Putting aside the issue of avoiding the brand new incoming resident staff, which occurs on July 1st of each year, there are much more serious concerns about the fatigue and supervision factors whenever care is entrusted to doctors-in-training – namely, interns (first year medical school graduates) and residents (post-graduate physicians in specialized fields of training). Over the last decade these “concerns” have finally made their way to the organization that governs the training of medical graduates, the Accreditation Council for Graduate Medical Education (ACGME). The central issue, however, has never changed – patient safety.
A landmark lawsuit from New York – the Libby Zion case – brought to the public’s awareness the dangers inherent in these post-graduate training programs.
For those who may not recall, the Libby Zion case involved the death of an 18 year old college freshman, who was taken by her parents to a New York hospital, on October 4, 1984, when she developed a fever of 103 and became agitated. By 6:30 a.m. the next day, Libby Zion was dead. The story is recounted well in a lengthy but highly informative piece entitled “The Doctor is Out.”
It turns out that this young lady was the daughter of Sidney Zion, the newspaper columnist, lawyer, and well-connected New York raconteur. The essential facts of the case are recounted by The Washington Post in a November 2006 article entitled “A Case that Shook Medicine.” The sub-heading is perhaps even more noteworthy – “How One Man’s Rage Over His Daughter’s Death Sped Reform of Doctor Training.”
After his 18-year-old daughter Libby died within 24 hours of an emergency hospital admission in 1984, Zion learned that her chief doctors had been medical residents covering dozens of patients and receiving relatively little supervision. His anger set in motion a series of reforms, most notably a series of work hour limitations instituted by the Accreditation Council on Graduate Medical Education (ACGME), that have revolutionized modern medical education.
Residency programs have been in existence for many years – reportedly since the latter part of the 19th Century They were generally characterized as being “notoriously rigorous” with these young physicians-in-training putting in over 100 hours a week in patient care.
What followed in the wake of Libby Zion’s death and her father’s much publicized outrage led to a series of events culminating most recently in the June 23, 2010 announcement of the newest set of residency workload recommendations. In large part, however, it was the intervening history that led to these “newest recommendations.”
In May 1986 Manhattan District Attorney Robert Morgenthau agreed to let a grand jury consider murder charges. Although it declined to indict, the jury issued a report strongly criticizing “the supervision of interns and junior residents at a hospital in New York County.”
In response, New York State Health Commissioner David Axelrod established a blue-ribbon panel of experts headed by Bertrand M. Bell, an outspoken primary care physician at the Albert Einstein College of Medicine in the Bronx, to evaluate the training and supervision of doctors in the state. Bell had long criticized the lack of supervision of physicians-in-training.
In 1989, New York state adopted the Bell Commission’s recommendations that residents could not work more than 80 hours a week or more than 24 consecutive hours and that senior physicians needed to be physically present in the hospital at all times. Hospitals instituted so-called night floats, doctors who worked overnight to spell their colleagues, allowing them to adhere to the new rules.
Finally, in 2003, the Accreditation Council for Graduate Medical Education issued its first set of guidelines, limiting residents to 80 hours of work per week. As noted in last week’s article in The New York Times –
Five years later (in 2008), a national panel of experts criticized the accrediting organization for not limiting those work hours enough and for failing to address duty hour violations among different training programs. They recommended more stringent guidelines, among them an eye-glazing mandatory nap calculation that has residents sleeping for five hours between 10 p.m. and 6 a.m. when they’ve already worked longer than 15 hours but may still have to work an additional nine hours.
What then emerged was last week’s announcement of the newest set of residency workload recommendations.
While the focus throughout the history of these changes in residency training program guidelines has apparently been the modifications and restrictions on resident hours, what simply should not be lost in the discussion is the additional focus on supervision of residents by senior, more experienced physicians.
The guidelines also include detailed expectations about direct supervision of younger residents by more experienced ones, in the hopes that a supervising doctor would catch any error before it affects a patient, according to Dr. Nasca.
In addition, the ACGME will step up its monitoring and enforcement of the requirements, conducting on-site visits of each institution annually beginning in July 2011. The site visits are likely to cost each institution about $12,000 to $15,000, according to Dr. Nasca.
Those programs that don’t comply with the rules could ultimately lose accreditation and be forced to disband.
The New York Times reporting on these new guidelines provides equal emphasis to the issue of supervision of these physicians-in-training.
“The pivotal dimension of teaching residents in the hospital is supervision,” Dr. Thomas J. Nasca, chief executive of the council and vice chairman of the task force, said during a telephone briefing Wednesday. Supervision “has not been standardized to a great extent. These standards set certain expectations.”
The guidelines are now open for a 45-day public-comment period and if approved by the board in September, will go into effect in July 2011.
The death of an 18 year old girl 26 years ago and the battle waged by her father have led to key changes in not only medical residency protocol – they have brought about a much more important end result – increased patient safety. It’s one thing for a physician-in-training to be exhausted; it’s quite another for patients to be injured and sometimes killed because of overly tired and inadequately supervised medical trainees.
One must wonder, however – would this system that existed for over 100 years have changed at all were it not for who it was who died and whose father it was that had the clout and power to bring about this change? At least Libby’s death appears to have not been in vain. The true test will be in the enforcement of compliance of these new “guidelines.”