Thursday, May 5, 2011

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

2 comments:

  1. Thank you for saying what needs to be said. A truly important post that should shake things up a bit.

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