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@Another Story of US Residency (3) @
Part3 From the Mid-1980s Onward (Continued from part 2)
The Libby Zion Case
There is one incident that cannot be ignored when discussing the state of U.S. residency programs from the mid-1980s onward. Libby Zion was an 18-year-old high school student living in New York. One day in 1984, she visited the emergency room at a New York hospital, an affiliated teaching hospital of the Cornell University Medical School due to a fever. While waiting in the ER, she became agitated, so the resident on duty administered an injection of meperidine to calm her down. However, her body temperature subsequently rose above 104F, and she died after suffering respiratory arrest. An investigation revealed that Libby had been taking phenelzine, an antidepressant and MAO inhibitor, for which meperidine administration is contraindicated. The resident who treated her made an error in judgment, which ultimately led to the patientfs death.? At the time the resident made that decision, he had already been working for 20 consecutive hours in the emergency room. Consequently, a link between the error and fatigue was suspected at that point.
Libbyfs father filed a lawsuit over the medical error that claimed his daughterfs life. However, as a reporter for The New York Times himself, he did not want to let the case end as merely a single instance of medical malpractice. He lobbied on the grounds that it was a systemic medical error caused by the residentfs long working hours. In court, his arguments were fully accepted, and subsequently, New York State enacted legislation to reduce the long working hours of residents.
Responses Outside New York State
In New York State, a tragedy actually occurred, leading to improvements in resident working conditions through legislation. However, even by the late 1980s, excessive workloads for residents remained unchanged in other states. Working 80 hours a week was commonplace, and working 100?120 hours a week was not uncommon.
The Accreditation Council for Graduate Medical Education (ACGME), which oversees postgraduate medical education in the United States, could not allow this situation to continue. This was because a second or third Libby Zion incident could happen anytime, anywhere.
The resident work standards proposed by the ACGME include limiting weekly work hours to no more than 80 hours and prohibiting continuous shifts exceeding 24 hours. After various twists and turns, these ACGME standards became mandatory for all U.S. residency programs starting in July 2003.
Is Resident Overtime Harmful to Patients?
Starting with the Libby Zion case, numerous medical errors believed to have been caused by resident overtime have been reported to date. Common sense suggests it is hard to imagine a resident who has just pulled an all-nighter making clear-headed judgments, and no one would want to be examined by such a resident. However, it is extremely difficult to prove a clear causal relationship between resident overtime and errors in judgment.
According to one report, the work capacity of a person who has not had adequate sleep for 24 hours is as impaired as that of someone with a blood alcohol concentration of 0.1%. If we accept this report, a consultation with a resident fresh off an all-nighter is virtually equivalent to a consultation with a doctor who is heavily intoxicated.
Next, letfs consider labor standards in industries outside of healthcare. Given that this is a life-or-death profession, looking at labor standards for pilots, weekly flight time is limited to 30 hours or less, and rest between flights must be at least 8 hours. Even when compared to the ACGMEfs revised standards from 2003, pilots are required to have far more rest. Based on this circumstantial evidence, it can be said with near certainty that resident overwork is harming patients.
Issues Arising from Improving Resident Working Conditions
In U.S. teaching hospitals, while residents are officially in a position to receive training, it is also a fact that they are utilized as a source of cheap labor for the hospital. Resident annual salaries range from $42,000 to $58,000 in early 80s. The professions that could potentially supplement residentsf work are Physician Assistants (PAs) and Nurse Practitioners (NPs); however, their annual salaries-$67,000?$77,000 for PAs and $53,000?$98,000 for NPs-are higher than those of residents.
Consequently, it is inevitable that teaching hospitals will face financial difficulties. Furthermore, it is a fact that reducing residentsf working hours will also reduce the amount of clinical training they receive. This will need to be compensated for in some way.
The Champion of Justice, Sued
The ACGME, mentioned earlier, is an organization that is seriously committed to addressing resident overwork and is clearly on the side of medical students and residents. However, this very champion of justice, the ACGME, is, of all things, being sued by medical students. The charge is gviolation of the Antitrust Law (Note).h The ACGME selects residents through a matching process, but the claim is that this matching system violates antitrust law. Because the matching system exists, resident applicants cannot negotiate directly with multiple hospitals, and hospitals, in turn, have no need to compete for applicants in various ways. This is reportedly the main point where the system runs afoul of antitrust law.
According to experts, there is a strong possibility that ACGME could lose this lawsuit. The matching system for resident selection has been in place in the U.S. for half a century, since 1952. I have heard that Japan is also considering introducing this system in conjunction with the mandatory clinical training program that began in 2004.
In Conclusion
Over the course of three installments, I have introduced gAnother Side of the U.S. Residency Story.h This gother worldh is the hidden side of the U.S. residency system-the flip side of its public image as grigorous yet rational and efficient postgraduate training.h This hidden world is marked by various poor working conditions that erode residentsf mental and physical health. However, the most serious issue is that doctors-whose mission is to save lives-are potentially harming patients, even while they are still in training. Does this not suggest that even in American society, which loudly champions human rights, the medical world has been considering healthcare solely from the physicianfs perspective, rather than the patientfs?? While U.S. residencies do have this unknown underbelly, they also possess a system capable of boldly reforming it when necessary. Therefore, I would like to emphasize that even when accounting for these hidden aspects, the U.S. residency system remains the fairest and most efficient postgraduate training system in the world.
Note: U.S. antitrust laws. A collective term for laws centered on the Sherman Act, enacted in the United States in 1890 to regulate attempts by large corporations to monopolize markets and to promote market vitality. Recently, Microsoft was sued for violating this law, attracting significant attention.
References
1) Gaba DM, Howard SK. Fatigue Among Clinicians and The Safety of Patients. NEJM 2002;347:1249-1255
2) Weinstein DF. Duty Hours for Resident Physicians-Tough Choices for Teaching Hospitals. NEJM 2002;347:1275-1278
3) Robins NS. The Girl Who Died Twice: Every Patientfs Nightmare: The Libby Zion Case and the Hidden Hazards of Hospitals. New York: Delacorte Press, 1995
4) Chae SH. Is the Match Illegal? NEJM 2003;348:352-356
The Libby Zion Case
There is one incident that cannot be ignored when discussing the state of U.S. residency programs from the mid-1980s onward. Libby Zion was an 18-year-old high school student living in New York. One day in 1984, she visited the emergency room at a New York hospital, an affiliated teaching hospital of the Cornell University Medical School due to a fever. While waiting in the ER, she became agitated, so the resident on duty administered an injection of meperidine to calm her down. However, her body temperature subsequently rose above 104F, and she died after suffering respiratory arrest. An investigation revealed that Libby had been taking phenelzine, an antidepressant and MAO inhibitor, for which meperidine administration is contraindicated. The resident who treated her made an error in judgment, which ultimately led to the patientfs death.? At the time the resident made that decision, he had already been working for 20 consecutive hours in the emergency room. Consequently, a link between the error and fatigue was suspected at that point.
Libbyfs father filed a lawsuit over the medical error that claimed his daughterfs life. However, as a reporter for The New York Times himself, he did not want to let the case end as merely a single instance of medical malpractice. He lobbied on the grounds that it was a systemic medical error caused by the residentfs long working hours. In court, his arguments were fully accepted, and subsequently, New York State enacted legislation to reduce the long working hours of residents.
Responses Outside New York State
In New York State, a tragedy actually occurred, leading to improvements in resident working conditions through legislation. However, even by the late 1980s, excessive workloads for residents remained unchanged in other states. Working 80 hours a week was commonplace, and working 100?120 hours a week was not uncommon.
The Accreditation Council for Graduate Medical Education (ACGME), which oversees postgraduate medical education in the United States, could not allow this situation to continue. This was because a second or third Libby Zion incident could happen anytime, anywhere.
The resident work standards proposed by the ACGME include limiting weekly work hours to no more than 80 hours and prohibiting continuous shifts exceeding 24 hours. After various twists and turns, these ACGME standards became mandatory for all U.S. residency programs starting in July 2003.
Is Resident Overtime Harmful to Patients?
Starting with the Libby Zion case, numerous medical errors believed to have been caused by resident overtime have been reported to date. Common sense suggests it is hard to imagine a resident who has just pulled an all-nighter making clear-headed judgments, and no one would want to be examined by such a resident. However, it is extremely difficult to prove a clear causal relationship between resident overtime and errors in judgment.
According to one report, the work capacity of a person who has not had adequate sleep for 24 hours is as impaired as that of someone with a blood alcohol concentration of 0.1%. If we accept this report, a consultation with a resident fresh off an all-nighter is virtually equivalent to a consultation with a doctor who is heavily intoxicated.
Next, letfs consider labor standards in industries outside of healthcare. Given that this is a life-or-death profession, looking at labor standards for pilots, weekly flight time is limited to 30 hours or less, and rest between flights must be at least 8 hours. Even when compared to the ACGMEfs revised standards from 2003, pilots are required to have far more rest. Based on this circumstantial evidence, it can be said with near certainty that resident overwork is harming patients.
Issues Arising from Improving Resident Working Conditions
In U.S. teaching hospitals, while residents are officially in a position to receive training, it is also a fact that they are utilized as a source of cheap labor for the hospital. Resident annual salaries range from $42,000 to $58,000 in early 80s. The professions that could potentially supplement residentsf work are Physician Assistants (PAs) and Nurse Practitioners (NPs); however, their annual salaries-$67,000?$77,000 for PAs and $53,000?$98,000 for NPs-are higher than those of residents.
Consequently, it is inevitable that teaching hospitals will face financial difficulties. Furthermore, it is a fact that reducing residentsf working hours will also reduce the amount of clinical training they receive. This will need to be compensated for in some way.
The Champion of Justice, Sued
The ACGME, mentioned earlier, is an organization that is seriously committed to addressing resident overwork and is clearly on the side of medical students and residents. However, this very champion of justice, the ACGME, is, of all things, being sued by medical students. The charge is gviolation of the Antitrust Law (Note).h The ACGME selects residents through a matching process, but the claim is that this matching system violates antitrust law. Because the matching system exists, resident applicants cannot negotiate directly with multiple hospitals, and hospitals, in turn, have no need to compete for applicants in various ways. This is reportedly the main point where the system runs afoul of antitrust law.
According to experts, there is a strong possibility that ACGME could lose this lawsuit. The matching system for resident selection has been in place in the U.S. for half a century, since 1952. I have heard that Japan is also considering introducing this system in conjunction with the mandatory clinical training program that began in 2004.
In Conclusion
Over the course of three installments, I have introduced gAnother Side of the U.S. Residency Story.h This gother worldh is the hidden side of the U.S. residency system-the flip side of its public image as grigorous yet rational and efficient postgraduate training.h This hidden world is marked by various poor working conditions that erode residentsf mental and physical health. However, the most serious issue is that doctors-whose mission is to save lives-are potentially harming patients, even while they are still in training. Does this not suggest that even in American society, which loudly champions human rights, the medical world has been considering healthcare solely from the physicianfs perspective, rather than the patientfs?? While U.S. residencies do have this unknown underbelly, they also possess a system capable of boldly reforming it when necessary. Therefore, I would like to emphasize that even when accounting for these hidden aspects, the U.S. residency system remains the fairest and most efficient postgraduate training system in the world.
Note: U.S. antitrust laws. A collective term for laws centered on the Sherman Act, enacted in the United States in 1890 to regulate attempts by large corporations to monopolize markets and to promote market vitality. Recently, Microsoft was sued for violating this law, attracting significant attention.
References
1) Gaba DM, Howard SK. Fatigue Among Clinicians and The Safety of Patients. NEJM 2002;347:1249-1255
2) Weinstein DF. Duty Hours for Resident Physicians-Tough Choices for Teaching Hospitals. NEJM 2002;347:1275-1278
3) Robins NS. The Girl Who Died Twice: Every Patientfs Nightmare: The Libby Zion Case and the Hidden Hazards of Hospitals. New York: Delacorte Press, 1995
4) Chae SH. Is the Match Illegal? NEJM 2003;348:352-356