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"[M]ake a habit of two things ã to help, or at least to do no harm."
-- Hippocrates (460-359 B.C.)
Dr. Gerard F. Sykes stands at the nurses' station on the 10th floor of the Bronx-Lebanon Hospital Center with a patient's chart in his hand. It is 2:20 in the morning on New Year's Eve and Sykes has just learned that one of his patients received 25,000 units of a blood thinner over the last four hours, a dose that should have been spaced over 16.
The patient, M.V., is a middle-aged man half-delirious with pain and complications from AIDS. When he was admitted earlier in the week with a hip fracture and a blood-clot in his leg, he was given Heparin to dissolve the clot so it wouldn't block the flow of blood to his heart or lungs and kill him. But now, at four times the potency prescribed, the drug coursing through his veins threatens to cause a massive stroke or internal bleeding. The nurse who told Sykes about the mistake said she does not know how it happened -- somehow, the digital IV pump was set wrong.
Dr. Sykes shakes his head, palm flat on the counter and thumb tapping as he scans the chart. It is his 19th straight hour at the hospital.
He draws a blood sample from M.V. -- it is the middle of the night, and the phlebotomists who normally do this, when they can be found, are home sleeping -- and notices that the needle puncture doesn't bleed, which seems unusual for someone with dangerously thin blood. "To be honest, I'm not sure if he did get 25,000 units," Sykes says as he carries the vials of blood down 12 floors to the lab. It is almost 3 a.m. now, and it is Sykes' eighth or ninth trip downstairs -- there are no messengers this late either, and even when there are, it is usually faster and more reliable for doctors here to carry the samples themselves.
The test to see how well M.V.'s blood is clotting will take an hour; until then, Sykes can do nothing for the man. While he waits, back on the 10th floor, Sykes inserts an IV line in a woman he suspects has a diseased pancreas, a woman with a history of intravenous drug use and poor veins -- the nurses said they could not find one that would take an IV -- who is scheduled for diagnostic tests in the morning.
There is still another half hour to go before Sykes learns whether M.V. is in danger, whether he should restart the original prescription or reverse it with blood-thickening medication. All he can do is fret and wait to see if the results or disaster will come first, writing up notes in other patients' charts, his hands chapped from the powder on the countless pairs of disposable gloves he has worn since seven the previous morning.
Before his shift is over, Sykes will discover that an entire batch of blood samples drawn the previous night never made it to the lab. A patient's blood-pressure will surge after nurses forget to give her her hypertension medication on time, and as dawn breaks, a diabetic man will start slipping into shock from low blood sugar. In the meantime, Sykes will be interrupted twice within 40 minutes for a "code" -- a patient in the intensive care unit whose heart has stopped, a call that sends most of the hospital's physicians heading for the elevators.
Sykes is a resident, a doctor in training, and the man with the blood-clot in Room 1003 is just one of his 30 patients tonight, including five admitted just hours ago. It is up to Sykes to make sure they are all alive in the morning. It is his job to see that their blood is drawn and tested, that their pain is eased, that their medication is properly prescribed, that their X-rays and CT scans are ordered for the next day. If no one else is available, he must do it all himself, and he must detail their complaints and progress, by hand, in their charts. By morning, the new patients must have been questioned, examined and diagnosed, and Sykes must have a plan, a course of treatment already begun. When Sykes' colleagues arrive for work 24-hours into his shift, it will be his job to tell them what has happened in the preceding night, and why, and how each patient is faring.
They will arrive in five hours, and in 12 hours Sykes will finally go to bed, 32 hours after he last woke up.
Dr. Gerard Sykes is one of the army of residents that cares for thousands of patients in New York City's teaching hospitals, the vast and bustling facilities that include virtually every one of the city's major medical centers: Bronx-Lebanon, Beth Israel, Bellevue, Columbia Presbyterian, Long Island Jewish, St. Luke's-Roosevelt, Montefiore, King's County.
Out of medical school for anywhere from a few weeks to three years, residents wear the white coat and stethoscope of their trade, and they are called "doctor" by patients, nurses and supervisors. They examine, diagnose and treat patients from first admission to final discharge. They order medication, draw blood and spinal fluid, perform surgery and deliver babies. Rarely, if ever, do the residents explain that they are not certified to practice on their own, that unlike "regular" doctors they often work for 24 hours with little or no sleep, that they are always supposed to be supervised but sometimes are not.
As the essence of a physician's training, residency comes after the broad academic background of medical school but before detailed training in subspecialties like gastroenterology, pediatric surgery or nephrology. It is in these three years that doctors learn by doing, plunging into a wide variety of duties in broadly chosen fields like surgery, psychiatry, pediatrics, emergency or internal medicine. It is technically called graduate medical education, and it is during this time that doctors are supposed to learn the practice, rather than the theory, of medicine.
Supporters of the modern medical training system, pioneered around the turn of the century, say it immerses young doctors in their profession and allows them to apprentice with their elders, see a wide variety of illnesses progress or respond to treatment, and undergo the rigors that forge physicians. It has trained countless doctors over the decades -- world-class physicians and researchers who provide top medical care and have unlocked many of the mysteries of human health and disease.
But to its critics, the current training system puts patients' lives into the hands of exhausted beginners with too much responsibility and too little supervision, letting students learn from mistakes made on real people and injuring or even killing an unknown number each year. Many say residency is little more than an excuse to exploit young physicians by making them do more work for less money than an experienced doctor or a handful of nurses and ancillary employees; one critic likens it to slavery.
Doctors themselves sometimes acknowledge the system's flaws. They tacitly recognize that residents have too little experience for real responsibility, often mentioning that, legally, attending physicians are responsible for their residents' mistakes. They joke among themselves, "Don't get sick in July," because that's when interns -- or first-year residents -- begin treating patients around the country, usually with no experience beyond medical school. One Connecticut pediatrician recounted a grim joke told at Columbia Presbyterian Medical Center, where she served her own residency and then helped manage the program: Resident surgeons maim in July and August -- when the interns are novices with careful supervision -- but they kill in September and October, when they have more self-confidence and less oversight.
The one advantage that Sykes and his patients supposedly have is that he is an intern in New York -- a state that, on paper at least, guarantees a broader safety net for patients while giving new doctors the hands-on training they need.
Eight years ago, New York, which trains 15 percent of the country's doctors, adopted what are still the nation's only regulations limiting the hours residents may work and stipulating how much supervision they must have.
The regulations are straightforward: No resident may work more than 24 hours straight, or average more than 80 hours a week over any four weeks. Every resident must have a full day off each week and at least eight hours off between shifts. An experienced supervising physician must be available around the clock, either in the hospital or, in some circumstances, no more than 30 minutes away and reachable by telephone.
For residents it still means lot of work, but less than the national standard: 36- or even 48-hour days, 100- to 120-hour weeks and supervisors often with just a year or two more experience than the residents and interns they oversee.
By adopting the new regulations, reformers in New York hoped fledgling physicians could get a comprehensive education while still guaranteeing patients safe care.
Every hospital in the state claims to comply with the rules, and all have changed how they train and supervise residents. But despite some improvement, even conscientious hospitals violate the rules occasionally, and some hospitals skirt or ignore the rules with impunity. State inspection reports show violations throughout the city, even in some of the most prestigious of New York's hospitals, and city investigators described "systemic noncompliance."
Critics say the state fails to enforce the regulations adequately. Residents past and present say superiors expect them to work much longer hours than permitted and claim hospitals all too often show the state inaccurate schedules. Many question whether the regulations could improve patient care much in the first place. And amid all this, no one really knows how dangerous overworked residents are to begin with: Few conclusive studies of residents' performance have been conducted, and no good comparisons with experienced doctors are available. Indeed, no one really knows how many mistakes any kind of doctor makes, or what training system is safest for patients.
Two hospitals in New York City -- Bronx-Lebanon and Beth Israel Medical Center -- illustrate how a profession that has historically fended off close scrutiny and interference from outsiders has reacted to regulation -- and how New York's residency experiment may be running aground only a few years after it began.
Dr. Sridhar Chilimuri arrived at Bronx-Lebanon from his native India nine years ago to begin his residency. Then, becoming a doctor in New York was no different than in any other state -- it was a grueling exercise in long hours and seemingly endless responsibility, an apprenticeship regulated only by the profession itself.
Every fourth night during his internship year, Chilimuri worked 36 hours straight from early one morning until the next evening. Often, Chilimuri would have 13 or 14 patients of his own, in addition to another 20 or so he was "covering" for colleagues at home asleep. While he was on call, any new admissions to his part of the hospital became his patients, too, and he became responsible for them until they were discharged. Once Chilimuri finished one of these marathon shifts on call, he often had just 12 hours off before he had to return to work for a normal, 12-hour day. Some residents -- especially surgeons -- had it even harder. They pulled 36-hour shifts every three days instead of every four; some regularly worked 48 hours straight.
Chilimuri's first day as an intern was July 1, the date interns traditionally start nationwide. He was assigned 14 patients and told to care for them. Despite some hospital work during medical school in India, he found the experience daunting.
"You're everything for these patients," said Chilimuri, now a gastroenterologist whose office in the Bronx is a nondescript, spare room with scattered piles of journals and photocopied forms and articles. "The patient doesn't know who you are. They don't see that July 1 is a new batch of interns."
Then came July 4, Chilimuri's first on-call shift, "the worst day in my entire life as a doctor." Twelve new patients arrived that night, but by 10 a.m. he had only finished admitting about half of them -- examining and interviewing them, making a preliminary diagnosis and ordering tests. His supervisor, a second-year resident with just a year more of experience than Chilimuri, admitted two more. "By then I was totally blanked out. I was very, very tired. I said, 'Listen, I've been around here for hours now. I don't know what I'm doing.'" Because it was so early in the year, other doctors helped out that morning.
Chilimuri is still at the Bronx-Lebanon Hospital Center on Grand Concourse Avenue. Now, however, he runs the internal medicine residency program that trained him, the same one that is training Sykes. But since his own internship, Chilimuri has seen, and instituted, many changes.
Not all of those, however, are entirely Chilimuri's doing.
Several of them stemmed from a patient he never met, a woman named Libby Zion who died in the emergency room of New York Hospital-Cornell Medical Center in 1984.
It would take five years, but Libby Zion's death transformed hospital care in New York and set it apart from the rest of the nation, at least on paper.
She died sedated and restrained more than seven hours after arriving at the hospital agitated and feverish. The intern in charge of her care that night had examined her, but no attending physician ever saw her. Exactly what killed Libby Zion still has not been conclusively established.
Libby Zion's father, journalist and one-time federal prosecutor Sidney Zion, made sure his daughter's story did not end with her death. He blamed the hospital's residency system, which let interns and junior residents admit, examine, diagnose and treat new patients during long shifts, often without direct supervision. At Zion's urging, Manhattan District Attorney Robert Morgenthau convened a grand jury to consider criminal charges against the hospital and the intern and doctors responsible for Libby Zion's care. But after amassing 1,419 pages of testimony and meeting 24 times over more than six months, the grand jury didn't indict anyone.
It did, however, issue a scathing critique of the medical training system.
Calling the system seriously flawed, the grand jury concluded that New York state should strictly regulate the number of hours interns and residents were allowed to work, as well as require "in-person consultations with more senior physicians" before interns or second-year residents make medical decisions.
The grand jury's report and Sidney Zion's relentless lobbying drew the public's attention.
The Commissioner of Health at the time created a committee headed by Dr. Bertrand Bell, a professor at the Albert Einstein College of Medicine in New York City. In October of 1987, the Ad Hoc Advisory Committee on Emergency Services, or Bell Committee, as it came to be known, released its final recommendations to the state: 80 hours a week with a day off, 24-hour or shorter shifts, and, perhaps most importantly, regular and in-person supervision by an attending physician or a doctor with at least four years of experience.
Two years later, new rules went into effect, similar to those recommended by Bell's committee but with a few significant changes. Surgeons, by many accounts the most overworked residents, received exemptions if the hospital could document that they had slept "adequately" and received more time off after a long shift. And if an attending physician is "immediately available by telephone and readily available in person when needed," on-site supervisors need only have three years of experience, including residency, once again letting residents -- albeit more experienced ones -- supervise their juniors.
But the idea remained simple: If residents worked fewer hours, they would be less tired; that would make them better doctors. If supervisors were more available, interns and junior residents would be more likely to turn to them for advice.
At the same time, it became more complicated to run a residency program. One response, like that at Bronx-Lebanon's Department of Medicine, adapts to the new rules by rearranging the schedule. Other programs, like the medicine department at Beth Israel Medical Center in Manhattan, use a "night-float" system to minimize long shifts and assign some residents to night-only duty for a month at a time. The training programs at both hospitals are affiliated with the Albert Einstein College of Medicine -- the same institution that Bell is affiliated with -- but the differences between the two systems run deep.
At Bronx-Lebanon Sykes begins his workdays early, usually before 7 a.m. He checks on all his patients and talks to the intern on call the night before to see what has changed. By 7:30, he is prepared to go on rounds with the floor's three other interns and two second-year residents.
Together, they walk from doorway to doorway, pausing in front of each semi-private room to discuss the patients inside as nurses and orderlies flow around them. The second-years ask questions and make suggestions. Then the other interns present their patients.
By 9:30 a.m., the residents are joined by Dr. Kalpana Uday, one of the 10th floor's two attending physicians, experienced doctors who oversee the residents and bear ultimate responsibility for patients. Again the group makes the rounds, occasionally entering a room to examine the patient or ask a few questions: How are you feeling? Do you have any pain? Do you know where you are, what day it is?
When he is on call, Sykes must pay particular attention during rounds: All these patients will be his once his colleagues go home in the evening. Trickling out at about 7 p.m., they tell Sykes which patients are in good shape and which are likely to need attention, what tests to run, whose blood to draw.
Then the long watch begins. Until 7:30 the next morning, when the other interns reappear, Sykes will be supervised by Dr. Vasant R. Patel, a second-year resident responsible for the 10th floor and one other. Elsewhere in the hospital, a third-year resident is available if necessary. And, if more experienced help is needed, Uday is on call at home tonight -- they can page her for consultation or, if necessary, ask her to come to the hospital. But, like so many residents, they won't -- they almost never do.
The internal medicine residency programs at Beth Israel and at Bronx-Lebanon are as different -- quite literally -- as night and day. On Beth Israel's 6 Dazian, Libby Zion's legacy is almost tangible. In effect, over the course of a week, five Beth Israel interns do the work of four at Bronx-Lebanon.
Residents here also work in teams, with two or sometimes three interns joining a single second-year and supervised by an attending physician. The two teams on each floor divvy up the patients and alternate responsibility for admitting new ones.
Today, among the drug addicts and alcoholics who fill the rooms on 6 Dazian, Dr. Marian Vandyck is on call.
Six Dazian -- the sixth floor of the Dazian Pavilion at Beth Israel Medical Center -- is a locked ward, a place where, to get in or out, you must have a key or be recognized by one of the staff. Today Vandyck, a 28-year-old intern from Ghana, has just five patients under her care. Among them are C.C., a 32-year-old woman with pneumonia who has been HIV positive for 10 years and takes methadone for her heroin addiction, and N.L., who is also HIV positive, also in her mid-30s, and appears to have meningitis. Six Dazian is a place for addicts and alcoholics who are admitted for other medical problems.
Vandyck started today at 7 a.m., and she spends a few minutes with C.C., who was admitted two days before. C.C. is still agitated, talking quickly about everything from her heroin addiction to her last visit to the hospital. The previous week, she had checked out of the emergency room with pneumonia, against medical advice. She laughs thinly without provocation, bright eyes darting around the room, hands scratching her shoulders, her side, her leg, her palms.
"Her affect is very inappropriate," Vandyck says once outside the room. She will call a psychiatry resident to examine the woman later in the day.
At 7:30 a.m., Vandyck meets with the other members of her team. Together, the three of them are responsible for 15 or 16 patients on any given day. By 8:30, they have been joined briefly by one of the medicine department's chief residents, and, once he has left, by Dr. Adrienne M. Fleckman, the associate director of medicine and their attending physician this month. She is a lively woman almost as intent on teaching her interns as on treating the patients. "Every day you have to read something," Vandyck lamented, half joking, after getting an assignment on alcoholic ketoacidocis. "Some attendings don't ask you, some do but maybe not every day. Dr. Fleckman likes teaching us."
Fleckman arrives with two paper plates flexing under a pair of cinnamon rolls, two Danishes and a muffin. By 8:45, she and her trailing residents are downstairs at radiology to look at CT scans, and later they stop by the microbiology lab on the 12th floor to examine a sputum sample from C.C. Collected after her antibiotics were started, there is no clear sign what caused the pneumonia, but Fleckman spends 20 minutes going over the microscope slide with the interns.
"This is pure mouth contamination," Fleckman said, drawing her pupils' attention to the purple-stained flecks and pink smears. "This is very nice for a non-diagnostic sputum." The two interns take turns peering through the eyepieces, shuffling with restrained impatience and eagerness to return to the floor.
Vandyck will admit just one patient today, and she will leave the hospital after a 12-hour day, shortly before 7 in the evening. When she goes, her patients will be "covered" for the next two hours by her partner, who is on call that evening, and then, after 9 p.m., by the intern who works the night shift.
Within their team, Vandyck and the other intern split their work. But unlike at Bronx-Lebanon, teams here split their day on call in half as well: One admits new patients from 7 a.m. to 3 p.m., the other from 3 p.m. until 9 p.m. Whoever is on call takes the floor's new admissions; the other intern works only with existing patients.
And at 9 p.m. the reinforcements arrive.
Along with the usual rotations within Beth Israel's medicine department -- nephrology, pulmonary, cardiac, detox, intensive care -- there is another: the night shift. Six days a week, in almost every internal medicine ward, a new shift takes over from 9 p.m. until 7 a.m. in what is known as a "night float" system. Under such systems, which became popular in the wake of the Bell regulations, the night-shift residents admit new patients, begin their treatment, and prepare their charts for the regular intern to read the next morning.
That means that, even on her evening shift every fourth day, Vandyck admits no new patients after 9 p.m. and can go home as soon as she is finished examining and writing up the patients she does have. When she admits patients in the morning or when she is not on call, Vandyck often leaves by 7 p.m., turning her patients over to her partner or the other team until 9 p.m., when the night shift takes over.
Once a month, Vandyck must stay up all night. Because the night floats get Fridays off, the floor's four interns take turns covering for them. On her one night each month, Vandyck works 24 hours straight, from 7 a.m. Friday to 7 a.m. Saturday, taking in new patients and keeping an eye on all the patients on the floor.
Night float systems are tailor-made for the Bell regulations. And, at hospitals without night floats, they make for somewhat wishful thinking.
If Bronx-Lebanon had a night-float system, Sykes mused eight hours into what turned out to be his 31-hour workday, "I'd only work until 9 or 10 tonight, go home, get a decent night's sleep. At least you get a decent night's sleep. Even if I finished at midnight, I could sleep until six or seven."
It is shortly before 12:30 on a Tuesday afternoon in January, and Dr. Raghunandan Loganathan, an intern in medicine at Bronx-Lebanon, has spent 29 hours on the job. Slightly bleary-eyed, he rummages through bins of sterile gauze pads, plastic-wrapped spinal-tap kits, catheters and gloves, looking without success for a feeding tube. A nurse comes in and quickly finds one.
The innocuous looking tube sealed in paper and plastic is for the toothless man in Room 1005 who was admitted to the hospital the night before from a nursing home. Eleven hours earlier, he did not respond when Loganathan and his second-year supervisor loudly asked him questions. When they picked up the man's arms and let go, his limbs fell with little resistance. The man's eyes had barely moved when Loganathan's penlight flashed across them. He has said nothing, and the intern knows little more than that the man was dehydrated, had high glucose levels and two minor bedsores.
It is Loganathan's job to find out what is wrong, and his job to fix it as well. Already the man is hooked up to an intravenous pump that is rehydrating him. The next step is to begin feeding him through a tube into his stomach.
There's only one problem: Loganathan is not supposed to be here -- he is five hours past the legal limit on his workday. He has gone 29 hours with only two-and-a-half hours of sleep and by law is no longer allowed to care for patients. Nevertheless, today he is expected to wind the feeding tube gently and carefully down the throat of the aging man in Room 1005 before heading home to bed.
The Bell regulations were written for situations like this. The Bell reforms have allowed interns and residents to work fewer hours than those who trained before them. But the reduction in hours that has taken place -- from 36 hours to 30, or even 24 -- hasn't necessarily made the job easier for residents, or safer for their patients.
Managed care and better out-patient medicine mean that even as work hours have decreased, interns are working harder, Chilimuri and others said. Hospitals now only admit the sickest cases, treating others as outpatients. "Mildly ill patients that would have been admitted years ago, we're treating at home now," said Dr. Jennifer Gruen, a Stamford pediatrician who finished her residency at Columbia Presbyterian Medical Center this summer. Once, residents measured the difficulty of a shift by the number of patients they admitted or treated. Now they face fewer patients, but they're more difficult to heal. In the end, it means at least as much work as before the Bell regulations.
That makes it more difficult to get rest. Several Bronx-Lebanon residents said it's common for them to get two or three hours of sleep, but all too often they get none at all.
And there is more to the frenetic pace of a night on call than lack of sleep. During his 31-hour shift, Sykes not only got no sleep, but he had no time to eat anything more than three or four peanut-butter cookies between his two breakfasts -- one at 8 a.m. on Monday and the other after 8 on Tuesday morning.
A central assumption of the Bell regulations is that doctors who work long hours get tired ã and that tired doctors are more dangerous to patients. It is clear that residency is unpleasantly tiring -- few doctors who argue with that. But is it dangerous for patients?
Doctors -- and especially residents, whose careers depend on their supervisors' approval -- are understandably reluctant to talk about the mistakes they make. It's also difficult to tie any particular mistake to exhaustion or overwork, researchers say. But by listening to residents and looking at the few studies that have been done, a sketchy -- and grim -- picture develops.
Sometimes, Gruen said, mistakes did happen on her shift. Her own worst one, though she does not attribute it to exhaustion or poor supervision, was miscalculating a dose of acyclovir, an anti-viral medicine she gave to an HIV-positive child for his chickenpox.
"It wasn't caught by the pharmacist, and it wasn't caught by the nurse," she said. "It ended up putting the child into renal failure."
The boy recovered, but "at that point I was ready to quit," Gruen said. "There are a lot of similar small errors in medicine. It's always our fault, but sometimes it's also a larger failure. You know that if you're chronically tired, you're going to make more mistakes. But it's hard to say whether you made a mistake because you were tired or because you make mistakes."
Studies of exhaustion in residents are notoriously disputed. Some show that residents perform mental tasks poorly after being on call, others show little or no effect. Part of the problem is a limited understanding in the general population -- and even among physicians -- about what exhaustion and sleep deprivation mean, according to sleep researchers and those who study "systems failure," or why errors are made.
"There's a lot known about how people make mistakes and how to prevent it," said Dr. Lucian L. Leape, a pediatric surgeon at the Harvard School of Public Health who has spent the last 10 years studying how and why physicians and others err. "One of the things we know is that people make more mistakes when they're sleepy."
It's an axiom that defenders of the medical-training system -- and doctors in general -- tend to ignore.
"We rely on physicians' sense of duty and conscientiousness," Leape said. "Even if they're tired, the feeling goes, they'll rise above it. I think there's a fair amount of evidence that's true. You can compensate for it with a fair amount of effort and adrenaline, but I don't think we want to design the system around it."
That idea -- that doctors can "rise above" their exhaustion -- is a "commonly held misconception," according to Dr. Steven K. Howard, an assistant professor of anesthesiology and a sleep researcher at the Stanford University School of Medicine in Palo Alto, Calif..
"I think we end up fooling ourselves more often than not," he said. "We've kind of tried to put blinders on as a profession."
In general, sleepiness makes certain types of tasks extremely difficult, Howard said, especially "vigilance tasks," like when an anesthesiologist in a dark operating room keeps an eye on the glowing lights of a patient's vital signs.
Two factors suggest that sleepiness causes a lot of mistakes, Howard said -- common sense and good science.
A study by sleep researchers and physicians at NASA and Stanford University shows what those who have worked the graveyard shift already know.The study showed that emergency-room doctors working night shifts got about a third less sleep than those who worked days -- 6 hours and 23 minutes as opposed to 9 hours and 24 minutes. At the same time, night-shift physicians were slower when inserting a breathing tube into a mannequin's airway. As the night progressed, night-shift doctors also started skipping parts of the standard procedure and made more mistakes.
Night-shift doctors were also slower at reading patient histories and deciding which patients needed attention first. Under one analysis, the doctors also made more mistakes in determining what procedures should be ordered for those patients.
Another study focused on the difference between two kinds of sleep deprivation: the acute kind, from staying up all night, and the chronic kind, which can come about just by getting an hour too little sleep each night. They seem different to most people, but the result is the same, meaning most residents are chronically short of sleep even before they go on call.
In one of a series of experiments with anesthesiology residents, Howard and his colleagues compared three groups: one that had just finished a night on call, one that was two days away from being on call but was working normal 12-hour shifts, and one that was allowed to "sleep in" for a couple days. By performing a set of standard sleep tests the researchers measured how tired each group was.
The study showed practically no difference between residents who had just been on call -- the acutely tired -- and those in the midst of "normal" shifts, or the chronically tired.
"Both sets of people are almost at pathological levels of daytime sleepiness," Howard said, "levels similar to what you see in narcolepsy."
Most of the studies that show no loss of cognitive ability after being on call don't account for chronic exhaustion, and instead compare the two exhausted groups against each other, Howard said. Research has also shown that tired people have difficulty judging accurately how tired they are. Together, the two factors lead many physicians to believe they can compensate for staying up all night.
"We're asking (residents) to learn a career under probably the worst conditions," Howard said. "It's almost as if we specifically designed the system to do this to people."
Long shifts without sleep, or with only a few hours, are common throughout New York's training hospitals. In addition to Loganathan and Sykes, several other Bronx-Lebanon residents tell stories about 30-hour shifts and caring for patients after more than 24 hours on the job. So do residents at Beth Israel -- Vandyck does not always get to go home as scheduled.
During her mid-January all-night shift on 6 Dazian, Vandyck worked 30 hours straight. And, although the Bell regulations permit doctors to stay more than 24 hours to finish writing up charts or tell their replacement about a patient, Vandyck was taking care of patients until she left.
Long shifts are common at public and private hospitals, world-famous or obscure. Although supposedly able to finish between 7 a.m. and 9 a.m. after being on call all night, "in actuality, you would really still take care of patients through to about noon," Gruen said about her own recently completed residency at Columbia Presbyterian. "On paper it's one schedule; in actuality, it's another."
Although the state allows "some leeway for turnover," it shouldn't be taken too far, said Wayne Osten, assistant director for the Health Care Surveillance division of the New York State Department of Health. "A couple of hours" should be enough.
The problem with the Bell regulations is that, like all rules, they can be broken. And they are ã with great regularity, according a 1994 report from the New York City Public Advocate's office.
In the report, Katherine Eban Finkelstein, then a policy analyst for the Advocate's office, looked at state inspection reports and investigated city-funded hospitals. She found routine violations.
Between 1989, when the regulations were adopted, and 1993, when the study was completed, the percentage of hospitals inspected by the state that violated the rules rose from 62 percent to 92 percent, according to the report. In 1993, more than half of the 12 hospitals surveyed that year had violations in several different departments. In 1994, the most recent year for which the Department of Health had numbers available, six of 10 hospitals inspected in New York City violated the regulations.
"There are too many violations to say the regulations have worked," Finkelstein said. "Inevitably, 24 hours turned into 36."
In most cases, the interns themselves make the decision to stay longer ãbut their superiors and peers expect them to, and to do so without complaining. Sometimes they don't make the choice alone.
A few days before his Dec. 30 shift, Sykes was on call on a different floor of the Bronx-Lebanon hospital. It was his last shift on that floor ã the next day, a Thursday, interns throughout the medicine department were moving to different floors and different kinds of patients. Because he would be "post-call," or recovering from the previous day and night, he wasn't supposed to show up on his new floor until Friday.
Even so, he decided to look in to introduce himself to his new attending physician and to see who would be on his new team. After a few minutes, he went home.
But as soon as he got home and prepared for bed, 30 hours after he had left it, his pager went off, Sykes said. He called in. His new second-year supervisor apologized, but said the attending physician on the new floor wanted him to come in.
"I was there for another hour," Sykes said. "I learned who was in the ward. It was a waste of time, really. ... When you're off, you're supposed to be off."
Finkelstein said her findings, too, showed officials knowingly breaking the rules. "They prepare false call sheets for the staff ã those call sheets have nothing to do with the real schedule they keep."
Chilimuri acknowledges that his residents work longer than they are scheduled to, but he points out ã as does every resident ã that being a doctor is not a 9-to-5, clock-punching job.
"Almost none of the residents finish on time," Chilimuri said. "Whatever needs the patient has on a given day, those have to be met. ... I don't see it really as a problem."
Emergency rooms seem to be the shining successes of the Bell working-hour regulations. And no wonder: Libby Zion died in an emergency room run by interns and second-year residents, so they came under the heaviest scrutiny.
Dr. John Bedolla is a third-year resident in the emergency department at St. Luke's-Roosevelt Hospital Center on Amsterdam Avenue. He's on call four days or nights a week, and a shift, for him, is 12 hours. He works 48 hours in a week. Interns work 60, or five shifts of 12 hours each. Bedolla remembers just one time in the last three years that he didn't finish work ã and leave ã when he was supposed to.
But the nature of emergency room medicine makes it easier to follow the rules, Bedolla said. Patients don't stay as long, and having doctors turn over every 12 hours doesn't mean as much to patients who will soon either be discharged or admitted to another floor.
Bedolla knows the other side of the working-hours experience as well ã for two years he was a resident in surgery, in Portland, Ore. "I'd work 40 hours at a time," he said, despite guidelines from medical certification boards that are similar to the Bell regulations. "Surgeons aren't exempt; they just refuse to comply. Emergency medicine is a much more intelligently built field."
The public, and journalists, focused heavily on working hours and resident exhaustion in the wake of Libby Zion's death. But physicians and reformers say the more important issue is really how much and how well interns are supervised, especially in the emergency room.
Sidney Zion has said he is disappointed that the regulations on supervision for other parts of the hospital did not go farther. "The original idea was to have someone always there, and then they said 10 minutes away. That's not so good."
For Dr. Keerti Sharma, now a third-year resident at Bronx-Lebanon, the supervision at her hospital may have cost one of her patients his life.
A 65-year-old woman with TB and a deadly form of lung cancer began having serious problems breathing while Sharma, then a new intern, was on call. "I was not sure what to do. I didn't get the help I needed," she said. "My second year was not helpful to me that night." He told her to keep increasing the amount of oxygen the patient was getting, but didn't tell her that, if necessary, the patient could be put on a ventilator. Eventually, the woman suffered permanent brain damage and later died.
"I never knew that I could call the attending," Sharma said, and she only later learned that she could have called the third-year resident always on call at the hospital. "I think I will always blame myself for that."
All but one of 12 city hospitals the state surveyed in 1993 violated the supervision rules, five of them in two or three departments. Finkelstein, in her report, found that 10 didn't have an attending physician on-site 24 hours a day or even within 30 minutes of the hospital. "Not surprisingly, surgeons are the greatest violators," Finkelstein said. In 1994, five of the 10 hospitals inspected were warned that they were violating supervision rules in at least one department. At Bronx-Lebanon, two departments were cited.
At both Bronx-Lebanon and Beth Israel, the attending physician examines new patients and goes over their treatment plans on morning rounds. In some cases, that means 12 hours or longer before anyone other than an intern or a second-year resident sees the patient.
Gruen said residents usually know when they're in over their heads ã but sometimes they can't reach the more experienced doctors. "Most of them were easily reachable by phone, but there were a few you knew not to even bother calling." Other times, residents have a hard time convincing attendings that they needed help.
Some attending physicians assumed the residents were simply unsure of themselves. "They would say, 'Oh, you can do it,'" Gruen said. "It's hard to say no to that." It only happened to Gruen a couple of times during her residency and "the patients both did fine," she said, though she was painfully aware of the chance that they wouldn't.
Uday, the attending physician on Sykes' floor in late December and early January, said being available by phone is enough.
"My opinion is biased, of course, but I believe the supervision works," she said, adding that she is called about a "serious, life and death" incident at most once every two weeks. "The quality of care is no different than when the care is provided by an attending," she added. "The other question is, what alternative is there?"
Gruen said that despite her experiences as an intern, the lack of close nighttime supervision wouldn't stop her from taking her own 2-year-old daughter to a teaching hospital for serious or unusual diseases. She would go not so much for the care that the residents provide as for the expertise of the attending physicians ã and for the fact that a doctor, however inexperienced, tired and undersupervised, is there 24 hours a day, unlike at most non-teaching hospitals.
"I honestly think sick patients get better care at a teaching hospital," Gruen said. "Certainly if residents worked fewer hours they could better care for them." But the alternative isn't an experienced doctor nearby all night ã the alternative is no doctor at all.
And in emergency care, Bedolla said, the rules for attending physicians being present are scrupulously followed in the wake of Libby Zion's death. Attending physicians have to approve any antibiotics administered in the ER, as well as any serious intervention or patient discharge. Also, if patients are admitted into another part of the hospital, the attending physician has to see them first ã a direct result of Libby Zion's death.
The Bell regulations' effect on the training system have not been formally evaluated ã an early study was never completed ã so there's no way of knowing how much patient care has improved. Furthermore, hospitals of all kinds are bad at keeping track of any mistakes, for both psychological and legal reasons.
"Most errors are not reported and not discussed," said Harvard's Leape, who worked on studies showing that physicians rarely report even major mistakes. "We have a saying that you don't report errors that you can hide." More grimly, some doctors joke that physicians bury their mistakes. "Probably less than 5 percent of errors are reported," Leape said. "And those that are, nothing is done about it."
The state doesn't distinguish between mistakes made by residents and attendings, but residents do make mistakes. At least 45 percent of the residents in a 1991 study admitted errors, a third of which led to death. Almost half of those surveyed never discussed their errors with their attending physicians. And more mistakes are made at teaching hospitals, another 1991 New York study found, where 4.1 percent of patients were discharged with "adverse events," compared to 2.3 percent at non-teaching hospitals.
Despite the risk to patients, interns are a very good deal for hospitals looking to bring in money and keep down costs.
For one thing, interns' hours are infinitely flexible, especially if you ignore the Bell regulations. "It's called slave labor," said Mark Levy, associate director of the Committee for Interns and Residents, a New York-based union. At $30,000 to $40,000 a year and 100 hours of work or more each week, "they're the cheapest workers in the hospital." So, hospitals cut costs by reducing nursing and support staff and the residents bear the brunt of it.
Because indigent patients tend to rely teaching hospitals, Medicare pays teaching hospitals up to $100,000 a year for each resident they train. In addition, the Bell regulations come with $200 million for hospitals statewide. One residency director at a prestigious Manhattan teaching hospital, speaking on the condition that he not be named, estimated that his hospital gets about a quarter-million dollars a year in federal and state subsidies for each intern, only some of which goes directly to training and salaries.
The state funds are meant to pay for supervising interns, reducing their work hours and hiring enough phlebotomists, messengers and orderlies to help them. Often, though, interns still draw blood samples, take samples to the lab for testing, and pick up the results themselves ã all tasks that are supposed to be performed by the ancillary staff to allow residents more time with patients and to study medicine. Sykes said he spends up to a third of his day on such routine duties, and during his day and night on call before the New Year, he inserted four IV lines and took seven blood samples.
Critics of the training system say the state enforces the Bell regulations badly. The state's health-care surveillance office is supposed to inspect hospitals every three years and respond to complaints, but in researching her 1994 report for the Public Advocate's office, Finkelstein found that inspections had actually been made only every five to six years. When it finds violations of the Bell regulations, the state can close hospitals for serious or frequent transgressions or fine them $2,000 for each violation, Osten said. But he added that the state is unlikely to decertify a hospital over residency regulations without a rash of fatal or near-fatal errors.
But even as state surveys show more Bell regulation violations, the number of inspectors in the city has dropped, from 37 full-time positions in 1992 to under 33 in 1996, according to Department of Health figures. The number of complaints filed with the Department of Health has also dropped steadily, from 22 in 1989 to just one in 1993. That may not be because the residents lack complaints, however.
Beth Israel requires residents to report problems in evaluation forms they fill out for each floor they rotate through. But at Bronx-Lebanon and elsewhere, residents are often afraid to complain.
To begin with, there are more medical students want residency positions in New York than there are slots to take them, a situation bound to worsen under federal plans to pay New York hospitals for training fewer doctors. "Programs tell you, well, if you don't like the hours, leave," Gruen said.
Attending physicians and program directors also have an immense and highly subjective say in whether a resident is "boarded," or certified ã without graduating from the program, residents aren't allowed to take the necessary tests. And supervisors can always find a reason to delay graduation, so most residents just keep quiet.
That's why Sykes didn't report the attending physician who made him come back to the hospital after he finished a shift on call.
"I'm bound to rotate to his floor again in the next 12 to 18 months," Sykes said, shrugging as he filled out patient charts early in the evening of his shift on call. "If I file a complaint, all he has to do is wait for me to show up again and he'll complain and complain. He'll find a medical reason."
Copyright 1997 Theo Francis
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