ll see you on Monday!