(Taffinder et al., 1998). Moreover, error rates were higher among residents after a night on call than during normal daytime hours (Grantcharov et al., 2001). Realistic patient simulators have also been used to evaluate the performance of anesthesiologists at night when fatigued and during regular workdays (Ou et al., 2001), as well as under conditions of acute sleep deprivation (e.g., awake for 25 hours) or being well rested (2 hours of extra sleep on average for four consecutive nights before the study) (Gaba, 1998; Weigner et al., 1998). Videotapes from the latter study showed sleep-deprived residents actually falling asleep while administering anesthesia.
Despite evidence that patient care may be compromised if a fatigued, sleep-deprived clinician is allowed to operate, administer anesthesia, manage a medical crisis, or deal with an unusual or cognitively demanding clinical presentation (Weigner and Ancoli-Israel, 2002), there is significant resistance to limiting the hours worked by resident physicians. Concerns have been expressed about reduced learning opportunities if resident work hours are curtailed (Greenfield, 2001; Holzman and Barnett, 2000; Suk, 2001), as well as decreased professionalism and commitment to patients (Holzman and Barnett, 2000). Current resident work hours have also been defended on economic grounds (Green, 1995; Patton et al., 2001; Thorpe 1990).
Only the state of New York limits the hours worked by resident physicians. The “Bell Regulations”4 were enacted following the death of Libby Zion, the 18-year old daughter of Sidney Zion, an attorney and writer for the New York Times, in 1984. Her death triggered an aggressive media campaign questioning the quality of care in teaching hospitals, as well as a grand jury investigation into her death (Asch and Parker, 1988; Kwan and Levy, 2002). Although neither the hospital nor physicians were faulted, the grand jury did find fault with the residency training system and physician staffing patterns that allowed Libby Zion’s death to occur. Five specific factors were identified as contributing to her death: (1) she was not examined by an attending physician with experience in emergency medicine when admitted to the ER in an agitated condition, complaining of fever; (2) after transfer to a medical unit, she was cared for by first- and second-year residents who were largely unsupervised; (3) she was admitted at 2:00 a.m., when both residents caring for her had been at work for 18 straight hours; (4) the first-year resident ordered that she be placed in physical restraints without reevaluating her condition; and (5) she was given meperidine (Demerol) despite the resident’s knowledge that she was also taking phenalzine.5