The working conditions of New York state hospital residents are once again under scrutiny. Last month, the state's Health Department conducted surprise inspections at 12 New York hospitals, looking for evidence of unsupervised or overly tired residents.
Without warning, teams of Health Department inspectors descended on seven New York City hospitals, as well as two in Buffalo, and one each on Long Island and in Rochester and Westchester.
Health Department spokesman Robert Hinckley says more inspections are planned.
In the course of the weekend visits, the inspectors studied residents' schedules and on-call rosters. In some cases, they even paged attending physicians to test their response times. According to Hinckley, the Health Department decided to mount the investigations after other routine hospital inspections led to concerns about resident supervision.
Hinckley would not comment on the inspectors' findings, and said only that the hospitals were very cooperative. He noted that any violations will result in education and training; no punitive measures will be taken.
"We do recognize that medicine is one of those professions where it isn't always a nine-to-five job, but there are regulations on the books, and when the public goes into the hospitals they don't want someone who's dead on their feet."
In 1989, following the highly publicized death of 18-year-old Libby Zion in a New York emergency room, the state implemented a set of regulations -- the so-called Bell regulations -- that require hospital residents to be closely supervised and not work more than 80 hours a week or 24 hours straight. Prior to the regulations, 100 hour weeks and 36-hour shifts were common. Zion's family blamed her death on the care she received from overworked and exhausted residents at New York Hospital.
In December, 1997, Mark Green, public advocate for the city of New York, issued a report declaring that "the problem of exhausted and poorly supervised residents continues unabated," and he cited several incidents that led to patient harm and even deaths. The Bell regulations (named for Bertrand Bell, M.D., Distinguished University Professor of Medicine at Albert Einstein College of Medicine and head of the commission that reviewed the use of residents after Zion's death) are often ignored, the report said.
Some 103 New York hospitals train 15,000 residents annually.
The hospitals receive millions of dollars for Bell regulation compliance through Medicare reimbursement rate adjustments. Between 1990 and 1996, hospitals received $1.2 billion in Bell funds, according to the New York public advocate. But hospitals have no incentive to comply with the regulations, Bell says.
"The hospitals took the money and ran," he says. "Giving money to institutions to comply with the law is not the way to go. Rather, what I think needs to be done is the law needs to be enforced as if it were a criminal law and people who do not comply go to jail."
Just how to enforce the regulations, however, is up for debate. Michael Noe, M.D., executive vice president and medical director of Buffalo General Health System, says inspectors who visited his hospital were frustrated by the absence of accurate time records, which raises the point of enforcement difficulties.
"We do not have residents punch in and out, so to speak. There is really no end to the kind of documentation one would require or might require to be sure about what was going on," he says. "Unfortunately regulations like these can become extremely burdensome in terms of demonstrating compliance."
Frederick Alley, president and CEO of Brooklyn Hospital Center, one of the hospitals inspected, agrees the regulations are necessary, but notes the need for some flexibility. "These men and women are here to get an education. In order to get a proper education, they need to have continuity with the patient. When that patient is in trouble, they need to be there with the attending, and that can from time to time conflict with working schedules," he says.