New regulations proposed in New York State this summer may radically restructure the traditional way doctors are trained in teaching hospitals in the Empire state and also would mandate intraoperative patient monitoring.
These regulations would be the first in the country to limit residents in training to a maximum of 16 hours on duty without a formal break. Concern about the long hours worked by residents was brought to the fore by the death of an I 8-yearold woman admitted via the emergency room to a large New York City teaching hospital and treated by a first year resident.
A Grand jury empanelled to investigate the death reported last January that the long grueling hours of unsupervised interns and residents led to the death of the young woman. (“Report of the Fourth Grand Jury for the April/May Term of 1986 Concerning the Care and Treatment of a Patient and the Supervision of Interns and Junior Residents at a Hospital in New York County”). The Grand jury made five recommendations and while some of them were specifically directed at emergency room care, several of them will have a direct effect on anesthesia training programs. In particular, the Grand jury stated that “the State Department of Health should promulgate regulations to insure that interns and junior residents… are supervised contemporaneously and in person by attending physicians. . ‘” In addition “The State Department of Health should promulgate regulations to limit consecutive working hours for interns and junior residents in teaching hospital.”
An Ad Hoc Advisory Committee on Emergency Services was then formed by the Commissioner of Health, Dr. David Axelrod to analyze the recommendations of the Grand jury and make further suggestions. The Ad Hoc Advisory Committee was comprised of nine prominent physicians with significant experience in graduate medical education; its report attacked the current entrenched system of medical training and further recommended that “house officers and/or full time attendings, who have direct patient care responsibilities and who work in areas other than the emergency room, shall not in general work for more than 16 consecutive hours per shift; shifts of 16 hours shall be separated by no less than eight hours of non-working time. In no case shall an individual person who has worked the maximum consecutive hours in one hospital, work in a different hospital in a consecutive fashion. Enforcement of this policy shall be the responsibility of the primary employer of the physician. The breech of this policy shall be considered medical misconduct” ‘The Ad Hoc Advisory Committee also endorsed the Grand jury’s concept of appropriate in-person and timely supervision of resident and intern physicians by attending physicians.
Resident Hours: Experience vs. Fatigue vs. Great New Costs
A recent study conducted in New York City found that residents, on average, work 78 hours per week. Of these 78 hours, 20 are call hours; therefore almost 60 hours are spent in formal work. Those in opposition to the proposed changes stress that illness has no shifts nor 24 hour limitations and that physicians in training need to learn to follow an illness throughout its course. They argue that the long hours toughen young doctors to the rigors of medical practice, expose them to the evolution of a patient’s illness and provide continuity of cam They also point out the economic implications of such a radical restriction in training hours. The president of the Greater New York Hospital Association, which represents private non-profit teaching hospitals projected that the rules would cost hospitals “tens and tens of millions” in additional operating costs.
The president of the Committee of Interns and Residents, which represents New York City house staff said that the interns and residents are often asked to fill in for missing support staff because of chronic ancillary staff shortages; they basically provide “cheap labor” for long hours at low wages. Those in favor of cutting the hours argue that with the growing sophistication of medicine, sleep deprivation among house officers has become even more dangerous to patients. The Manhattan District Attorney said the State’s proposals “will have a major impact on the quality of care in teaching hospitals… they would make New York hospitals lead the nation in the training of young doctors”.
Besides addressing this “software” issue, the State is also tackling the “hardware” side by proposing new regulations concerning minimum monitoring standards for Anesthesia practice; (New York State Code of Rules and Regulations Part 405.13). Of particular interest are the following two sections: “During the administration and conduct of all anesthesia except locals and epidurals unless medically indicated, the patient’s oxygenation shall be continuously monitored to ensure adequate oxygen concentration in the inspired gas and the blood through the use of a pulse oximeter” and “For every patient receiving general anesthesia with an endotracheal tube, the quantitative carbon dioxide content of expired gases shall be monitored through the use of end-tidal carbon dioxide analysis”.
Regs Could Open “Purse;” Questions Remain
Despite the cost of at least $10,000 per anesthetizing location to achieve compliance with the proposed regulations, most of the anesthesia community appears to be in agreement with the proposed standards. In a sense it “holds a Sun” to the heads of hospital administrators and forces them to loosen the budgetary purse strings. Criticism has focused on the fact that while the capnometry proposal supports a performance standard, the oximetry standard is a design standard mandating “pulse oximetry” rather than arterial saturation. Such a design-based standard can quickly become obsolete as better methods to measure Sao2 come on the market.
The recommendations of the Commissioner of Health are usually followed by the Hospital Review and Planning Council which allows for public comment. The Council is an arm of the State Department of Health that is empowered by the Legislature to regulate hospital physician-training programs in New York because their cost is borne by the public in the form of higher public and private insurance rates. It is expected that the rules could take effect as early as January 1988.
Dr. Lees is Professor and Chairman of Anesthesia, New York Medical College and an AFSFAC-newsletter Editorial Board member.