New ACGME work hour regulations for interns: friend or foe?

On the night of October 4, 1984, a young girl named Libby Zion was admitted to New York Hospital in Manhattan for fever, agitation and strange jerking movements. No one knew that her death the next morning would, 27 years later, drastically change the quality of physician training, for better or worse.

When Libby was evaluated in the emergency room that night, neither the ER physician nor her family physician Dr. Raymond Sherman, consulted by phone, were able to make a definitive diagnosis of what was going on with Libby.

They decided to admit her for hydration and observation. When an intern Dr. Luise Weinstein and a resident Dr. Gregg Stone evaluated her for the admission, they also were not sure of Libby’s cause of illness – Dr. Stone termed it “a viral syndrome with hysterical symptoms,” suggesting that Libby may be overreacting to a benign viral syndrome. They prescribed her Meperidine to control shaking, and Dr. Sherman approved the plan by phone without evaluating the patient. Dr. Weinstein went on to care for 40 other patients in the hospital that day, while Dr. Stone went to sleep in the next building, to be reached by beeper if needed.

Later on that night, the nurse contacted Weinstein when Libby became more agitated and started pulling out her intravenous lines. Weinstein ordered restraints and Haldol, a medication used for agitation, without re-evaluating the patient. She also did not notify Stone or Sherman. Libby finally calmed down later that morning, until 630 AM when a vital sign check showed that Libby had a dangerously high fever to 107. Measures were taken to reduce her temperature, but Libby soon suffered cardiac arrest and died.

On careful review, it was discovered that Libby was taking an antidepressant named Phenelzine. Combined with Meperidine given to her in the hospital, Phenelzine can cause fatal serotonin syndrome, symptoms of which include hyperthermia resulting in cardiac arrest.

What follow were outraged parents, a high-profile court trial and the image of the bedraggled, unsupervised intern wreaking damage in hospitals featured in the pages of the Washington Post, the New York Times and Newsweek. Libby’s parents believed that her death was caused by inadequate supervision and fatigue from long work hours. This sparked work hour regulations for residents and interns, which continued to evolve even 27 years later. In 2010, the Accreditation Council for Graduate Medical Education (ACGME) announced stricter work hour regulations, from 30-hour shifts in 2003 to 16-hour shifts to take effect in July 2011. It also stipulated that residents must have 8-10 hours off between shifts, with total work hours/week not exceeding 80 hours.

I have the distinct fortune of being the intern during this monumental transition – I am the only group of interns who during my first year of training have the opportunity to work 30-hour shifts while also transitioning to the 16-hour calls. As I keep my head above ground while my residency program goes through multiple trials of work hour changes to meet the new standards, I often ponder (despite lack of time) about what happened to Libby.

Looking carefully at the story, Libby did not die simply because interns were taking 30-hour calls. When Libby presented, multiple physicians missed her diagnosis, including the more experienced ER doctor and the Zion’s family physician, who should know that his patient Libby was taking Phenelzine before she came to the hospital. The decision to give her Meperidine was not made by the residents alone – it was approved by the well-seasoned, board-certified family physician Dr. Raymond Sherman. When Weinstein decided to give Libby restraints and Haldol, she was probably tired, but more importantly she was BUSY – she did not re-evaluate Libby or call for help, not because she was sleeping, but because she was covering 40 other patients.

Libby highlighted what was and is wrong with medicine today. Private physicians cannot and should not be allowed to manage patients who are sick enough to be admitted by phone – Experienced physicians need to evaluate patients in person and should not rely solely on residents’ accounts. Medication reconciliation and prevention of medication cross-reactions should not be left vulnerable to human errors and information technology needs to be effectively used.

Most importantly, from personal experience, I can testify that as an intern, I am more likely to make medical errors because I have to take care of an absurd number of patients, not because I am tired, and cutting calls from 30 to 16 hours will only exacerbate the situation. As my call hours are cut to sixteen, I am still forced to admit the same overwhelming number of patients I usually do on a 30-hour shift. As I struggle to get out at the 16th hour, there were numerous orders that I simply did not have time to execute, and the fate of the patients are left to the residents who stay overnight for 28-hour calls but remain overwhelmingly overworked. As I lose post-overnight call resting hours and accumulate more commute time from not being able to stay in the hospital, I end up spending MORE time working and less time sleeping. As I become more tired and take care of more patients in shorter periods of time, my learning has greatly diminished – I spend less time processing my patients and more time cramming 30-hour worth of paperwork into 16-hour shifts.

The solution stares us in the eye – interns need a stricter cap on the number of patients they can admit or care for at one time. Patient care can be improved and medical errors can be avoided if providers simply have more time – thorough assessments can be made and comprehensive plans can be formed. Sixteen-hour shift is not the answer – it only aggravates the actual source of the problem.

“angienadia” is an internal medicine physician who blogs at Primary Dx.

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  • Dr L. Harvey

    I fully agree with you, I trained in the ‘Pre-Zion” era when, as a surgical resident, I worked every other night, every other weekend call. Mistakes that might have been made were from juggling too many patients not from exhaustion.
    I also worry that the new regulations will also harm patient care in two significant ways.
    1) The ability to follow the changing patient status over hours is essential to the care of patients. That overall gestalt cannot be easily conveyed verbally or by notes to a ‘sign out’ and the new regulations will prohibit the calling of the earlier resident to discuss the patients condition. Thereby diminishing not improving patient care.
    2) The current group of residents are being trained to view health care as ‘shift work’, when they get out into the ‘real world’ they will find an entirely different situation. Health care professionals don’t work shifts (unless in the ER or possibly Anesthesiology) and these new care givers are about to be launched into a world where all their old assumptions are gone. Personally I make rounds 7 days a week on my hospitalized patients & even when ‘on vacation’ check in daily via phone with my covering provider to check on status. The residents find this attitude unbelievable while those of my era consider it routine.

  • ZDoggMD

    I agree wholeheartedly. As a hospitalist at an academic center, I’ve been through training without work hour rules and have subsequently seen the rules evolve. The fundamental problem is volume, not work hours. And no amount of mandated q2hr massages, nightly bedtime stories, or other such security blankets really addresses that problem.

  • MD

    Medical mistakes will happen no matter how long the shifts are, and no matter how experienced the physicians. Shortening the shifts, or having fewer patients to take care of will not change this.

    As physicians we work in a litigious environment where perfection is expected. We take care of thousands of patients and do a great job on 99.99%. Unfortunately, no one can be perfect, and these unfortunate outcomes will happen no matter what. This is the risk patients take entering our health care system. Similar to the risk we take hopping on a plane.

    I do not know what the solution is, other than to compensate these unfortunate victims. Leave the lawyers and suits out of it. If the providers making the mistake do not have a pattern of sloppy behavior, then it has to do with them being human.

    Look at the recent tragic case of the nurse who gave a fatal medication dose to a baby. This case went from a bad accident, to a horrible tragedy when she committed suicide. She was a good nurse for 27 years.

  • Muddy Waters

    I agree with MD. Occasional mistakes are inevitable in ANY profession, and our society has to accept the fact that you can’t always point a finger when something bad occurs. If, however, repetitive mistakes by a healthcare provider suggest a pattern of negligence, then that is a different matter entirely. Otherwise, we must sometimes accept our fate. That’s life, and it’s not always fair.

  • Dr Sam Girgis

    I work as a hospitalist in New York City. My residents always tell me that as patient load increases, resident learning and satisfaction decrease. This is well known. I believe shortening work hours is good to a certain point. No one wants a fatigued and sleep deprived physician caring for them. But we also don’t want to take away learning opportunities from residents as well. We need to find a happy medium.

    Dr Sam Girgis

  • Kristin

    I think one key point here is to ask what we want to accomplish. If we want to decrease physician error, we need to know what is actually causing the errors; if we want to know that, we need to be tracking outcome quality across a wide range of case types and geographical locations. Which we aren’t doing. EHR haven’t caught on yet in the big way I sincerely hope they do, and until there’s a massive amount of digitally-available standardized or standardizable data to mine, we won’t know what works and what doesn’t. Everyone has different opinions about what works–some doctors say run the interns for 120 hours a week and they’ll learn best, others say 80 hours, the EU caps its hours at something like 52 (and yet patients survive!)–but until we have hard data, this is all useless speculation.

    Making rules based on speculation is not, ultimately, a winning proposition. Until the numbers are in–until we can directly compared cases where a resident is on an 80-hour week with 30-hour calls to a week with 16-hour calls–we do not know what we’re doing. And that makes it a matter of blind luck if we do succeed in accomplishing anything. Not that we’ll know if we accomplish it, because we’re still not tracking outcomes. A few studies here and there, sure, but nothing like the vast studies we could be conducting if EHRs were compatible and the norm.

    I don’t care how bad current EHR technology sucks. I don’t care how much health care practitioners prefer paper. Until we digitize, we’re willfully standing in the Dark Ages.

  • 3rd Yr Med Student

    I completely agree with you that decreasing work hours is not the silver bullet that will drastically improve patient care. Like you eloquently described, Libby’s tragic story demonstrates the systemic problems in the field of medicine: the expectations for humans to be infallible and inadequate infrastructural support to not only prevent errors from occurring, but also quickly reacting to mitigate the damage of errors that do happen.

    As a green third year med student, I don’t have the experience to confidently counter or support your claim that the new work hour restrictions exacerbate the problem as illustrated by Libby’s story. But, what I can say, is that I think this new work hour restriction policy is a good opportunity for residency programs around the world to closely examine how to redesign the current system of delivery of patient care. Why not fix some of the systemic errors of large patient loads, technological solutions, and other work flow processes to improve the quality of care while at the same time operating under more humane work hours for residents? And of course, not diminishing the learning opportunities that are so integral to residency. This is not just a test of adaptation, but a time for innovation. And as third year med student, I feel privileged to be an inside observer as the change occurs July 2011.

  • Luke

    MD/Muddy Waters: Saying “Oh well, mistakes will happen” is NOT the right attitude. Zero mistakes might not be attainable, but it is still the goal we must aim for. Your own analogy with getting on a plane is apt.

    When I get on a plane, I can feel confident that the mechanical and electrical systems were just checked out. The pilot should be well-rested because they don’t fly more than 8 hours a day. And should the pilot be having an off-day, there’s the copilot as backup.

    The point is, the infrastructure is set up so that for a mistake to happen, an extraordinary chain of failures is required. I would hope this is what health care providers strive for.

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