Work Limits at Hospitals: Doctors Differ

A medical resident at an Orange County hospital who was catnapping after being up more than 36 hours caring for patients came within seconds of killing one of them. Groggy from a lack of sleep, he misunderstood which kind of insulin injection the nurse had asked him to give.

A resident at another county hospital who was winding up a 110-hour work week--typical for residents and interns across the state--was so tired after having gone without sleep for several days that he failed to give a sufficient amount of an anti-convulsive drug to stop a patient’s spasms. The next morning, the patient was found near death with a fractured skull in a pool of blood on the floor beside his bed.

These and other instances of patients’ receiving questionable care by interns and residents exhausted from lack of sleep were recounted with chilling precision by Dr. Mindy Cetel at a forum at UCI Medical Center in Orange Friday evening.

Nearly 100 residents, about 10 times the number who typically show up for these meetings, according to forum organizers, packed a small auditorium on the hospital grounds.

Cetel, a second-year neurology resident who was one of four speakers at the meeting, would not identify the residents or interns or the hospitals where these incidents occurred.

“The residents who told me about their experiences did so in confidence,” she said after the session. “They, and all doctors, feel terribly guilty when things like this occur.

“We’re going public with this information so something can be done to keep incidents like this from happening in the future,” Cetel said. “Things like this happen not because of bad doctors but because of bad working conditions.”

The gathering, sponsored by the local chapter of the California Assn. of Interns and Residents, heard the speakers dispute whether the roughly 800 residents at UCI Medical Center should support a bill now pending in the Legislature that would sharply curtail the number of hours residents may work.

Under AB 4679, the maximum work week would be slashed to 72 hours from the present 110-hour maximum. It also would limit shifts to 12 consecutive hours in emergency rooms and 16 hours in other departments.

Dr. Dave Powers, the UC Irvine professor of medicine who runs the residency program for the 80 doctors in the internal medicine program, was sharply critical of the legislation.

He argued that there is little evidence that lack of sleep has resulted in poor patient care. As for the examples of patients who allegedly received poor care because the residents or interns treating them were too tired, he said they were nothing more than isolated anecdotes.

“These are just war stories,” Powers said. “There are few if any deaths that occur the following morning.”

He said there has been a legislative overreaction in the wake of the death of Libby Zion, an 18-year-old woman who walked into a New York City hospital in 1984 with an earache and died hours later from a raging fever. She had been left strapped to her bed and unattended, allegedly because of poor medical care by a sleep-deprived resident.

Referring to legislation passed in New York that will sharply curtail residents’ hours beginning next year, Powers said: “If you look at the facts of that case, it is simply one of medical malpractice. I dare say that no one in this room would have done the same things that led up to the death of that patient.”

Dismissing the Assembly bill as “pie-in-the-sky” legislation, Powers warned the doctors that they would only be hurting themselves if it passes. It would prove so costly that the number of slots available for residency training programs would be sharply reduced, he said.

“With the budget cutbacks we have already been through, we’re having to reduce residency programs,” he said. “Do you want to make it even more difficult for people like yourselves to get into residency programs?”

But the other three speakers supported reducing the work hours.

However, one of them, Dr. Yolanda Brady, the chief resident in the internal medicine program, said that such changes should be made by individual hospitals and accreditation organizations, not by legislation.

“I’m a resident in internal medicine, my husband is a resident in obstetrics and gynecology and my father is a psychiatrist, so I know from personal experience that something has to be done about the hours that residents work,” she said. “But I am not in favor of the government doing it.”